One-liner#

Screen for and manage alcohol and opioid use disorders in primary care, including initiating medications for addiction treatment (MOUD), while recognizing withdrawal syndromes and knowing when to refer for higher levels of care.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

Alcohol withdrawal:

• Seizures or history of withdrawal seizures
• Delirium tremens (confusion, hallucinations, severe autonomic instability)
• Severe withdrawal (CIWA-Ar >15) without ability to monitor closely
• Hemodynamic instability

Opioid-related:

• Overdose (respiratory depression, altered mental status) → call 911, give naloxone
• Severe withdrawal with dehydration, unable to tolerate PO
• Suicidal ideation

Other:

• Stimulant intoxication with chest pain, severe hypertension, hyperthermia
• Benzodiazepine withdrawal (similar to alcohol—can be life-threatening)

Key history#

Screening tools:

Alcohol:

• AUDIT-C (3 questions): Score ≥4 (men) or ≥3 (women) = positive screen
  • How often do you have a drink containing alcohol?
  • How many drinks on a typical drinking day?
  • How often do you have 6+ drinks on one occasion?

Drugs:

• Single question screen: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?”
  • Any use = positive screen
• DAST-10 for more detailed assessment

Characterize use:

• Substance(s) used
• Route (oral, IV, intranasal, smoked)
• Frequency and amount
• Duration of use
• Last use (withdrawal risk)
• Prior quit attempts and treatments
• Prior withdrawal history (especially seizures for alcohol)

DSM-5 criteria for substance use disorder (2+ in 12 months):

• Using more or longer than intended
• Persistent desire or unsuccessful efforts to cut down
• Great deal of time obtaining, using, or recovering
• Craving
• Failure to fulfill major role obligations
• Continued use despite social/interpersonal problems
• Giving up important activities
• Use in physically hazardous situations
• Continued use despite physical/psychological problems
• Tolerance
• Withdrawal

Severity: Mild (2-3), Moderate (4-5), Severe (6+)

Assess for withdrawal risk:

Alcohol:

• Last drink
• Typical daily consumption
• History of withdrawal seizures or DTs
• CIWA-Ar score if in withdrawal

Opioids:

• Last use
• Type (short-acting vs long-acting)
• COWS score if in withdrawal

Comorbidities:

• Psychiatric: depression, anxiety, PTSD, bipolar (very common)
• Medical: liver disease, HIV, hepatitis C, endocarditis
• Other substance use (polysubstance common)

Social history:

• Housing stability
• Employment
• Legal issues
• Family/social support
• Readiness to change (precontemplation → contemplation → preparation → action → maintenance)

Focused exam#

General:

• Nutritional status
• Signs of intoxication or withdrawal
• Injection sites (track marks)

Vital signs:

• Tachycardia, hypertension, fever (withdrawal)
• Respiratory depression (opioid intoxication)

HEENT:

• Pupil size: pinpoint (opioid intoxication), dilated (opioid withdrawal, stimulants)
• Nasal septum (cocaine use)
• Dental health

Cardiovascular:

• Murmurs (endocarditis in IV drug users)

Abdominal:

• Hepatomegaly, ascites (liver disease)

Skin:

• Track marks, abscesses, cellulitis
• Jaundice
• Spider angiomata

Neurologic:

• Tremor (alcohol withdrawal)
• Altered mental status

Mental status:

• Mood, affect
• Suicidal ideation

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Alcohol use disorder:

Opioid use disorder:

When NOT to delay treatment for labs:

• Patient ready to start buprenorphine → can start same day
• Labs can be drawn at follow-up visit
• Don’t let “need for labs” be a barrier to treatment

Initial management#

Brief intervention (SBIRT):

• Screen → Brief Intervention → Referral to Treatment
• For risky use not meeting disorder criteria
• Motivational interviewing: express empathy, develop discrepancy, roll with resistance, support self-efficacy

Assess readiness to change:

• Precontemplation: not considering change → raise awareness
• Contemplation: considering change → explore ambivalence
• Preparation: ready to change → help plan
• Action: actively changing → support and reinforce
• Maintenance: sustaining change → prevent relapse

Harm reduction (even if not ready to quit):

• Naloxone prescription for all patients with OUD or on high-dose opioids
• Safe injection practices education
• Hepatitis/HIV testing and treatment
• Fentanyl test strips (where legal)

Management by diagnosis#

Alcohol use disorder#

Education:

• AUD is a medical condition, not a moral failing
• Medications can reduce cravings and help maintain sobriety
• Combination of medication + behavioral support most effective
• AA/mutual support groups helpful for many

Treatment:

Choosing a medication:

• Naltrexone: first-line for most; can start while still drinking
• Acamprosate: good for patients with liver disease; must be abstinent
• Gabapentin: good for comorbid anxiety, insomnia, or neuropathy
• Disulfiram: only for highly motivated patients with supervision

Alcohol withdrawal management (outpatient—mild to moderate only):

• CIWA-Ar <10 and no seizure/DT history: can manage outpatient
• CIWA-Ar 10-15: close outpatient monitoring or consider inpatient
• CIWA-Ar >15 or seizure/DT history: inpatient detox
• Thiamine 100 mg daily x 5 days, then ongoing supplementation
• Folate 1 mg daily
• Symptom-triggered benzodiazepine (e.g., chlordiazepoxide 25-50 mg Q6H PRN) with close monitoring
• Daily or every-other-day visits until stable
• If CIWA-Ar >15 or worsening → ED

CIWA-Ar scoring (10 items, max 67):

• Nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation
• <10: Mild; outpatient management possible
• 10-15: Moderate; close monitoring

• 15: Severe; inpatient recommended

• 20: High risk for seizures/DTs

Follow-up: Weekly during early recovery; then monthly; long-term maintenance.

Opioid use disorder#

Education:

• OUD is a chronic medical condition
• Medications (buprenorphine, methadone, naltrexone) are the most effective treatment
• Medication is not “replacing one addiction with another”—it’s treatment
• Stopping medication greatly increases overdose risk

X-waiver no longer required: As of 2023, any provider with DEA license can prescribe buprenorphine for OUD.

Treatment:

Buprenorphine induction (can be done in office or at home):

1. Patient must be in withdrawal (COWS ≥8-12, or 12-24 hours since last short-acting opioid)
2. Start with 2-4 mg sublingual
3. Reassess in 1-2 hours; give additional 2-4 mg if still in withdrawal
4. Day 1 max: 8 mg
5. Day 2: increase to 8-16 mg
6. Target maintenance: 16-24 mg/day (higher doses more effective)

Home induction option:

• Provide prescription and detailed instructions
• Patient starts when in moderate withdrawal
• Phone check-in on day 1-2
• Office visit within 1 week

Precipitated withdrawal: If buprenorphine given too early (before sufficient withdrawal), it can precipitate severe withdrawal. Wait for COWS ≥8-12.

Fentanyl considerations:

• Fentanyl is lipophilic; stays in fat tissue longer
• May need to wait 24-72 hours for sufficient withdrawal
• Higher risk of precipitated withdrawal
• Consider low-dose (micro-dosing) induction: start 0.5 mg buprenorphine, increase slowly over days while patient continues using
• Or use “Bernese method”: overlap buprenorphine with continued opioid use, gradually increasing buprenorphine
• Consider referral to addiction medicine for complex fentanyl cases

Pregnancy:

• Buprenorphine (mono-product, not Suboxone) is first-line for OUD in pregnancy
• Methadone also safe and effective; requires OTP
• Do NOT use naltrexone in pregnancy
• Refer to OB with addiction medicine experience
• Neonatal opioid withdrawal syndrome expected; not a reason to avoid treatment

COWS (Clinical Opiate Withdrawal Scale) scoring:

• 0-4: No withdrawal
• 5-12: Mild withdrawal
• 13-24: Moderate withdrawal
• 25-36: Moderately severe

• 36: Severe withdrawal

• Start buprenorphine when COWS ≥8-12

Naloxone prescribing:

• Prescribe to ALL patients with OUD
• Also prescribe to patients on high-dose opioids for pain
• Teach patient and family/friends how to use
• Narcan nasal spray 4 mg: 1 spray in nostril; repeat in 2-3 min if no response

Follow-up: Weekly x 4 weeks, then every 2 weeks x 2 months, then monthly.

Cannabis use disorder#

Education:

• Cannabis can cause dependence and withdrawal
• No FDA-approved medications
• Behavioral treatment is primary approach

Treatment:

• Motivational interviewing
• CBT
• Contingency management
• No medications proven effective

Withdrawal symptoms (if stopping heavy use):

• Irritability, anxiety, insomnia
• Decreased appetite
• Restlessness
• Usually mild; peaks at 2-3 days; resolves in 1-2 weeks

Follow-up: As needed; behavioral treatment referral.

Tobacco use disorder#

Education:

• Nicotine is highly addictive
• Multiple quit attempts are normal
• Medications double quit rates
• Combination therapy most effective

Treatment:

Combination therapy: Patch + short-acting NRT (gum or lozenge) more effective than either alone.

Follow-up: Set quit date; follow up within 1-2 weeks of quit date; then monthly.

Follow-up#

Alcohol use disorder:

• Weekly during early recovery and withdrawal management
• Monthly once stable
• Long-term maintenance (AUD is chronic)

Opioid use disorder:

• Weekly x 4 weeks after buprenorphine induction
• Every 2 weeks x 2 months
• Monthly once stable
• Urine drug screens at each visit initially; can space out once stable

General:

• Monitor for relapse
• Assess medication adherence and side effects
• Screen for comorbid psychiatric conditions
• Address social determinants (housing, employment)

Return precautions:

• Signs of withdrawal (especially alcohol—can be dangerous)
• Relapse
• Suicidal thoughts
• Medication side effects

When to refer:

• Severe alcohol withdrawal or DT history → inpatient detox
• Failed outpatient treatment → intensive outpatient or residential
• Severe OUD preferring methadone → opioid treatment program (OTP)
• Complex psychiatric comorbidity → addiction psychiatry

Patient instructions#

For alcohol use disorder:

• Alcohol use disorder is a medical condition. Medications and support can help you recover.
• Take your medication every day as prescribed. It helps reduce cravings.
• If you drink while taking naltrexone, you won’t feel the “buzz” as much—this is how it works.
• Avoid situations and people that trigger drinking, especially early in recovery.
• Consider attending AA or SMART Recovery meetings for support.
• Call us or go to the ED if you have shaking, sweating, confusion, or see things that aren’t there after stopping drinking.

For opioid use disorder:

• Buprenorphine is a medication that treats opioid addiction. It is not “trading one addiction for another.”
• Take your medication every day. Stopping suddenly puts you at high risk for overdose.
• Keep naloxone (Narcan) with you and make sure someone close to you knows how to use it.
• If you use other opioids while on buprenorphine, they won’t work as well—and mixing with benzos or alcohol is dangerous.
• Recovery is possible. Many people live full, healthy lives on medication-assisted treatment.

Smartphrase snippets#

.AUDEVAL Alcohol use disorder, [mild/moderate/severe] based on DSM-5 criteria. AUDIT-C score [X]. Last drink [timeframe]. No history of withdrawal seizures or DTs. CIWA-Ar [score if applicable]. LFTs: AST [X], ALT [X], GGT [X]. Discussed treatment options. Starting [naltrexone 50 mg daily / acamprosate 666 mg TID / gabapentin]. Thiamine and folate supplementation. Behavioral treatment referral offered. Follow-up in [1 week / 2 weeks].

.OUDSTART Opioid use disorder, [mild/moderate/severe]. Last opioid use [timeframe]. COWS score [X] consistent with [mild/moderate/severe] withdrawal. Initiating buprenorphine/naloxone [dose] sublingual. Discussed that medication is effective treatment, not “replacing one addiction with another.” Naloxone (Narcan) prescribed for overdose prevention. UDS obtained. Hepatitis C and HIV screening ordered. Follow-up in [1 week].

.OUDFOLLOWUP OUD follow-up on buprenorphine/naloxone [dose]. Patient reports [no cravings / occasional cravings / ongoing use]. UDS today: [results]. [Stable on current dose / increasing dose to X / discussing adherence]. Naloxone refill provided. Behavioral treatment: [engaged / referred / declined]. Follow-up in [2 weeks / 1 month].

Related pages#

• Alcohol Use Disorder (problem) — comprehensive ongoing management of AUD
• Opioid Use Disorder (problem) — comprehensive ongoing management of OUD including buprenorphine
• Depression — commonly comorbid with substance use
• Anxiety — commonly comorbid with substance use
• Insomnia — substance use affects sleep
• Chronic pain — opioid prescribing considerations