ORDER SETS

All patients, even residential, should have the “Standard Orders for All Admissions” as an
order set. If the patient has a specific allergy to a medication contained within the order set, or
there is another reason that a specific medication should not be ordered it can be changed or
deleted individually once you choose the “Review orders” button.

All patients using an Opiate should have the “Opiate Order Set” selected under the Doctor’s
order tab started on admission, again these can be changed or deleted individually before the
order is finalized. (PLEASE NOTE!!! If a patient is telling you they were taking Xanax, or some
other substance that they do not test positive for, always make sure to do a Fentanyl test. Many
items bought illegally are just plain Fentanyl, or Fentanyl containing, and they may not even
know that’s what it is)

Common Opiates (Opioids)

 Heroin
 Codeine (Many prescription cough liquids)
 Oxycodone (OxyContin, Roxicodone, Percocet, Percodan)
 Hydrocodone (Vicodin, Lorcet, Lortab, Norco)
 Tramadol (Ultram)
 Morphine (MS Contin)
 Fentanyl (Duragesic, “Street Percs”, “Blues”)
 Kratom

All patients using Alcohol or any Benzodiazepine should have the “Alcohol/Benzo Order Set”
selected on admission.

Common Benzodiazepines
 Alprazolam (Xanax)
 Clonazepam (Klonopin)
 Chlordiazepoxide (Librium)
 Diazepam (Valium)
 Lorazepam (Ativan)
 Oxazepam (Serax)
 Temazepam (Restoril)
 Triazolam (Halcion)
 MSAS Order Set

MSAS must be done initially and then AT LEAST every 4 hours for the first 48 hours. If you
just did one an hour ago and the patient looks bad or has complaints, then do another and use the
PRN MSAS to document. You do not need to wait until the next prescribed check time. These
are minimum guidelines.

Understand that the MSAS is reactive, both in dosing and in frequency. Until the patient is seen
by the MD in the morning, the expectation is that their symptoms are covered by MSAS
w/Ativan as follows:
 MSAS 0-5: repeat in 4 hours (or sooner if indicated)
 MSAS 6-7: Ativan 1mg + repeat in 4 hours (or sooner)
 MSAS 8-9: Ativan 2mg + repeat in 2 hours (or sooner)-Can then return to typical
monitoring depending on score at that time.
 MSAS 10-11: Ativan 3mg + repeat in 1 hour - Can then return to typical monitoring
depending on score at that time.
 MSAS 12+: Ativan 4mg + repeat in 1 hour and continue with q1 hour MSAS until
score is less than 12 x2. Can then return to typical monitoring depending on score at that
time.

Other notes about MSAS

 Be aware of some overlap in symptoms with COWS and MSAS

 Be aware of patient intoxication level. Some patients may come in blowing high BAC
and have an elevated pulse, or have baseline hypertension, or just came in from the
Arizona summer, or have confusion based on intoxication. These instances are times
when you should consider your patient and their level of WITHDRAWAL. If a patient is
highly intoxicated, so is vomiting, has baseline hypertension etc… they may be scoring
on the MSAS. (You or I could score on the MSAS on a bad day!), but it is only meant to
be used in the period of detox/withdrawal, not in the period of intoxication. Giving
someone Ativan who is already intoxicated can lead to fatal respiratory depression.
 Patients WILL come in still blowing higher than a zero on a BAC and be in active
withdrawal requiring medication, especially in heavy use.
 COWS Order Set

 Measure the subjective items as ones that are affected only by withdrawal.
o Runny nose/tearing should only be accounted for as attributed to withdrawal
symptoms, not allergies or a cold.
o Restlessness should be observed more than asked. Are they able to sit still during
the assessment or are they bouncing their leg?
o Bone or joint aches- only account for pain related to withdrawal. If the patient has
chronic back pain, ask them if it is worse than usual or about the same.
o GI upset- only over the past 30 minutes- not this morning or last night…
 The physician may ask you to contact them when they are scoring ABOVE a certain
number such as 9.
 Generally, induction of Subutex should be initiated only around 24 hours after last use of
Opioid.
 If the patient is detoxing from Methadone, induction of Subutex should only be initiated
at minimum of 48-72 hours.
o Patients on low doses of methadone (30 – 40 mg per day or less) generally
tolerate the transition to buprenorphine with minimal discomfort; whereas patients
on higher doses of methadone may find that switching causes significant dis-
comfort. Patients should be closely monitored during such a switch because there
is a risk that stable methadone patients may become unstable when changing to
buprenorphine.
 Don’t forget about additional medications! Supportive meds are extremely important in
the period before opiate replacement can occur and should be used as able. Clonidine is
especially useful in opiate withdrawal and can be given as long as BP and HR are not too
low.
 If the patient is having a hard withdrawal and supportive medications do not seem
effective, ask for something else.
 If the patient is having a hard withdrawal and taper medications do not seem effective,
ask for something else.
 We have a number of medications at our disposal that may be alternatives or supplements
to the standard order sets within reason.
 Standard Medications and Their Usages

Constipation- Colace, Milk of Magnesia, Mag Citrate

Cramping- Bentyl (Dicyclomine)
Diarrhea- Imodium
Nausea- Zofran (Ondansetron), Phenergan (Promethazine) IM and oral formulations for both
Heartburn- Maalox/Mylanta, TUMS
Anxiety- Clonidine, Hydroxyzine (Vistaril), Seroquel, Phenobarbital (SEVERE)
Sleep- Melatonin, Vistaril, Trazodone, Seroquel
(This is not a mix and match. If the patient is not achieving sleep on the dose prescribed
the MD should be contacted to advise of dose changes. We are not to give them multiple
different categories of sedatives)
Pain- Tylenol, Ibuprofen, Orajel, Robaxin (Methocarbamol)
Agitation/Psychosis- Seroquel, Phenobarbital, Zyprexa (Olanzapine), Haldol (Haloperidol) IM
and oral formulation
Seizure- Tegretol, Depakote, Gabapentin
Supplementation- MVI, Thiamine (B1), Folic Acid
Allergy- Vistaril, Benadryl, Epipen
Blood pressure- Clonidine, Lisinopril, Metoprolol TARTRATE (Make MD aware that succinate
must be ordered if requested)
o BP must be rechecked 30-60 minutes after dose is given for hypertension

Additional Orders

UDS on every patient on admit

BAC on every patient on admit (Yes even those who don’t report alcohol)
Insulin and AC/HS BS sets for diabetic (ascertain low, moderate, or high dose sliding scale per
MD)
Nicotine replacement (Nicotine Patch, Nicotine lozenge/gum) If these are obtained the patient
must commit to not smoke, it should not be a supplementation to smoking.
Lab draws- Labs need to be drawn on every patient AT ADMIT or the following day at the
latest. There are very serious medical complications from use, or outside of use, that need
to be checked for. If you don’t know how to do lab draws, let someone know, learn and
practice. This should not be reserved for only certain nurses to obtain and places the
patients in danger.
Tegretol/CBC lab draw- This needs to be done 4 days after start of Tegretol and should be drawn
as a trough level (Immediately before the next dose). If drawn after administration of the
medication it will be falsely elevated.
 Alcohol Withdrawal

MECHANISM OF
MEDICATION ACTION
EFFECTS SIDE EFFECTS

Not common during short-

Acts on the GABA Suppresses
Long/intermediate- term use. Sedation occurs if
benzodiazepine sub- withdrawal
acting benzodiazepines too high a dose is
receptor symptoms
administered.
Not common during short-
Suppresses
Enhance action of term use. Sedation occurs if
Barbiturates withdrawal
GABA too high a dose is
symptoms
administered.

Opiate Withdrawal

PRIMARY MECHANISM OF SIDE

MEDICATION USE ACTION
EFFECTS
EFFECTS
Suppresses most opiate
Reduces selected withdrawal symptoms, but is less
symptoms of opiate effective than methadone in Sedation,
Clonidine Opiate withdrawal by reducing insomnia, muscle and dizziness,
(Catapres) withdrawal suppressing over bone pain, and craving. May be low blood
activity of the locus supplemented with prescription or pressure.
coeruleus over the counter medications for
gastrointestinal distress.

Opiate Withdrawal and Substitution Therapy

PRIMARY MECHANISM OF
MEDICATION USE ACTION
EFFECTS SIDE EFFECTS

Suppresses opiate
withdrawal symptoms for
an average of 24 hours.
1) Buprenorphine Buprenorphine:
Has a “ceiling” effect Same as
(Subutex) Opiate Opiate agonist
Suboxone: Produces the methadone, but
2) Buprenorphine withdrawal (Occupies brain
same effect as above, but anaphylactic
with naloxone and/or opiate receptor sites.)
if injected, the naloxone shock seems
(Suboxone) substitution Naloxone: Opiate
acts as an opiate even less
therapy antagonist (Blocks
antagonist. Produces less common.
brain opiate sites).
sedation and respiratory
depression than
methadone.
 AMA Risk

Among inpatient drug-detoxification hospitalizations, only 13% received detoxification plus

rehabilitation during inpatient care, and up to 14-20% were DAMA;
Most commonly identified themes-
 Opioid use disorder
 co-occurring mental health disorder
 being on Medicaid
 more likely Friday or Saturday

Continuing care

Detox should not be considered substance use disorder treatment. In fact, the residential and
follow-on care is what is actually considered “treatment” and detox is responsible for medical
stabilization and connection to treatment, meaning residential, IOP, PHP, etc…
Significant resolution of life stressors and mental health conditions will NOT occur in detox and
the patients should be encouraged to consider this a time to focus on their physical wellness and
preparation for the next level of care where these issues can be addressed. Addressing all of these
items in detox can be overwhelming for patients and will result in significant anxiety, increase in
symptoms/cravings, as well as increase risks of AMA. We absolutely should be encouraging
general stress reduction and coping skill techniques in detox, however getting caught up in the
details of specific reasons for use and how to resolve them should be left to the clinical team and
aftercare.

Resource sites

https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/
asam-national-practice-guideline-supplement.pdf ASAM guidelines

http://www.williamwhitepapers.com/pr/Medications%20Used%20in%20the%20Treatment
%20of%20Addiction.pdf

http://www.williamwhitepapers.com/rm_rosc_library/ List of Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114033/ AMA