Opioid substitution and withdrawal — induction, COWS, pregnancy (MEQ)

(i) COWS and immediate care. COWS 15 is moderate withdrawal (band 13–24), consistent with last heroin ~14 h ago. She is a candidate for buprenorphine induction now if clinical picture and local protocol agree, or for symptomatic care while arranging methadone pathway. Supportive options: hydration, antiemetics, antidiarrhoeals, and α2-agonist cover (e.g. clonidine 0.1–0.2 mg oral every 6–8 h with BP monitoring) if agonist start is delayed. Do not force ultra-rapid detox.^[1][7]

(ii) OAT induction plan. Prefer maintenance OAT as disease-modifying care. Example A: buprenorphine (often ±naloxone per local pregnancy policy — some services prefer mono-product in pregnancy) start 2–4 mg SL, reassess 1–2 h, build toward ~8 mg day 1 if tolerated, then titrate to maintenance commonly 8–24 mg. Example B: methadone day-1 often 10–30 mg oral with slow titration (maintenance commonly 60–120 mg), ECG already essentially normal at QTc 430 ms — still monitor per protocol. Choose with obstetric-addiction liaison, logistics, and patient preference.^[2][3][7]

(iii) Pregnancy and partner. Explain that withdrawal risks miscarriage/preterm labour and return to street opioids; guidelines prefer agonist maintenance over detox in pregnancy. Counsel NAS: neonates may need monitoring/treatment after either methadone or buprenorphine; MOTHER found less NAS treatment burden and shorter stays with buprenorphine vs methadone in trial comparisons, but retention and individual factors matter — not a slogan for forced switches. Partner education: “clean baby via 5-day detox” is a high-risk myth; document shared decision-making and safeguarding without stigma.^[4][5][7]

(iv) Naloxone, HCV, benzos. Supply take-home naloxone and train patient/partner on slow breathing and emergency services (prior OD is a red flag). Arrange HCV RNA and antiviral pathway; harm-reduction advice if injecting continues. Assess diazepam quantity/dependence; sedative co-use raises OD risk on OAT — taper plan and avoid unsupervised polypharmacy.^[8][7]

(v) Mortality counselling. Retention in OST/OAT associates with lower mortality; risk rises after leaving treatment (Sordo). Detox-only pathways often return people to use at lost tolerance, a high-fatality window. Frame OAT as medical treatment that protects mother and baby by stabilising use and engagement.^[6]