A 28-year-old male heroin-dependent patient has been stable on methadone maintenance 80 mg/day for 6 months. He is now admitted for emergency cholecystectomy. Post-operatively, he develops severe agitation, piloerection, rhinorrhoea, and hypertension on day 2. Methadone was not given peri-operatively. What is the most appropriate immediate management?
- A Start clonidine 0.1 mg three times daily and withhold opioids
- B Administer naloxone to confirm opioid withdrawal
- C Resume methadone at his established dose and add appropriate analgesics for surgical pain ✓
- D Start buprenorphine 8 mg sublingually immediately
Explanation
In a patient stable on methadone maintenance, failure to continue the maintenance dose during hospitalisation will precipitate opioid withdrawal (COWS ≥12). The most appropriate intervention is to resume the documented methadone dose immediately — ideally verified with the prescribing clinic. Methadone does not provide adequate analgesia at maintenance doses; additional non-opioid analgesics or short-acting opioids are required for surgical pain and should be prescribed separately. Clonidine can manage mild withdrawal symptoms but does not address the underlying physical dependence. Naloxone would worsen the withdrawal state and should not be used diagnostically here.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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Written and medically reviewed by the StethoPrep medical team.