<p> PLACE LABEL HERE OPIOID WITHDRAWAL ORDERS</p><p>The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).</p><p>1.  Place INT LABORATORY ORDERS: 2. Pregnancy Test: serum hCG for any still menstruating female ≥ 12 years of age MEDICATIONS: 3. Clonidine 0.1 mg po q 4 hrs x 12 doses, then Clonidine 0.1 mg po q 6 hrs x 8 doses, then Clonidine 0.1 mg po q 8 hrs x 6 doses, then Discontinue Hold if BP < 90/60 4.  Insomnia: Trazodone 50 mg PO at bedtime X 4 days then prn (50 mg po q HS prn) PRN MEDICATIONS: 5. Electrolyte Replacement Protocol (form # 21340) 6. Nausea/Vomiting:  Zofran (ondansetron) 4 mg IV or PO q 6 hrs prn  If N/V persist, add Reglan (metoclopramide) 10 mg IV q 6 hrs prn (5 mg if > 65 years old) 7. Diarrhea:  Imodium (loperamide) 4 mg first dose, then 2 mg prn after every loose stool (max 16 mg /day) 8. Muscle Spasms/Twitching:  Flexeril (cyclobenzaprine) 5 mg PO q 8 hrs prn, if no relief after 1 hr, may repeat 5 mg dose x 1 dose (max 30 mg/day) or  Baclofen 5 mg PO q 8 hrs prn (max 15 mg/day) 9. Mild pain, temp > 100.5, HA:  Tylenol (acetaminophen) 650 mg PO or PR q 4 hrs prn (max 4 gm/day) 10. Anxiety, dysphoria, lacrimation or rhinorrhea:  Ativan (lorazepam) 1 mg IV q 8 hrs prn or  Xanax (alprazolam) 0.25 mg PO q 6 hrs prn, if not effective in 1hr, may repeat 0.25 mg x 1 dose (max dose 2 mg/day) 11. Lacrimation or rhinorrhea:  Benadryl (diphenhydramine) 25 mg PO q 4 hrs prn, if not effective after 30 minutes, may repeat 25 mg x 1 dose (max 300 mg/day) 12. Respiratory Depression (patient is symptomatic with respiratory rate < 8 breaths/min): Narcan (naloxone) 0.4 mg IV in 10 ml Normal Saline (0.04 mg/ml). Administer 1 ml IV q 2 min prn until respiratory rate ≥ 8 or a max of 2 mg (5 doses). Narcan may increase withdrawal symptoms.</p><p>______Date Time Physician Signature PID Number</p><p>Copy to pharmacy </p><p>*1-43095* FORM 1-43095 REV. 04/2018 Page 1 of 1</p>