I work in a mental health/drug detox clinic. We use the COWS for opiate withdrawal & once the client scores a 13 or higher, we use suboxone (naloxone + buprenorphine) to treat withdrawals. Within 30 minutes, the client is feeling better. We start them on 4mg BID & taper them down over a 6 day period. It works MUCH better than clonidine. We only use clonidine for HTN and if their BP can support it, we occasionally use it if someone is still having withdrawals once they've completed their suboxone protocol. Common side effects of suboxone are headache & constipation, so we treat those as needed with tylenol, ibuprophen, & laxatives. It works very well for most, but some heavy users will still have some break-through withdrawals. We just give them PRNs.
We use the CIWA for ETOH and benzo detox and treat them with librium. The first 24 hours dictates whether they will be on the moderate or severe protocol, depending on how much librium it takes to treat their withdrawals. Librium is a long acting benzodiazepine that's typically used for detox. It can effect blood pressure, so per our protocol, we never give it if BP is below 90/60. We use the CIWA to assess for DT's, but in many cases, we start the librium immediately after admission, regardless of score. We do not admit anyone with a BAL above 2.0. With our protocol, we give scheduled librium & we may give a PRN librium q6H. If we feel more is needed, we call our MD. There is a lot of wiggle room with our librium protocol and most clients can safely tolerate considerably more than we actually give, but I do try to discourage PRN doses toward the end of their protocol because it's better for them to taper down before cutting them off. If they continue to ask, I'll offer vistaril for anxiety and call our MD if I feel the protocol should be extended for this individual.
BTW, we only do our COWS until a 13 or greater is met and we only do the CIWA on admission. Our clients are with us for 7 days, unless an extension is needed for further treatment or for long term placement.