Guidance on Medical Protocols for Withdrawal Management for OASAS Certified Programs

New York State Office of Addiction Services and Supports (OASAS) certified programs that provide withdrawal management services must obtain and maintain approval for their medical protocols for withdrawal management from the OASAS Division of Medicine, Psychiatry, and Nursing (DMPN).

In September 2019, DMPN stopped routinely reviewing all medical protocols for withdrawal management and instead required programs seeking new certification or recertification for withdrawal management and stabilization services to complete an attestation verifying that their protocols met certain criteria. 

As the certifying agency for addiction treatment in New York State, OASAS is required to ensure and committed to ensuring that programs meet professional standards for high quality substance use disorder treatment. Therefore, all programs that provide withdrawal management services must submit their medical protocols for withdrawal management when submitting a new certification or recertification application effective June 1, 2026. 

DMPN will review the protocols and request revisions if the protocols are found to be inconsistent with this guidance or do not meet the standard of care for any reason. DMPN can be contacted for technical assistance if needed when programs are creating or revising withdrawal management protocols. Programs will be asked to complete and submit the current attestation form once DMPN gives final approval to their protocol. In addition to these reviews, OASAS will continue to retain the right to review a program’s medical protocols for withdrawal management at any time and, if protocols are not consistent with the criteria in this guidance or do not meet the standard of care for any reason, request revisions and initiate regulatory action as necessary and appropriate. 

For purposes of this guidance, “standard of care” refers to generally accepted clinical practices supported by current evidence-based guidelines and clinically accepted consensus.

Program medical directors should create or revise medical protocols to be consistent with the following.

Objective Measures

Protocols should specify that objective measures of withdrawal severity are used, including:

• Vital sign monitoring
• Validated withdrawal scales such as the:
  • Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar)
  • Clinical Institute Withdrawal Assessment for Benzodiazepine Scale (CIWA-B)
  • Clinical Opioid Withdrawal Scale (COWS)
  • Specific withdrawal scales a program uses are at the discretion of the program’s medical director, as long as scales are objective and validated.

Toxicology Testing

Protocols should indicate when specimens are collected for testing and how toxicology test results will inform treatment.  If urine will be used for toxicology testing, protocols should specify that direct observation of urine sample collection can be considered but should be used as a last resort in rare instances rather than as part of usual clinical practice. More information about toxicology testing can be found in the Toxicology Testing Guidance for OASAS-Certified Programs.

Assessment

Protocols should specify that patients are carefully assessed for complicated or serious withdrawal risk factors. Assessment domains include but are not limited to:

• Length of recent use
• Amounts of substance used
• Use of multiple substances
• History of serious withdrawal complications
• Unstable or complex co-occurring medical and psychiatric conditions
  • Signs of withdrawal while still intoxicated 

Behavioral Health Risk

Screening for co-occurring mental health conditions, including suicide, is required in OASAS-certified programs. Protocols should specify how patients are routinely screened and assessed for suicide risk, and how elevated suicide risk is mitigated during admission to the program and after discharge. Protocols should also indicate how co-occurring mental health conditions are screened, assessed, and addressed by the program, including referrals for mental health treatment post discharge. The Guidance for the Use of Screening Instruments for Co-Occurring Mental Health Conditions in NYS OASAS Certified Programs can assist programs in choosing mental health screening instruments and information about suicide screening can be found in the Guidance for Screening, Assessment, Intervention, and Monitoring for Suicide and Overdose Risk in OASAS Certified Programs.

Contraindications

Protocols should clearly state the populations and conditions that cannot be managed safely at the designated level of care and may require transfer to a higher level of care or managed in the current level of care with special safeguards in place. For example:

• Pregnant persons experiencing withdrawal from alcohol, benzodiazepines, or opioids and persons with unstable cardiovascular disease often cannot be managed safely with an ancillary withdrawal protocol in a residential or outpatient setting without specific considerations or additional monitoring.
• Individuals at risk for alcohol withdrawal with a history of serious withdrawal episodes that include seizures or delirium tremens often need medically managed withdrawal in a hospital.
• Individuals with unstable mental health symptoms or at elevated risk for suicide may need a program that can provide more intensive mental health treatment.

Preventative Care 

While the risk of intoxication and side effects from withdrawal management medications must be balanced carefully with the risk of acute withdrawal, protocols should emphasize prevention of withdrawal from alcohol and sedative-hypnotic medications such as benzodiazepines by initiating medication treatment at mild-to-moderate levels of withdrawal (i.e., CIWA-Ar of 8-10; CIWA-B of 15-19) or changing treatment when withdrawal severity is increasing despite treatment (e.g., CIWA-Ar rises from 6 to 9) as clinically appropriate.

Emergency Protocols

Protocols should clearly indicate when and by what means (i.e., in person, by telehealth) patients are urgently assessed by a medical professional. Protocols should also describe the process for transferring patients to a higher level of care such as a hospital emergency department or an intensive care unit if the patient is already in a hospital, where permitted by certification, scope of practice, and applicable law(s).

Overdose Risk

Protocols should specify that all patients, regardless of substances they use, are screened and assessed for overdose risk as described in the Guidance for Screening, Assessment, Intervention, and Monitoring for Suicide and Overdose Risk in OASAS Certified Programs
 

Initial and Follow-Up Assessments

Protocols should state:

• Which medical and nursing staff perform initial patient assessments, including admission medical histories and admission physical examinations
• The time frame for completing initial assessments
• The means by which all initial and follow-up assessments are completed (i.e., in person, by telehealth)
• How frequently patients are reassessed for signs and symptoms of withdrawal
• How frequently patients will be seen by a physician, physician assistant, or nurse practitioner for medical follow-up

Reconsulting Medical Staff

Protocols should establish clear and objective criteria for when a physician, physician assistant, or nurse practitioner is reconsulted after initiation of withdrawal management. These criteria should include but are not limited to:

• Unstable vital signs
• Acute change in medical condition or mental status
• Thoughts of harm to self or others
• Suspected adverse medication effects
• Withdrawal severity increasing despite treatment, even if severity is still in the mild-to-moderate range
• Withdrawal severity assessed to be high-to-severe

Opioids

• Initiation of and stabilization on medication for opioid use disorder (MOUD) rather than tapering the medication is the safest and most evidence-based standard of care for patients with opioid use disorder (OUD) and in opioid withdrawal.
• All protocols should emphasize initiation and stabilization on buprenorphine or methadone (if the program is certified federally and by OASAS to provide methadone) as the preferred treatments over long-acting injectable naltrexone.
• Once withdrawal symptoms have improved, all MOUD options should be presented to the patient.
• As part of discharge planning, all patients who are started on and want to continue taking MOUD should be given appointments with programs that can continue the medication post-discharge.
• For patients who refuse all MOUD even after the provider has explored the reasons for refusal several times and addressed any concerns or misconceptions about MOUD, protocols can include a buprenorphine or methadone taper option.
• Discharging patients without MOUD, however, should be the exception and consistent with patient choice and informed consent, including education about the increased risk of overdose following a period of abstinence if not taking MOUD.
   

Alcohol

• Medications for alcohol use disorder (MAUD) such as naltrexone and acamprosate are effective but underutilized evidence-based treatments.
• Protocols should include offering these medications and starting patients on their choice of MAUD prior to discharge.
• MAUD should be discussed several times with the patient during their treatment to ensure that the patient fully understands the benefits of MAUD before they decide if they will initiate treatment. 
   

Timing

When medically safe and appropriate, protocols should begin treatment of OUD in the mild-to-moderate ranges (e.g., COWS of 6-12).

Ancillary Medications

Protocols should make appropriate use of ancillary medications for withdrawal management such as those for:

• Sleep
• Nausea
• Diarrhea
• Pain
• Anxiety 

Tobacco and Nicotine

Protocols should include offering nicotine replacement therapies (NRT) to prevent nicotine withdrawal to patients who use tobacco or nicotine products, even if they are not willing to consider complete cessation from tobacco or nicotine products. Patients should also be offered other medication options for the long-term treatment of tobacco use disorder. 
 

LOCADTR

Protocols should specify that the most recent version of the LOCADTR is performed on admission and that the Concurrent Review Module of the LOCADTR is performed at least once during program admission, with the frequency and timing of subsequent Concurrent Review Modules determined as clinically appropriate given the care setting. 

Overdose Prevention

Protocols should specify that during their admission, all patients receive overdose prevention and education, including naloxone education and training, naloxone and drug test strips, and community-based services appropriate to the patients’ needs. Patients at elevated risk for overdose, including those who recently overdosed, should create an Overdose Safety Plan as described in the Guidance for Screening, Assessment, Intervention, and Monitoring for Suicide and Overdose Risk in OASAS Certified Programs.

Discharge Planning and Continuing Support

Protocols should specify that discharge plans are made in collaboration with the patient. Patients started on MAT should be given an appointment with a treatment provider or program that can continue the medication post-discharge. Discharge planning for patients started on methadone must start early in treatment and include a telehealth admission to an outpatient program that provides methadone. Patients should receive an adequate supply of medication that lasts from the day of discharge until their scheduled appointment.