Opioid detox at RECO Island is built on the two evidence-based pathways: buprenorphine induction, which is the gold standard for most opioid-dependent patients and stabilizes withdrawal within an hour, and comfort-medication-only detox, offered to patients pursuing complete abstinence. In both cases, MAT continuation — Sublocade, Vivitrol, or oral maintenance — is arranged before you leave, because the two weeks after opioid detox are the highest-mortality window in all of addiction medicine.
Opioid detox is medically supervised management of opioid withdrawal — the flu-like syndrome of muscle aches, nausea, diarrhea, insomnia, anxiety, and profound craving that follows abrupt cessation of chronic opioid use. It uses buprenorphine (the gold standard) or a combination of comfort medications to make withdrawal tolerable and, more importantly, to bridge safely to maintenance MAT that dramatically reduces post-detox overdose mortality.
Because unmedicated opioid withdrawal, while rarely lethal on its own, is severe enough that most patients relapse within days — and the resulting overdose mortality risk is very high because opioid tolerance drops rapidly during detox. The evidence is unequivocal: buprenorphine or methadone maintenance reduces overdose death by roughly 50% compared to abstinence-based approaches, and the transition from detox to maintenance is exactly where that mortality benefit is either captured or lost.
Buprenorphine binds tightly to opioid receptors with partial agonist activity, immediately relieves withdrawal symptoms, blocks the effect of other opioids for the duration of dosing, and can be transitioned to Sublocade (monthly injection) for compliance-friendly maintenance. Vivitrol is the alternative for patients who complete a 7-day opioid washout, offering monthly blockade of opioid effects without agonist activity.
Every opioid detox admission begins with detailed use history: which opioids (heroin, fentanyl, oxycodone, methadone, buprenorphine), route (injection, insufflation, oral), quantity per day, duration of use, time since last dose, prior detox attempts and outcomes, prior MAT experience, and mental-health comorbidities. Injecting users receive hepatitis B/C, HIV, and syphilis screening. Baseline labs include CMP, CBC, hepatic panel, urinalysis, urine drug screen (with confirmatory GC/MS testing for fentanyl analogues in ambiguous cases), and pregnancy testing.
The buprenorphine induction pathway is the gold-standard first choice for most opioid-dependent patients. COWS scoring is performed at admission and every 2 to 4 hours until induction is complete. Buprenorphine is initiated when the COWS score reaches 12 (moderate withdrawal) or higher — starting earlier risks precipitated withdrawal, which is a genuinely miserable clinical event. Standard first dose is 2 to 4 mg sublingual buprenorphine, with subsequent doses of 2 to 4 mg every 60 to 90 minutes until symptoms are controlled, up to a typical total day 1 dose of 8 to 16 mg divided. Day 2 dose is adjusted based on 24-hour symptom control.
Illicit fentanyl has changed the induction landscape significantly. Fentanyl deposits in adipose tissue and continues to leach into the bloodstream for days after last use, extending the precipitated-withdrawal window. For fentanyl users, our medical director uses a low-dose induction protocol (0.5 mg buprenorphine every 4 hours starting at COWS 8, titrating slowly over 24-48 hours) with generous adjunctive comfort medication. This approach — sometimes called the "Bernese method" — dramatically reduces precipitated withdrawal risk.
Comfort-medication-only detox is offered to patients pursuing complete abstinence — typically those planning Vivitrol continuation. It uses clonidine (0.1 to 0.2 mg q6h) for autonomic symptoms, ondansetron for nausea, loperamide for diarrhea, gabapentin (300 to 600 mg q8h) for craving and sleep, hydroxyzine for anxiety, and non-opioid analgesics for myalgia. It is meaningfully more uncomfortable than buprenorphine-assisted detox and has a higher AMA departure rate, so we discuss both pathways openly and let the patient choose.
Before discharge, every patient is offered MAT continuation. Sublocade — the monthly extended-release buprenorphine injection — is our most-used option because its once-monthly dosing dramatically improves compliance during the vulnerable first 3 months. Vivitrol (monthly extended-release naltrexone) is the alternative for patients who have completed a 7-day opioid washout. Oral buprenorphine-naloxone maintenance is the third option for patients who prefer daily dosing. Whichever MAT is chosen, the first post-discharge outpatient prescriber appointment is booked before departure, and a bridging prescription covers the interval.
You arrive at RECO Island. Full history, physical, labs, EKG if indicated. COWS score is documented at admission. If COWS is already 12 or higher, the induction begins immediately. If lower, we wait — and the anticipation is often the hardest part.
COWS-triggered buprenorphine induction: first 2-4 mg sublingual dose when COWS is 12 or higher, followed by additional 2-4 mg doses every 60-90 minutes until symptoms are controlled. Most patients report significant symptom relief within an hour of the first buprenorphine dose. Total day 1 dose is typically 8-16 mg divided. For fentanyl users, we use a slower low-dose induction protocol with generous comfort medication.
Withdrawal symptoms recede rapidly on buprenorphine; comfort-medication-only patients still have significant symptoms in this window and receive continuous adjunctive medication. Sleep begins to return. Appetite starts to come back. Nursing checks vitals and COWS q4h. Attending physician daily evaluation.
Physical withdrawal is largely resolved by day 3. Focus shifts to psychiatric evaluation for co-occurring conditions (depression, anxiety, PTSD, bipolar) and case management planning for MAT continuation. Case management identifies your post-discharge prescriber, books your first outpatient appointment, and secures a MAT prescription bridge.
Sublocade injection is administered on day 5-7 for patients continuing buprenorphine maintenance. Vivitrol induction requires a 7-day opioid washout, so patients pursuing that pathway may extend detox to day 7-10 to complete the washout before the injection. Oral MAT is dispensed as a bridge if the patient prefers daily dosing. Discharge is coordinated with a booked first outpatient appointment within 3 days.
The first 2 weeks after opioid detox are the highest-overdose-mortality window in all of addiction medicine, because tolerance drops rapidly while relapse risk remains high. MAT continuation is the single most protective intervention. Our alumni line is available 24/7 for the first 90 days; naloxone prescriptions are provided to every discharging patient and their family.
Precipitated withdrawal is the biggest clinical pitfall in buprenorphine induction. It happens when buprenorphine is given too early — while full opioid agonists are still on the receptor — and the partial agonist activity kicks the full agonist off, producing an abrupt severe withdrawal syndrome. Our protocol prevents it by strict COWS-triggered timing (never before COWS 12) and by using slower low-dose induction for fentanyl users where receptor kinetics are less predictable.
Opioid tolerance drops rapidly during detox. A patient who relapses on their old dose after even 5 days of abstinence is at very high risk of respiratory depression and overdose death. This is why we do not offer opioid detox as a standalone service. Every patient leaves with MAT (Sublocade, Vivitrol, or oral buprenorphine maintenance) prescribed and, when possible, administered before departure; every patient also leaves with a naloxone prescription for themselves and their family.
Opioid recovery has a distinctive 2-4 week post-acute phase after detox: profound anhedonia (inability to feel pleasure), fatigue, sleep disruption, mild autonomic symptoms, and craving. This is neurobiologically real and improves with time, MAT (which markedly attenuates PAWS), structured therapy, and time. We prepare every patient and family for it explicitly so it is not mistaken for treatment failure.
Pregnant opioid-dependent patients are stabilized on maintenance buprenorphine or methadone rather than tapered, per SAMHSA and ACOG guidance — tapering during pregnancy carries fetal risk. Patients with concurrent alcohol or benzodiazepine dependence require simultaneous management of those withdrawals. Patients on high-dose chronic pain regimens need coordinated pain-management planning with their outpatient provider. All of these situations are within our program's scope with appropriate care coordination.
Opioid detox at RECO Island is covered by every major commercial insurance plan and most managed Medicaid plans at the ASAM Level 3.7-WM per-diem rate. Sublocade is covered by Aetna, BlueCross BlueShield, Cigna, United, Humana, and most Medicaid plans as a medical benefit; Vivitrol is covered as either a medical or pharmacy benefit. Copays vary by plan and formulary tier.
Our admissions and case management teams verify benefits, secure prior authorization for MAT before discharge, and coordinate directly with the receiving outpatient prescriber so there is no gap in your maintenance prescription. Financing options are available for any residual out-of-pocket cost, including the Sublocade or Vivitrol copay if applicable.
Opioid withdrawal is severe but rarely lethal on its own — the real mortality risk is post-detox overdose, because tolerance drops rapidly while relapse risk remains high. That is why we never do opioid detox as a standalone service. Every patient leaves with MAT (Sublocade, Vivitrol, or oral buprenorphine) prescribed and, ideally, administered before discharge, plus a naloxone prescription for the patient and family. This combination — medical detox plus MAT continuation — reduces overdose mortality by roughly 50% compared to abstinence-based approaches.
Both are FDA-approved medications for opioid use disorder. Buprenorphine (Suboxone, Subutex, Sublocade) is a partial opioid agonist — it binds tightly to the receptor without fully activating it, which produces a ceiling effect that dramatically reduces overdose risk. Methadone is a full agonist — more potent, requires daily dosing at a certified methadone clinic, appropriate for patients who have not stabilized on buprenorphine. Our medical director walks each patient through both options and helps you choose based on your history, work schedule, and preferences.
Sublocade is the monthly extended-release buprenorphine injection. It delivers steady buprenorphine levels for 28 days, eliminating the need for daily dosing and dramatically improving compliance during the vulnerable first 3 months of recovery. Clinical evidence is very strong: Sublocade has substantially higher treatment retention rates than daily oral buprenorphine at 6 months. We prefer it for most patients as the maintenance MAT of choice after successful induction.
Precipitated withdrawal is an abrupt severe withdrawal syndrome that happens when buprenorphine is given too early — while full opioid agonists are still on the receptor — and the partial agonist activity displaces the full agonist. We prevent it with strict COWS-triggered timing (buprenorphine is never given before COWS is 12 or higher, indicating moderate withdrawal), and for fentanyl users we use a slower low-dose induction protocol because fentanyl deposits in adipose tissue and continues to leach out for days.
Yes, though it requires a 7-day opioid-free window before the Vivitrol injection to avoid precipitated withdrawal. Patients pursuing this pathway typically use comfort-medication-only detox (clonidine, ondansetron, loperamide, gabapentin) or transition off buprenorphine after initial stabilization, then receive Vivitrol on day 7-10. It is a valid pathway for patients pursuing complete abstinence but has a higher AMA-departure rate than the buprenorphine pathway.
Fentanyl detox is meaningfully different from heroin or prescription opioid detox because fentanyl deposits in adipose tissue and continues to leach into the bloodstream for days after last use. This extends the precipitated-withdrawal window and complicates buprenorphine induction. Our medical director uses a low-dose induction protocol — starting with 0.5 mg buprenorphine and titrating up over 24 to 48 hours — that dramatically reduces precipitated withdrawal risk in fentanyl users.
Yes, every patient leaves RECO Island with a naloxone prescription (or nasal spray in hand) and family education on how to use it. Post-detox overdose is a real risk even with MAT, and having naloxone available has saved many lives. We also offer take-home fentanyl test strips and harm-reduction education to family members.
Yes. Patients maintained on methadone through a certified opioid treatment program can be admitted for medical detox at RECO Island. Methadone taper protocols are meaningfully slower than heroin or buprenorphine detox because of methadone's long half-life; we coordinate directly with the referring OTP to plan the taper safely. Patients wishing to transition from methadone to buprenorphine maintenance receive extended-taper protocols.
Ready to begin?
Start opioid detox and MAT today.
Speak with an admissions counselor about whether opioid detox at RECO Island is the right next step. Insurance benefits verified within 24 hours. Everything confidential.
