Opioid withdrawal resident survival guide: Difference between revisions
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==Definition== | ==Definition== | ||
Opioids have analgesic and CNS depressant properties. These are sometimes abused outside of their clinical effects to achieve euphoria. Tolerance and physiological dependence develops when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms called as withdrawal. | [[Opioids]] have analgesic and CNS depressant properties. These are sometimes abused outside of their clinical effects to achieve [[euphoria]]. [[Tolerance]] and [[physiological dependence]] develops when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms called as withdrawal. | ||
Shown below is a table indicative of time to withdrawal symptoms for different opioids:<ref name="Jasinski-1978">{{Cite journal | last1 = Jasinski | first1 = DR. | last2 = Pevnick | first2 = JS. | last3 = Griffith | first3 = JD. | title = Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. | journal = Arch Gen Psychiatry | volume = 35 | issue = 4 | pages = 501-16 | month = Apr | year = 1978 | doi = | PMID = 215096 }}</ref><ref name="Kleber HD. Opiods: detoxification. In: Galanter M, Kleber HD, eds. The American Psychiatric Press textbook of substance abuse treatment. 2nd ed. Washington, D.C.: American Psychiatric Press, 1999:251-69."></ref> | Shown below is a table indicative of time to withdrawal symptoms for different opioids:<ref name="Jasinski-1978">{{Cite journal | last1 = Jasinski | first1 = DR. | last2 = Pevnick | first2 = JS. | last3 = Griffith | first3 = JD. | title = Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction. | journal = Arch Gen Psychiatry | volume = 35 | issue = 4 | pages = 501-16 | month = Apr | year = 1978 | doi = | PMID = 215096 }}</ref><ref name="Kleber HD. Opiods: detoxification. In: Galanter M, Kleber HD, eds. The American Psychiatric Press textbook of substance abuse treatment. 2nd ed. Washington, D.C.: American Psychiatric Press, 1999:251-69."></ref> | ||
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|- | |- | ||
| Heroin | | [[Heroin]] | ||
| 36-72 hours | | 36-72 hours | ||
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|- | |- | ||
| Methadone | | [[Methadone]] | ||
| 72-96 hours | | 72-96 hours | ||
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|- | |- | ||
| Buprenorphine | | [[Buprenorphine]] | ||
| 36-72 hours | | 36-72 hours | ||
| Line 49: | Line 49: | ||
* Iatrogenic withdrawal | * Iatrogenic withdrawal | ||
:* Rapid detoxification using naloxone/naltrexone in opioid dependents. | :* Rapid detoxification using naloxone/naltrexone in opioid dependents. | ||
:* Use of partial | :* Use of [[partial agonist]]s (buprenorphine) and/or agonist-antagonists ([[pentazocine]]) in a person not known to be opioid dependent. | ||
==Management== | ==Management== | ||
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{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left">'''Characterize the symptoms:''' <br> ❑ Flu like illness <br> ❑ Lacrimation/rhinorrhea <br> ❑ Sneezing <br> ❑ Anorexia <br> ❑ Nausea, vomiting & diarrhea </div>}} | {{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left">'''Characterize the symptoms:''' <br> ❑ Flu like illness <br> ❑ Lacrimation/rhinorrhea <br> ❑ Sneezing <br> ❑ Anorexia <br> ❑ Nausea, vomiting & diarrhea </div>}} | ||
{{familytree | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left">'''Examine the patient:''' <br> ❑ Pupillary dilatation <br> ❑ Gooseflesh (piloerection) <br> ❑ Yawning </div> }} | {{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left">'''Examine the patient:''' <br> ❑ Pupillary dilatation <br> ❑ Gooseflesh (piloerection) <br> ❑ Yawning <br> ❑ Increased bowel sounds </div> }} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | | | | }} | ||
{{familytree | | | | | | | | X01 | | | | | | | | | |X01=<div style="float: left; text-align: left">'''Consider alternative diagnosis:''' <br> ❑ Alcohol withdrawal <br> ❑ [[Sedative hypnotic|Sedative hypnotic withdrawal]] <br> ❑ [[Cholinergic|Cholinergic poisoning]] <br> ❑ [[Sympathomimetic|Sympathomimetic intoxication]] </div>}} | {{familytree | | | | | | | | X01 | | | | | | | | | |X01=<div style="float: left; text-align: left">'''Consider alternative diagnosis:''' <br> ❑ Alcohol withdrawal <br> ❑ [[Sedative hypnotic|Sedative hypnotic withdrawal]] <br> ❑ [[Cholinergic|Cholinergic poisoning]] <br> ❑ [[Sympathomimetic|Sympathomimetic intoxication]] </div>}} | ||
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{{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | {{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | | | | }} | ||
{{familytree | | | | | | | | D01 | | | | | | | | | |D01=<div style="float: left; text-align: left">Opioid agonists: <br> ❑ Methadone 20-35 mg daily or <br> ❑ Buprenorphine 4-16 mg daily <br> ❑ Taper by 3% daily over next several days | {{familytree | | | | | | | | D01 | | | | | | | | | |D01=<div style="float: left; text-align: left">Opioid agonists: <br> ❑ Methadone (pure agonist) 20-35 mg daily or <br> ❑ Buprenorphine (partial agonist) 4-16 mg daily <br> ❑ Taper by 3% daily over next several days | ||
<ref name="Senay-1977">{{Cite journal | last1 = Senay | first1 = EC. | last2 = Dorus | first2 = W. | last3 = Goldberg | first3 = F. | last4 = Thornton | first4 = W. | title = Withdrawal from methadone maintenance. Rate of withdrawal and expectation. | journal = Arch Gen Psychiatry | volume = 34 | issue = 3 | pages = 361-7 | month = Mar | year = 1977 | doi = | PMID = 843188 }}</ref> | |||
---- | ---- | ||
Nonopioid drugs: <br> ❑ Clonidine 0.2 mg every 4 hours tapered after day 3 or <br> ❑ Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily <br> ❑ Treatment duration 10 days for heroin; 14 days for methadone | Nonopioid drugs: <br> ❑ [[Clonidine]] 0.2 mg every 4 hours tapered after day 3 <ref name="O'Connor-1995">{{Cite journal | last1 = O'Connor | first1 = PG. | last2 = Waugh | first2 = ME. | last3 = Carroll | first3 = KM. | last4 = Rounsaville | first4 = BJ. | last5 = Diagkogiannis | first5 = IA. | last6 = Schottenfeld | first6 = RS. | title = Primary care-based ambulatory opioid detoxification: the results of a clinical trial. | journal = J Gen Intern Med | volume = 10 | issue = 5 | pages = 255-60 | month = May | year = 1995 | doi = | PMID = 7616334 }}</ref> | ||
or <br> ❑ [[Lofexidine]] 0.2 mg BD daily, titrated to 1.2 mg BD daily <ref name="Strang-1999">{{Cite journal | last1 = Strang | first1 = J. | last2 = Bearn | first2 = J. | last3 = Gossop | first3 = M. | title = Lofexidine for opiate detoxification: review of recent randomised and open controlled trials. | journal = Am J Addict | volume = 8 | issue = 4 | pages = 337-48 | month = | year = 1999 | doi = | PMID = 10598217 }}</ref> | |||
<br> ❑ Treatment duration 10 days for heroin; 14 days for methadone | |||
---- | ---- | ||
❑ General symptomatic management | ❑ General symptomatic management | ||
---- | ---- | ||
❑ Consult | ❑ Consult psychiatry | ||
</div> }} | </div> }} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | | | | }} | ||
{{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification }} | {{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification }} | ||
{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | }} | {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | }} | ||
{{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<br> For a patient | {{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<br> For a patient receiving about 8 mg of buprenorphine (or 35 mg methadone) <br> ❑ [[Naltrexone]] 25 mg day 1 <br> ❑ Naltrexone 50 mg days 2 to 15 <br> Clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 <br> ❑ Use both drugs to achieve better results </div> |F02=<div style="float: left; text-align: left">'''Ultra rapid detoxification:''' <br> ❑ '''Needs to be performed only be experienced practitioners''' <br> ❑ Anesthesize patient <br> ❑ Intubate and place on mechanical ventilation <br> ❑ Induce acute withdrawal with [[naloxone]] </div> }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Dont's== | |||
* Do not abruptly stop drugs that are being used to treat withdrawal. | |||
==References== | ==References== | ||
Revision as of 18:58, 13 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]
Definition
Opioids have analgesic and CNS depressant properties. These are sometimes abused outside of their clinical effects to achieve euphoria. Tolerance and physiological dependence develops when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms called as withdrawal. Shown below is a table indicative of time to withdrawal symptoms for different opioids:[1][2]
| Opioid | Peak withdrawal symptoms | Duration of symptoms |
|---|---|---|
| Heroin | 36-72 hours | 7-10 days |
| Methadone | 72-96 hours | 14 days |
| Buprenorphine | 36-72 hours | 7 days |
Causes
- Naturally occuring withdrawal
- Iatrogenic withdrawal
- Rapid detoxification using naloxone/naltrexone in opioid dependents.
- Use of partial agonists (buprenorphine) and/or agonist-antagonists (pentazocine) in a person not known to be opioid dependent.
Management
Shown below is an algorithm summarizing the approach to [[Opioid withdrawal]].
Characterize the symptoms: ❑ Flu like illness ❑ Lacrimation/rhinorrhea ❑ Sneezing ❑ Anorexia ❑ Nausea, vomiting & diarrhea | |||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Pupillary dilatation ❑ Gooseflesh (piloerection) ❑ Yawning ❑ Increased bowel sounds | |||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Alcohol withdrawal ❑ Sedative hypnotic withdrawal ❑ Cholinergic poisoning ❑ Sympathomimetic intoxication | |||||||||||||||||||||||||||||||||||||||
| Admit the patient | |||||||||||||||||||||||||||||||||||||||
Opioid agonists: ❑ Methadone (pure agonist) 20-35 mg daily or ❑ Buprenorphine (partial agonist) 4-16 mg daily ❑ Taper by 3% daily over next several days Nonopioid drugs:
❑ General symptomatic management ❑ Consult psychiatry | |||||||||||||||||||||||||||||||||||||||
| Detoxification | |||||||||||||||||||||||||||||||||||||||
Rapid detoxification: For a patient receiving about 8 mg of buprenorphine (or 35 mg methadone) ❑ Naltrexone 25 mg day 1 ❑ Naltrexone 50 mg days 2 to 15 Clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 ❑ Use both drugs to achieve better results | Ultra rapid detoxification: ❑ Needs to be performed only be experienced practitioners ❑ Anesthesize patient ❑ Intubate and place on mechanical ventilation ❑ Induce acute withdrawal with naloxone | ||||||||||||||||||||||||||||||||||||||
Dont's
- Do not abruptly stop drugs that are being used to treat withdrawal.
References
- ↑ Jasinski, DR.; Pevnick, JS.; Griffith, JD. (1978). "Human pharmacology and abuse potential of the analgesic buprenorphine: a potential agent for treating narcotic addiction". Arch Gen Psychiatry. 35 (4): 501–16. PMID 215096. Unknown parameter
|month=ignored (help) - ↑
- ↑ Senay, EC.; Dorus, W.; Goldberg, F.; Thornton, W. (1977). "Withdrawal from methadone maintenance. Rate of withdrawal and expectation". Arch Gen Psychiatry. 34 (3): 361–7. PMID 843188. Unknown parameter
|month=ignored (help) - ↑ O'Connor, PG.; Waugh, ME.; Carroll, KM.; Rounsaville, BJ.; Diagkogiannis, IA.; Schottenfeld, RS. (1995). "Primary care-based ambulatory opioid detoxification: the results of a clinical trial". J Gen Intern Med. 10 (5): 255–60. PMID 7616334. Unknown parameter
|month=ignored (help) - ↑ Strang, J.; Bearn, J.; Gossop, M. (1999). "Lofexidine for opiate detoxification: review of recent randomised and open controlled trials". Am J Addict. 8 (4): 337–48. PMID 10598217.