Opioid withdrawal resident survival guide: Difference between revisions

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==Management==
==Management==
Shown below is an algorithm summarizing the approach to <nowiki>[[Opioid withdrawal]]</nowiki>.
Shown below is an algorithm summarizing the approach to opioid withdrawal.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{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>}}  

Revision as of 22:07, 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; tolerance and physiological dependence develop when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms referred to 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

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Opioid withdrawal is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

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

[3]


Nonopioid drugs:
Clonidine 0.2 mg every 4 hours tapered after day 3 [4] or
Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily [5]


❑ Treatment duration 10 days for heroin; 14 days for methadone

❑ 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

  1. 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)
  2. 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.>
  3. 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)
  4. 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)
  5. 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.