Opioid withdrawal resident survival guide: Difference between revisions
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{{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 | | | | | | | | 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>}} | ||
{{familytree | | | | | | | | |!| | | | | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | | | | }} | ||
{{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | {{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | ||
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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> | 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> | 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 | ||
Revision as of 23:23, 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
- Discontinuation of heroin
- Discontinuation of methadone
- Rapid detoxification with naloxone or naltrexone in opioid dependent subjects
- Use of partial agonists (buprenorphine) and/or agonist-antagonists (pentazocine) in subjects 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) - ↑ 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.>
- ↑ 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.