Opioid withdrawal resident survival guide: Difference between revisions
Jump to navigation
Jump to search
No edit summary |
|||
| Line 29: | Line 29: | ||
| 72-96 hours | | 72-96 hours | ||
| 14 days | | 14 days or more | ||
|- | |- | ||
| Line 37: | Line 37: | ||
| 36-72 hours | | 36-72 hours | ||
| 7 days | | Intermediate between 7-14 days | ||
|- | |- | ||
| Line 54: | Line 54: | ||
==Management== | ==Management== | ||
Shown below is an algorithm | Shown below is an algorithm depicting the management of opioid withdrawal based on hospital concepts.<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref> | ||
{{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> ❑ | {{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left">'''Characterize the symptoms:''' <br>❑ Flu like illness <br>❑ Lacrimation<br> ❑ Rhinorrhea <br>❑ Sneezing<br> ❑ Yawning <br> ❑ Anorexia <br> ❑ Nausea<br> ❑ Vomiting<br> ❑ Abdominal cramps<br> ❑ Diarrhea<br> ❑ Myalgia<br> ❑ Arthralgia </div>}} | ||
{{familytree | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left">'''Examine the patient:''' <br> ❑ | {{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left">'''Examine the patient:''' <br> ❑ Increase or unchanged BP<br> ❑ Increase or unchanged HR<br> ❑ Increase or unchanged RR<br> ❑ Mydriasis <br> ❑ Piloerection <br> ❑ Tremor <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>}} | ||
| Line 64: | Line 64: | ||
{{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:<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref><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 | {{familytree | | | | | | | | D01 | | | | | | | | | |D01=<div style="float: left; text-align: left">Opioid agonists:<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref><br> ❑ Methadone (pure agonist) 20-35 mg daily<br> | ||
'''or'''<br> | |||
❑ Buprenorphine (partial agonist) 4-16 mg sublingual 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> | <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 <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><br> | ||
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> | |||
❑ Chlordiazepoxide | |||
<br> ❑ Treatment duration 10 days for heroin; 14 days for methadone | <br> ❑ Treatment duration 10 days for heroin; 14 days for methadone | ||
---- | ---- | ||
| Line 78: | Line 82: | ||
{{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref> }} | {{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref> }} | ||
{{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | }} | {{familytree | | | | |,|-|-|-|^|-|-|-|.| | | | | | | }} | ||
{{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<br> For a patient receiving about 8 mg of buprenorphine | {{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<ref name="O'Connor-1997">{{Cite journal | last1 = O'Connor | first1 = PG. | last2 = Carroll | first2 = KM. | last3 = Shi | first3 = JM. | last4 = Schottenfeld | first4 = RS. | last5 = Kosten | first5 = TR. | last6 = Rounsaville | first6 = BJ. | title = Three methods of opioid detoxification in a primary care setting. A randomized trial. | journal = Ann Intern Med | volume = 127 | issue = 7 | pages = 526-30 | month = Oct | year = 1997 | doi = | PMID = 9313020 }}</ref><br> For a patient receiving about 8 mg of buprenorphine or 35 mg of methadone<br> ❑ [[Naltrexone]]<br> | ||
:❑ Day 1: 25 mg | |||
:❑ Days 2 to 15: 50 mg<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:'''<ref name="Presslich-1989">{{Cite journal | last1 = Presslich | first1 = O. | last2 = Loimer | first2 = N. | last3 = Lenz | first3 = K. | last4 = Schmid | first4 = R. | title = Opiate detoxification under general anesthesia by large doses of naloxone. | journal = J Toxicol Clin Toxicol | volume = 27 | issue = 4-5 | pages = 263-70 | month = | year = 1989 | doi = | PMID = 2600989 }}</ref><ref name="Loimer-1991">{{Cite journal | last1 = Loimer | first1 = N. | last2 = Lenz | first2 = K. | last3 = Schmid | first3 = R. | last4 = Presslich | first4 = O. | title = Technique for greatly shortening the transition from methadone to naltrexone maintenance of patients addicted to opiates. | journal = Am J Psychiatry | volume = 148 | issue = 7 | pages = 933-5 | month = Jul | year = 1991 | doi = | PMID = 2053636 }}</ref><br>❑ Anesthetize patient<br> ❑ Induce acute withdrawal with [[naloxone]] <br> ❑ Consider intubation and mechanical ventilation if necessary </div> }} | |||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | | | | | | | | | | | | | | | | }} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Do's== | |||
*Restrict methadone and other opioid agonists to inpatient settings or licensed programs. | |||
*Administer chlordiazepoxide, a longer-acting benzodiazepine to augument clonidine in patients with insomnia or muscle cramps.<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> | |||
*Detoxification should be undertaken only under clinicians with special training, equipment, or both. | |||
==Dont's== | ==Dont's== | ||
* Do not abruptly stop drugs that are being used to treat withdrawal. | *Do not abruptly stop drugs that are being used to treat withdrawal. | ||
==References== | ==References== | ||
| Line 96: | Line 109: | ||
{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | |||
Revision as of 23:39, 30 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 or more |
| Buprenorphine | 36-72 hours | Intermediate between 7-14 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 depicting the management of opioid withdrawal based on hospital concepts.[3]
Characterize the symptoms: ❑ Flu like illness ❑ Lacrimation ❑ Rhinorrhea ❑ Sneezing ❑ Yawning ❑ Anorexia ❑ Nausea ❑ Vomiting ❑ Abdominal cramps ❑ Diarrhea ❑ Myalgia ❑ Arthralgia | |||||||||||||||||||||||||||||||||||||||
Examine the patient: ❑ Increase or unchanged BP ❑ Increase or unchanged HR ❑ Increase or unchanged RR ❑ Mydriasis ❑ Piloerection ❑ Tremor ❑ Increased bowel sounds | |||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Alcohol withdrawal ❑ Sedative hypnotic withdrawal ❑ Cholinergic poisoning ❑ Sympathomimetic intoxication | |||||||||||||||||||||||||||||||||||||||
| Admit the patient | |||||||||||||||||||||||||||||||||||||||
Opioid agonists:[3] ❑ Methadone (pure agonist) 20-35 mg daily or Nonopioid drugs: ❑ General symptomatic management ❑ Consult psychiatry | |||||||||||||||||||||||||||||||||||||||
| Detoxification[3] | |||||||||||||||||||||||||||||||||||||||
Rapid detoxification:[7] For a patient receiving about 8 mg of buprenorphine or 35 mg of methadone ❑ Naltrexone
❑ Clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 | |||||||||||||||||||||||||||||||||||||||
Do's
- Restrict methadone and other opioid agonists to inpatient settings or licensed programs.
- Administer chlordiazepoxide, a longer-acting benzodiazepine to augument clonidine in patients with insomnia or muscle cramps.[5]
- Detoxification should be undertaken only under clinicians with special training, equipment, or both.
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.>
- ↑ 3.0 3.1 3.2 Huitink, J.; Buitelaar, D. (2003). "Management of drug and alcohol withdrawal". N Engl J Med. 349 (4): 405–7, author reply 405-7. PMID 12879900. 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) - ↑ 5.0 5.1 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.
- ↑ O'Connor, PG.; Carroll, KM.; Shi, JM.; Schottenfeld, RS.; Kosten, TR.; Rounsaville, BJ. (1997). "Three methods of opioid detoxification in a primary care setting. A randomized trial". Ann Intern Med. 127 (7): 526–30. PMID 9313020. Unknown parameter
|month=ignored (help) - ↑ Presslich, O.; Loimer, N.; Lenz, K.; Schmid, R. (1989). "Opiate detoxification under general anesthesia by large doses of naloxone". J Toxicol Clin Toxicol. 27 (4–5): 263–70. PMID 2600989.
- ↑ Loimer, N.; Lenz, K.; Schmid, R.; Presslich, O. (1991). "Technique for greatly shortening the transition from methadone to naltrexone maintenance of patients addicted to opiates". Am J Psychiatry. 148 (7): 933–5. PMID 2053636. Unknown parameter
|month=ignored (help)