Opioid withdrawal resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vidit Bhargava, M.B.B.S [2]; Vendhan Ramanujam M.B.B.S [3]

Definition

Opioid withdrawal refers to the arrays of signs and symptoms following the abrupt cessation of opioids among chronic users.

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

Management

Diagnostic Approach

Shown below is an algorithm depicting the management of opioid withdrawal.[3]

 
 
Characterize the symptoms:
❑ Flu like illness
❑ Lacrimation
❑ Rhinorrhea
❑ Sneezing
❑ Yawning
Anorexia
Nausea
❑ Vomiting
❑ Abdominal cramps
Diarrhea
Myalgia
Arthralgia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Increased or unchanged blood pressure
❑ Increased or unchanged heart rate
❑ Increased or unchanged respiratory rate
Mydriasis
❑ Piloerection
Tremor
❑ Increased bowel sounds
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
❑ Alcohol withdrawal
Sedative hypnotic withdrawal
Cholinergic poisoning
Sympathomimetic intoxication
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ A. Either of the following
❑ Cessation of or reduction in opioid use that has been heavy and for several weeks or longer
❑ Administration of an opioid antagonist after a period of opioid use

❑ B. Three or more of the following (developing within minutes to several days after criterion A)

❑ Diarrhea
❑ Dysphoric mood
❑ Fever
❑ Insomnia
❑ Lacrimation or rhinorrhea
❑ Muscle aches
❑ Nausea or vomiting
❑ Pupillary dilation, piloerection, or sweating
❑ Yawning
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider treatment with:
❑ Opioid maintenance treatment
or
❑ Medically supervised withdrawal (detoxification)
 
 
 
 
 
 
 
 
 
 

Treatment Approach

Opioid Maintenance Treatment

 
 
 
 
 
 
 
 
 
Induction-day 1
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the opioid(s) that the patient has been using
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Short acting opioids
 
 
 
 
 
Long acting opioids
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Discontinue short acting opioids
❑ Look for withdrawal symptoms (12-24 hours after last dose)
 
Withdrawal symptoms absent:
❑ Reevaluate the suitability for induction
 
❑ Taper down long acting opioids
❑ Methadone to ≤30 mg/day
❑ LAAM to ≤40 mg/48 hours

❑ Look for withdrawal symptoms:

❑ For methadone: 24+ hours after last dose
❑ For LAAM: 48+ hours after last dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms present:
❑ Administer buprenorphine 4mg & Naloxone 1 mg
❑ Observe for 2+ hours
 
Withdrawal symptoms relieved:
❑ Day 1 dose established
❑ Send home patient
❑ Patient should return on day 2 for forward induction
 
Withdrawal symptoms present:
❑ Administer buprenorphine 2 mg
❑ Observe 2+ hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms not relieved:
❑ Repeat
❑ Buprenorphine 4mg (up to maximum of 8mg/24 hours)
❑ Naloxone 1 mg (up to maximum of 2 mg/24 hours)
 
 
 
 
 
Withdrawal symptoms not relieved:
❑ Repeat
❑ Buprenorphine 2mg (up to maximum of 8mg/24 hours)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms relieved:
❑ Day 1 dose established
❑ Send home patient
❑ Patient should return on day 2 for forward induction
 
 
 
 
 
Withdrawal symptoms not relieved:
Manage withdrawal symptoms symptomatically
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]
❑ Chlordiazepoxide as needed
❑ Return next day for repeat induction attempt
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Induction-day 2 forward
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
On return withdrawal symptoms absent:
❑ Administer a daily dose established equal to total buprenorphine & naloxone administered on previous day
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
On return withdrawal symptoms present:
❑ Administer dose equal to
Total amount of buprenorphine & naloxone administered on previous day
+
4mg of buprenorphine (up to maximum of 12mg on day 2)
&
1mg of naloxone (up to maximum of 3mg on day 2)
❑ Observe 2+ hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms relieved:
❑ Daily buprenorphine & naloxone dose established
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms not relieved:
❑ Administer buprenorphine 4 mg (up to maximum of 16mg on day 2) & naloxone 1 mg (up to maximum of 4 mg on day 2)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms relieved:
❑ Daily buprenorphine & naloxone dose established
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms not relieved:
Manage withdrawal symptoms symptomatically
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]
❑ Chlordiazepoxide as needed
❑ On subsequent induction days, if the patient returns experiencing withdrawal symptoms, continue increasing dose (up to a maximum of buprenorphine 32 mg/day & naloxone 8 mg/day
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilization phase (1-2 months):
❑ Transition when patient has:
❑ No withdrawal symptoms
❑ Minimal or no side effects
❑ No uncontrollable craving for opioid agonists
❑ Begin with buprenorphine/naloxone combination, increasing dose by 2/0.5-4/1 mg per week till stabilization is achieved, most stabilizing at 16/4-24/6 mg
❑ As patient stabilizes, transition to alternate day or every third day regimen by doubling and tripling daily doses respectively
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Maintenance phase:

❑ Maintain at same dose as daily stabilization dose
❑ Decide total treatment duration based on:

❑ Stable housing & income
❑ Patients motivation, doctors comfort in tapering
❑ Presence of psychosocial support
❑ Absence of legal support
❑ Other drugs & alcohol abuse
 
 
 
 
 
 
 
 
 

Detoxification (Medically Supervised Withdrawal) With Buprenorphine

 
 
 
 
 
 
Detoxification
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Short acting opioids
 
 
 
 
 
OAT (methadone/LAAM)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Induction phase:
❑ Take patient off offending agent, inducing withdrawal
❑ Administer 1st dose of buprenorphine/naloxone 4/1 mg, when patient shows initial symptoms of withdrawl
❑ Repeat once after 2-4 hours if indicated
❑ ↑ dose to 12/3 - 16/4 mg over next 2 days, to establish stabilization dose
 
 
 
 
 
Induction phase:
❑ Taper methadone to ≤ 30 mg/day
Taper LAAM ≤ 40 mg/48 hour
❑ Induce by buprenorphine monotherapy 2 mg, repeated after 2-4 hours to a maximum dose of 8mg in 24 hour period
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dose reduction phase:
❑ Begin only if documented negative toxicology results, or patient admitted to hospital

Long period reduction:
❑ Reduce dose by 2 mg every week


Moderate period reduction:
❑ Perform detoxification over 10-14 days
❑ Reduce dose by 2 mg every 2-3 days


Short period reduction:
Perform over 3 days
Dose reduction by half every day
 
 
 
 
 
Dose reduction phase
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Rapid discontinuation:
❑ Taper buprenorphine monotherapy over 3-6 days, then discontinue
 
 
 
 
Gradual dose reduction:
❑ Switch to buprenorphine/naloxone combination therapy
❑ Stabilize combination dosage over 1 week
❑ Taper gradually over next 2 weeks, then discontinue
 
 
 
 
 

Do's

  • Treat the patient for a duration of 10 days for heroin withdrawal and 14 days for methadone withdrawal.
  • Restrict methadone and other opioid agonists to inpatient settings or licensed programs.
  • Administer chlordiazepoxide, a longer-acting benzodiazepine to augment clonidine in patients with insomnia or muscle cramps.[4]
  • Detoxification should be undertaken only under clinicians with special training, equipment, or both.
  • Start buprenorphine at least two days before starting naltrexone during detoxification.

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. 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)
  4. 4.0 4.1 4.2 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. 5.0 5.1 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.


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