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

Shown below is an algorithm used for diagnosis and management of withdrawal from opioids, based on treatment guidelines issued by Substance Abuse and Mental Health Services Administration (US).[3]

Diagnostic Approach

Shown below is an algorithm depicting the management of opioid withdrawal.[4]

 
 
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

 
 
 
 
 
 
 
 
 
Induction: (day 1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify the opioid's 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)
 
 
 
 
 
❑ Taper 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/naloxone 4/1 mg
❑ Observe for 2+ hours
 
Withdrawal symptoms absent:
❑ Reevaluate the suitability for induction
 
Withdrawal symptoms present:
❑ Administer buprenorphine 2 mg
❑ Observe for 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 relieved:
❑ Day 1 dose established
❑ Send patient home
❑ Schedule patient to return on day 2 for forward induction
 
Withdrawal symptoms not relieved:
❑ Repeat buprenorphine 2mg (up to maximum of 8mg/24 hours)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Withdrawal symptoms relieved:
❑ Day 1 dose established
❑ Send patient home
❑ Schedule patient to 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,[5] or
Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily [6]
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,[5]
or
Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily [6]
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):
❑ 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

  • Start stabilization phase, when patient is asymptomatic, suffering minimal or no side effects and no longer craving for opioids.
  • For initiating buprenorphine induction, ensure that the patient is exhibiting signs of early withdrawal and has stopped using all illicit opioids.
  • Toxicology screens must be performed atleast once a month to assess progress.
  • Frequency of visits should be as follows:
  • During stabilization phase atleast once a week.
  • During maintenance phase, anywhere from biweekly to monthly visits is considered satisfactory, however must be tailored to meet patients needs.
  • Use following measures to assess efficacy of treatment:
  • No evidence of ongoing drug abuse of any kind.
  • Toxicity from opioid use is absent.
  • Adverse effects due to medical treatment are absent or minimal.
  • Patient is stable with respect to psycho-social elements.
  • Treatment adherence is good.

Dont's

  • Do not abruptly stop drugs that are being used to treat withdrawal.
  • Do not prefer, short term (3 day) reduction for detoxification unless there is a strong reason for the same such as impending incarceration, foreign travel, job requirement etc.

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. "4 Treatment Protocols - Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction - NCBI Bookshelf". Retrieved 9 February 2014.
  4. 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)
  5. 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)
  6. 6.0 6.1 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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