Opioid withdrawal resident survival guide

Revision as of 21:51, 13 January 2014 by Rim Halaby (talk | contribs)
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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]

Definition

Opioids have analgesic and CNS depressant properties. These are sometimes abused outside of their clinical effects to achieve euphoria. Tolerance and physiological dependence develops when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms called 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

  • Naturally occuring withdrawal
  • Iatrogenic withdrawal
  • Rapid detoxification using naloxone/naltrexone in opioid dependents.
  • Use of partial agonists (buprenorphine) and/or agonist-antagonists (pentazocine) in a person 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

[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. 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)
  3. 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)
  4. 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.