Opioid withdrawal resident survival guide
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 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) - ↑
- ↑ 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.