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]; 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
- 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
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
❑ B. Three or more of the following (developing within minutes to several days after criterion A)
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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
❑ Look for withdrawal symptoms:
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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
| Withdrawal symptoms not relieved: ❑ Repeat | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
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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
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Stabilization phase (1-2 months): ❑ Transition when patient has:
❑ 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
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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: Moderate period reduction: 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
- ↑ 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.>
- ↑ 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) - ↑ 4.0 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) - ↑ 5.0 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.