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
Shown below is an algorithm used for diagnosis and treatment of withdrawal from opioids, based on hospital concepts[3] and treatment guidelines issued by Substance Abuse and Mental Health Services Administration (Center for Substance Abuse Treatment, US).[4]
Diagnostic Approach
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 | |||||||||||||||||||||||||||||
Probable diagnosis: ❑ Opioid withdrawal Differential 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
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) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Withdrawal symptoms subside & return or still present: ❑ Administer buprenorphine 4 mg & naloxone 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 4 mg (up to maximum of 8 mg/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 2 mg (up to maximum of 8 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: ❑ Manage withdrawal symptoms symptomatically
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Induction-Day 2 & forward | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
On return withdrawal symptoms absent: ❑ Administer a daily dose = Total buprenorphine & naloxone or total buprenorphine administered on previous day ❑ For symptomatic relief
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On return withdrawal symptoms present: ❑ Administer a daily dose = Total buprenorphine & naloxone or total buprenorphine administered on previous day + 4 mg of buprenorphine (up to maximum of 12 mg/24 hours) & 1 mg of naloxone (up to maximum of 3 mg/24 hours) ❑ Observe 2+ hours | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Withdrawal symptoms relieved: ❑ Daily buprenorphine & naloxone dose established ❑ Continue for 5 more days | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Withdrawal symptoms not relieved: ❑ Administer buprenorphine 4 mg (up to maximum of 16 mg/24 hours) & naloxone 1 mg (up to maximum of 4 mg/24 hours) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Withdrawal symptoms relieved: ❑ Daily buprenorphine & naloxone dose established ❑ Continue for 5 more days | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Withdrawal symptoms not relieved: ❑ Manage withdrawal symptoms symptomatically
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❑ No withdrawal symptoms ❑ Minimal or no side effects ❑ No uncontrollable cravings for opioid agonists | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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
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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 8 mg 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 | ||||||||||||||||||||||||||||||||||||||||||||
† OAT: Opioid agonist therapy; LAAM: Levo-α-acetylmethadol
Do's
- A signed release of information from patients who are currently enrolled in Opioid Treatment Programs (OTPs) or other programs should be obtained before initiating buprenorphine treatment.
- Initiation of buprenorphine treatment should be carefully timed such that the patients should be in the early stages of withdrawal.
- Patients should be carefully explained regarding the advantages of waiting and should be urged to wait until they begin to experience the symptoms of withdrawal.
- Consider patients history and concerns and counsel about potential side effects from buprenorphine overdosing or underdosing before initiation.
- Buprenorphine should be administered as sublingual tablets.
- Asses the dose taken.
- Assess the amount of time the medication is allowed to dissolve under the tongue.
- After initiation, periodic reassessment regarding the patient’s motivation for treatment should be done in order to assess the duration for various aspects of treatment.
- During induction, patients should be advised to avoid driving or operating other machinery until they are familiar with the effects of buprenorphine and until their dose is stabilized.
- Pregnant women and patients on long-acting opioids should be inducted and maintained on buprenorphine monotherapy, and the number of doses should be limited.
- Non pregnant women started on buprenorphine monotherapy for induction should be switched to a buprenorphine and naloxone combination on day 2 to minimize the possibility of abuse.
- A lowest possible dose of (2/0.5 mg) of buprenorphine/naloxone for induction treatment can be considered in patients who are not physically dependent on opioids but who have a known history of opioid addiction, have failed other treatment modalities, and have a demonstrated a need to cease the use of opioids.
- Doses should be increased more rapidly, or to a higher maintenance dose level along with intensive psychosocial treatments in patients who experience withdrawal symptoms during induction or who feel compelled to use illicit drugs. Strongly warn those who continue to take illicit opioids.
- To determine the adequacy of clinical response, toxicology testing for drugs of abuse should be done.
- Start stabilization phase, when patient is asymptomatic, suffering minimal or no side effects and no longer craving for 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 initiate induction until the patients have symptoms of withdrawal.
- 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
- ↑ 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 Treatment Protocols - Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction - NCBI Bookshelf". Retrieved 9 February 2014.
- ↑ 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) - ↑ 6.0 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.