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:

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

Admit the patient

Opioid agonists: ❑ Methadone 20-35 mg daily or ❑ Buprenorphine 4-16 mg daily ❑ Taper by 3% daily over next several days Nonopioid drugs: ❑ Clonidine 0.2 mg every 4 hours tapered after day 3 or ❑ Lofexidine 0.2 mg BD daily, titrated to 1.2 mg BD daily ❑ Treatment duration 10 days for heroin; 14 days for methadone

References

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