Opioid withdrawal resident survival guide: Difference between revisions
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{{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | {{familytree | | | | | | | | C01 | | | | | | | | | |C01=Admit the patient }} | ||
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{{familytree | | | | | | | | D01 | | | | | | | | | |D01=<div style="float: left; text-align: left">Opioid agonists: <br> ❑ Methadone (pure agonist) 20-35 mg daily or <br> ❑ Buprenorphine (partial agonist) 4-16 mg daily <br> ❑ Taper by 3% daily over next several days | {{familytree | | | | | | | | D01 | | | | | | | | | |D01=<div style="float: left; text-align: left">Opioid agonists:<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref><br> ❑ Methadone (pure agonist) 20-35 mg daily or <br> ❑ Buprenorphine (partial agonist) 4-16 mg daily <br> ❑ Taper by 3% daily over next several days | ||
<ref name="Senay-1977">{{Cite journal | last1 = Senay | first1 = EC. | last2 = Dorus | first2 = W. | last3 = Goldberg | first3 = F. | last4 = Thornton | first4 = W. | title = Withdrawal from methadone maintenance. Rate of withdrawal and expectation. | journal = Arch Gen Psychiatry | volume = 34 | issue = 3 | pages = 361-7 | month = Mar | year = 1977 | doi = | PMID = 843188 }}</ref> | <ref name="Senay-1977">{{Cite journal | last1 = Senay | first1 = EC. | last2 = Dorus | first2 = W. | last3 = Goldberg | first3 = F. | last4 = Thornton | first4 = W. | title = Withdrawal from methadone maintenance. Rate of withdrawal and expectation. | journal = Arch Gen Psychiatry | volume = 34 | issue = 3 | pages = 361-7 | month = Mar | year = 1977 | doi = | PMID = 843188 }}</ref> | ||
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{{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification }} | {{familytree | | | | | | | | E01 | | | | | | | | | |E01=Detoxification<ref name="Huitink-2003">{{Cite journal | last1 = Huitink | first1 = J. | last2 = Buitelaar | first2 = D. | title = Management of drug and alcohol withdrawal. | journal = N Engl J Med | volume = 349 | issue = 4 | pages = 405-7; author reply 405-7 | month = Jul | year = 2003 | doi = | PMID = 12879900 }}</ref> }} | ||
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{{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<br> For a patient receiving about 8 mg of buprenorphine (or 35 mg methadone) <br> ❑ [[Naltrexone]] 25 mg day 1 <br> ❑ Naltrexone 50 mg days 2 to 15 <br> Clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 <br> ❑ Use both drugs to achieve better results </div> |F02=<div style="float: left; text-align: left">'''Ultra rapid detoxification:''' <br> ❑ '''Needs to be performed only be experienced practitioners''' <br> ❑ Anesthesize patient <br> ❑ Intubate and place on mechanical ventilation <br> ❑ Induce acute withdrawal with [[naloxone]] </div> }} | {{familytree | | | | F01 | | | | | | F02 | | | | | |F01=<div style="float: left; text-align: left">'''Rapid detoxification:'''<br> For a patient receiving about 8 mg of buprenorphine (or 35 mg methadone) <br> ❑ [[Naltrexone]] 25 mg day 1 <br> ❑ Naltrexone 50 mg days 2 to 15 <br> Clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 <br> ❑ Use both drugs to achieve better results </div> |F02=<div style="float: left; text-align: left">'''Ultra rapid detoxification:''' <br> ❑ '''Needs to be performed only be experienced practitioners''' <br> ❑ Anesthesize patient <br> ❑ Intubate and place on mechanical ventilation <br> ❑ Induce acute withdrawal with [[naloxone]] </div> }} | ||
Revision as of 22:13, 29 January 2014
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; tolerance and physiological dependence develop when these are used chronically, any abrupt cessation precipitates an array of signs & symptoms referred to 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
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 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:[3] ❑ 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[3] | |||||||||||||||||||||||||||||||||||||||
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) - ↑ 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.>
- ↑ 3.0 3.1 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) - ↑ 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.