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:

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 depicting the management of opioid withdrawal based on hospital concepts.

Characterize the symptoms: ❑ Flu like illness ❑ Lacrimation ❑ Rhinorrhea ❑ Sneezing ❑ Yawning ❑ Anorexia ❑ Nausea ❑ Vomiting ❑ Abdominal cramps ❑ Diarrhea ❑ Myalgia ❑ Arthralgia

Examine the patient: ❑ Increase or unchanged BP ❑ Increase or unchanged HR ❑ Increase or unchanged RR ❑ Mydriasis ❑ Piloerection ❑ Tremor ❑ Increased bowel sounds

Consider alternative diagnosis: ❑ Alcohol withdrawal ❑ Sedative hypnotic withdrawal ❑ Cholinergic poisoning ❑ Sympathomimetic intoxication

Admit the patient

Start opioid agonists: ❑ Methadone (pure agonist) 20-35 mg daily or ❑ Buprenorphine (partial agonist) 4-16 mg sublingual daily ❑ Taper by 3% daily over next several days Add 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 ❑ Chlordiazepoxide as needed ❑ Treatment duration 10 days for heroin; 14 days for methadone ❑ General symptomatic management ❑ Consult psychiatry

Detoxification

Rapid detoxification: For a patient receiving about 8 mg of buprenorphine or 35 mg of methadone ❑ Detoxify while awake or under mild sedation ❑ Add naltrexone ❑ Day 1: 25 mg ❑ Days 2 to 15: 50 mg ❑ Add clonidine 0.1-0.2 mg four times daily, tapered on days 2 and 3 ❑ Antiemetic agents as needed ❑ Analgesics as needed

Ultra rapid detoxification: ❑ Detoxify under heavy sedation or general anesthesia ❑ Induce acute withdrawal with naloxone ❑ Consider intubation and mechanical ventilation if necessary ❑ Antiemetic agents as needed ❑ Analgesics as needed

BD: Twice daily; BP: Blood pressure; HR: Heart rate; RR: Respiratory rate

Do's

• Restrict methadone and other opioid agonists to inpatient settings or licensed programs.
• Administer chlordiazepoxide, a longer-acting benzodiazepine to augument clonidine in patients with insomnia or muscle cramps.
• 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

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