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; 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:

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: ❑ 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: ❑ 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 ❑ General symptomatic management ❑ Consult psychiatry

Detoxification

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.