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 | |||||||||||||||||||||||||||||||||||||||
Consider alternative diagnosis: ❑ Alcohol withdrawal ❑ Sedative hypnotic withdrawal ❑ Cholinergic poisoning ❑ Sympathomimetic intoxication | |||||||||||||||||||||||||||||||||||||||
| 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: ❑ General symptomatic management ❑ Consult psychaitry | |||||||||||||||||||||||||||||||||||||||
| Detoxification | |||||||||||||||||||||||||||||||||||||||
Rapid detoxification: For a patient recieving about 8 mg of buprenorphine (or 35 mg methadone) ❑ Naltrexone 25 mg day 1 ❑ Naltrexone 50 mg day 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 palce on mechanical ventilation ❑ Induce acute withdrawal with naloxone | ||||||||||||||||||||||||||||||||||||||