II. Symptoms
- Onset of Opioid Withdrawal symptoms 6 to 72 hours after last use (depending on Opioid used)
- General Symptoms
- Classic triad for Opioid Withdrawal
- Piloerection
- Rhinorrhea
- Lacrimation
III. Signs
- See Clinical Opioid Withdrawal Scale (COWS)
- Tachycardia
- Diaphoresis
- Mydriasis
- Yawning
- Restlessness
IV. Management: General protocol for cessation of Opioids
- Maintain hydration during cessation
- Opioid Withdrawal may be extremely uncomfortable but not life threatening
- Contrast with Alcohol and Benzodiazepine Withdrawal which are potentially life threatening
- However, continued Opioid Abuse has a very high mortality due to Opioid Overdose risk
- Small to moderate chronic daily Opioid use: Stop Opioid cold turkey
- Less than 10 days of daily Opioid or
- Morphine Sulfate (or equivalent dose of other Opioid) <30 mg per day
- Moderate to high chronic daily Opioid use
- Taper by 10% per week up to as fast as 10% daily
- Consider detoxification admission for non-compliant patients
- Methadone protocol
- Buprenorphine protocol
V. Management: Alpha Adrenergic Central Agonist (e.g. Clonidine)
- Mechanism
- Decreases sympathetic CNS stimulation (noradrenergic response)
- Typically used in combination with other agents below (e.g. Gabapentin)
- Adverse effects include Dry Mouth, sedation, Dizziness, Bradycardia and Hypotension
- Preparations
- Clonidine (Catapres) 0.1 mg orally every 8-12 hours for 5 days
- Lofexidine (Lucemyra)
- Released in 2018, and similar to Clonidine, but at $330/day (Clonidine is $1/day)
- (2018) Presc Lett 25(9): 54
- Bryce (2019) Am Fam Physician 99(6): 393-4 [PubMed]
- Alpha Adrenergic Central Agonist Indications
VI. Management: Other medications
- Withdrawal and craving symptoms
- Tizanidine 4-8 mg orally every 8 hours
- Baclofen 10 mg orally every 8 hours
- Gabapentin (Neurontin) 300 mg orally every 8 hours
- May be used with Tramadol
- Tramadol taper
- Gastrointestinal symptoms
- Dicyclomine (for abdominal cramping)
- Loperamide (for Diarrhea)
- Psychiatric symptoms
- Hydroxyzine (for Agitation)
- Trazodone (for Insomnia)
- Miscellaneous symptoms
- NSAIDs (for myalgias)
VII. Management: Medication Assisted Therapy Initiation
- See Buprenorphine for medication activity and precautions
- Indications
- Opioid Dependence AND
- Patient wishes to enter Chemical Dependency treatment AND
- Active Opioid Withdrawal with Clinical Opioid Withdrawal Scale (COWS) >8-9
- Giving Buprenorphine without withdrawal, will precipitate withdrawal
-
Buprenorphine may be given in the emergency department without a DEA X-Waiver
- However, Buprenorphine may not be prescribed without a waiver
- Allows for administration of a single dose in ED (or up to 3 doses in 72 hours if patient returns)
- Dosing: May be initiated in Emergency Department
- Day 1: Buprenorphine sublingual 4-8 mg
- Dose of 4-8 mg may be repeated every 30-60 minutes until patient has significant improvement
- Day 2: Buprenorphine sublingual 16 mg
- Day 3: Buprenorphine sublingual 16 mg
- Day 1: Buprenorphine sublingual 4-8 mg
- Protocol
- Patient administered first dose or doses in Emergency Department
- Close follow-up (1-3 days) arranged with a Buprenorphine capable clinic
- Resources
- SAMSHA Buprenorphine Practitioner Locator
- References
- Strayer and Swaminathan in Herbert (2018) EM:Rap 18(9): 3-6
VIII. Course
- Expect withdrawal symptoms for at least 7 days (up to weeks)
IX. References
- Orman and Starr in Herbert (2016) EM:Rap 16(10): 3
- Strayer in Herbert (2020) EM:Rap 20(6):10-2