Opioid Withdrawal

Aka: Opioid Withdrawal, Narcotic Withdrawal

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II. Pathophysiology

  1. Although Opioid Withdrawal is not directly life threatening, it increases mortality by triggering ilicit Opioid use, abuse and Overdose
  2. Opioid Dependence may develop with as little as 2 weeks of regular Opioid use
  3. Severity of withdrawal is relative to the dosage and duration of use

III. Symptoms

  1. Onset of Opioid Withdrawal symptoms 6 to 72 hours after last use (depending on Opioid used)
  2. General Symptoms
    1. Anxiety
    2. Irritability
    3. Restlessness
    4. Gastrointestinal upset (e.g. Nausea, Vomiting, Diarrhea)
    5. Diffuse pain, cramping or myalgias
  3. Classic triad for Opioid Withdrawal
    1. Piloerection
    2. Rhinorrhea
    3. Lacrimation
  4. Precipitated withdrawal with Rapid Onset Symptoms (opioid Antagonist induced)
    1. Vomiting
    2. Agitation
    3. Delirium
    4. Significant Catecholamine release
      1. Autonomic Instability
      2. Pulmonary Edema

IV. Signs

  1. See Clinical Opioid Withdrawal Scale (COWS)
  2. Tachycardia
  3. Diaphoresis
  4. Mydriasis
  5. Yawning
  6. Restlessness

V. Evaluation

  1. Clinical Opioid Withdrawal Scale (COWS)

VI. Management: General protocol for cessation of Opioids

  1. Maintain hydration during cessation
  2. Opioid Withdrawal may be extremely uncomfortable but not life threatening
    1. Contrast with Alcohol and Benzodiazepine Withdrawal which are potentially life threatening
    2. However, continued Opioid Abuse has a very high mortality due to Opioid Overdose risk
  3. Small to moderate chronic daily Opioid use: Stop Opioid cold turkey
    1. Less than 10 days of daily Opioid or
    2. Morphine Sulfate (or equivalent dose of other Opioid) <30 mg per day
  4. Moderate to high chronic daily Opioid use
    1. Taper by 10% per week up to as fast as 10% daily
    2. Consider detoxification admission for non-compliant patients
      1. Methadone protocol
      2. Buprenorphine protocol (see below)
  5. Other measures
    1. See Opioid Abuse for preventive measures (e.g. home Naloxone, STD Screening)

VII. Management: Alpha Adrenergic Central Agonist (e.g. Clonidine)

  1. Mechanism
    1. Decreases sympathetic CNS stimulation (noradrenergic response)
    2. Typically used in combination with other agents below (e.g. Gabapentin)
    3. Adverse effects include Dry Mouth, sedation, Dizziness, Bradycardia and Hypotension
  2. Preparations
    1. Clonidine (Catapres) 0.1 mg orally every 8-12 hours for 5 days
    2. Lofexidine (Lucemyra)
      1. Released in 2018, and similar to Clonidine, but at $330/day (Clonidine is $1/day)
      2. (2018) Presc Lett 25(9): 54
      3. Bryce (2019) Am Fam Physician 99(6): 393-4 [PubMed]
  3. Alpha Adrenergic Central Agonist Indications
    1. Non-life threatening Symptoms and Signs
    2. Anxiety
    3. Gastrointestinal symptoms
      1. Nausea or Vomiting
      2. Diarrhea
      3. Abdominal Muscle cramps
    4. Other withdrawal symptoms (Piloerection, Yawning, sneezing, Rhinorrhea)

VIII. Management: Other Medications

  1. Withdrawal and craving symptoms
    1. Tizanidine 4-8 mg orally every 8 hours
    2. Baclofen 10 mg orally every 8 hours
    3. Gabapentin (Neurontin) 300 mg orally every 8 hours
      1. May be used with Tramadol
    4. Tramadol taper
      1. Tramadol 100 mg every 6 hours for one day, then
      2. Tramadol 100 mg every 8 hours for one day, then
      3. Tramadol 50 mg every 8 hours for one day, then
      4. Tramadol 50 mg every 12 hours for one day, then
      5. Tramadol 50 mg once
  2. Gastrointestinal symptoms
    1. Dicyclomine (for abdominal cramping)
    2. Loperamide (for Diarrhea)
  3. Psychiatric symptoms
    1. Hydroxyzine (for Agitation)
    2. Trazodone (for Insomnia)
  4. Miscellaneous symptoms
    1. NSAIDs (for myalgias)

IX. Management: Medication Assisted Therapy Initiation

  1. See Buprenorphine for full protocol. medication activity and precautions
  2. Indications
    1. Opioid Dependence AND
    2. Patient wishes to enter Chemical Dependency treatment AND
    3. Active Opioid Withdrawal with Clinical Opioid Withdrawal Scale (COWS) >8
      1. Giving Buprenorphine without withdrawal, will precipitate withdrawal
      2. Last short acting Opioid >12 hours ago
      3. Last extended release Opioid >24 hours ago
      4. Last Methadone dose >72 hours ago
  3. Buprenorphine no longer requires an X-Waiver for use
    1. Buprenorphine, as of 2022, may also be prescribed in U.S. without a waiver
  4. Dosing: May be initiated in Emergency Department
    1. Day 1: Buprenorphine sublingual 4 to 8 mg
      1. Dose of 4 to 8 mg may be repeated every 30-60 minutes until patient has significant improvement
      2. Most patients will require 8 mg dose
    2. Day 2: Buprenorphine sublingual 16 mg
    3. Day 3: Buprenorphine sublingual 16 mg
    4. May be continued for 3 to 7 days, or until follow-up with recovery provider
  5. Protocol
    1. Patient administered first dose or doses in Emergency Department
    2. Close follow-up (1-3 days) arranged with a Buprenorphine capable clinic
  6. Resources
    1. SAMSHA Buprenorphine Practitioner Locator
      1. https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
      2. 1-800-662-HELP
  7. References
    1. Strayer and Swaminathan in Herbert (2018) EM:Rap 18(9): 3-6

X. Course

  1. Expect withdrawal symptoms for at least 7 days (up to weeks)

XI. References

  1. Bartscherer and Welsh (2023) Crit Dec Emerg Med 37(4): 16-7
  2. Orman and Starr in Herbert (2016) EM:Rap 16(10): 3
  3. Strayer in Herbert (2020) EM:Rap 20(6):10-2

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