II. Symptoms

  1. Classic triad for Opioid Withdrawal
    1. Piloerection
    2. Rhinorrhea
    3. Lacrimation
  2. Other general symptoms
    1. Cramping
    2. Myalgias
    3. Nausea
    4. Diarrhea

III. Management: General protocol for cessation of Opioids

  1. Maintain hydration during cessation
  2. Opioid Withdrawal is uncomfortable but not life threatening
    1. Contrast with Alcohol and Benzodiazepine Withdrawal which are potentially life threatening
  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

IV. 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)
  2. Preparations
    1. Clonidine (Catapres) 0.1 mg orally every 8-12 hours for 5 days
    2. Lucemyra (Lofexidine)
      1. Released in 2018, and similar to Clonidine, but at $330/day (Clonidine is $1/day)
      2. (2018) Presc Lett 25(9): 54
  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)

V. 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)

VI. Management: Medication Assisted Therapy Initiation

  1. See Buprenorphine for 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) >8-9
  3. Buprenorphine may be given in the emergency department without a DEA X-Waiver
    1. However, Buprenorphine may not be prescribed without a waiver
    2. Allows for administration of a single dose in ED (or up to 3 doses in 72 hours if patient returns)
  4. Dosing: May be initiated in Emergency Department
    1. Day 1: Buprenorphine sublingual 4-8 mg
    2. Day 2: Buprenorphine sublingual 16 mg
    3. Day 3: Buprenorphine sublingual 16 mg
  5. Protocol
    1. Patient administered first dose in Emergency Department
    2. Close follow-up (1-3 days) arranged with a Buprenorphine capable clinic
  6. References
    1. Strayer and Swaminathan in Herbert (2018) EM:Rap 18(9): 3-6

VII. Course

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

VIII. References

  1. Orman and Starr in Herbert (2016) EM:Rap 16(10): 3

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Ontology: Opioid withdrawal (C0029104)

Concepts Mental or Behavioral Dysfunction (T048)
ICD10 F11.3
SnomedCT 268687009, 192221004, 87132004
DSM4 292.0
English Opioid Withdrawal, Mental and behav dis due to use opioids: withdrawal state, Mental and behavioral disorders due to use of opioids: withdrawal state, Mental and behavioural disorders due to use of opioids: withdrawal state, Opioid withthdrawal state, [X]Mental and behav dis due to use opioids: withdrawal state, [X]Mental and behavioral disorders due to use of opioids: withdrawal state, [X]Mental and behavioural disorders due to use of opioids: withdrawal state, [X]Opioid withthdrawal state, Mental and behavioral disorders due to use of opioids, withdrawal state, Mental and behavioural disorders due to use of opioids, withdrawal state, opioid withdrawal, opioid withdrawal (diagnosis), narcotic withdrawal, withdrawal narcotic, narcotics withdrawal, [X] Mental and behavioural disorders due to use of opioids: withdrawal state (& [cold turkey, opiate withdrawal]) (disorder), [X] Mental and behavioural disorders due to use of opioids: withdrawal state (& [cold turkey, opiate withdrawal]), [X]Mental and behavioral disorders due to use of opioids: withdrawal state (disorder), [X] Mental and behavioral disorders due to use of opioids: withdrawal state (& [cold turkey, opiate withdrawal]), [X]Cold turkey, opiate withdrawal, Opioid withdrawal, Narcotic withdrawal, Opioid withdrawal (disorder), opioids; withdrawal state, withdrawal state; opioids
German Psychische und Verhaltensstoerungen durch Opioide: Entzugssyndrom
Spanish [X]trastornos mentales y del comportamiento debidos al uso de opiáceos: estado de abstinencia, [X]trastornos mentales y del comportamiento debidos al uso de opiáceos: estado de abstinencia (trastorno), abstinencia de narcóticos, abstinencia de opiáceos (trastorno), abstinencia de opiáceos
Dutch onthoudingstoestand; opioïden, opioïden; onthoudingstoestand, Psychische stoornissen en gedragsstoornissen door gebruik van opioïden; Onthoudingstoestand