CD
Opioid Withdrawal
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Opioid Withdrawal
, Narcotic Withdrawal
See Also
Opioid
Symptoms
Classic triad for Opioid Withdrawal
Piloerection
Rhinorrhea
Lacrimation
Other general symptoms
Cramping
Myalgias
Nausea
Diarrhea
Management
Gene
ral protocol for cessation of
Opioid
s
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
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
Lucemyra (Lofexidine)
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
Non-life threatening Symptoms and Signs
Anxiety
Gastrointestinal symptoms
Nausea
or
Vomiting
Diarrhea
Abdominal muscle cramps
Other withdrawal symptoms (Piloerection, yawning, sneezing,
Rhinorrhea
)
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
Tramadol
100 mg every 6 hours for one day, then
Tramadol
100 mg every 8 hours for one day, then
Tramadol
50 mg every 8 hours for one day, then
Tramadol
50 mg every 12 hours for one day, then
Tramadol
50 mg once
Gastrointestinal symptoms
Dicyclomine (for abdominal cramping)
Loperamide
(for
Diarrhea
)
Psychiatric symptoms
Hydroxyzine
(for
Agitation
)
Trazodone
(for
Insomnia
)
Miscellaneous symptoms
NSAID
s (for myalgias)
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
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
https://www.samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
1-800-662-HELP
References
Strayer and Swaminathan in Herbert (2018) EM:Rap 18(9): 3-6
Course
Expect withdrawal symptoms for at least 7 days (up to weeks)
References
Orman and Starr in Herbert (2016) EM:Rap 16(10): 3
Strayer in Herbert (2020) EM:Rap 20(6):10-2
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