Opioid withdrawal: Difference between revisions

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==Background==
==Background==
*Withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine). <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref>
*Natural derivatives: [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)
*Symptoms are usually uncomfortable but not life-threatening  
*Synthetic: [[Fentanyl]], [[Hydromorphone]], [[Buprenorphine]], [[Methadone]], [[Meperidine]], [[Dextromethorphan]] (- UDS)
*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use
*Symptoms are usually uncomfortable but not life-threatening and manifest with agitation and restlessness but '''does not cause altered mental status'''
*Symptoms may resemble that of [[Influenza]] <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref>
**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
**life-threatening in neonates
**Withdrawal can be life-threatening in neonates


==Clinical Presentation==
===Adult Opioid Withdrawal===
*Onset: within hours of cessation
*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing opiod withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>
*Symptoms resemble severe case of influenza <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref>
*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more
*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
*[[Buprenorphine]]: 4-48 hours, peak 96 hours, duration 14-21 days


===Precipitated Withdrawal===
*[[Naloxone]]: onset 1-3 min, duration: 30-60min
*Butorphanol or nalbuphine: 15 min, duration: 90 min
*[[Naltrexone]]: 15-30min, duration 12-24hours
*[[Buprenorphine]]: 10-15min, duration 12-24 hours
===Neonatal Opioid Withdrawal===
*[[Heroin]]: onset within 24hrs
*[[Methadone]]: onset within 2-3 days due to large volume of distribution<ref>Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.</ref>
*[[Buprenorphine]]: onset within 2-3 days
==Clinical Features==
Time to peak and duration of symptoms depends on the half-life of the drug involved
===Early symptoms===
===Early symptoms===
*Agitation/restlessness
*Agitation/restlessness
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*[[Vomiting]]
*[[Vomiting]]


*Unlike alcohol or benzo withdrawal, unlikely to have seizures
*'''Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''
**Typically normal mental status despite agitation
*'''Altered mental status is also not part of opiod withdrawal signs'''


==Onset==
==Differential Diagnosis==
*Time to peak and duration of symptoms depends on the half-life of the drug involved. 
''Differential is largely based on clinical symptoms and history''
**Heroin: onset 6-12 hours, peak 36-72 hours, duration 7-10 days
*[[Sepsis]]
**Methadone: onset 30 hours, peak 72-96 hours, duration 14 days or more
*[[Influenza]]
*[[Clonidine]] withdrawal
*[[Sympathomimetic]] use


*If naloxone-induced withdrawal, typically symptom duration < 1 hour
{{Sedative/hypnotic withdrawal types}}


==Workup==
==Evaluation==
*Normally a clinical diagnosis
*Clinical diagnosis
**Consider a [[urine tox]]
**Consider [[urine toxicology screen]]
**Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS]) can be used to determine severity


==Assessment==
==Management==
* Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS])
''Treatment is largely supportive without the need for any pharmacologic intervention in the ED unless there is serious hemodynamic abnormalities''
** Can be used to determine severity
===Supportive Care===
*PO/IV hydration
*Electrolyte repletion
===Opioid replacement===
*Opioid administration such as [[morphine]] can be given as needed for symptom control


==Differential Diagnosis==
===[[Clonidine]]===
*A central α<sub>2</sub> agonist that does suppress the sympathetic hyperactivity that results during acute withdrawal
*Dosing:  0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms
**Major adverse effect is hypotension
*Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release{{Citation needed|reason=Reliable source needed|date=March 2016}}
 
===[[Lofexidine]]===
*A newer central alpha<sub>2</sub> agonist
 
===[[Buspirone]]===
*Generally reserved for outpatient therapy
*Decreases serotonergic activity<ref>Van den Brink W et al. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry 2006; 51:635.</ref>
 
===[[Benzodiazepines]]===
*Can be added along with with clonidine for adequate sedation
===[[Antihistamines]]===
 
===[[Methadone]]===
*Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
*Dose: 10mg IM or 20mg PO


==Treatment==
==Disposition==
#PO/IV hydration PRN
*Patients who need long term detoxification can be admitted or transferred to detox facilities
#[[Clonidine]]
*If patients are going to continue to use opioids then those who are stable can be discharged
#*Mild opioid withdrawal - 0.1 - 0.3 mg PO
*Patients with severe withdrawal requiring sedation and continued monitoring should be admitted
#**Monitor heart rate and blood pressure and may titrate to effect
#*5mcg/kg PO (as long as SBP >90)
#[[Benzodiazepines]] (e.g. diazepam 10-20mg IV)
#*Can add with clonidine for adequate sedation
#Antihistamines
#*[[Diphenhydramine]]
#*[[Hydroxyzine]] 50-100mg PO QID x5d
#[[Antiemetics]]
#Antidiarrheals
#*[[Loperamide]] or Octreotide
#[[NSAIDS]]


For select cases:
==External Links==
*Buprenorphine
**Partial agonist, may induce withdrawal in opioid intoxicated patients
*Methadone 10mg IM or 20mg PO
**Consider if withdrawal precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given


==See Also==
==See Also==
*[[Neonatal abstinence syndrome]]
*[[Neonatal abstinence syndrome]]
*[[Opioid toxicity]]
*[[Opioid toxicity]]
*[[Harbor:Opiate Withdrawal/MAT/BUP]]
==References==
<references/>


==Source==
[[Category:Toxicology]]
<references>
</references>
*Tintinalli
[[Category:Tox]]

Revision as of 22:57, 1 September 2019

Background

  • Natural derivatives: Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS)
  • Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS)
  • Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine) [1] or as a result of cessation of use
  • Symptoms are usually uncomfortable but not life-threatening and manifest with agitation and restlessness but does not cause altered mental status
  • Symptoms may resemble that of Influenza [2]
    • Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
    • Withdrawal can be life-threatening in neonates

Adult Opioid Withdrawal

  • Heroin: onset 6-12 hours, peak 24-72 hours, duration 7-10 days[3]
  • Methadone: onset 24-72 hours, peak 4-6 days, duration 14 days or more
  • Fentanyl: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
  • Buprenorphine: 4-48 hours, peak 96 hours, duration 14-21 days

Precipitated Withdrawal

  • Naloxone: onset 1-3 min, duration: 30-60min
  • Butorphanol or nalbuphine: 15 min, duration: 90 min
  • Naltrexone: 15-30min, duration 12-24hours
  • Buprenorphine: 10-15min, duration 12-24 hours

Neonatal Opioid Withdrawal

Clinical Features

Time to peak and duration of symptoms depends on the half-life of the drug involved

Early symptoms

  • Agitation/restlessness
  • Anxiety
  • Muscle aches
  • Increased tearing
  • Insomnia
  • Runny nose
  • Sweating
  • Yawning
  • Skin-Crawling
  • May be tachycardic and/or tachypneic but not necessarily

Late symptoms

  • Unlike alcohol or benzodiazepine withdrawal, patients rarely have seizures
  • Altered mental status is also not part of opiod withdrawal signs

Differential Diagnosis

Differential is largely based on clinical symptoms and history

Sedative/hypnotic withdrawal

Evaluation

Management

Treatment is largely supportive without the need for any pharmacologic intervention in the ED unless there is serious hemodynamic abnormalities

Supportive Care

  • PO/IV hydration
  • Electrolyte repletion

Opioid replacement

  • Opioid administration such as morphine can be given as needed for symptom control

Clonidine

  • A central α2 agonist that does suppress the sympathetic hyperactivity that results during acute withdrawal
  • Dosing: 0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms
    • Major adverse effect is hypotension
  • Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release[citation needed]

Lofexidine

  • A newer central alpha2 agonist

Buspirone

  • Generally reserved for outpatient therapy
  • Decreases serotonergic activity[5]

Benzodiazepines

  • Can be added along with with clonidine for adequate sedation

Antihistamines

Methadone

  • Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
  • Dose: 10mg IM or 20mg PO

Disposition

  • Patients who need long term detoxification can be admitted or transferred to detox facilities
  • If patients are going to continue to use opioids then those who are stable can be discharged
  • Patients with severe withdrawal requiring sedation and continued monitoring should be admitted

External Links

See Also

References

  1. Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88.
  2. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95
  3. Herring, A et al. Managing opiod withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487
  4. Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.
  5. Van den Brink W et al. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry 2006; 51:635.