Opioid withdrawal

Background

• Withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine).
• Symptoms are usually uncomfortable but not life-threatening
  • 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

Clinical Presentation

• Onset: within hours of cessation
• Symptoms resemble severe case of influenza

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

• Abdominal cramping
• Diarrhea
• Dilated pupils
• Goose bumps
• Nausea
• Vomiting

• Unlike alcohol or benzo withdrawal, unlikely to have seizures
  • Typically normal mental status despite agitation

Onset

• Time to peak and duration of symptoms depends on the half-life of the drug involved.
  • Heroin - Peak 36-72 hours, duration 7-10 days
  • Methadone - Peak 72-96 hours, duration 14 days or more

• If naloxone-induced withdrawal, typically symptom duration < 1 hour

Workup

• Normally a clinical diagnosis
  • Consider a urine tox

Treatment

1. Clonidine
   • 5mcg/kg PO (as long as SBP >90)
2. Hydroxyzine
   • 50-100mg PO QID x5d
3. Antiemetics
4. Antidiarrheals
5. NSAIDS
6. PO/IV hydration

See Also

• Neonatal abstinence syndrome
• Opioid toxicity

Source

• Tintinalli