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).  
*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>
*Symptoms are usually uncomfortable but not life-threatening  
*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
**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions

Revision as of 17:29, 8 March 2016

Background

  • Withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine). [1]
  • 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

  • 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: onset 6-12 hours, peak 36-72 hours, duration 7-10 days
    • Methadone: onset 30 hours, peak 72-96 hours, duration 14 days or more
  • If naloxone-induced withdrawal, typically symptom duration < 1 hour

Workup

  • Normally a clinical diagnosis

Assessment

  • Clinical Opiate Withdrawal Score (COWS)
    • Can be used to determine severity

Differential Diagnosis

Treatment

  1. PO/IV hydration PRN
  2. Clonidine
    • Mild opioid withdrawal - 0.1 - 0.3 mg PO
    • 5mcg/kg PO (as long as SBP >90)
  3. Antihistamines
  4. Antiemetics
  5. Antidiarrheals
  6. NSAIDS

For select cases:

  • 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

Source

  • Tintinalli
  1. Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88.