Opioid withdrawal: Difference between revisions
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==Clinical Presentation== | ==Clinical Presentation== | ||
*Time to peak and duration of symptoms depends on the half-life of the drug involved. | *Time to peak and duration of symptoms depends on the half-life of the drug involved. | ||
=== | ===Adult Opioid Withdrawal Times=== | ||
*[[Heroin]]: onset 6-12 hours, peak 36-72 hours, duration 7-10 days | *[[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 | *[[Methadone]]: onset 30 hours, peak 72-96 hours, duration 14 days or more | ||
*If symptoms are from [[naloxone]]-induced withdrawal, typically the duration of symptoms are generally < 1 hour but can be severe | *If symptoms are from [[naloxone]]-induced withdrawal, typically the duration of symptoms are generally < 1 hour but can be severe | ||
===Neonatal Opioid Withdrawal Times=== | |||
*[[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 | |||
===Early symptoms=== | ===Early symptoms=== |
Revision as of 03:45, 9 March 2016
Background
- 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
Clinical Presentation
- Time to peak and duration of symptoms depends on the half-life of the drug involved.
Adult Opioid Withdrawal Times
- 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 symptoms are from naloxone-induced withdrawal, typically the duration of symptoms are generally < 1 hour but can be severe
Neonatal Opioid Withdrawal Times
- Heroin: onset within 24hrs
- Methadone: onset within 2-3 days due to large volume of distribution[3]
- Buprenorphine: onset within 2-3 days
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
- Sepsis
- Influenza
- Clonidine withdrawal
- Sympathomimetic use
Diagnosis
- Clinical diagnosis
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
- Clonidine
- Mild opioid withdrawal - 0.1 - 0.3 mg PO
- Monitor heart rate and blood pressure and may titrate to effect
- 5mcg/kg PO (as long as SBP >90)
- Mild opioid withdrawal - 0.1 - 0.3 mg PO
- 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:
- 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
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
See Also
References
- ↑ Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88.
- ↑ Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95
- ↑ Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.