Opioid withdrawal

Background

• Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine). 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
  • 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.

Estimated Time to Onset of Withdrawal

• 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

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 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
  • Consider a UDS
  • Clinical Opiate Withdrawal Score (COWS) can be used to determine severity

Management

• PO/IV hydration PRN
• 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)
• 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

• Neonatal abstinence syndrome
• Opioid toxicity