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

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)
• 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