Opioid withdrawal
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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
Adult Opioid 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
Neonatal Opioid Withdrawal
- Heroin: onset within 24hrs
- Methadone: onset within 2-3 days due to large volume of distribution[3]
- Buprenorphine: onset within 2-3 days
Clinical Presentation
Time to peak and duration of symptoms depends on the half-life of the drug involved
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
Opioid replacement
- Opioid administration such as morphine can be given as needed for symptom control
Clonidine
- A central alpha 2 agonist that does suppress the sympathetic hyperactivity that results during acute withdrawal
- Dosing: 0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms
- Major adverse effect is hypotension
- Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release[citation needed]
Buspirone
- Generally reservered for outpatien thterapy
- Decreases serotonergic activity[4]
Benzodiazepines
- Can be added along with with clonidine for adequate sedation
- Antihistamines
Methadone
- Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
- Dose: 10mg IM or 20mg PO
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.
- ↑ Van den Brink W et al. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry 2006; 51:635.