Opioid withdrawal

Background

• Natural derivatives: Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS)
• Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS)
• 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

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
• Buprenorphine: onset within 2-3 days

Clinical Features

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

• 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

Sedative/hypnotic withdrawal

• Toxic alcohols
  • Ethanol
  • Ethylene glycol
  • Methanol
  • Isopropyl alcohol
• Benzodiazepines
  • Flunitrazepam (Rohypnol)
• Gamma hydroxybutyrate (GHB)
• Barbiturates
• Opioids
• Chloral hydrate

Evaluation

• Clinical diagnosis
  • Consider urine toxicology screen
  • 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

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

Benzodiazepines

• Can be added along with with clonidine for adequate sedation

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

• Neonatal abstinence syndrome
• Opioid toxicity

References

Authors

Daniel Ostermayer, David Xu, Jordan Swartz, Ross Donaldson, Daniel Eggeman, Michael Holtz, Neil Young, Marissa Camilon, Claire