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. | ||
*Symptoms resemble severe case of influenza <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref> | **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 naloxone-induced withdrawal, typically symptom duration < 1 hour | |||
*Symptoms may resemble severe case of influenza <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref> | |||
===Early symptoms=== | ===Early symptoms=== | ||
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**Typically normal mental status despite agitation | **Typically normal mental status despite agitation | ||
== | ==Differential Diagnosis== | ||
== | ==Diagnosis== | ||
* | *Clinical diagnosis | ||
**Consider a [[urine tox]] | **Consider a [[urine tox]] | ||
**Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ 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: | For select cases: | ||
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*Methadone 10mg IM or 20mg PO | *Methadone 10mg IM or 20mg PO | ||
**Consider if withdrawal precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given | **Consider if withdrawal precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given | ||
==Disposition== | |||
==See Also== | ==See Also== | ||
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*[[Opioid toxicity]] | *[[Opioid toxicity]] | ||
== | ==References== | ||
<references | <references/> | ||
[[Category:Tox]] | [[Category:Tox]] | ||
Revision as of 02:31, 9 March 2016
Background
- Withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine). [1]
- Symptoms are usually uncomfortable but not life-threatening
- Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
- life-threatening in neonates
Clinical Presentation
- Time to peak and duration of symptoms depends on the half-life of the drug involved.
- 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 naloxone-induced withdrawal, typically symptom duration < 1 hour
- Symptoms may resemble severe case of influenza [2]
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 benzo withdrawal, unlikely to have seizures
- Typically normal mental status despite agitation
Differential Diagnosis
Diagnosis
- Clinical diagnosis
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)
- 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