Opioid withdrawal: Difference between revisions
Elcatracho (talk | contribs) |
Elcatracho (talk | contribs) |
||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Natural derivatives: [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS) | *Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS) | ||
*Synthetic: [[Fentanyl]], [[Hydromorphone]], [[Buprenorphine]], [[Methadone]], [[Meperidine]], [[Dextromethorphan]] (- 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]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use | *Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use | ||
Revision as of 19:19, 15 January 2021
Background
- Natural derivatives (Opiates): 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) [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 24-72 hours, duration 7-10 days[3]
- Methadone: onset 24-72 hours, peak 4-6 days, duration 14 days or more
- Fentanyl: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
- Buprenorphine: 4-48 hours, peak 96 hours, duration 14-21 days
Precipitated Withdrawal
- Naloxone: onset 1-3 min, duration: 30-60min
- Butorphanol or nalbuphine: 15 min, duration: 90 min
- Naltrexone: 15-30min, duration 12-24hours
- Buprenorphine: 10-15min, duration 12-24 hours
Neonatal Opioid Withdrawal
- Heroin: onset within 24hrs
- Methadone: onset within 2-3 days due to large volume of distribution[4]
- 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
- 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
- Benzodiazepines
- Flunitrazepam (Rohypnol)
- Gamma hydroxybutyrate (GHB)
- Baclofen
- Barbiturates
- Opioids
- Chloral hydrate
Evaluation
- Clinical diagnosis
- Consider urine toxicology screen and BMP if signs of dehydration
- 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 α2 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]
Lofexidine
- A newer central alpha2 agonist
Buspirone
- Generally reserved for outpatient therapy
- Decreases serotonergic activity[5]
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
External Links
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
- ↑ Herring, A et al. Managing opiod withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487
- ↑ 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.