Opioid withdrawal: Difference between revisions

(Format)
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==Clinical Presentation==
==Clinical Presentation==
*Onset: within hours of cessation
*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


==Onset==
==Differential Diagnosis==
*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


==Workup==
==Diagnosis==
*Normally a clinical 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


==Assessment==
==Management==
* Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS])
*PO/IV hydration PRN
** Can be used to determine severity
*[[Clonidine]]
 
**Mild opioid withdrawal - 0.1 - 0.3 mg PO
==Differential Diagnosis==
***Monitor heart rate and blood pressure and may titrate to effect  
 
**5mcg/kg PO (as long as SBP >90)
==Treatment==
*[[Benzodiazepines]] (e.g. diazepam 10-20mg IV)
#PO/IV hydration PRN
**Can add with clonidine for adequate sedation
#[[Clonidine]]
*Antihistamines
#*Mild opioid withdrawal - 0.1 - 0.3 mg PO
**[[Diphenhydramine]]  
#**Monitor heart rate and blood pressure and may titrate to effect  
**[[Hydroxyzine]] 50-100mg PO QID x5d
#*5mcg/kg PO (as long as SBP >90)
*[[Antiemetics]]
#[[Benzodiazepines]] (e.g. diazepam 10-20mg IV)
*Antidiarrheals
#*Can add with clonidine for adequate sedation
**[[Loperamide]] or Octreotide
#Antihistamines
*[[NSAIDS]]
#*[[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]]


==Source==
==References==
<references>
<references/>
</references>
 
*Tintinalli
[[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
    • Consider a urine tox
    • Clinical Opiate Withdrawal Score (COWS) can be used to determine severity

Management

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

See Also

References

  1. Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88.
  2. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95