Opioid withdrawal

Revision as of 03:31, 9 March 2016 by Ostermayer (talk | contribs) (Estimated Time to Onset of Withdrawal)

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
    • 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

Clinical Presentation

  • Time to peak and duration of symptoms depends on the half-life of the drug involved.

Estimated Time to Onset of 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

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 UDS
    • 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.