Opioid withdrawal

Revision as of 03:38, 9 March 2016 by Ostermayer (talk | contribs) (Disposition)

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
  • 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

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 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

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

  • 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

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