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Opioid withdrawal

Clinical features of opioid withdrawal

Opioid withdrawal involves a constellation of symptoms, typically several of the following at the same time:

  • psychological symptoms, such as dysphoria, cravings, insomnia and fatigue
  • flu-like physical symptoms, such as myalgias, chills, nausea and diarrhea.

Objective signs of withdrawal

Objective signs of withdrawal are usually not present except on sudden cessation of high doses of potent opioids such as heroin or parenteral hydromorphone. These signs include:

  • agitation, restlessness
  • tearing, yawning, runny nose
  • vomiting
  • sweating, piloerection (goosebumps)
  • tachycardia, hypertension.
  • Symptoms begin about six to 24 hours after last use, peak in two to three days and largely resolve in five to 10 days. Cravings, insomnia and dysphoria can last for weeks or months.

Risks associated with opioid withdrawal

Unlike alcohol withdrawal, opioid withdrawal does not cause seizures, arrhythmias, delirium or psychosis. However, it does pose other significant risks:

  • Women who are pregnant and who go into withdrawal are at risk of miscarriage (first trimester) or premature labour (third trimester).
  • Neonates born to women who are physically dependent on opioids sometimes experience prolonged withdrawal that requires treatment with morphine to prevent complications such as seizures.
  • Patients are at risk of suicide during withdrawal, particularly if it is sudden, untreated and forced (e.g., in a prison).
  • Due to loss of tolerance, patients who have gone through withdrawal are at high risk of overdose if they relapse to their previous dose after one or two weeks of abstinence.

Treating opioid withdrawal

Treating withdrawal is an essential first step in the treatment of opioid addiction. Patients with severe physical dependence often continue to use high doses of opioids, primarily to avoid withdrawal symptoms. However, treatment of withdrawal in itself rarely leads to long-term recovery. Withdrawal management should almost always be combined with opioid agonist maintenance treatment and formal addiction treatment.

Withdrawal should be avoided in pregnant women who are dependent on opioids. The safest treatment is long-term methadone or buprenorphine maintenance under the care of a specialized centre (e.g., the T-CUP program at Toronto's St. Joseph's Health Centre, or Fir Square in Vancouver).

If a woman insists on tapering and discontinuing opioids, the relatively safest time is during the second trimester.

Prescribing clonidine to manage withdrawal

It is thought that clonidine acts by central inhibition of the hyper-noradrenergic state that occurs in opioid withdrawal.

Follow these safety precautions when prescribing clonidine to manage withdrawal:

  • Use clonidine with caution in patients with pre-existing heart disease or those who are on antihypertensives.
  • Caution patients about the risk of dizziness/syncope, and advise them to avoid driving or using the bathtub until they know how they will tolerate the dose.
  • Warn patients about the risks of overusing clonidine. Let them know that if they stay on clonidine for longer than two consecutive weeks they will need to taper off the medication because abrupt discontinuation may lead to rebound hypertension.

Protocol for clonidine dosing

Prescribing buprenorphine-naloxone to manage withdrawal

Buprenorphine-naloxone (Suboxone), a partial mu opioid agonist, is more effective than clonidine and other treatments in relieving withdrawal symptoms and retaining patients in treatment (Amato et al., 2004; Blondell et al., 2007; Brigham et al., 2007; Caldiero et al., 2006; Gowing et al., 2002).

Note that managing withdrawal with buprenorphine-naloxone constitutes off-label use in Canada (the official indication is for maintenance therapy).

Buprenorphine binds more tightly than other opioids to the mu opioid receptors. If the patient takes buprenorphine while other opioids are still on board, buprenorphine will displace the other opioids from the receptors, triggering rapid onset of withdrawal.Precipitated withdrawal

To avoid precipitated withdrawal, the patient should take buprenorphine only after the physician is reasonably certain that other opioids have left the system; in other words:

  • It has been at least 12 hours since the patient took an immediate-release opioid, 24 hours since the patient took a controlled release opioid or three days since the patient took methadone.
  • The patient is in moderate withdrawal (definite withdrawal, not mild or borderline). Moderate withdrawal can be determined by history and exam or with a standardized scale such as the COWS (Clinical Opioid Withdrawal Scale). A score of 13 or more on the COWS indicates that the patient is in withdrawal and may safely be given the first dose of buprenorphine.

Protocol for inpatient or outpatient withdrawal management with buprenorphine-naloxone