From the Guidelines
Narcotic withdrawal should be managed with a gradual tapering of opioids, rather than abrupt discontinuation, to minimize the risk of severe withdrawal symptoms and relapse, as recommended by the CDC clinical practice guideline for prescribing opioids for pain - United States, 2022 1.
Symptoms of Narcotic Withdrawal
Narcotic withdrawal occurs when someone who is physically dependent on opioids suddenly stops or reduces their use. Symptoms typically begin within 8-24 hours after the last dose and include:
- Muscle aches
- Restlessness
- Anxiety
- Lacrimation
- Runny nose
- Sweating
- Yawning
- Insomnia
- Dilated pupils As withdrawal progresses, symptoms may intensify to include:
- Diarrhea
- Abdominal cramping
- Goosebumps
- Nausea
- Vomiting
- Elevated heart rate and blood pressure
Management of Narcotic Withdrawal
Management often involves medication-assisted treatment with:
- Buprenorphine (starting at 4-8mg sublingually, titrated up to 16-24mg daily) or methadone (starting at 20-30mg daily, gradually increased) 1
- Clonidine (0.1-0.2mg every 6 hours) can help manage autonomic symptoms Supportive medications include:
- Loperamide for diarrhea
- Ondansetron for nausea
- NSAIDs for pain
- Trazodone for insomnia Medical supervision is strongly recommended, especially for patients with comorbidities. Long-term treatment should include counseling, support groups, and possibly maintenance therapy with buprenorphine or methadone to prevent relapse and support recovery.
Prevention of Narcotic Withdrawal
Prevention is the preferred approach to management of opioid withdrawal symptoms and is achieved by decreasing the dose of opioid over time rather than abruptly discontinuing the medication, commonly referred to as “weaning” 1. Clinicians should determine with patients how functional benefit will be evaluated and establish treatment goals before initiating opioid therapy, and periodically reassess to ensure that opioids are helping to meet patient goals 1.
From the FDA Drug Label
Physical dependence is manifested by withdrawal symptoms after abrupt discontinuation of a drug or upon administration of an antagonist Physical dependence is expected during opioid agonist therapy of opioid addiction. The opioid abstinence or withdrawal syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis Other symptoms also may develop, including: irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate.
Narcotic withdrawal symptoms are expected during opioid agonist therapy of opioid addiction and can be characterized by a range of physical and psychological symptoms, including restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis, as well as irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate 2.
From the Research
Narcotic Withdrawal Symptoms and Treatment
- Narcotic withdrawal symptoms can be severe and include anxiety, anorexia, insomnia, restlessness, and muscular aching 3, 4, 5
- Buprenorphine is an effective treatment for managing opioid withdrawal, with studies showing it to be more effective than clonidine or lofexidine in terms of severity of withdrawal, duration of withdrawal treatment, and likelihood of treatment completion 4
- Methadone is also used to manage opioid withdrawal, but it has significant abuse potential and can cause adverse cardiac effects, such as QTc interval prolongation 6, 5
- Naltrexone is an opioid antagonist that can be used to precipitate acute withdrawal, followed by a "rescue" with buprenorphine/naloxone, as seen in a case study where a patient was successfully transitioned from methadone to buprenorphine/naloxone within 2 hours 6
- Clonidine can be used in combination with naltrexone to reduce the intensity of naltrexone-induced withdrawal symptoms, allowing for a rapid and safe withdrawal from methadone 3
Rapid Opiate Detoxification
- Rapid opiate detoxification (ROD) is a technique that involves inducing rapid narcotic withdrawal in a controlled environment using narcotic antagonists, while suppressing withdrawal symptoms with sedative drugs 7
- ROD can be an effective tool in the treatment of heroin addiction, but the optimal method is yet to be determined and it is probably most suited to designated outpatient centers 7
- A study of 25 consecutive heroin-addicted patients found that ROD was effective in all patients, with none experiencing withdrawal symptoms after discharge 7
Comparison of Treatments
- Buprenorphine and methadone appear to be equally effective in managing opioid withdrawal, but data are limited 4
- Clonidine and naltrexone can be used in combination to facilitate withdrawal from methadone, but the efficacy of this approach is not well established 3, 5
- The use of buprenorphine to support transition to naltrexone treatment is an aspect worthy of further research 4