From the Guidelines
Narcotic withdrawal should be managed with a combination of medications and supportive care, prioritizing the use of buprenorphine or methadone for severe cases, as recommended by the most recent guidelines 1.
Management of Narcotic Withdrawal
Narcotic withdrawal occurs when someone who has been using opioids regularly stops or reduces their use, leading to uncomfortable physical and psychological symptoms.
- Treatment typically involves a combination of medications and supportive care.
- For mild to moderate withdrawal, medications like clonidine (0.1-0.2mg every 6 hours) can help manage symptoms such as anxiety, sweating, and rapid heart rate.
- For more severe cases, medication-assisted treatment with buprenorphine (starting at 4-8mg sublingually on day 1, then adjusted based on symptoms) or methadone (20-30mg initially, then titrated) is recommended, as these medications have been shown to be effective in managing withdrawal symptoms and reducing the risk of relapse 1.
Supportive Measures
Supportive measures include:
- Maintaining hydration
- Managing specific symptoms with medications like loperamide for diarrhea (4mg initially, then 2mg after each loose stool)
- Providing psychological support
Withdrawal Symptoms
Withdrawal symptoms typically begin 8-24 hours after the last opioid use, peak within 36-72 hours, and gradually improve over 5-10 days, though psychological symptoms may persist longer.
- The intensity of withdrawal depends on the specific opioid used, dosage, duration of use, and individual factors.
Long-term Recovery
Long-term recovery often requires ongoing treatment, including counseling and support groups, to address the underlying addiction and prevent relapse.
- Clinicians should prioritize patient education and discussion before starting opioid therapy, ensuring that patients are aware of expected benefits, common risks, serious risks, and alternatives to opioids 1.
- The use of opioid therapy should be carefully considered, with a focus on weighing the benefits against the risks, and alternative treatments should be explored whenever possible 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.
The symptoms of narcotic withdrawal include 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 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 a rapid and safe 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