From the Guidelines
Opiate withdrawal management in the pre-hospital setting should focus on supportive care and symptom relief while arranging transport to definitive care, with the goal of stabilization and transport to a facility where definitive treatment can be initiated. Symptoms of opiate withdrawal typically begin 8-24 hours after last opioid use and include anxiety, agitation, muscle aches, insomnia, sweating, yawning, runny nose, tearing, dilated pupils, goosebumps, abdominal cramping, nausea, vomiting, and diarrhea, as noted in the study by 1. Pre-hospital treatment includes maintaining airway, breathing, and circulation while addressing dehydration with IV fluids like normal saline.
Symptom management may include:
- Ondansetron 4mg IV/IM for nausea
- Loperamide 4mg orally for diarrhea
- Acetaminophen 1000mg or ibuprofen 400mg for pain and fever
- Clonidine 0.1-0.2mg orally can help with autonomic symptoms like hypertension and tachycardia if available and authorized, as suggested by 1
- Benzodiazepines such as diazepam 5-10mg IV/IM may be used for severe agitation or seizures under medical direction
Naloxone should be available but is not used to treat withdrawal. Reassurance and a calm environment are essential as withdrawal, while extremely uncomfortable, is rarely life-threatening except in patients with significant comorbidities. The goal is stabilization and transport to a facility where definitive treatment, possibly including medication-assisted therapy with methadone or buprenorphine, can be initiated, as recommended by 1.
From the FDA Drug Label
Opioid withdrawal. This can include: shaking, sweating more than normal, feeling hot or cold more than normal, runny nose, watery eyes, goose bumps, diarrhea, vomiting and muscle aches.
The symptoms of opiate withdrawal include:
- Shaking
- Sweating
- Feeling hot or cold
- Runny nose
- Watery eyes
- Goose bumps
- Diarrhea
- Vomiting
- Muscle aches
For treatment of opiate withdrawal in a pre-hospital setting, buprenorphine may be used, but it should be administered under the guidance of a medical professional. The dosage and administration of buprenorphine should be carefully managed to minimize the risk of adverse reactions and to ensure safe and effective treatment. 2
From the Research
Opiate Withdrawal Symptoms
- Opiate withdrawal symptoms can be severe and include vomiting, diarrhea, and delirium 3
- The symptoms can be suppressed using clonidine hydrochloride, an alpha-adrenergic agonist, which is a non-opiate substance 4
- Opioid withdrawal management strategies aim to relieve suffering associated with withdrawal, provide appropriate diagnosis and screening, engage patients in initiation of OUD treatment, and use harm reduction strategies 5
Treatment of Opiate Withdrawal
- Managed withdrawal is a necessary step prior to drug-free treatment or as the endpoint of long-term substitution treatment 3
- Opioid antagonists plus minimal sedation can be used for opioid withdrawal, but the quality of the evidence for this treatment is very low 3
- Clonidine is a reasonably safe, specific, and effective agent for detoxifying opiate addicts, and seems best suited for use as a transitional treatment between opiate dependence and induction onto the opiate antagonist naltrexone 6
- Treatment with medications for opioid use disorder (MOUD) using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone 7
Pre-Hospital Treatment
- There is limited information available on pre-hospital treatment of opiate withdrawal, but hospital settings provide a valuable opportunity for clinicians to engage and initiate management and treatment of OUD 7
- A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids 7
- Proper management of opioid withdrawal and initiation of MOUD in the hospital can improve outcomes in patients with OUD, and clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up 7