From the Guidelines
Clonidine should be prescribed at 0.1-0.2 mg orally every 4-6 hours as needed for opiate withdrawal symptoms when initiating Suboxone treatment, with a maximum daily dose of 0.8 mg, as recommended by recent studies 1. When starting Suboxone, it is essential to manage opiate withdrawal symptoms effectively to improve patient comfort and adherence to treatment.
- Clonidine helps reduce noradrenergic hyperactivity in the locus coeruleus, alleviating symptoms like anxiety, agitation, muscle aches, sweating, and rhinorrhea.
- The medication should be started 12-24 hours after the last opioid use and continued through the induction phase of Suboxone, which typically begins when the patient is in moderate withdrawal (COWS score ≥12-16).
- Suboxone should be initiated at 2-4 mg sublingually, with additional doses as needed up to 8-16 mg on day one, then stabilized at 16-24 mg daily.
- It is crucial to monitor blood pressure closely, as clonidine can cause hypotension, and taper the medication over 2-4 days when discontinuing to prevent rebound hypertension.
- Clonidine should be used cautiously in patients with cardiovascular disease, and patients should be advised about potential side effects, including sedation, dry mouth, and dizziness, as noted in the study 1.
- This adjunctive approach helps improve comfort during the transition to Suboxone maintenance therapy, and nonopioid treatments like α2-adrenergic agonists, antiemetics, benzodiazepines, and antidiarrheals may also be considered for symptomatic patients, as discussed in the studies 1.
From the Research
Prescribing Clonidine for Opiate Withdrawal
When starting Suboxone, clonidine can be prescribed to alleviate opiate withdrawal symptoms. The following points should be considered:
- Clonidine hydrochloride, an alpha-2-noradrenergic agonist, has been shown to significantly attenuate the opiate withdrawal syndrome in studies 2, 3.
- Dosage regimens of clonidine must be individualized according to symptoms and side effects and closely supervised due to varying sensitivity to clonidine's sedative, hypotensive, and withdrawal-suppressing effects 2.
- Clonidine can be used as a transitional treatment between opiate dependence and induction onto the opiate antagonist naltrexone 2.
Comparison with Buprenorphine
- Buprenorphine has been found to be superior to clonidine in enabling opiate dependent patients to successfully complete an outpatient detoxification program 4.
- Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion 5.
- A study comparing buprenorphine and clonidine found that buprenorphine was superior in alleviating most of the subjective and objective opiate withdrawal symptoms 6.
Key Considerations
- The completion rate for buprenorphine was higher than for clonidine in a study comparing the two treatments 4.
- Buprenorphine and methadone appear to be equally effective for managing opioid withdrawal, but data are limited 5.
- The rate of dose taper may affect treatment outcome, but it is not possible to draw any conclusions from the available evidence on the relative effectiveness of different rates of tapering the buprenorphine dose 5.