From the Guidelines
For managing opioid withdrawal with less than 8 medications, I recommend a simplified regimen using buprenorphine-naloxone (Suboxone) as the primary medication, as it is supported by the most recent and highest quality study 1.
Key Components of the Regimen
- Start with 4-8mg of buprenorphine-naloxone on day one when withdrawal symptoms appear (COWS score >8), then adjust to 12-16mg daily based on symptom control, as suggested by 1.
- Supplement with clonidine 0.1-0.2mg every 6 hours as needed for autonomic symptoms like sweating and anxiety.
- Loperamide 4mg initially followed by 2mg after each loose stool (maximum 16mg/day) can manage diarrhea.
- For sleep, use trazodone 50-100mg at bedtime.
- Acetaminophen 650mg every 6 hours and/or ibuprofen 400mg every 6 hours can address pain and fever.
- Ondansetron 4mg every 8 hours as needed helps with nausea.
Rationale
This approach targets multiple withdrawal symptoms while using fewer than 8 medications. Buprenorphine works by partially activating opioid receptors to reduce cravings and withdrawal symptoms, while the adjunctive medications address specific symptoms through different mechanisms.
Considerations
It is crucial to supervise this regimen with a healthcare provider who can monitor for complications and adjust dosing as needed, especially considering the variability in patient response and the potential for opioid withdrawal, as noted in 1 and 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medications for Opioid Withdrawal
- Buprenorphine is more effective than clonidine or lofexidine for managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates 2, 3, 4
- Buprenorphine and methadone appear to be equally effective, but data are limited 3, 4
- Methadone and buprenorphine can be used for opioid detoxification, but treatment with medications for opioid use disorder (MOUD) is associated with superior treatment outcomes and reduced relapse compared to detoxification alone 5
- Other medications such as alpha 2 agonists, benzodiazepines, and antiemetics can be used to manage withdrawal symptoms 5
Comparison of Medications
- Buprenorphine is more effective than clonidine or lofexidine in terms of severity of withdrawal, duration of withdrawal treatment, and likelihood of treatment completion 2, 3, 4
- Buprenorphine and methadone have similar capacity to ameliorate opioid withdrawal, without clinically significant adverse effects 3
- Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal 4
Novel Approaches
- A novel low-dose approach to buprenorphine induction, also known as the 'microinduction' method, may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids 5
- Newer agents such as tramadol and tizanidine are being explored for the treatment of opioid withdrawal, exploiting μ-opioid receptor agonism and α2-adrenergic receptor agonism respectively 6