From the Guidelines
A comprehensive inpatient regimen for opioid withdrawal should include buprenorphine (Subutex) or methadone for opioid replacement therapy, starting with appropriate doses based on withdrawal severity and gradually tapering, as this approach has been shown to be effective in managing withdrawal symptoms and improving patient outcomes 1.
Key Components of the Regimen
- Buprenorphine or methadone for opioid replacement therapy, with initial dosing based on withdrawal severity and gradual tapering
- Clonidine (0.1-0.2mg every 4-6 hours) to manage autonomic symptoms like sweating and anxiety
- Supportive medications, such as:
- Loperamide (2-4mg as needed) for diarrhea
- Ondansetron (4-8mg every 8 hours) for nausea
- Acetaminophen (650mg every 6 hours) or NSAIDs for pain
- Hydroxyzine (25-50mg every 6 hours) or trazodone (50-100mg at bedtime) for sleep disturbances
Importance of Individualization and Support
The regimen should be individualized based on the patient's specific withdrawal symptoms, medical history, and the particular opioid they were using. Psychological support through counseling and planning for post-discharge treatment are also crucial components for long-term recovery 1.
Rationale for Buprenorphine and Methadone
Buprenorphine and methadone have been shown to be effective in reducing the severity of withdrawal symptoms and improving patient outcomes, with buprenorphine potentially being superior to other modalities of opioid withdrawal treatment 1.
Monitoring and Hydration
Adequate hydration, nutritional support, and regular vital sign monitoring are essential to ensure patient safety and comfort during the withdrawal process 1.
From the FDA Drug Label
The first dose of Buprenorphine Sublingual Tablets should be administered only when objective and clear signs of moderate opioid withdrawal appear, and not less than 4 hours after the patient last used an opioid It is recommended that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible. The dosing on the initial day of treatment may be given in 2 mg to 4 mg increments if preferred. In a one-month study, patients received 8 mg of Buprenorphine Sublingual Tablets on Day 1 and 16 mg Buprenorphine Sublingual Tablets on Day 2.
For an inpatient going through opioid withdrawal, a good regimen may involve:
- Administering the first dose of Buprenorphine Sublingual Tablets when objective signs of moderate opioid withdrawal appear, at least 4 hours after the patient's last opioid use.
- Starting with a dose of 8 mg on Day 1 and 16 mg on Day 2, as seen in some studies 2.
- Titration to an adequate treatment dose as rapidly as possible, with increments of 2 mg to 4 mg if preferred.
- The maintenance dose is generally in the range of 4 mg to 24 mg buprenorphine per day, with a recommended target dosage of 16 mg as a single daily dose 2.
From the Research
Opioid Withdrawal Management
- Opioid withdrawal management can be effectively done using medications such as buprenorphine or methadone 3, 4, 5, 6
- Buprenorphine has been shown to be more effective than clonidine or lofexidine in managing opioid withdrawal in terms of severity of withdrawal, duration of withdrawal treatment, and the likelihood of treatment completion 5
- Methadone and buprenorphine appear to be equally effective, but data are limited 5
Treatment Protocols
- A practical opioid withdrawal protocol utilizing buprenorphine and the Clinical Opiate Withdrawal Scale can be used to address opioid withdrawal during inpatient treatment of a primary medical condition 3
- The protocol includes order sets with appropriate and modifiable orders that can be submitted in the electronic medical record to deliver seamless care for opioid withdrawal 3
- Collaboration with case managers is essential for providing appropriate resources and ensuring a safe discharge 3
Medication Options
- Buprenorphine can be used to modify the signs and symptoms of withdrawal in participants who are primarily opioid dependent 5
- Methadone can be used for opioid maintenance therapy in hospitalized patients 4
- Clonidine can be used to treat methadone withdrawal, but it may not be as effective as buprenorphine or methadone in managing opioid withdrawal 7, 5
Hospital Setting
- The hospital setting provides a valuable opportunity for clinicians to engage and initiate management and treatment of opioid use disorder (OUD) 6
- Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed 6
- Clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up 6