From the Guidelines
The recommended treatment for acute heroin withdrawal is medication-assisted therapy with opioid agonists, specifically buprenorphine (Subutex) or buprenorphine-naloxone (Suboxone), starting with 4-8mg on day one, titrated up to 16-24mg daily based on symptom control, as it has been shown to be effective in managing opioid withdrawal symptoms and improving treatment outcomes 1.
Key Considerations
- Treatment should begin when the patient is in mild to moderate withdrawal (typically 12-24 hours after last opioid use) to avoid precipitated withdrawal 1.
- Methadone is an alternative, starting at 20-30mg daily and increasing by 5-10mg every few days as needed, with typical maintenance doses of 60-120mg daily 1.
- Supportive medications can help manage specific symptoms: clonidine (0.1-0.2mg every 4-6 hours) for autonomic symptoms, loperamide for diarrhea, ondansetron for nausea, and non-opioid pain relievers for pain and discomfort.
- Adequate hydration, nutritional support, and monitoring of vital signs are essential.
Rationale
The use of buprenorphine for acute heroin withdrawal is supported by several studies, including a systematic review by Gowing et al. (2017) that found buprenorphine to be more effective than clonidine or lofexidine in managing opioid withdrawal symptoms 1. Additionally, a meta-analysis by Meader (2010) found that buprenorphine and methadone were the most effective methods of opioid detoxification 1. The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine also recommend the use of buprenorphine for opioid use disorder in pregnancy 1.
Monitoring and Follow-up
Patients should be closely monitored for withdrawal symptoms, and the dose of buprenorphine should be adjusted as needed. Following acute withdrawal management, patients should transition to long-term treatment that may include maintenance medication and comprehensive addiction counseling. It is essential to address the patient's overall health and well-being, including their physical and mental health, to ensure the best possible outcomes.
From the FDA Drug Label
Lofexidine may mitigate, but not completely prevent, the symptoms associated with opioid withdrawal syndrome, which may include feeling sick, stomach cramps, muscle spasms or twitching, feeling of cold, heart pounding, muscular tension, aches and pains, yawning, runny eyes and sleep problems (insomnia). The SOWS-Gossop, a patient-reported outcome (PRO) instrument, evaluates the following opioid withdrawal symptoms: feeling sick, stomach cramps, muscle spasms/twitching, feeling of coldness, heart pounding, muscular tension, aches and pains, yawning, runny eyes and insomnia/problems sleeping Patients Dependent on Heroin or Other Short-acting Opioid Products At treatment initiation, 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 Heroin Withdrawal During the induction phase of methadone maintenance treatment, patients are being withdrawn from heroin and may therefore show typical withdrawal symptoms, which should be differentiated from methadone-induced side effects
The recommended treatment for acute heroin withdrawal includes:
- Lofexidine: to mitigate opioid withdrawal symptoms, with a total daily dose of 2.88 mg for up to 14 days 2
- Buprenorphine: administered sublingually as a single daily dose, with the first dose given when objective signs of moderate opioid withdrawal appear, and not less than 4 hours after the patient last used heroin 3
- Methadone: used in a methadone maintenance treatment program, with careful titration of the initial dose to the individual, and monitoring for adverse effects such as respiratory depression and systemic hypotension 4 Key considerations:
- Treatment should be individualized and monitored closely for adverse effects
- Patients should be advised of the potential for withdrawal symptoms and the importance of follow-up visits
- The use of multiple medications and supportive measures may be necessary to manage withdrawal symptoms effectively 2, 3, 4
From the Research
Treatment Options for Acute Heroin Withdrawal
- Methadone hydrochloride is a commonly used opiate agonist for both withdrawal and maintenance therapy, but it produces dependence and withdrawal symptoms upon abrupt discontinuation 5.
- Alpha 2-adrenergic agonists, such as clonidine, decrease opiate withdrawal symptoms by decreasing central adrenergic hyperarousal, but often cause hypotension 5.
- Buprenorphine hydrochloride is a partial opiate agonist that attenuates opiate craving and causes minimal withdrawal upon abrupt discontinuation, showing promise in treating heroin-dependent populations 5, 6.
- Lofexidine, an alpha-2 agonist, can be used to manage acute withdrawal symptoms before starting maintenance treatment with either methadone or buprenorphine 7.
- High-dose methadone produces superior opioid blockade and comparable withdrawal suppression to lower doses in opioid-dependent humans 8.
Comparison of Treatment Options
- Buprenorphine and methadone appear to be equally effective in managing opioid withdrawal, but data are limited 6.
- Buprenorphine is more effective than clonidine or lofexidine in terms of severity of withdrawal, duration of withdrawal treatment, and likelihood of treatment completion 6.
- Lofexidine has been shown to be effective in reducing withdrawal symptoms and could potentially aid in recovery and withdrawal 7.
Evolution of Treatment Approaches
- The pharmacological management of heroin withdrawal syndrome has progressed from opioid replacement taper with morphine, codeine, and methadone to the utilization of clonidine and buprenorphine 9.
- More recent advances in treating opioid use disorder have changed the goals of opioid withdrawal management to achievement of abstinence from all opioids to facilitation of long-term treatment with medications for opioid use disorder 9.