From the Guidelines
Buprenorphine is the most effective medication for managing opiate withdrawal, with a recommended initial dose of 2-4mg sublingually, repeated at 2-hour intervals as needed, until resolution of withdrawal symptoms, as evidenced by recent studies 1. Opiate withdrawal can be managed with several medications and supportive care. The most effective medications include methadone, buprenorphine (Suboxone), and clonidine.
- Methadone is typically started at 20-30mg daily and adjusted based on symptoms
- Buprenorphine is usually initiated at 2-4mg sublingually once withdrawal symptoms begin, then increased to 12-16mg daily as needed, with a total dose given on day 2 that can be prescribed as the daily dose 1
- Clonidine, a non-opioid option, is prescribed at 0.1-0.2mg every 4-6 hours to reduce autonomic symptoms like sweating and anxiety. Supportive medications can also help with specific symptoms:
- Loperamide (2-4mg as needed) for diarrhea
- Ondansetron (4-8mg every 8 hours) for nausea
- NSAIDs like ibuprofen (400-600mg every 6 hours) for pain. Adequate hydration, nutrition, and rest are crucial during withdrawal. The process typically lasts 7-10 days, with symptoms peaking around days 2-4. These medications work by either replacing the opioid effect more safely (methadone, buprenorphine) or by targeting specific withdrawal symptoms (clonidine and supportive medications). Following acute withdrawal management, long-term treatment with medication-assisted therapy and counseling is recommended to prevent relapse, as recent studies have shown that buprenorphine is probably similar in effectiveness to tapered doses of methadone in the treatment of opioid withdrawal 1. It is also important to note that buprenorphine may produce acute opioid withdrawal in patients on full mu agonists, and patients should discontinue all opioids the night before initiation, with the dose depending on the duration of action 1. Additionally, potential harms of implementing buprenorphine include precipitation of opioid withdrawal and adverse effects such as respiratory depression, although this is rare unless the patient is also receiving sedatives/hypnotics such as benzodiazepines 1.
From the Research
Remedies for Opiate Withdrawal
- Buprenorphine has been found to be effective in alleviating opiate withdrawal symptoms, with studies showing it to be superior to clonidine in controlling withdrawal symptoms 2, 3, 4.
- Buprenorphine can be used to manage opioid withdrawal precipitated by buprenorphine itself, with rapid increases in buprenorphine dose being an effective treatment 5.
- Comparison of buprenorphine with methadone has shown that both are effective in managing opioid withdrawal, with buprenorphine possibly resolving withdrawal symptoms more quickly 3, 4.
- Clonidine or lofexidine are also used to manage opioid withdrawal, but buprenorphine has been found to be more effective in terms of severity of withdrawal, duration of withdrawal treatment, and likelihood of treatment completion 3, 4.
Factors Affecting Opiate Withdrawal
- Concurrent benzodiazepine dependence can exacerbate the opiate withdrawal syndrome, with co-dependent patients reporting more severe withdrawal symptoms 6.
- The rate of buprenorphine dose reduction may affect treatment outcome, but the evidence is uncertain and more research is needed 4.
Treatment Outcomes
- Buprenorphine has been shown to be effective in reducing the intensity of withdrawal symptoms, with patients staying in treatment for longer and being more likely to complete withdrawal treatment 3, 4.
- The use of buprenorphine to support transition to subsequent relapse prevention treatment with naltrexone is an area worthy of further research 4.