From the Guidelines
The management of opioid withdrawal should primarily involve the use of opioid agonists like buprenorphine, initiated at 2-4mg when withdrawal symptoms appear, then titrated to 16mg daily, as this approach has been shown to effectively alleviate withdrawal symptoms and cravings. The treatment of opioid withdrawal may be symptomatic, often involving the use of α2-adrenergic agonists such as clonidine or lofexidine as well as antiemetics, atypical antipsychotics, and other medications targeting the withdrawal symptoms 1.
Key Considerations
- 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.
- The initiation of buprenorphine requires that patients must be experiencing opioid withdrawal, and the presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale 1.
- A daily dosage of 16 mg of buprenorphine is sufficient to suppress illicit opioid use in most patients with opioid use disorder (OUD), but sufficient dosages can vary and range from 4-24 mg daily 1.
Supportive Care
- Supportive medications include loperamide for diarrhea, ondansetron for nausea, acetaminophen or NSAIDs for pain, and trazodone for insomnia.
- Adequate hydration, nutrition, and electrolyte replacement are essential.
- Withdrawal management should be followed by a comprehensive treatment plan including counseling, behavioral therapy, and consideration of maintenance therapy with methadone, buprenorphine, or naltrexone to prevent relapse.
Medication-Assisted Treatment
- Methadone can be used as an alternative to buprenorphine, starting at 20-30mg daily, titrated based on symptoms.
- Clonidine, an alpha-2 adrenergic agonist, can be used at 0.1-0.3mg every 6-8 hours to manage autonomic symptoms like hypertension, tachycardia, and sweating.
- Naltrexone can be considered for maintenance therapy to prevent relapse, but it should only be initiated after the patient has been opioid-free for a sufficient period to avoid precipitating withdrawal.
From the FDA Drug Label
Lofexidine tablets are a non-opioid prescription medicine used in adults to help with the symptoms of opioid withdrawal that may happen when you stop taking an opioid suddenly. Lofexidine tablets will not completely prevent the symptoms of opioid withdrawal, 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 management of opioid withdrawal may include the use of lofexidine tablets to help with symptoms. However, it is essential to note that lofexidine tablets:
- Do not completely prevent the symptoms of opioid withdrawal
- Are not a treatment for opioid use disorder
- Should be used as part of a complete treatment program for opioid use disorder, as prescribed by a healthcare provider
- Must be taken exactly as directed by a healthcare provider, with gradual stopping to avoid increased blood pressure 2
Additionally, buprenorphine hydrochloride is another medication that may be used in the management of opioid withdrawal, but it carries a risk of abuse, addiction, and overdose, and should be used with caution and careful monitoring 3.
From the Research
Management of Opioid Withdrawal
The management of opioid withdrawal involves various medications and treatment approaches. The following are some key points to consider:
- Alpha2-adrenergic agonists: These medications, such as clonidine and lofexidine, can be used to manage opioid withdrawal symptoms 4, 5, 6. They can reduce the severity of withdrawal symptoms, but may have adverse effects such as hypotension and dizziness.
- Buprenorphine: This medication is also effective in managing opioid withdrawal symptoms 7, 8. It can reduce the severity of withdrawal symptoms and improve treatment outcomes, with fewer adverse effects compared to alpha2-adrenergic agonists.
- Methadone: Methadone is another medication that can be used to manage opioid withdrawal symptoms 4, 7, 6. It can reduce the severity of withdrawal symptoms, but may have a longer duration of action and more adverse effects compared to buprenorphine.
Comparison of Treatment Approaches
The following are some key points to consider when comparing different treatment approaches:
- Buprenorphine vs. methadone: Buprenorphine and methadone appear to be equally effective in managing opioid withdrawal symptoms, but buprenorphine may have a quicker resolution of withdrawal symptoms and fewer adverse effects 7, 8.
- Buprenorphine vs. alpha2-adrenergic agonists: Buprenorphine is more effective than alpha2-adrenergic agonists, such as clonidine and lofexidine, in managing opioid withdrawal symptoms 7, 8.
- Alpha2-adrenergic agonists vs. methadone: Alpha2-adrenergic agonists and methadone appear to be equally effective in managing opioid withdrawal symptoms, but alpha2-adrenergic agonists may have more adverse effects 4, 5, 6.
Key Considerations
The following are some key considerations when managing opioid withdrawal:
- Individualized treatment: Treatment should be individualized based on the patient's specific needs and medical history 4, 7, 5, 6, 8.
- Monitoring and support: Patients should be closely monitored and supported during the withdrawal process to minimize adverse effects and improve treatment outcomes 4, 7, 5, 6, 8.
- Combination therapy: Combination therapy, such as using multiple medications or combining medication with behavioral therapy, may be effective in managing opioid withdrawal symptoms 4, 7, 5, 6, 8.