What is the recommended treatment for opioid withdrawal?

From the Guidelines

The recommended treatment for opioid withdrawal involves a combination of medications and supportive care, with buprenorphine being the first-line medication due to its effectiveness in reducing withdrawal symptoms and cravings. Medication-assisted treatment (MAT) is the gold standard, and it typically includes buprenorphine (typically 8-24mg daily) or methadone (starting at 20-30mg daily and titrating as needed) in combination with behavioral therapies 1. For symptom management, clonidine (0.1-0.3mg every 6-8 hours) can help with autonomic symptoms like sweating and anxiety, while supportive medications include loperamide for diarrhea, ondansetron for nausea, and NSAIDs for pain 1.

Key Considerations

• Withdrawal typically lasts 7-10 days for short-acting opioids and up to 14 days for longer-acting ones.
• Beyond medications, hydration, nutritional support, and rest are crucial.
• Psychological support through counseling and behavioral therapies significantly improves outcomes.
• Buprenorphine should be administered only to patients in active opioid withdrawal as confirmed by history and physical examination, and its use requires careful monitoring due to the risk of precipitating withdrawal symptoms if the patient is currently receiving opioids and not yet in withdrawal 1.
• The presence of at least mild withdrawal symptoms should be verified by the administration of a validated opioid withdrawal scale before initiating buprenorphine treatment 1.

Treatment Approach

• Buprenorphine is the preferred medication for opioid withdrawal treatment due to its effectiveness and safety profile, with a daily dosage of 16 mg often sufficient to suppress illicit opioid use in most patients with opioid use disorder (OUD) 1.
• Methadone is another effective option, particularly for those with severe OUD, but its use requires careful consideration due to the potential for respiratory depression and opioid toxicity 1.
• A comprehensive treatment plan should include medication-assisted treatment, behavioral therapies, and supportive care to address the physical and psychological aspects of opioid withdrawal and improve outcomes.

From the FDA Drug Label

To prevent occurrence of precipitated withdrawal in patients dependent on opioids, or exacerbation of a pre-existing subclinical withdrawal syndrome, opioid-dependent patients, including those being treated for alcohol dependence, should be opioid-free (including tramadol) before starting naltrexone hydrochloride treatment An opioid-free interval of a minimum of 7 to 10 days is recommended for patients previously dependent on short-acting opioids. Patients transitioning from buprenorphine or methadone may be vulnerable to precipitation of withdrawal symptoms for as long as two weeks If a more rapid transition from agonist to antagonist therapy is deemed necessary and appropriate by the healthcare provider, monitor the patient closely in an appropriate medical setting where precipitated withdrawal can be managed In every case, healthcare providers should always be prepared to manage withdrawal symptomatically with non-opioid medications because there is no completely reliable method for determining whether a patient has had an adequate opioid-free period

The recommended treatment for opioid withdrawal is to manage withdrawal symptomatically with non-opioid medications. Patients should be opioid-free for a minimum of 7 to 10 days before starting naltrexone hydrochloride treatment.

• Key considerations:
  • Opioid-free interval: at least 7-10 days for short-acting opioids
  • Monitoring: closely monitor patients transitioning from buprenorphine or methadone
  • Management: manage withdrawal symptomatically with non-opioid medications
  • Healthcare provider preparation: always be prepared to manage withdrawal in an appropriate medical setting 2 2

From the Research

Treatment Options for Opioid Withdrawal

The recommended treatment for opioid withdrawal typically involves medication-assisted treatment, which may include:

• Methadone, a full opioid agonist, to suppress opioid withdrawal symptoms and attenuate the effects of other opioids 3
• Buprenorphine, a partial agonist, to suppress opioid withdrawal symptoms and attenuate the effects of other opioids 4, 5, 3, 6, 7
• Naltrexone, an opioid antagonist, to block the effects of opioid agonists, although it can precipitate opioid withdrawal if administered too quickly after the use of full or partial opioid agonists 4, 3

Medication-Assisted Treatment Strategies

Medication-assisted treatment strategies for opioid withdrawal may involve:

• Transitioning from full mu opioid agonists to buprenorphine, which may precipitate withdrawal, and using dosing strategies to soften withdrawal symptoms and facilitate transfer 5
• Using high-dose buprenorphine, as well as adjunctive medications including benzodiazepines, to treat naltrexone-precipitated withdrawal in the setting of chronic buprenorphine treatment 4
• Using buprenorphine therapy in the setting of induced opioid withdrawal from oral naltrexone, with significant improvement in withdrawal symptoms within a few hours 7

Important Considerations

Important considerations for medication-assisted treatment of opioid withdrawal include:

• Ensuring access to approved treatment, such as methadone, which has the strongest evidence for effectiveness 3
• Addressing potential barriers to expansion of buprenorphine treatment, including concerns of diversion and abuse, insufficient knowledge, and lack of access to addiction specialists and treatment resources 6
• Implementing good office practice, including urine drug screens, pill counts, and use of prescription monitoring programs, to minimize the risk of diversion and abuse 6