From the Guidelines
The recommended treatment for opioid withdrawal in a hospital setting is buprenorphine, typically started at 4-8mg sublingually when moderate withdrawal symptoms appear, then titrated up to 16-24mg daily in divided doses, as it has been shown to be effective in alleviating withdrawal symptoms and reducing the risk of relapse 1.
Key Considerations
- Buprenorphine is the first-line medication for opioid withdrawal, due to its ability to reduce withdrawal severity and minimize the risk of relapse 1.
- Methadone can be used as an alternative, initiated at 10-30mg orally and titrated by 5-10mg daily based on symptoms, but it carries a higher risk of opioid toxicity compared to buprenorphine 1.
- Symptom-directed treatment, including clonidine, ondansetron, loperamide, and acetaminophen or NSAIDs, can be used to target specific withdrawal symptoms in patients not transitioning to maintenance therapy.
- Adequate hydration, electrolyte replacement, and nutritional support are essential components of treatment.
- Treatment typically continues for 5-10 days, with planning for post-discharge maintenance therapy or rehabilitation to prevent relapse.
Potential Harms and Considerations
- Buprenorphine may precipitate opioid withdrawal in patients who are opioid dependent but not yet showing signs/symptoms of withdrawal, but this can be overcome with sufficient dosing 1.
- Adverse effects of buprenorphine, including respiratory depression, are rare unless the patient is also receiving sedatives/hypnotics such as benzodiazepines 1.
- Methadone carries a higher risk of opioid toxicity, particularly if the patient is discharged and subsequently uses additional opioids 1.
From the FDA Drug Label
2.3 Induction Prior to induction, consideration should be given to the type of opioid dependence (i.e., long- or short-acting opioid products), the time since last opioid use, and the degree or level of opioid dependence 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 It is recommended that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible.
The recommended treatment for opioid withdrawal in a hospital setting involves administering buprenorphine when objective and clear signs of moderate opioid withdrawal appear.
- For patients dependent on short-acting opioid products, the first dose of buprenorphine should be given not less than 4 hours after the patient last used an opioid.
- For patients dependent on long-acting opioid products, the first dose of buprenorphine should be given not less than 24 hours after the patient last used a long-acting opioid product. The dosage of buprenorphine should be titrated to clinical effectiveness and achieved as rapidly as possible, with a recommended target dosage of 16 mg as a single daily dose 2.
From the Research
Treatment of Opioid Withdrawal in Hospitals
The treatment of opioid withdrawal in a hospital setting can be managed through various methods, including:
- Medications such as buprenorphine, methadone, and non-opioid medications like alpha 2 agonists, benzodiazepines, and antiemetics 3
- Symptomatic control using medications like olanzapine and clonidine 4
- Buprenorphine-based regimens, which have been shown to be effective in managing opioid withdrawal 5, 6
Medication Options
Some medication options for opioid withdrawal treatment include:
- Buprenorphine, a partial mu-opioid receptor agonist with high affinity and low intrinsic activity 7
- Methadone, which has been shown to be equally effective as buprenorphine in some studies 5, 6
- Clonidine, an alpha 2 agonist that can be used for symptomatic control 4, 5, 6
Hospital Setting Considerations
In a hospital setting, considerations for opioid withdrawal treatment include:
- Initiating maintenance treatment with medications for opioid use disorder (MOUD) 3
- Ensuring a smooth discharge with adequate and timely follow-up 3
- Addressing harm reduction in patients with opioid use disorder (OUD) 3
- Establishing a buprenorphine program in the emergency department (ED) to provide evidence-based treatment for OUD 7