What is the recommended approach for managing fentanyl withdrawal?

From the Guidelines

Fentanyl withdrawal management should be approached with a conversion to enteral methadone, following a specific tapering schedule, as outlined in the Pediatrics study 1. The approach involves converting continuous intravenous fentanyl to enteral methadone, with the initial dose calculated by dividing the methadone dose by 6, due to its longer half-life, and then providing this amount orally in 4 divided doses every 6 hours for 48 hours.

• Key steps in the tapering schedule include:
  • Days 1-2: Methadone dose divided by 6, given in 4 divided doses every 6 hours
  • Days 3-4: 80% of the original daily dose in 3 divided oral doses every 8 hours
  • Days 5-6: 60% of the original daily dose in 3 divided oral doses every 8 hours
  • Days 7-8: 40% of the original daily dose in 2 divided oral doses every 12 hours
  • Days 9-10: 20% of the original daily dose once per day
  • Day 11: Discontinuation of methadone This approach is based on the study by Meyer and Berens, as referenced in the Pediatrics journal 1, which provides a structured method for managing fentanyl withdrawal by gradually reducing the dose of methadone over a period of 11 days.
• It is essential to note that this method may need to be adjusted based on individual patient needs and responses to treatment, and should be carried out under medical supervision due to the potential risks associated with fentanyl withdrawal. The use of supportive medications, such as clonidine for autonomic symptoms, ondansetron for nausea, and loperamide for diarrhea, may also be necessary to manage specific symptoms that arise during the withdrawal process, as part of a comprehensive treatment plan 1.

From the FDA Drug Label

For patients requiring discontinuation of opioids, a gradual downward titration is recommended since it is not known at what dose level the opioid may be discontinued without producing the signs and symptoms of abrupt withdrawal. Opioid withdrawal symptoms (such as nausea, vomiting, diarrhea, anxiety, and shivering) are possible in some patients after conversion or dose adjustment The recommended approach for managing fentanyl withdrawal is a gradual downward titration of the dose, as it is not known at what dose level the opioid may be discontinued without producing the signs and symptoms of abrupt withdrawal. This approach can help minimize the risk of opioid withdrawal symptoms, such as:

• Nausea
• Vomiting
• Diarrhea
• Anxiety
• Shivering 2

From the Research

Fentanyl Withdrawal Management

• Fentanyl withdrawal management is a crucial step in treating individuals with opioid dependence, and various studies have investigated the most effective approaches to manage withdrawal symptoms.
• According to a study published in 2017 3, buprenorphine is more effective than clonidine or lofexidine in managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates.
• Another study from 2009 4 also found that buprenorphine is more effective than clonidine or lofexidine, and may offer some advantages over methadone in terms of quicker resolution of withdrawal symptoms and higher completion rates.
• A 2019 study 5 compared the intensity of withdrawal symptoms during opioid taper in patients with chronic pain, using either an individualized or fixed starting dosage, and found that the fixed starting dosage protocol resulted in a lower mean daily withdrawal score and a lower rate of high-intensity withdrawal symptoms.

Comparison of Buprenorphine and Methadone

• Studies have shown that buprenorphine and methadone have similar capacities to ameliorate opioid withdrawal, without clinically significant adverse effects 3, 4.
• However, buprenorphine may offer some advantages over methadone, including a quicker resolution of withdrawal symptoms and possibly higher completion rates 4.

Tapering Strategies

• A 2019 study 6 suggested that tapering SSRI treatment hyperbolically and slowly to doses much lower than therapeutic minimums can minimize withdrawal symptoms.
• Another study from 2020 7 highlighted the importance of person-specific tapering medication, which enables doctors to flexibly prescribe and adapt the medication required for responsible and person-specific tapering.
• The use of tapering strips, which allow for a gradual and flexible reduction of medication, has been proposed as a practical solution for managing psychotropic drug withdrawal 7.