From the Guidelines
The first-line treatment for managing opiate withdrawal is buprenorphine, typically administered as Suboxone (buprenorphine/naloxone) or Subutex (buprenorphine alone). This recommendation is based on the most recent and highest quality study available, which suggests that buprenorphine is a safe and effective treatment for opioid withdrawal, and potentially superior to other modalities of opioid withdrawal treatment 1.
Key Considerations for Buprenorphine Treatment
- Treatment usually begins when the patient is in mild to moderate withdrawal, with an initial dose of 2-4mg sublingually, followed by additional 2-4mg doses every 1-2 hours as needed, up to 16mg on the first day 1.
- The dose is then stabilized over subsequent days, typically between 12-24mg daily.
- Buprenorphine is preferred because it is a partial opioid agonist that effectively relieves withdrawal symptoms while having a ceiling effect on respiratory depression, making it safer than full agonists.
- It has high affinity for opioid receptors, displacing other opioids and preventing their effects if used.
Alternative Treatment Options
- For patients who cannot take buprenorphine, methadone (starting at 20-30mg daily and titrating upward) or symptom-directed therapy with clonidine, loperamide, and other medications may be used 1.
- Adequate hydration, nutritional support, and addressing comorbid psychiatric conditions are also essential components of withdrawal management.
- Treatment should transition to a maintenance phase to prevent relapse, as withdrawal management alone has high relapse rates.
Important Considerations for Treatment
- Buprenorphine should be administered only to patients in active opioid withdrawal as confirmed by history and physical examination, due to its high binding affinity and partial agonist properties, which may induce significant withdrawal symptoms if the patient is currently receiving opioids and not yet in withdrawal 1.
- Particular care is required when transitioning from methadone to buprenorphine because of the risk of severe and prolonged precipitated 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 first-line treatment for managing opiate withdrawal is not explicitly stated in the provided drug label. However, lofexidine tablets are mentioned as a non-opioid prescription medicine used to help with the symptoms of opioid withdrawal in adults.
- Key points about lofexidine tablets include:
- Used to help with symptoms of opioid withdrawal
- Not a treatment for opioid use disorder
- May be prescribed as part of a complete treatment program for opioid use disorder
- Not known if safe and effective in children 2
From the Research
Opiate Withdrawal Treatment
The first-line treatment for managing opiate withdrawal is a crucial aspect of opioid dependence management. According to the available evidence, several medications have been used to manage opiate withdrawal, including buprenorphine, methadone, clonidine, and lofexidine.
Comparison of Treatments
- Buprenorphine has been shown to be more effective than clonidine or lofexidine in managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates 3, 4.
- Buprenorphine and methadone appear to be equally effective in managing opioid withdrawal, but data are limited 3, 4.
- Tramadol may be comparable to buprenorphine in the management of mild to moderately severe heroin withdrawal, but more research is needed to confirm this finding 5.
Treatment Outcomes
- Buprenorphine is associated with a lower average withdrawal score, longer treatment duration, and higher treatment completion rates compared to clonidine or lofexidine 3, 4.
- Methadone and buprenorphine have similar treatment outcomes, but buprenorphine may offer some advantages in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal 4.