From the Guidelines
For patients experiencing opioid withdrawal who do not plan to stop using opioids, the recommended approach is medication-assisted treatment (MAT) with opioid agonist therapy, specifically with buprenorphine, as it is a more recent and higher quality recommendation compared to methadone 1.
Key Considerations
- Buprenorphine should be initiated at 4-8mg sublingually when the patient is in mild to moderate withdrawal (typically 12-24 hours after last opioid use) and increased to 16-24mg daily as needed 1.
- Methadone is also an option, typically started at 20-30mg daily and titrated based on withdrawal symptoms 1.
- These medications should be prescribed as part of a comprehensive program that includes regular monitoring and harm reduction strategies.
- Clonidine (0.1-0.2mg every 6 hours) can help manage specific withdrawal symptoms like anxiety and autonomic hyperactivity.
- Supportive medications may include loperamide for diarrhea, ondansetron for nausea, and NSAIDs for pain.
Benefits and Risks
- This approach works by preventing withdrawal symptoms and reducing cravings while minimizing the risks associated with illicit opioid use, including overdose and infectious disease transmission 1.
- Potential harms of implementing the recommendations include precipitation of opioid withdrawal after receiving buprenorphine in the patient who is opioid dependent but not yet showing signs/symptoms of opioid withdrawal, although this complication can be overcome with sufficient buprenorphine dosing 1.
Monitoring and Follow-up
- Clinicians should follow up frequently (at least monthly) with patients engaging in opioid tapering or MAT, and team members (e.g., nurses, pharmacists, and behavioral health professionals) can support the clinician and patient during the ongoing process 1.
- Clinically significant opioid withdrawal symptoms can signal the need to further slow the taper rate or adjust the treatment plan.
From the Research
Opiate Withdrawal Treatment Approach
The recommended treatment approach for opiate (opioid) withdrawal in a patient who does not plan to stop using opiates (opioids) is a complex issue.
- Medication-assisted treatment (MAT) is a crucial component of opioid use disorder (OUD) treatment, as it has been shown to reduce opioid craving, increase treatment retention, and reduce illicit opioid use 2, 3, 4.
- Buprenorphine is a partial mu-opioid receptor agonist that is commonly used for opioid withdrawal treatment, and it has been shown to be effective in reducing opioid withdrawal symptoms and attenuating the effects of other opioids 2, 3, 5.
- Methadone is a full opioid agonist that is also used for OUD treatment, and it has been shown to be effective in reducing opioid craving and increasing treatment retention 3, 4, 5.
- Naltrexone is an opioid antagonist that can be used for OUD treatment, but it requires patients to be detoxified prior to initiation of therapy, which can be a challenge for patients with active OUD 3, 4, 5.
Patient Beliefs and Preferences
Patient beliefs and preferences play a significant role in determining the effectiveness of MAT.
- Patients' beliefs about the efficacy, safety, and consistency with being drug-free of each MAT option can predict their stated preferences for a particular MAT or for no MAT 6.
- Efforts to increase MAT enrollment following detoxification might benefit from including patient beliefs as one set of factors to assess and target for change 6.
Treatment Challenges
There are several challenges associated with OUD treatment, including:
- Poor adherence to treatment recommendations and high rates of relapse and increased risk of overdose after leaving treatment 3.
- Limited access to approved treatment options, such as methadone and buprenorphine, due to stigma and lack of certified physicians 3, 5.
- The need for a multifaceted approach to establish a pro-buprenorphine culture and promote a culture of acceptance for MAT options 2.