From the Guidelines
Buprenorphine-naloxone (Suboxone) is the most indicated medication for an 18-year-old man experiencing opioid withdrawal symptoms after stopping hydromorphone. The patient's symptoms, including fatigue, runny nose, nausea, diarrhea, and tachycardia, are consistent with opioid withdrawal. According to the most recent and highest quality study 1, buprenorphine may produce acute opioid withdrawal in patients on full mu agonists, and the recommended initiation dose is 2-4 mg, repeated at 2-hour intervals, if well tolerated, until resolution of withdrawal symptoms.
Key Considerations
- The patient should be assessed for the severity of withdrawal using tools such as the Clinical Opiate Withdrawal Scale, as mentioned in 1.
- Buprenorphine should be administered only to patients in active opioid withdrawal, as confirmed by history and physical examination, to avoid precipitated withdrawal 1.
- The typical starting dose is 4-8 mg sublingually on the first day, titrated up to 16-24 mg daily as needed, as guided by 1 and supported by 1.
Treatment Approach
- Treatment should begin when the patient is in moderate withdrawal (typically 12-24 hours after last opioid use) to avoid precipitated withdrawal.
- Buprenorphine is a partial opioid agonist that relieves withdrawal symptoms while producing less euphoria and respiratory depression than full agonists.
- The naloxone component deters misuse by injection.
- This medication effectively manages withdrawal symptoms while providing a pathway to either medically supervised withdrawal or longer-term maintenance treatment.
Referral and Ongoing Care
- The patient should be referred to a healthcare provider with a waiver to prescribe buprenorphine for comprehensive assessment and ongoing care, as opioid use disorder treatment typically requires both medication and behavioral therapy components for optimal outcomes, as emphasized in 1.
From the FDA Drug Label
5.10 Precipitation of Opioid Withdrawal Signs and Symptoms Because of the partial agonist properties of buprenorphine, Buprenorphine Sublingual Tablets may precipitate opioid withdrawal signs and symptoms in individuals physically dependent on full opioid agonists if administered sublingually or parenterally before the agonist effects of other opioids have subsided.
The prescription medication most indicated for this patient is buprenorphine.
- The patient is experiencing symptoms of opioid withdrawal after stopping hydromorphone.
- Buprenorphine is a partial agonist at the mu-opioid receptor and can help manage opioid withdrawal symptoms.
- However, it is essential to note that buprenorphine may precipitate opioid withdrawal signs and symptoms if administered before the agonist effects of other opioids have subsided 2.
From the Research
Prescription Medication for Opioid Withdrawal
The patient's symptoms, including fatigue, runny nose, nausea, diarrhea, and tachycardia, are consistent with opioid withdrawal. Considering the patient's history of hydromorphone use and recent cessation, the following prescription medications are indicated for managing opioid withdrawal:
- Buprenorphine: Studies have shown that buprenorphine is effective in managing opioid withdrawal, with a lower average withdrawal score and higher treatment completion rates compared to clonidine or lofexidine 3.
- Lofexidine: Lofexidine has been shown to be safe and effective in managing opioid withdrawal symptoms, with a higher likelihood of opioid cessation success compared to clonidine 4, 5.
- Methadone: Methadone is also an effective medication for managing opioid withdrawal, with similar capacity to ameliorate opioid withdrawal as buprenorphine 3, 6.
Key Considerations
When selecting a prescription medication for opioid withdrawal, the following factors should be considered:
- Efficacy: Buprenorphine and lofexidine have been shown to be effective in managing opioid withdrawal symptoms.
- Safety: Lofexidine has been associated with adverse events such as QT prolongation, hypotension, orthostasis, and bradycardia 4.
- Treatment duration: The maximum course of treatment for lofexidine is 14 days, while buprenorphine and methadone can be used for longer periods.
- Patient factors: The patient's age, duration of opioid exposure, physical status, and other considerations may influence the nature and duration of withdrawal symptoms 4.