What is the treatment for abdominal pain due to withdrawal?

Treatment of Abdominal Pain Due to Withdrawal

Opioids should be the first-line treatment for abdominal pain due to withdrawal, with morphine being the preferred choice for opioid-naïve patients, titrated to symptoms with no dose limit. 1

Assessment of Withdrawal-Related Abdominal Pain

When evaluating abdominal pain due to withdrawal, it's essential to:

• Use a standardized scoring system to assess pain intensity 1
• Look for objective signs of pain such as tachypnea and grimacing 1
• Document the rationale for administering any comfort medication 1

Pharmacological Management

First-Line Treatment: Opioids

• For opioid-naïve patients:

  • Start with bolus doses of 2 mg intravenous morphine, titrated to effect 1
  • Follow with an infusion if pain persists 1

• For patients already on opioids:

  • Continue the same opioid at the current dose when starting withdrawal management 1
  • For breakthrough pain, administer bolus doses:
    • Morphine/hydromorphone: 2× the hourly infusion rate every 15 minutes as needed 1
    • Fentanyl: A bolus equal to the hourly infusion rate every 5 minutes as needed 1
  • If patient requires 2 bolus doses in an hour, double the infusion rate 1

Second-Line Treatment: Sedatives

• Only use sedatives after pain and dyspnea are treated with opioids 1
• Benzodiazepines can be used in combination with opioids 1
• For benzodiazepine-naïve patients:
  • Start with 2 mg intravenous midazolam bolus 1
  • Follow with an infusion of 1 mg/h 1
• For breakthrough agitation:
  • Administer 1-2× the hourly infusion rate every 5 minutes 1
  • Double the infusion rate if 2 bolus doses are needed in an hour 1

Third-Line Options

• Barbiturates or propofol can be used when benzodiazepines are ineffective 1
• Antinauseants should be ordered as needed with opioids 1

Special Considerations for Opioid Withdrawal

For patients specifically experiencing opioid withdrawal:

• Buprenorphine effectively alleviates withdrawal symptoms and can initiate medication for addiction treatment (MAT) 1
• Clonidine or lofexidine (α2-adrenergic agonists) can be used for symptomatic relief 1
• Antiemetics may help control nausea and vomiting associated with withdrawal 1

Benzodiazepine Withdrawal Management

For abdominal pain related to benzodiazepine withdrawal:

• Use a gradual taper to discontinue benzodiazepines or reduce the dosage to prevent withdrawal reactions 2
• Abrupt discontinuation can precipitate acute withdrawal reactions, which can be life-threatening 2
• Gastrointestinal symptoms including abdominal pain, nausea, and vomiting can occur within 48 hours of withdrawal and may last up to 8 days 3

Monitoring and Follow-up

• Use a validated, standardized assessment tool to continuously evaluate symptoms 1
• Document the rationale for each dose of medication administered 1
• Adjust medication dosing based on patient response:
  • Increase doses if pain persists
  • Consider adding adjunctive medications for specific symptoms

Pitfalls and Caveats

• Avoid withholding analgesia due to concerns about masking symptoms - early administration of analgesia does not interfere with diagnosis and may facilitate it by reducing symptom severity 4
• Be aware that narcotic bowel syndrome can develop with chronic opioid usage, characterized by worsening abdominal pain despite continued or escalating doses 1
• Consider that withdrawal symptoms may be misdiagnosed as other conditions, particularly in post-surgical patients 5
• Withdrawal from ataractic drugs (antipsychotics) can also cause gastrointestinal symptoms within 48 hours of discontinuation, lasting 1-8 days 3

By following this structured approach to managing abdominal pain due to withdrawal, clinicians can effectively control symptoms while minimizing complications and supporting patients through the withdrawal process.