From the Guidelines
Abrupt cessation, or "cold turkey" treatment, is not recommended for substance withdrawal due to the risk of significant morbidity and mortality, particularly with opioids, benzodiazepines, and other central nervous system depressants. The most recent and highest quality study, published in 2020 in the Mayo Clinic Proceedings 1, emphasizes the importance of avoiding abrupt withdrawal and instead recommends a comfortable and safe tapering regimen, obtaining agreement from another physician to offer care, or replacing full mu agonists with buprenorphine. This approach is crucial in reducing the risk of overdose and other complications associated with sudden cessation.
Key Considerations for Substance Withdrawal
- Opioid withdrawal: medication-assisted treatment with buprenorphine-naloxone or methadone is safer and more effective than cold turkey 1
- Benzodiazepine withdrawal: gradual tapering over 8-12 weeks, with conversion to long-acting benzodiazepines, is recommended to minimize the risk of severe withdrawal syndrome 1
- Alcohol withdrawal: medical supervision is essential, and a medically supervised detox typically includes benzodiazepines like diazepam or lorazepam, with dosing adjusted based on symptoms
- Substances with milder withdrawal symptoms, such as caffeine or nicotine, may still benefit from tapering or replacement therapies to minimize discomfort and reduce the risk of relapse
Risks Associated with Cold Turkey Treatment
- Significant physiological disturbances as the body readjusts to functioning without the substance
- Risk of overdose, particularly with opioids and benzodiazepines
- Increased risk of morbidity and mortality, particularly with abrupt cessation of central nervous system depressants
- Potential for severe withdrawal symptoms, including seizures, dysphoria, anxiety, and irritability 1
From the FDA Drug Label
The risk is increased with concurrent abuse of buprenorphine hydrochloride with alcohol and/or other CNS depressants. Dependence Both tolerance and physical dependence can develop during use of opioid therapy Physical dependence is a state that develops as a result of a physiological adaptation in response to repeated drug use, manifested by withdrawal signs and symptoms after abrupt discontinuation or a significant dose reduction of a drug Withdrawal may be precipitated through the administration of drugs with opioid antagonist activity (e.g., naloxone), mixed agonist/antagonist analgesics (e.g., pentazocine, butorphanol, nalbuphine), or partial agonists (e.g., buprenorphine). Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient [see DOSAGE AND ADMINISTRATION] If buprenorphine hydrochloride is abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur, typically characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis
The efficacy of abrupt cessation (cold turkey) treatment for substance withdrawal is not supported by the FDA drug label, as it is actually contraindicated due to the risk of withdrawal syndrome.
- Key points:
- Physical dependence can develop during opioid therapy
- Abrupt discontinuation can lead to withdrawal signs and symptoms
- Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient 2
From the Research
Efficacy of Abrupt Cessation Treatment
- The efficacy of abrupt cessation (cold turkey) treatment for substance withdrawal is a topic of discussion in various studies 3, 4.
- According to a study published in 1991, the requirement of immediate and abrupt quitting can be an obstacle to the acceptance and accomplishment of abstinence as a long-term outcome 3.
- A 2017 study found that both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment, and recommends methadone or buprenorphine-naloxone treatment over abstinence-based treatment for all patient groups 4.
- Other studies discuss the importance of medication-assisted treatment and pharmacotherapy for substance use disorders, highlighting the effectiveness of medications such as methadone, buprenorphine, and naltrexone 5, 6, 7.
Comparison with Other Treatment Options
- A study published in 2017 compared the effectiveness of abstinence-based treatment with methadone and buprenorphine-naloxone maintenance, and found that both methadone and buprenorphine-naloxone are more effective than abstinence-based treatment 4.
- The study also found that methadone has higher treatment retention rates than buprenorphine-naloxone, while buprenorphine-naloxone has a lower risk of overdose 4.
Limitations and Concerns
- A 2018 study discussed the potential stigma against opioid-use disorder pharmacotherapy, and recommended referring to pharmacotherapy for substance use disorders as simply "medication" to bring clarity and precision to this effective treatment approach 7.
- The study also highlighted the importance of transparent descriptions of existing services to bridge the gap between treatment utilization and treatment need for substance use disorders 7.