What is the recommended treatment for heroin withdrawal?

Treatment of Heroin Withdrawal

Buprenorphine is the first-line treatment for heroin withdrawal due to its superior safety profile, higher completion rates, and less severe withdrawal symptoms compared to other options. 1

Initial Assessment and Stabilization

• Use Clinical Opiate Withdrawal Scale (COWS) to quantify withdrawal severity:

  • COWS <8: Mild withdrawal - not ready for buprenorphine
  • COWS >8: Moderate to severe withdrawal - proceed with buprenorphine 1

• Confirm appropriate timing since last heroin use:

  • Short-acting opioids (like heroin): >12 hours
  • Extended-release formulations: >24 hours
  • Methadone maintenance: >72 hours 1

Buprenorphine Protocol

Day 1 (Induction)

1. Initial dose: 4-8 mg sublingually based on withdrawal severity
2. Reassess after 30-60 minutes
3. Administer additional doses at 2-hour intervals if withdrawal symptoms persist
4. Target stabilization dose: 16 mg daily for most patients 1

Day 2 and Beyond

• The total dose given on day 1 can be prescribed as the daily dose
• Continue to adjust based on withdrawal symptoms 1

Alternative Option: Methadone

• Similar effectiveness to buprenorphine but with lower completion rates (78% vs 89%)
• No ceiling effect on respiratory depression (higher overdose risk)
• Requires daily dosing at certified Opioid Treatment Programs
• More protracted withdrawal profile 1, 2
• Common withdrawal symptoms during methadone induction: lacrimation, rhinorrhea, sneezing, yawning, excessive perspiration, goose-flesh, fever, chilliness, restlessness, irritability, weakness, anxiety, depression, dilated pupils, tremors, tachycardia, abdominal cramps, body aches, involuntary movements, anorexia, nausea, vomiting, diarrhea 2

Adjunctive Medications for Symptom Management

• Nausea/vomiting: Promethazine or other antiemetics
• Anxiety/muscle cramps: Benzodiazepines (use with caution due to respiratory depression risk)
• Diarrhea: Loperamide
• Insomnia: Trazodone or mirtazapine
• Pain: Acetaminophen
• Autonomic symptoms: α2-adrenergic agonists (clonidine or lofexidine) - start with small doses and monitor for hypotension 1

Tapering Options

For patients transitioning to abstinence after stabilization:

• Standard taper: Reduce dose by 10% or less per week

• Slow taper: 10% reduction per month (for prolonged opioid therapy)

• Moderate taper: Initial reduction of 5-10% followed by continued slow reductions

• Fast taper: 10% per week until 30% of original dose, then 10% weekly reductions 3, 1

• Important: Each new dose should be 90% of the previous dose rather than a straight-line taper 3

Monitoring and Support

• Close observation during the taper process
• Clinician availability to treat symptoms and manage fears
• Provide overdose prevention education and take-home naloxone kit
• Screen for hepatitis C and HIV
• Monitor vital signs regularly, especially blood pressure and heart rate 1

Potential Pitfalls to Avoid

1. Administering buprenorphine too early (before adequate withdrawal) - can precipitate severe withdrawal
2. Inadequate dosing for withdrawal symptom control
3. Failing to recognize pain as a withdrawal symptom
4. Converting outpatients to methadone without special expertise
5. Not addressing drug interactions, particularly with benzodiazepines 1
6. Abrupt discontinuation of treatment - can lead to severe withdrawal 4

Protracted withdrawal syndrome may occur months after opioid elimination, with symptoms including dysphoria, irritability, insomnia, and anhedonia, which should be expected and treated appropriately 1.