From the Guidelines
Severe opioid withdrawal syndrome should be treated with buprenorphine as the first-line medication, due to its safety and effectiveness, as implied by several systematic reviews 1.
Treatment Approach
The treatment of severe opioid withdrawal syndrome requires a comprehensive approach that combines medications and supportive care.
- The recommended first-line medication is buprenorphine, which can be started at 4-8mg sublingually when withdrawal symptoms are moderate, then titrated up to 16-24mg daily as needed.
- Alternatively, methadone can be initiated at 20-30mg orally and increased by 5-10mg daily until withdrawal symptoms are controlled, usually at 60-120mg daily.
- For patients who cannot take opioid agonists, clonidine may be used at 0.1-0.3mg orally every 6-8 hours to manage autonomic symptoms.
Supportive Care
Supportive medications and care are crucial in managing opioid withdrawal symptoms, including:
- Ondansetron 4-8mg for nausea
- Loperamide 4mg initially then 2mg after each loose stool for diarrhea
- Acetaminophen/NSAIDs for pain
- Trazodone 50-100mg at bedtime for insomnia
- Intravenous fluids may be necessary to prevent dehydration
Monitoring and Long-term Management
Treatment should occur in a monitored setting for severe cases, with vital signs checked regularly.
- After acute withdrawal management, patients should transition to long-term maintenance therapy with either buprenorphine or methadone, combined with counseling and psychosocial support.
- This approach works by either partially (buprenorphine) or fully (methadone) activating opioid receptors to prevent withdrawal, while clonidine reduces the sympathetic nervous system hyperactivity that causes many withdrawal symptoms, as suggested by studies on opioid withdrawal management 1.
From the Research
Treatment Options for Severe Opioid Withdrawal Syndrome
The treatment for severe opioid withdrawal syndrome typically involves medication-assisted therapy. Some of the commonly used medications include:
- Methadone: a μ-opioid receptor agonist that can help alleviate withdrawal symptoms 2, 3
- Buprenorphine: a partial agonist that can help manage opioid withdrawal 2, 4, 5
- Alpha2-adrenergic agonists: such as clonidine and lofexidine, which can help suppress withdrawal symptoms 2, 4, 5, 6
- Naltrexone: an opioid antagonist that can be used for relapse prevention 2, 6
Comparison of Treatment Options
Studies have compared the effectiveness of different treatment options for opioid withdrawal. For example:
- Buprenorphine has been shown to be more effective than clonidine or lofexidine in terms of severity of withdrawal, duration of withdrawal treatment, and likelihood of treatment completion 4
- Buprenorphine and methadone appear to be equally effective, but data are limited 4
- The rate of dose tapering for buprenorphine may affect treatment outcome, but the evidence is uncertain 4
Clinical Considerations
When treating patients with severe opioid withdrawal syndrome, it is essential to consider individual factors that may influence treatment response. For example:
- Sex: most studies have included primarily male participants, and there is a need for research on sex differences in response to withdrawal treatment 4
- Transition to subsequent relapse prevention treatment: the use of buprenorphine to support transition to naltrexone treatment is an area worthy of further research 4
- Stabilizing patients with opioid use disorder: managing withdrawal in the context of stabilizing patients with opioid use disorder to extended-release naltrexone is an area for future research 5