What is the recommended treatment for heroin withdrawal?

Treatment of Heroin Withdrawal

Buprenorphine is the recommended first-line treatment for heroin withdrawal, with initiation at 4-8 mg sublingually when objective signs of moderate withdrawal appear, and titration to a target dose of 16 mg daily. 1

Initial Assessment and Treatment Protocol

Buprenorphine Induction

• Begin buprenorphine only when patient shows clear signs of moderate withdrawal (typically not less than 4 hours after last heroin use) 1, 2
• Use Clinical Opiate Withdrawal Scale (COWS) to assess withdrawal severity:
  • Mild: 5-12
  • Moderate: 13-24
  • Moderately severe: 25-36
  • Severe: >36 1
• Initial dosing protocol:
  • Start with 4-8 mg sublingually
  • Reassess after 30-60 minutes
  • Administer additional doses at 2-hour intervals if withdrawal symptoms persist
  • Target stabilization dose of 16 mg daily (range 4-24 mg) 1, 2

Methadone Alternative

• Methadone is an effective alternative but has several disadvantages compared to buprenorphine:
  • No ceiling effect on respiratory depression (higher overdose risk)
  • Requires daily dosing
  • More restricted administration (only in certified Opioid Treatment Programs) 1, 3
  • Lower completion rates (78% vs 89% for buprenorphine) 1

Adjunctive Medications for Symptom Management

For specific withdrawal symptoms that persist despite buprenorphine or methadone:

• Nausea/vomiting: Promethazine or other antiemetics
• Anxiety/muscle cramps: Benzodiazepines (short-term use only)
• Diarrhea: Loperamide
• Insomnia: Trazodone or mirtazapine
• Pain: Acetaminophen
• Autonomic symptoms: α2-adrenergic agonists (clonidine or lofexidine) - monitor for hypotension 1

Maintenance Phase

• After stabilization, maintain buprenorphine at 16 mg daily (range 4-24 mg) 1, 2
• Dosages higher than 24 mg provide no additional clinical advantage 2
• Consider transitioning to buprenorphine/naloxone combination for maintenance to reduce diversion risk 2
• No maximum recommended duration of maintenance treatment - continue as long as patient is benefiting 2

Special Considerations

Avoiding Precipitated Withdrawal

• Ensure patient is in mild to moderate withdrawal before administering buprenorphine to prevent precipitated withdrawal 1, 2
• For patients transitioning from methadone or other long-acting opioids, wait at least 24 hours after last dose and until clear signs of moderate withdrawal appear 2

Overdose Prevention

• Provide overdose prevention education
• Dispense take-home naloxone kit
• Screen for hepatitis C and HIV 1

Discontinuation

• If discontinuation is planned, implement gradual tapering (10% or less reduction per week)
• For long-term users (≥1 year), use slower taper of 10% per month 1
• Monitor for protracted withdrawal syndrome, which may occur months after discontinuation 1

Clinical Pitfalls to Avoid

• Premature buprenorphine initiation: Starting before adequate withdrawal can precipitate severe withdrawal symptoms
• Inadequate dosing: Underdosing leads to continued withdrawal symptoms and potential relapse
• Abrupt discontinuation: Can lead to severe withdrawal; always taper gradually
• Overlooking comorbidities: Screen for and address psychiatric and medical comorbidities
• Failure to provide comprehensive care: Medication should be combined with appropriate social and medical services 1, 2, 3