What is the recommended treatment for opioid withdrawal in an inpatient setting?

Treatment of Opioid Withdrawal in the Inpatient Setting

Buprenorphine is the preferred first-line medication for treating opioid withdrawal in the inpatient setting due to its superior safety profile, less severe withdrawal symptoms, and higher treatment retention rates compared to other options. 1, 2

Assessment and Initial Management

• Use the Clinical Opiate Withdrawal Scale (COWS) to assess severity:

  • Mild withdrawal: 5-12
  • Moderate withdrawal: 13-24
  • Moderately severe withdrawal: 25-36
  • Severe withdrawal: >36

• Timing of medication initiation is crucial:

  • For short-acting opioids (heroin): Begin treatment when objective signs of moderate withdrawal appear (typically ≥4 hours after last use) 3
  • For long-acting opioids (methadone): Wait until clear signs of moderate withdrawal appear (generally ≥24 hours after last use) 3

Medication Options

1. Buprenorphine (First-line)

• Initial dosing protocol:

  • Start with 4-8 mg sublingually based on withdrawal severity
  • Reassess after 30-60 minutes
  • Administer additional doses at 2-hour intervals if withdrawal symptoms persist
  • Target stabilization dose: 16 mg daily for most patients 2, 3
  • Maximum daily dose on first day should not exceed 8-16 mg 3

• Advantages:

  • Ceiling effect on respiratory depression (safer)
  • Less severe withdrawal symptoms
  • Higher completion rates (89% vs 78% for methadone)
  • Longer treatment retention 1, 2

2. Methadone (Alternative option)

• Initial dosing protocol:

  • First dose: 20-30 mg (never exceed 30 mg initially)
  • Wait 2-4 hours to evaluate effect
  • Additional 5-10 mg if withdrawal symptoms persist
  • Total first-day dose should not exceed 40 mg 4
  • Subsequent dose adjustments based on withdrawal control at peak effect (2-4 hours after dosing)
  • Maintenance dose typically 80-120 mg/day 4

• Important considerations:

  • Can be administered in inpatient settings for up to 72 hours without Opioid Treatment Program involvement 1, 5
  • Higher risk of overdose due to no ceiling effect on respiratory depression
  • Effective but with lower completion rates than buprenorphine 2
  • Requires careful monitoring for respiratory depression 4

3. Adjunctive Medications for Symptom Management

For patients who cannot receive opioid agonist therapy or as supplements to primary treatment:

• α2-adrenergic agonists: Clonidine or lofexidine for autonomic symptoms (monitor for hypotension) 1, 2
• Antiemetics: Promethazine for nausea/vomiting 1, 2
• Benzodiazepines: For anxiety and muscle cramps (use cautiously due to respiratory depression risk) 1, 2
• Antidiarrheals: Loperamide for diarrhea 1
• Sleep aids: Trazodone or mirtazapine for insomnia 2
• Pain management: Acetaminophen for pain 2

Inpatient Protocol Implementation

1. Assessment phase:

   • Document opioid use history (type, amount, duration, last use)
   • Perform COWS assessment
   • Screen for contraindications to medications

2. Stabilization phase:

   • Administer buprenorphine or methadone according to protocols above
   • Titrate to effective dose that controls withdrawal symptoms
   • Monitor for adverse effects (sedation, respiratory depression)

3. Discharge planning:

   • Begin coordination with outpatient treatment providers early
   • Provide overdose prevention education
   • Dispense take-home naloxone kit
   • Screen for hepatitis C and HIV
   • Arrange prompt follow-up with addiction treatment services 2

Special Considerations

• Precipitated withdrawal risk: Ensure adequate time since last opioid use before starting buprenorphine to avoid precipitated withdrawal 3

• Patients on maintenance therapy: For patients already on methadone or buprenorphine maintenance, continue their verified outpatient dose during hospitalization 1

• Pain management: For patients requiring pain management:

  • Continue maintenance therapy and add short-acting opioid analgesics as needed
  • Consider dividing daily buprenorphine dose and administering every 6-8 hours to leverage analgesic properties 1

• Hospital-based rapid methadone initiation: Recent evidence supports more rapid titration protocols (up to 60 mg day 1,70 mg day 2) in carefully selected patients without end-organ failure, arrhythmia, concurrent benzodiazepine/alcohol use, or advanced age 6

By implementing these evidence-based approaches to opioid withdrawal management in the inpatient setting, clinicians can effectively manage withdrawal symptoms while establishing a foundation for long-term recovery.