From the Guidelines
For clients entering detox for alcohol while on methadone maintenance, I recommend several as-needed medications to manage withdrawal symptoms, prioritizing benzodiazepines like lorazepam or chlordiazepoxide as first-line treatment for alcohol withdrawal symptoms, as supported by the most recent and highest quality study 1.
Medications for Withdrawal Symptoms
- Benzodiazepines: lorazepam (0.5-2mg every 4-6 hours PRN) or chlordiazepoxide (25-100mg every 6-8 hours PRN) are recommended for alcohol withdrawal symptoms, with dosing based on symptom severity using the CIWA-Ar scale 1.
- For nausea: ondansetron 4-8mg every 8 hours PRN or promethazine 12.5-25mg every 6 hours PRN can be effective.
- Acetaminophen 650mg every 6 hours PRN (maximum 3000mg daily) helps with pain and fever.
- Loperamide 2-4mg PRN after loose stools (maximum 16mg daily) addresses diarrhea.
- Hydroxyzine 25-50mg every 6 hours PRN can manage anxiety and insomnia.
Methadone Maintenance
- It's crucial to continue the client's prescribed methadone dose during detox to prevent opioid withdrawal, typically administered once daily, as methadone dose adjustments may be necessary to manage chronic pain in patients with HIV 2, 3.
Monitoring and Precautions
- Regular monitoring of vital signs, withdrawal symptoms, and sedation levels is essential, as benzodiazepines combined with methadone can increase sedation risk.
- Methadone is known to prolong the heart rate QTc, and patients should be advised of the risk of arrhythmia when taking methadone 3.
From the Research
Medications for Alcohol Detoxification with Methadone Maintenance Therapy
- Benzodiazepines can be prescribed as needed for clients undergoing alcohol detoxification who are also receiving daily methadone maintenance therapy, with dosage adjusted according to concomitant use of alcohol, benzodiazepines, and cocaine 4.
- Clonidine can be used in conjunction with benzodiazepines to manage withdrawal symptoms 4.
- Non-opiate-based painkillers can be administered to clients undergoing methadone detoxification 4.
- Naltrexone can be given to clients after completion of methadone detoxification, typically on the seventh day 4.
- Barbiturates can be used to treat mixed alcohol-benzodiazepine withdrawal syndrome, with dosage determined by sedative tolerance tests 5.
- Dexmedetomidine is an alternative pharmacological agent for the treatment of alcohol withdrawal syndrome, particularly in critically ill patients 6.