What is the recommended treatment for opioid withdrawal syndrome?

Treatment of Opioid Withdrawal Syndrome

Buprenorphine is the first-line treatment for opioid withdrawal syndrome, with a recommended target dose of 16mg daily for most patients. 1

Initial Assessment and Preparation

• 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 1

• Critical safety step: Ensure patient is in mild-to-moderate withdrawal before starting buprenorphine to avoid precipitated withdrawal

  • Minimum opioid-free interval of 7-10 days for short-acting opioids
  • Up to 2 weeks may be needed for patients transitioning from methadone or buprenorphine 2

Buprenorphine Initiation Protocol

1. Day 1: Start with 2-4mg sublingually after mild withdrawal symptoms appear

   • Additional 2-4mg doses at 2-hour intervals as needed
   • Typical first-day total: 4-8mg 1

2. Day 2: Prescribe the total dose given on day 1 as the daily maintenance dose

   • Reassess and increase if withdrawal symptoms persist 1

3. Maintenance phase: Target 16mg daily for most patients

   • This dose is typically sufficient to suppress illicit opioid use 1

Alternative: Methadone Treatment

• Can be administered in inpatient settings for up to 72 hours without Opioid Treatment Program involvement
• Initial dose: 30-40mg daily
• Can increase in 5-10mg increments if withdrawal persists
• Warning: Higher risk of overdose due to no ceiling effect on respiratory depression 1

Comparison of Treatment Options

Aspect	Buprenorphine	Methadone
Effectiveness	Higher completion rates (89% vs 78%)	Effective but lower completion rates
Safety	Ceiling effect on respiratory depression	No ceiling effect, higher overdose risk
Administration	Sublingual, less frequent dosing	Oral, daily dosing required
Regulations	X-waiver needed for OUD treatment	Restricted to certified OTPs for OUD
Withdrawal profile	Less severe symptoms	More protracted withdrawal

Managing Precipitated Withdrawal

If precipitated withdrawal occurs (which can happen despite proper preparation, especially with fentanyl use):

• Administer high-dose buprenorphine rapidly (2mg every 1-2 hours)
• Total doses of up to 20mg may be needed to reverse withdrawal symptoms 3
• Monitor closely for respiratory depression and sedation 1

Supportive Medications for Specific Symptoms

• Sleep disturbances: Short-term use of trazodone or mirtazapine 1
• Autonomic symptoms: α2-adrenergic agonists such as clonidine or lofexidine 1
• Avoid: Opioid agonist/antagonists (e.g., nalbuphine, butorphanol) as they can precipitate withdrawal 1

Tapering Protocol

For patients requiring discontinuation of maintenance therapy:

• Gradual taper of 10% or less of original dose per week 1
• Sample schedule:
  1. Weeks 1-2: Reduce by 10% to 90% of original dose
  2. Weeks 3-4: Reduce to 80% of original dose
  3. Weeks 5-6: Reduce to 70% of original dose
  4. Weeks 7-8: Reduce to 60% of original dose
  5. Weeks 9-10: Reduce to 50% of original dose 1

Important Cautions

• Overdose risk: Patients may be more sensitive to opioids after discontinuing treatment, with potentially fatal outcomes 2
• Hepatotoxicity: Monitor for signs of liver dysfunction; discontinue if acute hepatitis symptoms develop 2
• Mental health: Be alert for depression and suicidal ideation, which have been reported with naltrexone treatment 2

Non-pharmacological Approaches

Integrate these supportive measures throughout treatment:

• Regular exercise
• Stress reduction techniques
• Sleep hygiene practices
• Cognitive behavioral therapy 1