Recommended Medications for Inpatient Opioid Detoxification
Buprenorphine is the most effective first-line medication for inpatient opioid detoxification, producing less severe withdrawal symptoms, fewer adverse effects, and higher treatment retention rates compared to non-opioid alternatives. 1
Primary Medication: Buprenorphine
Dosing Protocol
- Confirm time since last opioid use before initiating buprenorphine: >12 hours for short-acting opioids (e.g., heroin), >24 hours for extended-release formulations 2, 1
- Assess withdrawal severity using Clinical Opiate Withdrawal Scale (COWS) 2, 1
- For moderate to severe withdrawal (COWS >8): Administer 4-8 mg sublingual buprenorphine initially 2
- Reassess after 30-60 minutes following initial dose 2
- Target a total daily dose of 16 mg for most patients, which can be administered once daily or divided into multiple doses 2, 1
- For patients with mild withdrawal (COWS <8): Reassess in 1-2 hours before administering buprenorphine 2
Important Considerations
- Buprenorphine should be administered only to patients in active opioid withdrawal to prevent precipitated withdrawal 2
- Particular caution is required when transitioning patients from methadone to buprenorphine due to risk of severe and prolonged precipitated withdrawal 2
- A single high dose of buprenorphine (24 mg) has been studied for inpatient detoxification with favorable results 3
- Standard detoxification duration is typically 17-21 days for outpatient settings, but may be shorter for inpatient settings 4
Alternative Primary Medication: Methadone
- Methadone is an effective alternative for opioid detoxification 2
- Methadone is probably similar in effectiveness to tapered doses of buprenorphine in the treatment of opioid withdrawal 2
- For patients on methadone maintenance (>72 hours), consider continuing methadone rather than switching to buprenorphine 2
- Methadone administration for detoxification in inpatient settings must comply with federal regulations 5
Adjunct Medications for Symptom Management
For Autonomic Symptoms
- α2-Adrenergic agonists (clonidine, lofexidine) for sweating, tachycardia, and hypertension 2, 1
- Lofexidine is FDA-approved specifically for opioid withdrawal management 1
For Gastrointestinal Symptoms
- Antiemetics (promethazine) for nausea and vomiting 2, 1
- Antidiarrheals (loperamide) for diarrhea 2, 1
For Psychological Symptoms
- Benzodiazepines for anxiety, muscle cramps, and reducing catecholamine release during withdrawal 2, 1
- Monitor closely for respiratory depression when combining with opioids 1
Monitoring During Detoxification
- Regular assessment of vital signs and withdrawal symptoms throughout the detoxification process 1
- Use COWS to objectively measure withdrawal severity and guide medication dosing 2
- Document rationale for all symptom management medications 2
Special Considerations
- Inpatient buprenorphine initiation shows better retention in subsequent outpatient treatment compared to detoxification-only approaches 6
- For patients with chronic pain or those unable to cease opioids long enough to prevent precipitated withdrawal, micro-dosing strategies may be considered 7
- Alternate-day dosing of buprenorphine is possible but results in greater withdrawal symptoms compared to daily dosing 8
- Older patient age has been found to be a predictor of successful treatment completion 4