What is the management for a patient with opioid withdrawal symptoms, including abdominal cramps, decreased appetite, nausea, vomiting, and muscle aches, after stopping oxymorphone (Opana) two days ago?

Management of Opioid Withdrawal After Stopping Oxymorphone

For this patient presenting with classic opioid withdrawal symptoms 2 days after stopping oxymorphone, initiate buprenorphine in the emergency department to effectively alleviate withdrawal symptoms, combined with symptomatic management using antiemetics and alpha-2 agonists. 1

Clinical Presentation Confirmation

The patient's symptoms are consistent with uncomplicated opioid withdrawal from oxymorphone (a short-acting opioid):

• Gastrointestinal symptoms: Abdominal cramping, nausea, vomiting, decreased appetite 1
• Musculoskeletal symptoms: Muscle aches (myalgias) 1
• Pupillary findings: Pupils equal, round, and reactive to light (dilated pupils are typical in withdrawal but normal reactive pupils don't exclude withdrawal) 1
• Timeline: 48 hours post-cessation is appropriate for short-acting opioid withdrawal (typically >12 hours onset) 1

Primary Treatment: Buprenorphine Administration

Buprenorphine is the most effective treatment for opioid withdrawal and should be administered in the ED. 1

Key Administration Points:

• Any DEA-licensed physician can administer (but not prescribe) buprenorphine in the ED for up to 72 hours without an X-waiver 1
• Buprenorphine is superior to clonidine/lofexidine in reducing withdrawal severity, has fewer adverse effects, and patients are more likely to stay in treatment 1
• Confirm the patient is in mild opioid withdrawal before administering to avoid precipitated withdrawal 1, 2
• For oxymorphone (short-acting), ensure >12 hours since last use 1

Dosing Strategy:

• Start with initial dose and titrate based on symptom response 1
• Not more than one day's medication may be given at one time 1
• Treatment may continue for up to 72 hours while arranging referral for ongoing addiction treatment 1

Symptomatic Management

Nausea and Vomiting Treatment:

Prophylactic antiemetics are highly recommended for patients with opioid-related nausea: 2

• First-line agents:

  • Phenothiazines (prochlorperazine 10 mg PO q6h) 2
  • Dopamine receptor antagonists (metoclopramide 10-20 mg PO or haloperidol 0.5-1 mg PO q6-8h) 2

• If nausea persists despite initial treatment:

  • Add serotonin receptor antagonists (ondansetron) 2
  • Consider combination therapy: metoclopramide plus ondansetron for synergistic relief 2
  • Administer antiemetics around the clock for 1 week if needed, then transition to as-needed dosing 2

Additional Symptomatic Treatments:

• Alpha-2 agonists (clonidine or lofexidine) for catecholamine-mediated symptoms if buprenorphine unavailable or as adjunct 1
• Benzodiazepines for anxiety and muscle cramps 1
• Loperamide for diarrhea (though not mentioned in this case) 1

Critical Management Principles

What NOT to Do:

• Never use opioid analgesics (morphine, oxycodone, hydromorphone) for chronic visceral abdominal pain in withdrawal, as they perpetuate dependence and risk narcotic bowel syndrome 1
• Avoid methadone in the ED setting due to long duration of action and potential interference with ongoing treatment programs 1

Essential Next Steps:

• Arrange referral for medication-assisted treatment (MAT) for opioid use disorder - this is required when administering buprenorphine under the 72-hour rule 1
• Provide written treatment referral information at minimum 1
• Consider initiating MAT directly if resources available 1

Common Pitfalls to Avoid

• Administering buprenorphine before adequate withdrawal onset will precipitate severe withdrawal 1, 2
• Undertreating nausea leads to poor medication adherence and potential relapse 2
• Failing to arrange addiction treatment referral negates the benefit of ED withdrawal management 1
• Confusing withdrawal symptoms with other acute conditions - withdrawal is "subjectively severe but objectively mild" and rarely life-threatening as a sole condition 1, 3