What is the recommended management for a patient experiencing opioid withdrawal?

Management of Opioid Withdrawal

Buprenorphine is the first-line treatment for opioid withdrawal and should be initiated once the patient demonstrates objective signs of moderate withdrawal (COWS score ≥8-12), with a typical starting dose of 2-4 mg sublingual, titrated every 2 hours until symptoms resolve. 1, 2

Confirming Active Withdrawal Before Treatment

• Use the Clinical Opiate Withdrawal Scale (COWS) to confirm moderate to severe withdrawal (score ≥8-12) before initiating any pharmacotherapy. 2
• Look for objective signs including tachypnea, rising respiratory rate, dilated pupils, excessive perspiration, goose-flesh, grimacing, and accessory muscle use. 2
• Critical timing requirement: For short-acting opioids (heroin), wait at least 4 hours after last use; for long-acting opioids (methadone), wait at least 24 hours to avoid precipitating severe withdrawal. 3

First-Line Pharmacotherapy: Buprenorphine

• The American College of Emergency Physicians recommends buprenorphine or methadone over non-opioid strategies (α2-adrenergic agonists plus antiemetics) as more effective options. 1
• Buprenorphine is preferred over methadone due to its superior safety profile—specifically, its partial agonist activity creates a ceiling effect on respiratory depression, eliminating the risk of subsequent opioid toxicity if patients use additional opioids after discharge. 1, 2
• Induction dosing: Start with 2-4 mg sublingual on Day 1, with doses given in 2-4 mg increments as needed; target 8 mg on Day 1 and 16 mg on Day 2, then maintain at 16 mg daily. 2, 3
• Rapid induction over 1-2 days is superior to gradual induction over several days, which leads to high dropout rates. 3
• Maintenance dosing ranges from 4-24 mg daily, with 16 mg as the recommended target dose; higher doses provide no additional clinical advantage. 3

Alternative and Adjunctive Medications

• When buprenorphine is contraindicated or as adjunctive therapy, use clonidine or lofexidine for autonomic symptoms (tachycardia, hypertension, sweating, anxiety). 2, 4
• Gabapentin can be used as an adjunctive agent to manage withdrawal symptoms. 5, 6, 7
• For symptomatic relief: ondansetron or promethazine for nausea/vomiting, loperamide for diarrhea, and benzodiazepines (2 mg IV midazolam) for severe anxiety or muscle cramps in opioid-naive patients. 2
• A non-opioid protocol using scheduled tizanidine, hydroxyzine, and gabapentin has shown 94% completion rates in medically supervised withdrawal settings. 7

Managing Concomitant Benzodiazepine Use

• Do not categorically deny buprenorphine treatment to patients using benzodiazepines or other CNS depressants—the risk of untreated opioid use disorder outweighs the risks of concomitant use. 3
• Cessation of benzodiazepines is preferred in most cases; consider gradual taper or monitoring in a higher level of care. 3
• If a patient is sedated at time of buprenorphine dosing, delay or omit that dose. 3
• Educate patients about the increased risk of respiratory depression, overdose, and death with concomitant use of benzodiazepines, alcohol, or other CNS depressants. 3

Transition to Maintenance Treatment

• After induction, transition to buprenorphine-naloxone combination products (Suboxone) for maintenance treatment to deter diversion and misuse. 3
• Continue maintenance treatment indefinitely—there is no maximum recommended duration, and patients should continue as long as they are benefiting. 3
• Extended-release naltrexone injection can be initiated after successful withdrawal completion, with an 89% success rate when patients choose this option. 7, 8

Critical Pitfalls to Avoid

• Never administer buprenorphine to patients currently on opioids or not yet in withdrawal—this will precipitate severe, prolonged withdrawal due to buprenorphine's high receptor affinity displacing full agonists. 2, 3
• Never combine buprenorphine with opioid antagonists (naloxone, naltrexone) during induction—this precipitates withdrawal. 2
• Do not abruptly discontinue opioids without a tapering protocol—this causes severe withdrawal symptoms requiring hospitalization. 5, 6, 3
• Patients maintained on higher methadone doses (>30 mg) are more susceptible to precipitated withdrawal during buprenorphine induction. 3
• Methadone carries increased risk of opioid toxicity if patients use additional opioids post-discharge due to its long duration of action—this risk does not exist with buprenorphine. 1

Special Populations and Considerations

• For adolescents: Buprenorphine is the only FDA-approved medication for opioid use disorder in this population. 5
• For pregnant patients: Continue opioid addiction treatment throughout pregnancy—the benefits outweigh the risk of neonatal opioid withdrawal syndrome (NOWS), which is treatable. 3
• Anticipate protracted withdrawal symptoms (dysphoria, irritability, insomnia, anhedonia) that may persist for months after acute withdrawal resolves; continue adjunctive medications as needed. 2, 6
• Check baseline liver function tests before initiating buprenorphine, as cases of hepatitis and hepatic events have been reported. 3

Monitoring and Follow-Up

• Short-term inpatient withdrawal without medication-assisted treatment has a 63% relapse rate at one month and 77% at six months—medically supervised withdrawal must be followed by maintenance treatment. 8
• Use validated withdrawal assessment tools (COWS, Sophia Observation Withdrawal Symptoms Scale, Modified Narcotic Abstinence Scale) to monitor symptoms during treatment. 2, 6
• Coordinate with other prescribers to ensure awareness of buprenorphine treatment and minimize polypharmacy risks. 3
• Counsel patients on safe storage to prevent unintentional pediatric exposure, which can cause fatal respiratory depression. 3