What are the symptoms and treatment options for an adult patient with a history of opioid use disorder experiencing narcotic withdrawal?

Opioid Withdrawal: Symptoms and Management

Clinical Presentation of Opioid Withdrawal

Opioid withdrawal produces a constellation of distressing but rarely life-threatening symptoms that typically begin 6-24 hours after last use, with timing dependent on the specific opioid's half-life. 1

Core Withdrawal Symptoms

The characteristic symptoms of opioid withdrawal include: 2

• Autonomic symptoms: Sweating, piloerection (goosebumps), mydriasis (dilated pupils), lacrimation (tearing), rhinorrhea (runny nose), tachycardia, hypertension, fever, tachypnea
• Gastrointestinal symptoms: Nausea, vomiting, diarrhea, abdominal cramping
• Musculoskeletal symptoms: Myalgias (muscle aches), arthralgias (joint pain), back pain
• Psychological symptoms: Anxiety, irritability, restlessness, dysphoria, feelings of hopelessness, drug cravings
• Other symptoms: Insomnia, yawning, increased sensitivity to pain 2

Timing of Withdrawal Onset

The onset varies significantly based on the opioid used: 2, 1

• Short-acting opioids (heroin, morphine IR, oxycodone IR): Symptoms begin >12 hours after last use
• Extended-release formulations (OxyContin): Symptoms begin >24 hours after last use
• Methadone maintenance: Symptoms begin >72 hours after last use (up to 30 hours for methadone's long half-life) 2, 1

Assessment of Withdrawal Severity

Use the Clinical Opiate Withdrawal Scale (COWS) to objectively quantify withdrawal severity and guide treatment decisions. 2, 1

The COWS assesses 11 clinical signs including pulse rate, sweating, restlessness, pupil size, bone/joint aches, runny nose/tearing, GI upset, tremor, yawning, anxiety, and piloerection: 3

• COWS <8: Mild or less withdrawal - no buprenorphine indicated
• COWS >8: Moderate to severe withdrawal - buprenorphine 4-8 mg SL indicated 2

Evidence-Based Treatment Approach

First-Line Treatment: Buprenorphine

Buprenorphine is the preferred first-line treatment for opioid withdrawal, demonstrating clear superiority over all alternatives with an 85% probability of being most effective. 1, 3

Critical Safety Requirements Before Administration

Buprenorphine must only be given to patients in active withdrawal to avoid precipitating severe withdrawal due to its high receptor binding affinity and partial agonist properties: 2

• Confirm adequate time since last opioid use (see timing above)
• Verify COWS score >8 before first dose
• Special caution for methadone patients: Wait minimum 72 hours and consider continuing methadone instead, as precipitated withdrawal from methadone is particularly severe and prolonged 2, 3

Buprenorphine Dosing Protocol

Initial dosing: 2, 3

• Give 4-8 mg sublingual based on withdrawal severity (COWS score)
• Reassess after 30-60 minutes
• Additional 2-4 mg doses can be given at 2-hour intervals if withdrawal persists
• Target Day 1 total: 8 mg (range 4-8 mg)
• Day 2 and maintenance: 16 mg daily (range 4-24 mg, though 16 mg is standard for most patients)

Discharge planning: 2, 3

• Prescribe buprenorphine/naloxone 16 mg sublingual daily for 3-7 days or until follow-up appointment
• Note: As of 2023, the X-waiver requirement has been eliminated, expanding prescribing access 3
• Non-waivered providers can administer (but not prescribe) buprenorphine for up to 72 hours while arranging referral 2, 3

Management of Precipitated Withdrawal

If buprenorphine precipitates withdrawal, give more buprenorphine as the primary treatment, as it can overcome precipitated withdrawal with sufficient dosing: 2, 3

Adjunctive symptomatic management includes:

• Clonidine or lofexidine for autonomic symptoms
• Antiemetics (promethazine, ondansetron) for nausea/vomiting
• Benzodiazepines for anxiety and muscle cramps
• Loperamide for diarrhea 3

Alternative Treatment: Methadone

Methadone has similar effectiveness to buprenorphine for withdrawal management but is less commonly used in emergency settings due to regulatory restrictions and its long duration of action. 2, 3

Key considerations: 2, 4

• Particularly appropriate for patients already on methadone maintenance
• Risk of opioid toxicity if patient uses additional opioids after discharge due to methadone's long half-life
• Requires specialized program enrollment for ongoing treatment

Symptomatic Treatment Options

When buprenorphine or methadone are contraindicated or unavailable, alpha-2 adrenergic agonists provide symptomatic relief: 2, 3

• Clonidine or lofexidine: Treat autonomic symptoms (tachycardia, hypertension, sweating)
• Antiemetics: Promethazine or ondansetron for nausea/vomiting
• Benzodiazepines: For anxiety and muscle cramps
• Loperamide: For diarrhea
• NSAIDs: For myalgias and arthralgias 2

Critical Harm Reduction Measures

At discharge, provide comprehensive harm reduction interventions: 2, 1

• Overdose prevention education and take-home naloxone kit
• Hepatitis C and HIV screening
• Reproductive health counseling
• Emphasize that relapse risk is dramatically increased after detoxification due to loss of tolerance 3

Common Pitfalls to Avoid

Never administer buprenorphine to patients not in active withdrawal - this will precipitate severe withdrawal symptoms that can be more distressing than natural withdrawal: 2

Do not discontinue buprenorphine once started - discontinuation precipitates withdrawal and dramatically increases relapse risk to more dangerous opioids: 3

Do not confuse anxiety from life stressors with withdrawal symptoms - methadone at maintenance doses does not act as a tranquilizer, and increasing the dose will not relieve general anxiety: 4

Avoid using dopamine agonists like ropinirole - these are not evidence-based treatments for opioid withdrawal and have significant adverse effects: 3

Duration of Treatment Considerations

There is no maximum recommended duration of maintenance treatment with buprenorphine - patients may require treatment indefinitely, and buprenorphine should not be tapered to comply with opioid dose guidelines due to its ceiling effect on respiratory depression: 3