F11.2
DESCRIPTION
Opioid withdrawal is generally poorly tolerated, but not dangerous, except in very frail debilitated patients or during pregnancy, with an increased risk of miscarriage in the first trimester and of preterm delivery in the third trimester.
Signs and symptoms of opiate intoxication:
- Pinpoint pupils
- Drowsiness
- Clammy skin
- Euphoria
- Respiratory depression
- Hallucinations
Signs and symptoms of opiate withdrawal:
- Nausea/vomiting
- Myalgia
- Gooseflesh
- Diarrhoea
- Abdominal cramps
- Restlessness / agitation
- Rhinorrhoea and lacrimation
GENERAL MEASURES
- The identification and evidence-based management of opioid dependence among patients who are admitted to hospital will increase their likelihood of completing their primary admission-related treatment. Sub-optimal management of opioid withdrawal will increase the likelihood of absconding from hospital.
- It is extremely important to counsel patients managed for opioid withdrawal upon discharge. Patients’ opioid tolerance will be reduced after the down-tapering of methadone (or similar medication) during hospital stay. Upon discharge, patients should be advised to use opioids with caution due to their increased risk of accidental overdose. Opioid related overdose deaths must be prevented.
- Special considerations apply during pregnancy, consult an expert.
- Concomitant withdrawal from opioids and other “downer” drugs, like benzodiazepines or alcohol may complicate withdrawal, consult an expert.
MEDICINE TREATMENT
Monitor for objective signs of withdrawal using a rating scale like the objective opioid withdrawal scale (OOWS)
https://medicine.yale.edu/sbirt/OOWS_251773_284_5_v1.pdf
Mild withdrawal (OOWS <4)
May be managed on an outpatient basis.
Symptomatic treatment:
- Diazepam, oral, 5–20 mg/day in divided doses.
- Taper off over 5–7 days.
For stomach cramps:
- Hyoscine butylbromide, oral, 20 mg 8 hourly as required.
For headaches:
- Paracetamol, oral, 1 g 4–6 hourly when required.
- Maximum dose: 15 mg/kg/dose.
- Maximum daily dose: 4 g in 24 hours.
For muscle pains:
- NSAID, e.g.:
- Ibuprofen, oral 400 mg 8 hourly, with meals, as required.
For diarrhoea:
- Loperamide, oral, 4 mg immediately.
- Then 2 mg after each loose stool.
- Maximum dose: 16 mg in 24 hours.
Moderate to severe withdrawal (OOWS ≥4)
Hospitalise patient.
Opioid assisted withdrawal
- Goal is to safely alleviate withdrawal symptoms without causing intoxication or overdose.
- Symptomatic medication listed above may be used to reduce methadone need.
Day 1:
- Wait for early evidence of withdrawal (OOWS ≥4)
- Methadone, oral, 5–10 mg.
- If symptoms are still present after 2-4 hour, give another 5–10 mg.
- Repeat until objective withdrawal symptoms are adequately managed (OOWS <4).
- The total 24-hour dose should rarely be more than 30 mg. Consult a person experienced in opioid withdrawal if >30 mg/day is required.
Day 2:
- Methadone, oral.
- Repeat total dose of day 1 as a single or 2 divided doses.
- Monitor for on-going signs and symptoms of withdrawal.
- If the signs and symptoms of withdrawal are still present on day 2, top-up doses of 5 mg may be given at 2–4 hourly intervals with a total daily dose of up to 30 mg. Consult a person experienced in opioid withdrawal if symptoms not controlled on 30 mg/day.
Day 3 onwards:
- Methadone, oral.
- Repeat total dose of day 2 if top-ups were needed and begin reductions on day 4.
- If no top-ups required on day 2 and withdrawal symptoms are adequately controlled, begin dose reduction.
- Decrease dose by 10–20% per day over a period of 3–10 days.
- The withdrawal regimen may be shortened, if the patient’s withdrawal symptoms allow it.
If methadone is unavailable:
- Tramadol, oral, 200 mg 12 hourly for 14 days may attenuate withdrawal symptoms.
Opioid poisoning
See Opioid poisoning.
REFERRAL
- Patients with an opioid use disorder should be offered a referral to access opioid substitution therapy and/or other evidence-based treatment and support.
- Patients identified with current/ recent history of injecting drug use should be provided with sterile injecting equipment (1 ml insulin needles and alcohol swabs) upon discharge from hospital, as well as a referral to a community- based needle and syringe programme.