| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222, or the nearest international regional poison center. Contact information for regional poison centers around the world is available at the website referenced below.[1] |
| Clinical and laboratory features |
| Individuals with opioid dependence typically experience withdrawal after administration of an antagonist or within 4 to 48 hours of cessation of opioid use. |
| Iatrogenic withdrawal (eg, administration of antagonist) is potentially life threatening, while naturally occurring withdrawal is usually not. |
| Common signs of opioid withdrawal include mydriasis, yawning, diaphoresis, increased bowel sounds, and piloerection. Mental status is usually normal. |
| Other signs and symptoms can include dysphoria, restlessness, rhinorrhea, lacrimation, myalgias, arthralgias, nausea, vomiting, abdominal cramping, diarrhea, tachycardia, and hypertension. Patients may describe themselves as sick from not using opioids. |
| Diagnostic evaluation |
| Diagnosis of opioid withdrawal is made by history alone. |
| Laboratory evaluation is helpful only to assess associated conditions (eg, serum electrolyte concentrations in the setting of significant vomiting or diarrhea). |
| Treatment |
| If withdrawal is naturally occurring, the clinician may opt to manage the patient with either opioid or non-opioid adjunctive medication. Whenever possible, we use a single class of medication for treatment of acute withdrawal. Methadone or buprenorphine is a good choice. |
| Methadone 10 mg intramuscularly or 20 mg orally is usually sufficient to relieve symptoms of acute withdrawal without producing intoxication. |
| Buprenorphine 4 to 8 mg sublingually can be given for acute withdrawal. If symptoms persist 30 to 60 minutes after initial dose, a second and subsequent doses can be given up to 24 mg total in 24 hours. |
| Fluid resuscitation is given if needed due to losses. 250 to 500 mL intravenous boluses of isotonic crystalloid may be repeated as needed. |
Adjunctive medications* may include alpha-2 adrenergic agonists, benzodiazepines, antiemetics, and antidiarrheals. Useful medications may include: - For nausea and vomiting, promethazine 25 mg intramuscularly or intravenously
- For diarrhea, loperamide 4 mg orally or octreotide 50 mcg subcutaneously
- For anxiety or dysphoria or muscle cramps, diazepam 1 to 10 mg orally, intravenously, or intramuscularly
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| For iatrogenic withdrawal (due to an opioid antagonist), only adjunctive medications should be used, NOT opioids. |
