Medications for management of acute opioid withdrawal in adults in the emergency setting

Medication	Initial dose (adult)	Indication
Opioid
Methadone	10 mg IM or 20 mg orally (for patient not currently taking methadone) May give an additional half-dose if significant withdrawal symptoms persist 1 hour after IM dose or 2 hours after oral dose; maximum in first 24 hours: 20 mg IM or 40 mg orally	Acute opioid withdrawal.* Not recommended for management of acute withdrawal triggered by an opioid antagonist (naloxone, naltrexone, nalmefene). May prolong QTc interval; refer to clinical topic for ECG screening indications.
Buprenorphine	Standard initiation (NOTE: Before beginning this regimen, patient needs to have entered mild-moderate withdrawal generally with COWS score >8): starting dose is typically 8 mg sublingually^¶; if withdrawal persists 30 to 60 minutes later, can give additional 8 mg doses every 1 or more hours, up to 32 mg total in 24 hours, but higher doses are occasionally required or 0.3 to 0.9 mg IV every 6 to 12 hours Alternative low-dose initiation "microdosing" (NOTE: Can begin without waiting for onset of withdrawal signs): 0.5 to 2 mg SL with frequent (eg, every 1 to 2 hours) redosing^¶	Acute opioid withdrawal.* Alternative low-dose initiation may be preferred for treating individuals who are not yet having signs of withdrawal, with high levels of opioid dependence, cannot abstain from opioid use long enough to tolerate a standard induction, or when transitioning from methadone to buprenorphine. If used to manage acute withdrawal triggered by an opioid antagonist (naloxone, naltrexone, nalmefene), the buprenorphine dose should be tailored to the agent and the dose that precipitated the withdrawal.
Non-opioid adjunctive medications*
Clonidine	0.1 to 0.3 mg orally every hour with monitoring of blood pressure and heart rate (0.8 mg maximum total daily dose); check blood pressure prior to each dose and hold the dose if hypotension is present	Anxiety, restlessness, dysphoria with elevated or normal blood pressure and heart rate.
Lofexidine	0.54 mg orally every 5 to 6 hours as needed; maximum 2.88 mg/24 hours
Diazepam	5 to 10 mg orally or IV; may repeat after 5 to 10 minutes until symptoms subside Alternative benzodiazepines if diazepam not available: Lorazepam 1 to 2 mg IV may be given every 10 minutes until symptoms subside Midazolam 2 mg IV may be given every 5 to 10 minutes until symptoms subside Hold doses if patient does not remain hemodynamically stable	Hypertension and tachycardia precipitated by long-acting antagonist (eg, naltrexone, nalmefene). Anxiety, restlessness, dysphoria, insomnia, muscle cramping.
Ondansetron	4 to 8 mg IV or IM; 8 mg ODT or orally; every 4 to 8 hours as needed	Nausea, vomiting.
Diphenhydramine	50 mg IV, IM, or orally every 6 hours as needed
Hydroxyzine	50 to 100 mg IM or orally every 6 hours as needed
Loperamide	4 mg orally, followed by 2 mg every loose stool; maximum: 16 mg/24 hours	Diarrhea, stomach cramps.
Octreotide	50 micrograms SUBQ every 6 hours as needed
Bismuth subsalicylate	524 mg orally every 30 to 60 minutes as needed; maximum 4200 mg/24 hours
Acetaminophen	650 to 1000 mg orally every 4 to 6 hours as needed; maximum 4000 mg/24 hours	Pain, myalgia.
Ibuprofen	600 mg orally every 6 to 8 hours as needed; maximum 2400 mg/24 hours	Pain, myalgia.
Baclofen	5 to 10 mg orally up to three times per day	Muscle cramping.

For additional information on managing symptoms of withdrawal in patients cared for in a non-emergency setting, refer to the UpToDate topics discussing treatment of opioid use disorder. The approach to treatment of iatrogenic withdrawal (eg, weaning from prolonged opioid infusions) is reviewed separately; refer to UpToDate topic reviews of opioid withdrawal in critically ill patients.

IM: intramuscular; ECG: electrocardiogram; COWS: Clinical Opiate Withdrawal Scale; IV: intravenous; SUBQ: subcutaneous; SL: sublingual; ODT: orally disintegrating tablet.

* Opioids are generally more effective than non-opioid adjunctive medications and should be offered to patients with opioid withdrawal. Refer to UpToDate topics on opioid withdrawal in adults.

¶ Buprenorphine buccal film has greater bioavailability compared with sublingual tablets and film. 450 mcg buccal buprenorphine ≈ 1 mg SL buprenorphine.

Graphic 54978 Version 17.0

خرید پکیج

Medications for management of acute opioid withdrawal in adults in the emergency setting