Opioid withdrawal in adults: Rapid overview of diagnosis and management

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 Society guideline links: Regional poison control centers.

Clinical and laboratory features

Individuals with opioid use and tolerance typically experience withdrawal after administration of an antagonist or within 4 to 48 hours of cessation of opioid use.

Withdrawal from cessation of an opioid agonist is not life-threatening, but withdrawal that is untreated or undertreated places the patient at risk of overdose from self-treating with illicit opioids. Precipitated withdrawal (eg, administration of antagonist) is potentially life threatening.

Common signs and symptoms 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

Opioid withdrawal is a clinical diagnosis in a patient with a history of cessation of opioid use or having received an opioid antagonist or partial agonist (eg, naloxone, buprenorphine).

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.

We typically administer buprenorphine 8 mg SL for acute withdrawal. If symptoms persist 30 to 60 minutes after initial dose, a second and subsequent doses can be given up to 32 mg total in 24 hours, but higher doses are occasionally required.

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.

Clonidine is the first-line non-opioid medication for patients with normal or elevated blood pressure. Administer clonidine 0.1 to 0.3 mg orally every hour (0.8 mg maximum total daily dose) with close monitoring for hypotension.

Other useful medications may include:

For nausea and vomiting, ondansetron 4 mg IV or IM; 8 mg ODT or orally every 4 to 8 hours as needed
For diarrhea, loperamide 4 mg orally or octreotide 50 mcg subcutaneously
For anxiety or dysphoria or muscle cramps, diazepam 5 to 10 mg orally, IV, or IM

In a patient who declines buprenorphine and is not taking methadone, 10 mg intramuscularly or 20 mg orally of methadone is usually sufficient to relieve symptoms of acute withdrawal without producing intoxication.

For precipitated withdrawal (eg, from an opioid antagonist), buprenorphine and/or non-opioid adjunctive medications are reasonable options. The buprenorphine dose should be tailored to the agent and the dose that precipitated the withdrawal.

SL: sublingually; IV: intravenous; IM: intramuscular; ODT: orally disintegrating tablet.

* Additional information about adjunct therapy can be found in the UpToDate topic discussing emergency management of acute opioid withdrawal and the accompanying table listing useful medications.

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Opioid withdrawal in adults: Rapid overview of diagnosis and management