Opioid withdrawal in adolescents: Rapid overview of diagnosis and management

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.

Signs and symptoms of opioid withdrawal include:

• Mydriasis, yawning, diaphoresis, piloerection (goosebumps)
• Rhinorrhea, lacrimation
• Myalgias, arthralgias
• Nausea, vomiting, abdominal cramping, increased bowel sounds
• Dysphoria, restlessness (mental status is usually normal)
• Tachycardia and hypertension can be present but not as severe as in ethanol or sedative-hypnotic withdrawal
• Patients may describe themselves as sick from not using opioids

Withdrawal from cessation of an opioid agonist is not life-threatening, while precipitated withdrawal (eg, administration of antagonist) can produce sudden surges in catecholamines and hemodynamic instability.

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).

Use COWS to determine severity of withdrawal, to guide therapy, and to assess response to therapy.

If withdrawal is occurring from cessation of opioid use and the adolescent has COWS score >5, we suggest buprenorphine and non-opioid adjunctive medications (if needed):

• Start buprenorphine 2 mg (ie, 2 mg/0.5 mg of buprenorphine-naloxone) SL (we generally start buprenorphine after the appropriate amount of time following the most recent opioid exposure has passed^*).
• If withdrawal persists 30 to 60 minutes later and lack of sedation, can give additional 2 to 4 mg dose SL.
• For continued withdrawal, can give additional 2 to 4 mg SL every 1 to 2 hours up to 16 mg total in 24 hours, however some patients may require up to 24 mg.
• If COWS score increases, stop induction, treat symptoms with non-opioid adjunctive medications, and reassess in 24 hours. Increasing COWS score may suggest buprenorphine-precipitated withdrawal.

If withdrawal is occurring from cessation of opioid use and the adolescent has mild withdrawal (COWS score 5 to 12) or has had recent opioid exposure, a reasonable option is non-opioid adjunctive medications (eg, clonidine). If the adjunctive medications do not adequately control withdrawal symptoms or mild withdrawal becomes moderate to severe (COWS score increases to >12), we then start buprenorphine.

An adolescent who declines buprenorphine (eg, wants to use naltrexone for long-term management of OUD) or is not a candidate for buprenorphine (eg, co-occurring severe alcohol or sedative use disorder) should be treated with non-opioid adjunctive medications.

For precipitated withdrawal (due to an opioid antagonist), buprenorphine and/or non-opioid adjunctive medications are reasonable options, although experience with buprenorphine to treat precipitated withdrawal in adolescents is limited.

• Clonidine is the first-line non-opioid medication for patients with normal or elevated blood pressure. Administer clonidine 0.1 mg (0.05 mg in younger adolescents) orally every 6 to 8 hours with close monitoring for hypotension.
• For nausea and vomiting, can give ondansetron 4 to 8 mg IV/IM/orally every 4 to 8 hours as needed.
• For diarrhea, can give loperamide 4 mg orally followed by 2 mg every loose stool, maximum 8 mg/24 hours.
• For pain and myalgias, can give acetaminophen 10 to 15 mg/kg orally every 4 to 6 hours as needed; maximum daily dose 75 mg/kg/24 hours, not to exceed 4000 mg/24 hours.