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 |
|
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¶Δ; 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) redosingΔ |
|
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 or for patients ≥90 kg up to 1.2 mg/day); check blood pressure prior to each dose and hold the dose if hypotension is present |
|
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 IV every 5 to 10 minutes until symptoms subside Alternative benzodiazepines if diazepam not available:
Hold doses if patient does not remain hemodynamically stable |
|
Ondansetron | 4 to 8 mg IV or IM; 8 mg ODT or orally; every 4 to 8 hours as needed |
|
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 |
|
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 |
|
Ibuprofen | 600 mg orally every 6 to 8 hours as needed; maximum 2400 mg/24 hours | |
Baclofen | 5 to 10 mg orally up to three times per day |
|
COWS: Clinical Opiate Withdrawal Scale; ECG: electrocardiogram; IM: intramuscular; IV: intravenous; ODT: orally disintegrating tablet; SL: sublingual; SUBQ: subcutaneous.
* 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.
¶ Generally administered as a sublingual film or tablet containing buprenorphine 8 mg and naloxone 2 mg. The naloxone component has no clinically significant effect when administered sublingually. It is included to deter misuse (eg, IV injection or intranasal use) of buprenorphine. Sublingual film strengths include buprenorphine-naloxone 2 mg/0.5 mg, 4 mg/1 mg, 8 mg/2 mg, and 12 mg/3 mg. Sublingual film may be split in half if needed to deliver the appropriate dose.
Δ Buprenorphine buccal film has greater bioavailability compared with sublingual tablets and film (ie, buprenorphine-naloxone). 450 mcg buccal buprenorphine ≈ 1 mg SL buprenorphine.