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.
Other useful medications may include:
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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.