Opioid Withdrawal Support

Withdrawal Symptoms

Opioid withdrawal may cause a patient great discomfort and dysphoria and generally will lead the patient to continued use of opioids. Opioid withdrawal symptoms are not typically considered a medical emergency unless withdrawal is precipitated by naloxone administered in the event of an opioid overdose.

Patients may refer to their withdrawal symptoms as flu-like. Common withdrawal symptoms include:

• Restlessness, Irritability, Anxiety, Insomnia, Yawning, Nausea, Vomiting, Diarrhea, Dilated pupils, Sweating, Piloerection

The timeline of symptoms can vary depending upon the particular opioid(s) the patient has ingested.

• Short acting opioids (e.g. oxycodone/acetaminophen): symptoms usually begin within 6-12 hours of the last dose
• Long acting opioids (e.g. methadone, extended-release morphine): symptoms may not begin for up to 30 hours after the last dose
• Peak withdrawal symptoms are usually seen around 72 hours.

Assessment

Withdrawal symptoms can be assessed through a variety of scales but most commonly, providers use Clinical Opioid Withdrawal Scale (COWS), Objective Opioid Withdrawal Scale (OOWS), or Subjective Opioid Withdrawal Scale (SOWS).

• ASAM National Practice Guidelines Exit Disclaimer: You Are Leaving www.ihs.gov 
• Clinical Opiate Withdrawal Scale (COWS) Exit Disclaimer: You Are Leaving www.ihs.gov 
• Objective Opioid Withdrawal Scale (OOWS) Exit Disclaimer: You Are Leaving www.ihs.gov 
• Subjective Opioid Withdrawal Scale (SOWS) Exit Disclaimer: You Are Leaving www.ihs.gov 

Screen for Substance Use Disorders (SUD)

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Exit Disclaimer: You Are Leaving www.ihs.gov  is an evidence based approach that can be applied in a variety of clinical practice settings to quickly identify patients who suffer from and/or who are at risk for developing substance use disorders and promote engagement in treatment.

• Screening quickly assesses the degree of substance use.
• A brief intervention creates awareness of the substance use and motivates the patient toward a change in behavior.
• Referral to treatment connects the patient with specialty care

Opioid Use Disorder (OUD)

Opioid use disorder (OUD) is defined by ASAM as a primary, chronic disease of brain reward, motivation, memory, and related circuitry with a dysfunction in these circuits being reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Resources:

• DSM-5 Criteria for Opioid Use Disorder Exit Disclaimer: You Are Leaving www.ihs.gov 
• IHS Pain and Opioid Use Disorder Exit Disclaimer: You Are Leaving www.ihs.gov page

Clinical Considerations

Medication Assisted Treatment (MAT)

A patient experiencing opioid withdrawal may be a candidate for induction of MAT at the visit at which they present. MAT should be initiated when the patient is in mild-moderate opioid withdrawal to prevent precipitated withdrawal.

Outpatient Setting

Buprenorphine can be prescribed WITHOUT A DATA WAIVER by an authorized prescriber who can prescribe controlled substances under the following circumstances:

• Not more than one day’s medication may be administered or given to a patient at one time
• Treatment may not be carried out for more than 72 hours The 72-hour period cannot be renewed or extended

Inpatient Setting

Buprenorphine and Methadone can be prescribed by an authorized prescriber who can prescribe controlled substances WITHOUT A DATA WAIVER under the following circumstances:

• Patient with opioid dependency who is admitted for a non-opioid dependency purpose, for the purpose of preventing opioid withdrawal

Resources:

• TIP 63 from SAMHSA Exit Disclaimer: You Are Leaving www.ihs.gov 
• ASAM National Practice Guidelines Exit Disclaimer: You Are Leaving www.ihs.gov 
• IHS Medication Assisted Recovery Exit Disclaimer: You Are Leaving www.ihs.gov 

Non-Opioid Pharmacologic Support

Treatment of opioid withdrawal symptoms is typically directed at the particular withdrawal symptoms experienced by a given patient. A number of non-opioid treatment options are available and may include:

• NSAIDs (for aches and pains)
• Anti-emetics (for nausea and vomiting)
• Alpha 2 agonists (for psychomotor agitation)
• Anti-diarrheal agents
• Anti-anxiety agents

Resources:

• ASAM National Practice Guidelines Exit Disclaimer: You Are Leaving www.ihs.gov 

Naloxone

Naloxone is an opioid antagonist. It is used to rapidly reverse a known or suspected opioid overdose.

Patients presenting in opioid withdrawal are likely to be at increased risk for opioid overdose. Providing these patients with naloxone is highly recommended.

Resources:

• NIDA Naloxone Factsheet Exit Disclaimer: You Are Leaving www.ihs.gov 
• IHS Naloxone