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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).

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.

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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:

  • 3 Day Rule Exit Disclaimer: You Are Leaving www.ihs.gov ” – allows prescriber to administer buprenorphine (not prescribe) for acute withdrawal symptoms
  • 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

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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

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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.

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