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
- Clinical Opiate Withdrawal Scale (COWS)
- Objective Opioid Withdrawal Scale (OOWS)
- Subjective Opioid Withdrawal Scale (SOWS)
Screen for Substance Use Disorders (SUD)
Screening, Brief Intervention, and Referral to Treatment (SBIRT) 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:
- 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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