Opioid withdrawal management

Withdrawal syndrome

Symptoms are similar for all opioids, but are of varying severity and duration depending on opioid taken. For example, physical symptoms of heroin withdrawal commence six to 12 hours after last use and last for approximately five days. Symptoms are very unpleasant, but are rarely life-threatening (providing adequate hydration and electrolyte balance is maintained) and include:

• lacrimation, rhinorrhoea and sneezing
• yawning
• hot and cold flushes, sweating and piloerection
• craving
• anxiety, restlessness and irritability
• disturbed sleep
• gastrointestinal tract symptoms (for example anorexia, abdominal pain, nausea, vomiting and diarrhoea)
• muscle, bone and joint aches and pains, headache, muscle cramps
• tremor.

Severity of signs and symptoms may be assessed using validated withdrawal scales such as the Clinical Opiate Withdrawal Scale (COWS) available in Appendix 2 (page 189) of the National Guidelines for Medication-Assisted Treatment of Opioid Dependence.

Predictors of opioid withdrawal

• withdrawal is unlikely if use is intermittent only
• high intake for a longer duration (more than six months) is associated with more severe withdrawal
• short-acting opioids and injected slow release morphine result in more rapid onset and shorter duration withdrawal
• longer-acting opioids (eg methadone, and oral slow release preparations) result in slower onset, but longer-lasting withdrawal.

Medication regimes

Buprenorphine (Suboxone®) is routinely used for opioid withdrawal management. In the outpatient setting, an authority must be obtained from the Drugs of Dependence Unit prior to commencing Suboxone in the community.

Since 4 April 2011, any GP may obtain an authority to prescribe for up to five patients at a time. Inpatients in a public hospital can be prescribed buprenorphine for up to two weeks for opioid withdrawal without an authority.

Suboxone should not be started until there is clear evidence of objective withdrawal (pupil dilation and piloerection are good indicators) and a COWS score of 6 or more to avoid the risk of precipitated withdrawal (see Appendix 2 of the National Guidelines for Medication-Assisted Treatment of Opioid Dependence for information on COWS). Suboxone doses should be administered under the direct supervision of the pharmacist and not given as take home doses.

Buprenorphine / Naloxone (Suboxone®) Prescribing

Outpatient setting - Recommended regimes

The GP can prescribe a fixed daily dose or a flexible dose range (with upper and lower limits on any particular day) and can provide instructions for the pharmacist or withdrawal worker regarding dose titration.

• Day 1 - 4 mg at onset of withdrawal and additional 2 to 4 mg 4 to 6 hours later prn if severe withdrawal
• Day 2 - 4mg mane, additional 2 to 4 evening dose prn
• Day 3 - 4mg mane, additional 2mg evening dose prn
• Day 4 - 2mg mane, additional 2mg evening dose prn
• Day 5 - 2mg mane then cease

It is recommended that buprenorphine is not continued beyond this - please phone the Alcohol and Drug Information Service (ADIS) on 1300 13 1340 and ask to speak to the duty doctor for further advice.

Symptomatic medications that may be helpful include:

• Diazepam 5 to 10mg QID prn for a maximum of seven to 10 days
• Metoclopramide 10 to 20mg TDS prn for nausea
• Simple analgesia (for example paracetamol, NSAIDs)
• Antidiarrhoeal (for example loperamide).

Inpatient and acute hospital setting - Recommended regimes

Inpatient withdrawal is recommended if poly-drug withdrawal is anticipated, the person has social circumstances likely to make cessation of drug use difficult, or has significant physical or psychological co-morbidities (see the information about withdrawal settings on the page called Substance withdrawal management).

Suboxone remains the treatment of choice for opioid withdrawal uncomplicated by the need for acute analgesia, etc.

• Day 1 - 4 mg at onset of withdrawal and additional 2 to 4 mg 4 to 6 hours later prn if severe withdrawal
• Day 2 - 4mg mane, additional 2 to 4 evening dose prn
• Day 3 - 4mg mane, additional 2mg evening dose prn
• Day 4 - 2mg mane, additional 2mg evening dose prn
• Day 5 - 2mg mane then cease

It is recommended that buprenorphine is not continued beyond this - please phone the Drug and Alcohol Clinical Advisory Service on 7087 1742 for further advice.

• Symptomatic medications that may be helpful include:
  • Diazepam 5 to 10mg QID prn for a maximum of seven to 10 days
  • Metoclopramide 10 to 20mg TDS prn for nausea
  • Simple analgesia (for example paracetamol, NSAIDs)
  • Antidiarrhoeal (for example loperamide).
• Clonidine (an alpha-2 adrenergic agonist) may be used in an inpatient setting if Suboxone is inappropriate or unavailable. BP monitoring should be undertaken (pre-dose) and clonidine should be withheld if systolic BP <90mm Hg. Suggested dosing regime:
  • Initial test dose of 50mcg - if systolic BP remains above 90mm Hg, administer a further 50mcg after one hour
  • First day 1.5 mcg per kg QID (for example 70kg patient dose is 100mcg QID)
  • Subsequent days 3 to 4mcg per kg QID (for example 70kg patient dose is 200 to 250mcg QID).

Acute public hospital setting

See SA Health Guideline for the medical management of people at risk of opioid withdrawal for detailed advice.

Further information and advice

Alcohol and Drug Information Service (ADIS) 1300 13 1340
ADIS is a telephone information, counselling, and referral service.

Drug and Alcohol Clinical Advisory Service (DACAS)
DACAS provides a telephone and email service for South Australian health professionals seeking clinical information and clarification around clinical procedures, guidelines and evidence-based practice.

Telephone: (08) 7087 1742 - 24 hours 7 days/week including public holidays or e-mail your enquiry to: HealthDACASEnquiries@sa.gov.au.

This service does not provide proxy medical cover and cannot assume responsibility for direct patient care.