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Fast Fact and Concept #95: Opioid Withdrawal

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Title: Fast Fact and Concept #95: Opioid Withdrawal

Author(s): Deb Gordon; June Dahl

Physical dependence is a normal and predictable neurophysiological response to regular treatment with opioids for more than 1-2 weeks duration i.e. continuous or near continuous opioid blood levels (thus, one Percocet tablet per day will not lead to physical dependence). Physical dependence is characterized by a withdrawal syndrome when the opioid is abruptly discontinued, if an opioid antagonist (naloxone) is given, or when drug blood levels fall below a critical level. Withdrawal can also be caused by administration of a mixed agonist-antagonist (e.g., buprenorphine, butorphanol, nalbuphine, pentazocine).

Important definitions

Tolerance: state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug?s effects over time.

Physical dependence: state of adaption manifested by a drug class specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist.

Addiction / psychological dependence: primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors. Characterized by one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Signs and symptoms of opioid withdrawal syndrome include yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, crampy abdominal pains, diarrhea, and muscle aches and pains. Unlike withdrawal from alcohol or benzodiazepines, opioid withdrawal is not life threatening. Emergence of withdrawal symptoms varies with half-life of the particular opioid; within 6-12 hours after the last dose of morphine/hydromorphone/oxycodone or 72-96 hours following methadone (see Fast Fact #75: Methadone For Pain; Fast Fact #86: Methadone: Starting dose information). Duration and intensity of withdrawal symptoms can be variable and are related to clearance of the drug; withdrawal from morphine is short (5-10 days) but more protracted with methadone.

Prevention The opioid withdrawal syndrome is preventable. Patients treated with opioids of more than one to two weeks should be instructed to gradually reduce the dose of opioid before discontinuing use. Dose reductions of 25% every day or two will generally prevent signs and symptoms of withdrawal. An alternative recommendation is: give half the previous dose for the first 2 days and then reduce the dose by 25% every 2 days. When the dose reaches the equivalent of 30mg /day of PO morphine, this dose is given for 2 days, and then the drug is discontinued.

Treatment If needed, Clonidine (Catapres?) 0.1-0.2mg PO Q 4-6 hours PRN or by transdermal patch (Catapres TTS ® -1-(2.5mg) which provides 0.1mg daily delivery for 7 days) can be used to treat autonomic hyperactivity symptoms (however, it will not relieve insomnia). The major drawback of clonidine therapy is the tendency to cause hypotension.

References:

McCaffery M, Pasero C. Pain: Clinical Manual. 2nd Ed. Mosby, St Louis, 1999. American Academy of Pain Medicine (AAPM), American Pain Society (APS), American Society of Addiction Medicine (ASAM). Definitions Related to the Use of Opioids for the Treatment of Pain. Consensus Statement, 2001. http://www.ampainsoc.org/

Acknowledgement: The Fast Fact is adapted with permission from: Pain Management Fast Facts-??Minute Inservice; University of Wisconsin Pain Team, D Gordon, RN.

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing. Gordon D and Dahl J. Fast Facts and Concepts #95 Opioid Withdrawal August 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

Creation Date: 8/2003

Format: Handouts

Purpose: Instructional Aid, Self-Study Guide, Teaching

Audience(s)
Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Nurses

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Addiction, Chronic non-malignant pain, Controlled substance regulations, Pain, Pain assessment, Pain treatment


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