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Opioids are a class of analgesics that may cause central nervous system depression, and the potential to cause a euphoric effect. Opioid use disorder (OUD) is characterized by the abuse of prescribed medication and substances containing opioids, or heroin used illicitly. Opioid addiction is a chronic, relapsing illness, associated with significantly increased rates of morbidity and mortality.
Opioid withdrawal occurs when someone who is physiologically dependent upon opioids stops them abruptly. The signs and symptoms of opioid withdrawal include:
Co-occurring conditions in patients with opioid use disorders include major depression, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, and antisocial personality disorder.
Opioids must be consumed daily for three or more weeks for physiologic dependence to develop and require medically supervised withdrawal. In those who are tolerant , shorter periods of relapse will trigger withdrawal after shorter periods of use. Withdrawal will only occur in those who have developed tolerance to the opioid.
The purpose of supervised opioid withdrawal is to safely transition the patient to medication-assisted treatment. Supervised withdrawal alone does not result in sustained abstinence, nor addresses reasons one became dependent on opioids or the damage that the addiction has caused to relationships, employment, finances, and overall health of the patient.
Medications used in the treatment of withdrawal symptoms include opioid agonists such as methadone and buprenorphine (a partial agonist), as well as alpha-2 adrenergic agonists such as clonidine and Lofexidine. Medications are described in four categories:
Once these medications are administered they are slowly tapered overall several weeks.
The treatment of opioid withdrawal at home is warranted. Withdrawal can actually be precipitated by buprenorphine and a full antagonist like naltrexone, and is often more acute and severe than withdrawing spontaneously. Complications can require hospitalization, and even intensive care unit admission.
Although seizures are rare, it and may indicate concurrent withdrawal from alcohol or benzodiazepines. Additionally, severe nausea and vomiting with dehydration will require aggressive intravenous rehydration and correction of electrolyte abnormalities on a medical unit.
Individuals experiencing opioid withdrawal are at risk of suicide that is driven by fear that accompanies opioid withdrawal. They should be assessed for suicidality throughout supervised withdrawal.
Treatment can be provided at several levels of care, including outpatient, intensive outpatient, partial hospital, residential (medically-supervised) programs, or inpatient (medically-managed) services. In general, higher levels of care are provided to patients with more severe conditions, such as co-occurring medical disease or mental disorders.
Higher rates of relapse in the first month following supervised withdrawal are normal if withdrawal is not followed by transition to maintenance treatment. There needs to be collaboration between the patient and their healthcare provider on a treatment plan to maximize the chance of longer-term success.