Opioid withdrawal - Revision history

Danbot: Add MedicationDose entries (clonidine, methadone) with SMW annotations

2026-03-20T18:27:58Z

Add MedicationDose entries (clonidine, methadone) with SMW annotations

@@ Línea 97: / Línea 97: @@
 *Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
 *Dose: 10mg IM or 30mg PO
 ==Disposition==

Ostermayer: /* Management */

2024-07-04T09:27:15Z

Management

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	===Opioid replacement===		===Opioid replacement===
	*Opioid administration such as [[morphine]] can be given as needed for symptom control		*Opioid administration such as [[morphine]] can be given as needed for symptom control

			==[[Buprenorphine]]==
			{{Suboxone protocol}}

	===[[Clonidine]]===		===[[Clonidine]]===

Rossdonaldson1: /* Late symptoms */

2023-10-18T17:10:21Z

Late symptoms

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	*[[Vomiting]]		*[[Vomiting]]

	*'''Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''		;Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''
	*'''Altered mental status is also not part of ~~opiod~~ withdrawal signs'''		;Altered mental status is also not part of opioid withdrawal signs'''

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1 at 17:09, 18 October 2023

2023-10-18T17:09:02Z

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	~~{{Adult top}} [[Opioid withdrawal (peds)]]''~~
	==Background==		==Background==
	*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)
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	===Adult Opioid Withdrawal===		===Adult Opioid Withdrawal===
	*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing ~~opiod~~ withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>		[[File:OpioidWithdrawalCourse.jpg\|thumb\|Graph of opoid withdrawal course durcation<ref>Brain Commun. 2019 Oct 16;1(1):fcz025. doi: 10.1093/braincomms/fcz025. eCollection 2019. Dependence, withdrawal and rebound of CNS drugs: an update and regulatory considerations for new drugs development Alicja Lerner 1, Michael Klein 2</ref>]]
			*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing opioid withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>
	*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more		*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more
	*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days		*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
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	*[[Naltrexone]]: 15-30min, duration 12-24hours		*[[Naltrexone]]: 15-30min, duration 12-24hours
	*[[Buprenorphine]]: 10-15min, duration 12-24 hours		*[[Buprenorphine]]: 10-15min, duration 12-24 hours

			===Neonatal Opioid Withdrawal===
			*[[Heroin]]: onset within 24hrs
			*[[Methadone]]: onset within 2-3 days due to large volume of distribution<ref>Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.</ref>
			*[[Buprenorphine]]: onset within 2-3 days

	==Clinical Features==		==Clinical Features==

Rossdonaldson1 at 19:25, 4 October 2023

2023-10-04T19:25:03Z

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	*[[Naltrexone]]: 15-30min, duration 12-24hours		*[[Naltrexone]]: 15-30min, duration 12-24hours
	*[[Buprenorphine]]: 10-15min, duration 12-24 hours		*[[Buprenorphine]]: 10-15min, duration 12-24 hours

	~~===Neonatal Opioid Withdrawal===~~
	*[[Heroin]]: onset within 24hrs
	*[[Methadone]]: onset within 2-3 days due to large volume of distribution<ref>Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.</ref>
	*[[Buprenorphine]]: onset within 2-3 days

	==Clinical Features==		==Clinical Features==

Rossdonaldson1 at 19:19, 4 October 2023

2023-10-04T19:19:40Z

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			{{Adult top}} [[Opioid withdrawal (peds)]]''
	==Background==		==Background==
	*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)

Cmb23: /* Methadone */

2023-09-28T17:04:45Z

Methadone

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	==Management==		==Management==
	''Treatment ~~is largely supportive without the need~~ for ~~any pharmacologic intervention~~ in the ~~ED unless there is serious hemodynamic abnormalities~~''		''Treatment should include symptomatic treatment as well as discussing medications for opioid use disorder including methadone and buprenorphine. Buprenorphine should be offered to be initiated in the emergency department to patients who are interested and meet criteria for initiation, and linkage to care should be facilitated.'' <ref> Hawk K, Hoppe J, Ketcham E, LaPietra A, Moulin A, Nelson L, Schwarz E, Shahid S, Stader D, Wilson MP, D'Onofrio G. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021 Sep;78(3):434-442. doi: 10.1016/j.annemergmed.2021.04.023. Epub 2021 Jun 23. PMID: 34172303. </ref>

	===Supportive Care===		===Supportive Care===
	*PO/IV hydration		*PO/IV hydration
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	===[[Methadone]]===		===[[Methadone]]===
	*Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given		*Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
	*Dose: 10mg IM or ~~20mg~~ PO		*Dose: 10mg IM or 30mg PO

	==Disposition==		==Disposition==

Jscottgeorge: /* Background */

2021-06-14T21:35:32Z

Background

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	*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use		*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use
	*Symptoms are usually uncomfortable but not life-threatening and manifest with agitation and restlessness but '''does not cause altered mental status'''		*Symptoms are usually uncomfortable but not life-threatening and manifest with agitation and restlessness but '''does not cause altered mental status'''
	*Symptoms may resemble ~~that~~ of [[Influenza]] <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref>		*Symptoms may resemble those of [[Influenza]] <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref>
	**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions		**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
	**Withdrawal can be life-threatening in neonates		**Withdrawal can be life-threatening in neonates

Elcatracho: /* Background */

2021-01-15T19:19:18Z

Background

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	==Background==		==Background==
	*Natural derivatives: [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)
	*Synthetic: [[Fentanyl]], [[Hydromorphone]], [[Buprenorphine]], [[Methadone]], [[Meperidine]], [[Dextromethorphan]] (- UDS)		*Synthetic: [[Fentanyl]], [[Hydromorphone]], [[Buprenorphine]], [[Methadone]], [[Meperidine]], [[Dextromethorphan]] (- UDS)
	*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use		*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use

Elcatracho: /* Evaluation */

2021-01-15T19:13:08Z

Evaluation

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	==Evaluation==		==Evaluation==
	*Clinical diagnosis		*Clinical diagnosis
	**Consider [[urine toxicology screen]]		**Consider [[urine toxicology screen]] and BMP if signs of dehydration
	**Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS]) can be used to determine severity		**Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS]) can be used to determine severity