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PRACTICE GUIDELINES
OFFICE-BASED OUTPATIENT WITHDRAWAL TECHNIQUES:
A GUIDE - OPIATES
The TSPP Executive Council approved the Guideline during its
meeting on November 16, 2002. The Guideline was tentatively approved on April
21, 2002 by the Executive Council. The Guideline was published in the April/May
2002 TSPP Newsletter for review and comment by TSPP members.
Withdrawal from Opiates
The duration of withdrawal will depend on the half-life of the opiate: symptoms
will appear 4-12 hours after last dose.
Peak Withdrawal Symptoms/Most Symptoms Over:
Meperidine (Demerol): 8-12 hours/4-5 days
Heroin: 36-72 hours/7-10 days
Hydromorphone (Dilaudid): 36-72 hours/7-10 days
Codeine: 36-72 hours/7-10 days
Hydrocodone (Vicoden): 36-72 hours/7-10 days
Oxycodone (Oxycontin): 36-72 hours/7-10 days
Signs and Symptoms of Opiate Withdrawal
Early Symptoms
Anorexia
Anxiety
Craving
Dysphoria
Fatigue
Headache
Increased respiratory rate
Irritability
Lacrimation
Mydriasis (mild)
Perspiration
Piloerection (goose flesh)
Restlessness
Rhinorrhea
Yawning
Later Symptoms
Abdominal cramps
Broken sleep
Hot or cold flashes
Increased blood pressure
Increased pulse
Low-grade fever
Muscle and bone pain
Muscle spasm (hence the term kicking the habit)
Mydriasis (with dilated fixed pupils at the peak)
Nausea and vomiting
Clonidine-Aided Detoxification
1. Oral
Day 1: 0.1-0.2 mg orally every 4 hours up to 1 mg
Day 2-4: 0.1-0.2 mg orally every 4 hours up to 1.2 mg
Day 5 to completion: Reduce 0.2 mg/day; given in divided doses; the night-time
dose
should be reduced last; or reduce total dosage by one-half each day not to
exceed 0.4 mg/day
2. Patch
The clonidine patch comes in three strengths (#1, #2, #3) and delivers over one
week the equivalent of a daily dose of oral clonidine (e.g., #2 patch = 0.2 mg
oral clonidine, daily, etc.).
One technique is to apply one #2 patch for patients under 100 lbs, two #2
patches if they weigh 100-200 lbs and three #2 patches for those over 200 lbs.
Also, on day one (the day the patch is applied) oral clonidine may be necessary-
0.2 mg q 6hours for 24 hours, then 0.1 mg q 6 hours for the second 24 hours.
The patches should be removed if systolic pressure falls below 80 mm hg or
diastolic below 50 mg hg.
Advantages of patch:
• Patients don't have to take pills several times a day
• Even blood levels of medication
• Buildup of withdrawal symptoms during night is prevented
Blood pressure monitoring is important as hypotension can occur especially in
thin patients. Advise patient to take blood pressure before and 20 minutes after
a dose of Clonidine. If “lightheaded” or dizzy, patient should lie down.
Adequate fluid intake is important. Contact physician if dizziness continues.
Useful Medications for Symptom Control During Opiate Withdrawal
Provide medications the patient is allowed some control over:
Lomotil, 2 tablets qid, prn diarrhea
Kaopectate 30 cc prn after a loose stool
Pro- Banthine, 15 mg or Bentyl 20 mg q 4h prn abdominal cramps
Tylenol, 650 mg q 4h prn for headache
Feldene, 20 mg daily or Naprosyn, 375 mg q 8h for back, joint, and bone pain
Mylanta, 30 ml q 2h prn for indigestion
Phenergan suppositories, 25 or 50 mg, prn nausea
Atarax, 25 mg q 4h prn nausea
Librium, 25 mg q 4h prn for anxiety
Benadryl, 50 mg or temazepam 30 mg hs prn sleep
Doxepin 10 to 20 mg , po, hs, for insomnia, anxiety, dysphoria
A patient has a right to be informed that alternative treatments to the
withdrawal procedure described above are methadone maintenance or outpatient
withdrawal using methadone. These procedures can be carried out in licensed
Texas Department of Health approved opioid agonist treatment programs.
Reference:
Kleber HS Opioids: Detoxification. In Galanter M and Kleber HD. Textbook of
substance abuse treatment, 2nd edition, The American Psychiatric Press
Washington, DC 1999, pp 251-269. |
FEDERATION
OF TEXAS PSYCHIATRY