FEDERATION OF TEXAS PSYCHIATRY

   A United Voice for Texas Psychiatry

The Federation of Texas Psychiatry unites Texas' professional psychiatric organizations. Voting member organizations - the Texas Society of Psychiatric Physicians, the Texas Academy of Psychiatry, and the Texas Society of Child and Adolescent Psychiatry. Associate member organizations - the Texas Foundation for Psychiatric Education and Research, the Texas Osteopathic Medical Association and the Texas Medical Association - together represent about 45,000 physicians in Texas united in advocacy for patients and quality psychiatric care.


 

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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.

 

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Last modified: 02/12/14