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The Management of Opiod Withdrawal

Opioids are a class of drug that includes prescription medications such as Oxycontin (oxycodone), Vicodin (hydrocodone and acetaminophen), Dilaudid (hydromorphone) and morphine. Opioids also include opiates, such as heroin, opium and codeine.

According to NICE (the National Institute for Health and Care Excellence), 150,000 people are in treatment for opioid misuse in the UK. [1] Prescriptions for opioids have also doubled in the period from 1998 to 2018. [2]

Opioids occupy an unusual position, in that they include both illegal drugs, such as heroin, and legal ones, such as the prescription opioids listed above. The legality of some opioids means that they may be easier to access than other illegal drugs.

Opioids are highly addictive and cause withdrawal symptoms when the user stops taking them.

What is opioid withdrawal syndrome?

Opioid withdrawal syndrome occurs when someone stops taking opioids. This causes physical withdrawal symptoms. These symptoms can be severe, or moderate, depending on various factors.

Factors that determine the severity of withdrawal include the length of time the person has been using opioids, the number of opioids they take on a regular basis, their general health, and psychological factors such as neuroticism and anxiety. [3]

Withdrawal symptoms occur because your body gets accustomed to a supply of opioids. When the access to opioids is cut off, it takes time for it to adapt.

There are different levels of opioid withdrawal, ranging from mild to severe. They can be measured using scales such as the ‘Subjective Opioid Withdrawal Scale’ (SOWS), which allocates a score from 0-4 (where ‘0’ equates to ‘not at all’ and ‘4’ to ‘extremely) to various questions such as ‘I feel anxious’, ‘I am perspiring’ and so on. According to SOWS, a score of 1 to 10 qualifies as mild withdrawal, 11 to 20 moderate withdrawal, and 21 to 30 severe withdrawal. [4]

Effect of opioids on the body

The body actually produces its own opioids. These opioids attach to opioid receptors in the gastrointestinal tract, the spinal cord and the brain. This produces a range of effects. It causes a reduction in pain, which is why opioids are used as pain medication. It also causes breathing to slow down, and it lowers anxiety levels.

You might wonder why people take opioids if the body produces its own supply. The answer is that it does not produce anywhere near enough to give you a ‘high’: just enough to adjust to certain states, such as pain or hyperventilation. When people take opioids, they take them in much larger amounts than the body produces. This leads to several things:

• A reduction in pain, caused by opioids affecting the spinal cord, which is responsible for sending messages around the body.
• Pleasure, caused by activity in the limbic system of the brain.
• Slower breathing, also caused by the activity of opioids in the brain.

General principles for managing withdrawal

Before we get into the specific management of opioid withdrawal, it may be helpful to talk about a few general principles.

Patients in withdrawal need round-the-clock medical care. Withdrawal can be dangerous, especially rapid withdrawal, and doctors and nurses need to be on hand in case something goes wrong.

Those in withdrawal need a calm and quiet environment. They may wish to sleep, do mild activities such as walking or meditate. They should not be made to exercise, as this could exacerbate any withdrawal symptoms and put them in danger.

Those in withdrawal need reassurance from medical staff, as they may be feeling anxious or depressed. This is not the same as therapy. Withdrawal is not the time for therapy, and forcing therapy on someone with withdrawal symptoms is not a good idea. People need to be in the right place mentally in order to commence therapy. Only once the withdrawal has been completed can therapy begin.

Some service users may become agitated or difficult to manage during withdrawal. This is natural and is a response to what they are going through. You can use behaviour management strategies for dealing with difficult behaviour. [5]

What are opioid withdrawal symptoms and how long do they take to set in?

It is important to note that opioid withdrawal symptoms are not generally life-threatening. They can be unpleasant, but generally, they resemble the symptoms of the flu.

However, as mentioned above, they can be more or less severe depending on the length of time during which the person has been using opioids and the severity of their usage.

Withdrawal symptoms set in within a few hours from the point at which someone stops using heroin. Other opioids take a little longer for the withdrawal symptoms to set in.

According to Noeline Latt, heroin withdrawal happens between four and six hours after the substance user stops using heroin. The peak effect occurs around 18 to 72 hours after cessation, and the duration is between 5 and 10 days.

For methadone, Latt estimates that withdrawal sets in after 24 to 48 hours. The peak effect is at around 3 to 4 days, and the duration can be between 2 and several weeks.

Finally, for buprenorphine, the onset is between 2 and 3 days, the peak effect is at 5 days, and the duration is several weeks. Buprenorphine is often used as a substitute for other opioids to ease withdrawal, as the withdrawal phase is longer and more manageable than e.g. heroin withdrawal.

Symptoms of opioid withdrawal include a flu-like illness with nausea, vomiting, rhinorrhoea, aches and pains. There may also be insomnia and strong cravings for opioids.

A full list of signs and symptoms is included below.

Physical symptoms:

• Hot and cold flushes
• Abdominal cramps
• Nausea
• Diarrhoea
• Vomiting
• Piloerection ‘cold turkey’
• Rhinorrhoea
• Lacrimation
• Sweating
• Aches and cramps in bones and muscles

Neuropsychiatric symptoms:

• Cravings
• Depression
• Restlessness and agitation
• Insomnia

Physical signs of withdrawal:

• Dilated pupils
• Restlessness
• Tachycardia, hypertension
• Piloerection
• Sweating
• Needle track marks
• Low-grade fever
• Yawning [6]

Treatments for opioid withdrawal

Someone with opioid withdrawal will not normally need to go to the hospital unless they have a co-occurring illness or are dependent on alcohol or benzodiazepine. Pregnancy and severe vomiting would also indicate that the person in withdrawal may need hospitalisation.

Opioid users are not obliged to go through withdrawal from opioids; they can go straight to opioid maintenance treatment. However, many opioid users choose to go through withdrawal. Those that do have three main options, as outlined in Latt’s Addiction Medicine.

The ‘simplest and most effective’ of these three options is buprenorphine treatment [7]. Whereas in previous years, methadone has been the treatment of choice for heroin users coming off the drug, buprenorphine is now the most popular opioid used for this purpose. It brings a quicker and safer relief from withdrawal than methadone because the dose can be increased rapidly if needed. In general, buprenorphine has a higher success rate than symptomatic treatment and going ‘cold turkey’.

There are some cases in which buprenorphine might not be the ideal solution. As Latt points out, general practitioners in Australia need to be licensed to prescribe opioids for addiction, which adds a layer of difficulty. In other cases, such as when the opioid user has a lot of pain, methadone might be preferred to buprenorphine due to its greater pain alleviation.

Rapid detoxification with naltrexone is also a popular option in many countries. This service is mainly offered in the private sector.

No matter what form of detox service users opt for, they need to be provided with rest, good nutrition and hydration, and reassurance.

We will now take a closer look at the three main options for opioid withdrawal, as outlined above: opioid replacement therapy using buprenorphine/methadone, symptomatic treatment, and rapid detox using naltrexone.

Tapering opioid replacement therapy

In tapering opioid replacement therapy, buprenorphine and methadone are used as a replacement for more dangerous opioids. Buprenorphine and methadone cause less severe withdrawal symptoms than opioids like heroin and opium. The dosage of buprenorphine and methadone can be gradually decreased in order to wean the service user off opioids safely.

There are some risks with buprenorphine. If it is given to the service user too early after the last dose of opioids, it may precipitate opioid withdrawals. According to Latt, it is important to wait ‘for at least 8 hours after the last dose of heroin, and 24 hours after the last low dose of methadone.’ [8] There is also a greater risk of precipitating withdrawal symptoms when higher doses of buprenorphine are administered.

It is also worth pointing out that, while there are obvious benefits to detoxing from opioids, longer-term opioid maintenance is better for preventing relapses. Furthermore, there is an elevated risk of overdose when detoxing, since a quick detox followed by a relapse can quite easily lead to overdose. The risk is not as great in an inpatient setting, where patients can be monitored. However, it should still be taken into account when service users are deciding what option to go for.

Symptomatic treatment

Some may decide to go through withdrawal without recourse to opioid replacement. In this case, there will be withdrawal symptoms to manage. There are several good medications for the treatment of opioid withdrawal symptoms. They include:

• This is used to treat insomnia and restlessness. It should be administered nightly and reduced slowly over the course of 2 to 3 days.
• Hyoscine butylbromide. This medication is used for treating abdominal cramps. It can be administered every 6 hours.
• This is to help with defecation. Atropine sulphate can be used if the service user experiences diarrhoea.
• Administered 3 to 4 times a day, this reduces withdrawal symptoms. Both clonidine and lofexidine (which is used for the same purpose) lower blood pressure, so care should be taken when administering these medications.

Rapid detox induced by naltrexone

Naltrexone is used in a variety of treatment contexts. It is an opioid antagonist, which means that it blocks opioid receptors. When administered soon after the most recent dose of heroin or another opioid, it causes rapid withdrawal. To make detox even quicker, some service users have been put under light sedation (rapid detox) or even general anaesthesia (Ultra Rapid Opiate Detox). Medications such as anti-emetics and clonidine are then used to control withdrawal symptoms.

Rapid detox (especially Ultra Rapid Opiate Detox) is relatively unstudied and could be risky. Naltrexone induced withdrawal can cause various adverse effects, such as nausea, vomiting, depression and confusion. Prolonged anaesthesia carries its own risks. For these reasons, rapid detox using naltrexone is rarely performed outside of private clinics and controlled studies.

In a sense, the manner in which patients go through withdrawal is less important than what comes after: preventing relapses. This is where the majority of service users struggle, and where therapy and counselling come into their own.

Complications of opioid withdrawal

Complications may result if symptoms of opioid withdrawal are left untreated. For example, vomiting is a common symptom of withdrawal. If any vomitus is breathed into the lungs, through aspiration, this can lead to aspiration pneumonia. Aspiration pneumonia is a lung infection and can lead to a lung abscess if untreated. However, with the help of medical staff, all of this can easily be avoided. Service users should be monitored throughout withdrawal to prevent complications like this.

Another complication results from diarrhoea. If someone loses a lot of electrolytes and fluid through diarrhoea, this can lead to serious dehydration, circulatory problems and even heart attack. Again, this can be avoided fairly easily by replacing lost fluid and electrolytes.

What these complications highlight is the importance of detoxing in a safe, controlled environment. Detoxing at home can be dangerous.

Final thoughts

Opioid withdrawal symptoms can be unpleasant but are unlikely to put the service user in danger unless they are left completely untreated. With the help of opioid replacements such as buprenorphine and methadone and medications such as diazepam and clonidine, opioid withdrawal is now safer than ever.

References

[1] https://www.nice.org.uk/guidance/cg52/evidence/drug-misuse-opioid-detoxification-full-guideline-196515037

[2] https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30471-1/fulltext

[3] https://pubmed.ncbi.nlm.nih.gov/3779283/

[4] Noeline Latt, Addiction Medicine, (Oxford University Press, 2009), p. 437.

[5] https://www.ncbi.nlm.nih.gov/books/NBK310652/table/part4.t1/?report=objectonly

[6] Noeline Latt, Addiction Medicine, (Oxford University Press, 2009), p. 214.

[7] Noeline Latt, Addiction Medicine, (Oxford University Press, 2009), p. 215.

[8] Noeline Latt, Addiction Medicine, (Oxford University Press, 2009), p. 216.

Useful resources

https://www.ncbi.nlm.nih.gov/books/NBK310652/#part4.s2

https://www.nice.org.uk/guidance/cg52/evidence/drug-misuse-opioid-detoxification-full-guideline-196515037

https://bnf.nice.org.uk/treatment-summary/substance-dependence.html

https://pubmed.ncbi.nlm.nih.gov/3779283/aspiration

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