see also:

• opiates and opioids

• if withdrawal is due to interruption of normal use, and opioid receptor antagonists such as naltrexone have not been given, and withdrawal is not desirable, then contact AOD team to develop a treatment plan
  • identify withdrawal early and refer to AOD and start Rx early
    • early signs include yawning, diarrhoea, diaphoresis, N/V, dilated pupils, rhinorrhoea, piloerection
    • The primary aim of opioid withdrawal treatment in the ED is to relieve patient distress and reduce harm
    • Ask them what has worked in the past and reassure that their symptoms will be treated
    • Rx options:
      • start or continue methadone
      • start or continue suboxone films
      • sometimes oxycodone can be used while titrating methadone, and for a patient in acute pain
      • once acute withdrawal phase managed, consider long acting injectable buprenorphine
    • On discharge, educate:
      • take home naloxone packs
      • where to seek sterile equipment
      • card for DirectLine
      • offer Addiction Medicine telephone follow up
• if severe withdrawal reaction causing vomiting and diarrhoea:
  • consider iv fluids to rehydrate and replace GIT fluid losses, sweat and provide usual maintenance fluids
  • monitor electrolytes, glucose, fluid balance
• adjunctive Rx for Mx of acute withdrawal:
  • anti-emetics such as:
    • ondansetron 4-8mg s/l or iv, or,
    • promethazine 25mg im or slow iv
  • anti-diarrhoeal agent such as:
    • loperamide 4mg o, or,
    • octreotide 50mcg s/c
  • agents to reduce GIT cramps such as:
    • hyoscine
  • non-opiate analgesics such as:
    • non-steroidal anti-inflammatory drugs (NSAIDs)
    • paracetamol (acetaminophen)
  • clonidine (Catapres) if hypertensive eg. 0.1-0.3mg orally each hour until hypertension controlled
  • benzodiazepines should NOT be used 1st line as Rx as they may cause sedation and mask symptoms while not appropriately treating withdrawal