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Opioid_withdrawal_protocol.pdf

Mental Health and Addiction Services: Brief/Social Detox Unit
OPIOID WITHDRAWAL PROTOCOL
Clinical Features of Opioid Withdrawal
- detected & monitored using the Opioid Withdrawal Scale
(OWS)
Physical signs/symptoms
Lacrimation, rhinorrhea, yawning Dilated pupils, nausea/vomiting Diaphoresis, chills, piloerection, mild tachycardia and/or hypertension Myalgias, abdominal cramps, diarrhea Psychological symptoms
Anxiety and dysphoria Craving for opioids Restlessness, insomnia, fatigue Onset & Duration of Symptoms
Anxiety, fear of withdrawal, craving for drug, diaphoresis, chills, Piloerection, anorexia, dilated pupils, anxiety, irritability dysphoria, restlessness, mild-moderate insomnia, tremor, mild tachycardia and/or hypertension, abdominal cramps Beginning 24-36 hours from last Abdominal cramps, diarrhea, myalgias, muscle spasms (esp. in lower opioid use (Peak at 72 h) extremities), nausea, vomiting, diarrhea, severe insomnia, violent yawning  Methadone withdrawal may take longer to manifest clinically (24-48h from last dose) than withdrawal from other opioids, but may persist 2-3 weeks or longer  Physical withdrawal symptoms generally resolve by 5-10 days  Psychological withdrawal symptoms (dysphoria, insomnia) may last weeks to months Complications of Opioid Withdrawal:
 Opioid withdrawal is not life threatening in otherwise healthy individuals. However, the risk of serious
medical complications is higher in pregnant women and neonates. o Pregnancy-associated risks: spontaneous abortion, pre-term labour o Neonatal abstinence syndrome: seizures, death if not identified & treated  There is a serious risk of flight, suicide (precipitated by anxiety, dysphoria), and overdose on relapse (because patients begin to lose their tolerance to opioids within 3-7 days after last use).
IMPORTANT:

 Continually assess all patients for suicide risk  Screen for pregnancy  Warn patients about overdose if they resume opioid use at previous dose. Developed by:
Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN
Mental Health and Addiction Services: Brief/Social Detox Unit

Step 1: Symptomatic Protocol + Clonidine
Symptomatic Protocol
Target symptoms
Dosing guideline
Nausea and vomiting
5mg-10mg orally up to every 4 hours as needed Diarrhea
4mg orally for diarrhea, then 2mg orally as needed for loose bowel movements (Maximum dose =16mg/24h) Myalgias
325mg-650mg orally every 4 hours as needed (Maximum dose = 4000mg/24h) 500mg orally twice daily with meals for 4 days, then reduce to twice daily as needed Anxiety, dysphoria,
25mg-50mg orally three times daily as needed lacrimation, rhinorrhea
Insomnia

50mg-100mg orally at bedtime x 4 days, then as needed for insomnia Clonidine
Dose

Monitoring
 Check blood pressure (BP) one hour later. If BP<90/60, if marked postural hypotension occurs or if HR<60- do not prescribe further If <91kg (or <200lbs):
 Check BP prior to each dose and withhold dose if  Clonidine 0.1mg orally 4 times daily x 4 days BP<90/60, if marked postural hypotension or  Clonidine 0.05mg orally 4 times daily x 2 days  Clonidine 0.025mg orally 4 times daily x 2 days, Assess Opioid Withdrawal Score (OWS) at least every
24 hours:
If >91kg (or >200lbs):
If after 24 hours the OWS is 10-14 (suggesting
 Clonidine 0.2mg orally 4 times daily x 4 days moderate withdrawal symptoms)- proceed to step 2
 Clonidine 0.1mg orally 4 times daily x 2 days  Clonidine 0.05mg orally 4 times daily x 1 day,  If after 24 hours, the OWS is >15 (suggesting severe
 Clonidine 0.025mg orally 4 times daily for 1 day, withdrawal symptoms)- proceed to step 3
Developed by:
Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN
Mental Health and Addiction Services: Brief/Social Detox Unit

Step 2: Symptomatic Protocol + Intensified Clonidine
Intensified Clonidine
Monitoring
If <91kg (or <200lbs):
 Check BP prior to each dose and withhold dose if  Clonidine 0.2mg orally 4 times daily x 4 days BP<90/60, if marked postural hypotension or  Clonidine 0.1mg orally 4 times daily x 2 days  Clonidine 0.05mg orally 4 times daily x 1 day  Clonidine 0.025mg orally 4 times daily for 1 day, then stop Assess Opioid Withdrawal Score (OWS) at least

every 24 hours:
If >91kg (or >200lbs):
If after 24 hours at step 2, the OWS is >15
 Clonidine 0.3mg orally 4 times daily x 4 days (suggesting severe withdrawal symptoms)-  Clonidine 0.2mg orally 4 times daily x 1 day proceed to step 3
 Clonidine 0.1mg orally 4 times daily x 1 day,
 Clonidine 0.05mg orally 4 times daily x 1 day
 Clonidine 0.025mg orally 4 times daily for 1 day, then stop.
Step 3: Symptomatic Protocol + Intensified Clonidine + Phenobarbital
Intensified Clonidine + Phenobarbital
Clonidine dose
Monitoring
If <91kg (or <200lbs):
 Check BP prior to each dose and withhold dose if  Clonidine 0.2mg orally 4 times daily x 4 days BP<90/60, if marked postural hypotension occurs  Clonidine 0.1mg orally 4 times daily x 2 days  Clonidine 0.05mg orally 4 times daily x 1 day  Assess Opioid Withdrawal Score (OWS) at
 Clonidine 0.025mg orally 4 times daily for 1 day, then stop least every 24 hours

If >91kg (or >200lbs):
 Clonidine 0.3mg orally 4 times daily x 4 days  Clonidine 0.2mg orally 4 times daily x 1 day  Clonidine 0.1mg orally 4 times daily x 1 day,  Clonidine 0.05mg orally 4 times daily x 1 day  Clonidine 0.025mg orally 4 times daily for 1 day then stop.
Phenobarbital dose:
Monitoring
Phenobarbital 30mg-60mg orally twice daily as needed for  Hold dose in presence of marked sedation, hypotension (BP<90/60), dizziness, ataxia, listlessness Step 4: Refer to a methadone prescribing physician
- Methadone 10mg orally 3 times daily for 3-4 days, then taper by 10mg/day (5mg/day on final day).
Developed by:
Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN
Mental Health and Addiction Services: Brief/Social Detox Unit
- NOTE: Methadone-related deaths have occurred almost exclusively at doses in excess of 30mg/day 10

References:

1. Kahan M., Wilson L. (2002). Managing Alcohol, Tobacco and other Drug Problems: A Pocket Guide for Physicians and Nurses. Toronto: Centre for Addiction and Mental Health (CAMH). 2. College of Physicians and Surgeons of Ontario: Methadone Maintenance Guidelines November 2005 3. Stolbach A, Hoffman RS. Opioid withdrawal in the emergency se4. Virani AS, Bezchlibnyk-Butler KZ, Jeffries JJ. Clinical Handbook of Psychotropic Drugs 18th Revised Version 5. Meehan WJ, Adelman SA, Rehman Z, et al. Opioid 6. Naranjo, CA, Bremner KE, Pharmacotherapy of substance use disorders. Can J Clin Pharmacol 1994; 2: 55-71. 7. Weaver MF, Hopper JA. Opioid withdrawal management during tr (Last 8. Korsten, TR, O’Connnor PG. Current Concepts: Management of Drug and Alcohol Withdrawal. N Engl J Med 9. Connery HS, Kleber HD. American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders, 2nd Edition (2007). Focus Psychiatry 2007; V: 2. 10. Saskatchewan Ministry of Health/ Saskatchewan College of Family Physicians, SMA. Concurrent Disorders and Withdrawal Management Protocols/Guidelines and Services. Updated by the Addictions Medical Advisory Committee 2008. 11. Hauser L, Anupindi R, Moore W. Hydroxyzine for the treatment of acute opioid withdrawal: A clinical experience. Resident and Staff Physician 2006; 52: 6. Developed by:
Dr, Peter Butt MD SCFP (EM), Melanie McLeod BSP, ACPR, PharmD Candidate, Christi Becker-Irvine RN

Source: http://www.casagrandealliance.org/cgadownloads/CGA/opioid%20withdrawal%20protocol.pdf

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