opiate withdrawal

Last edited 07/2020

Withdrawal from heroin causes cold turkey:-

Objective signs of opiate withdrawal (1):

• yawning
• coughing
• sneezing
• runny nose
• lachrymation (lacrimation)
• raised blood pressure
• increased pulse
• dilated pupils
• cool, clammy skin
• diarrhoea
• nausea
• fine muscle tremor

Subjective signs of opiate withdrawal (1):

• restlessness
• irritability
• anxiety

(The signs listed above may also be useful objective signs)

Other subjective signs include:

• sleep disorders
• depression
• drug craving
• abdominal cramps

Other possible clinical featurs include (2)

• nausea and vomiting
• insomnia
• arthralgia and myalgia
• Pilo-erection "goosebumps"

Immediate Treatment

• opiate withdrawal syndrome carries minimal risk of long term harm, but is intensely unpleasant and most opioid users will do anything to avoid it (2)
• is important that withdrawal symptoms are managed effectively in order to prevent illicit drug use
• is important to explain to an individual whose supply of Methadone is interrupted that it may be well over 24 hours before significant withdrawal symptoms develop if they have been consistently taking their medication hitherto
• withdrawal symptoms, however unpleasant they may be, are not likely to be fatal (2)
• if opiate withdrawal in pregnancy then seek expert obstetric advice

Where withdrawal symptoms are of sufficient severity to warrant medical treatment, several options are available
Symptomatic treatment in an adult - seek expert advice and consult local guidance.

An example of options for symptomatic treatment in an adult is presented - medication required is based on the various presenting symptoms (2):

• propranolol 40 mg orally 8 hrly -relief of somatic anxiety
• loperamide 4 mg orally single dose then 2mg after each episode of diarrhoea [16mg per day maximum] -symptomatic treatment of diarrhoea
• hyoscine butylbromide 10-20 mg orally 6 hrly -relief of stomach cramps
• promethazine hydrochloride 25 mg orally 12 hrly -anti-emetic,sedative and hypnotic
• prochlorperazine 5-10mg tds prn, Metoclopramide 10mg tds prn-anti-emetic-consider "Buccastem"3-6mg 12hrly prn if vomiting is severe
• paracetamol 1g orally 6 hrly -relief of pain
• ibuprofen 200-400mg tds pc prn-[provided no contra-indications; may require PPI cover] relief of pain
• consider Diazepam 5-10mg tds prn if agitation or insomnia is severe
• ropinirole 250mcg nocte for restless legs-a rare but extremely distressing symptom which also exacerbates insomnia

Notes:

• cold turkey begins approximately 6 hours after the last dose, peaks at 36-48 hours and then wanes. (1)

The respective Summary of Product Characteristics (SPCs) must be consulted before prescribing any of medication mentioned above.

Reference:

• (1) RCGP (2007). Drug misuse and dependence: UK guidelines on clinical management.
• (2) Royal Wolverhampton NHS Trust Drug Guidelines. Withdrawal of Drug (s) of Dependence (Accessed 29/7/2020)