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1. Management of Opioid Intoxication

Recognize and treat acute intoxication.

Patients with opioid use disorders frequently relapse and present with intoxication.

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Table Reference Number

Level of Intoxication

Indicators

Treatment

Mild to moderate

Drowsiness, pupillary constriction, slurred speech

Specific treatment is usually not required

Severe overdose (may be fatal)

Respiratory depression, stupor, coma

Requires treatment in inpatient or ER setting

May require ventilatory assistance

Use naloxone to reverse

Reverse respiratory depression by administering naloxone.

  • Usual dose is 0.05–0.4 mg i.v., with the lower dose used in opioid-dependent individuals; with significant respiratory depression, 2.0 mg i.v. is suggested.

  • A positive response (with increases in respiratory rate and volume, increased systolic blood pressure, and pupillary dilation) should occur within 2 minutes.

  • If there is no response, the same or a higher dose (e.g., 0.8 mg) of naloxone can be given twice more at 5-minute intervals.

  • Failure to respond to naloxone suggests a concurrent, or completely different, etiology for the problem (e.g., barbiturate overdose, head injury).

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2. Management of Opioid Withdrawal

The goals of management are to ameliorate acute opioid withdrawal symptoms and facilitate entry into a long-term treatment program.

Monitor for withdrawal from other substances.

Concurrent use of or withdrawal from other substances (particularly alcohol, benzodiazepines, or other anxiolytic or sedative agents) can complicate the treatment of opioid withdrawal.

To control opioid withdrawal symptoms, stabilize the patient with methadone or buprenorphine, then gradually taper.

Methadone

  • The daily stabilization dose should be based on the response of objective signs of withdrawal to a methadone dose of 10 mg every 2–4 hours as needed.

  • During the first 24 hours, 10–40 mg of methadone will stabilize most patients and control withdrawal symptoms.

  • Once the stabilization dosage is determined, methadone can be slowly tapered (e.g., by 5 mg/day).

  • When the methadone dosage drops below 20–30 mg/day, many patients begin to complain of renewed (but milder) withdrawal symptoms. These may be ameliorated by the addition of clonidine (see below).

Buprenorphine

  • Stabilization and suppression of withdrawal symptoms typically occur at a dosage of 8 mg/day or less on an inpatient basis and 8–32 mg/day on an outpatient basis.

  • Tapering and discontinuation of buprenorphine occur over 10–14 days, with dosage reductions of 2 mg/day.

If opioids are discontinued abruptly, consider using clonidine to suppress withdrawal symptoms.

  • Clonidine suppresses nausea, vomiting, diarrhea, cramps, and sweating but does little to reduce muscle aches, insomnia, and drug craving.

  • Be aware that some patients are extremely sensitive to clonidine and experience profound hypotension, even at low doses.

  • On day 1, clonidine-aided detoxification involves either a test-dose approach or a treatment dose ranging from 0.1 to 0.3 mg in three divided doses. Thereafter, dosage is adjusted until withdrawal symptoms are reduced.

  • If blood pressure falls below 90/60 mm Hg, the next dose should be withheld.

  • Tapering can be resumed while the patient is monitored for signs of withdrawal.

  • Advantages over methadone:

    • Clonidine does not produce opioid-like tolerance or physical dependence.

    • Use of clonidine avoids the postmethadone rebound in withdrawal symptoms.

    • If indicated, an opioid antagonist (e.g., naltrexone) can be used immediately after the course of withdrawal.

  • Disadvantages:

    • Side effects include insomnia, sedation, and hypotension.

    • Clonidine will not ameliorate some symptoms of opioid withdrawal, such as insomnia and muscle pain.

    • Clonidine is contraindicated in patients with moderate to severe hypotension and cardiac, renal, or metabolic disease.

  • Clonidine-assisted detoxification is easiest to carry out in inpatient settings.

  • Outpatient detoxification with clonidine is a reasonable approach with experienced staff; outpatients should not be given more than a 3-day supply of clonidine for unsupervised use.

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3. Management of Opioid Dependence

For patients with a prolonged history (>1 year) of opioid dependence, consider providing agonist maintenance treatment (e.g., methadone or buprenorphine).

  • Agonist maintenance treatment reduces the morbidity, mortality, and other deleterious effects associated with opioid dependence, even if abstinence is never achieved.

  • Treatment aims to facilitate engagement in a comprehensive program of rehabilitation that can improve overall functioning through addressing substance use, psychosocial issues, and psychiatric and somatic needs.

  • Implementation is described in Table 8.

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Table Reference Number
Implementation of Methadone, Buprenorphine, or Naltrexone

As an alternative strategy, consider maintenance therapy using naltrexone, an opioid antagonist that blocks effects of usual street doses of opioids.

Clonidine pretreatment can minimize naltrexone-precipitated withdrawal symptoms in opioid-dependent patients who are in transition to narcotic antagonist treatment, but patients must be monitored for the initial 8 hours (because of the potential severity of naltrexone-induced withdrawal) as well as receive careful monitoring of blood pressure throughout withdrawal.

Avoid use of ultrarapid opioid detoxification.

Induction of opioid withdrawal by administration of naltrexone while patients are under general anesthesia has an adverse risk/benefit ratio and a lack of proven efficacy.

Consider combining psychosocial treatments with opioid agonist or antagonist therapies to improve treatment adherence and prevent relapse.

The following treatments may be helpful:

  • Cognitive-behavioral therapies

  • Behavioral therapies including contingency management

  • Psychodynamic psychotherapies

  • Drug counseling

  • Group and family therapies

  • Self-help groups

Table Reference Number

Level of Intoxication

Indicators

Treatment

Mild to moderate

Drowsiness, pupillary constriction, slurred speech

Specific treatment is usually not required

Severe overdose (may be fatal)

Respiratory depression, stupor, coma

Requires treatment in inpatient or ER setting

May require ventilatory assistance

Use naloxone to reverse

Table Reference Number
Implementation of Methadone, Buprenorphine, or Naltrexone

References

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