Assessment and Management of Opioid, Benzodiazepine, and Sedative-Hypnotic Withdrawal Roger Cicala, M. D. Assistant Medical Director Tennessee Physician s Wellness Program Step 1 Don t 1
It is legal in every state to taper a pain patient s medication slowly to avoid withdrawal symptoms. Unless you have special certification, in most states it is NOT legal to detoxify a substance abuser. There are gray areas and certain circumstances where a pain doctor will need to handle withdrawal including hospitalized patients, non abusing patients with physical dependence, patient requests, etc. Tapering versus Detoxification To use schedule II opiates for detoxification from opiate addiction, a special registration is required: (21 Code of Federal Regulation 1306.07(a)). Drug Abuse Treatment Act of 2000 allows physicians to use schedule III agents to detoxify chemical dependent patients in an office setting, provided the physician qualifies for and obtains a waiver issued through the Substance Abuse and Mental Health Services (SAMHSA) and the DEA. ** ** State regulations may require further registration 2
Tapering when it is necessary to discontinue a pain patient's opioid therapy by tapering or weaning doses, there are no restrictions with respect to the drugs that may be used. This is not considered "detoxification" as it is applied to addiction treatment. Patricia Good, Chief of Policy Section, Office of Diversion and Control Opioid Withdrawal Symptoms Opiate craving Sweating Restlessness Nervousness Fatigue Rhinorrhea Dilated pupils Yawning Increased respiration Irritability Anxiety Dysphoria Piloerection Muscle twitching Headache Anorexia 3
Severe Opioid Withdrawal Symptoms Fever Tachycardia Cutaneous Hypersensitivity Hypertension Isomnia Hot/cold flashes Nausea Vomiting Bone pain Muscle Aches/spasms Abdominal Cramps Diarrhea Benzodiazepine / Sedative Withdrawal Symptoms Anxiety / Agitation Hypertension / Tachycardia Sensory Hypersensitivity Insomnia Confusion / Delerium Cramps / Hyperreflexia Seizures Nightmares Mania Tremor / Fasciculations Tinnitus / Dizziness Lethargy 4
Time Course of Withdrawal Onset proportional to T1/2 of agent, daily amount. Duration somewhat proportional to rate of receptor turnover. Duration somewhat proportional to T 1/2 of agent. Severity somewhat proportional to daily dose. Severity less proportional to duration of use. Sedative Hypnotic and Benzodiazepine Tapering 5
Sedative / Benzo Withdrawal Peak symptoms not for 3-6 days Duration of withdrawal 3-6 weeks Mentation may improve for more than 6 months. Secondary symptoms (insomnia, anxiety, etc.) may not normalize for a year. Symptom rebound occurs - it is not withdrawal. INSOMNIA - 1 year plan. Sedative / Benzo Withdrawal CAN BE FATAL!! Concurrent alcohol use / abuse in 1/3 of benzodiazepine dependent patients. Severity of withdrawal seems worse in females. Patients with abuse history, strong family history of abuse, concurrent daily alcohol, significant psychiatric issues are not candidates for tapering. 6
Benzodiazepine Tapering Dose reduced 10% to 20% every 2 weeks. If withdrawal Sxs occur hold at that level for 1 month. The final 20% should be tapered over a month. Benzodiazepine Cross Tapering Chlordiazepoxide, Clonazepan, Phenobarbital are most commonly used. Patient started on equivalent dose, may need to be increased until stable. Stable dose continued 1 week, then reduced 20% every 3 days. The last 25% of dose is removed over 2 weeks. Cross tapering is recommended for Alprazolam and Soma tapering - but rate of tapering may need to be slower. 7
Opioid Tapering Opioid Withdrawal Onset 6 hours (short acting) to 36 hours (methadone). Peak Sxs 12 hours (short) to 72 hours (long acting). Duration 5 to 14 days. Secondary withdrawal - episode of withdrawal symptoms lasting hours to a couple of days - may occur for 6 months. 8
Standard Opioid Tapering Minor withdrawal symptoms occur 10% dose reductions per day or 25% every 3 days usually tolerated well. Clonidine 0.2 mg q 4-6 hours markedly reduces withdrawal severity. Usually tapered over 10 to 14 days. Low dose benzodiazepines or TCAs may also be useful. Rapid Detoxification Naltrexone or Buprenorphine, with or without clonidine and benzodiazepine. Withdrawal symptoms are more pronounced than tapering on first day. Withdrawal process is quicker. Long acting partial agonist minimizes effect of opiate if patient cheats. 9
Buprenorphine Detoxification Not appropriate for high dose opioids: majority of patients at 60 mg Methadone per day will have withdrawal symptoms. Usually begin after 12 hours abstinence - patient in mild withdrawal. Begin with 2 mg dose SL, repeated every 2 hours to maximum 16 or even 32 mg first day.. Once stable dose is reached it is usually continued for 2 to 3 days Patient is then tapered over 2 to 3 weeks. May use adjunctive medications if needed. Buprenorphine Detoxification from Long Acting Opiates Taper to methadone 30 mg / day equivalent 24 hrs after last dose, give buprenorphine 2 mg Withdrawal symptoms present? Yes Give buprenorphine 2 mg Withdrawal symptoms continue? Yes Repeat dose up to maximum 8 mg/24 hrs No No Daily dose established Withdrawal symptoms relieved? No Manage withdrawal symptomatically Daily Yes dose established Increase to 16 mg / day on day 2 Adapted from H. Heit, M. D.; www.asam.org 10
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