Opiate withdrawal



Methadone is never to be prescribed for or supplied to patients in the ED


Background

  • All patients should promptly receive appropriate analgesia to relieve their pain
  • Opiates should be used, if necessary, to relieve symptoms of physically painful conditions (e.g. limb fractures) irrespective of whether the patient has a history of dependence or not

Please remember that

  • For most heroin addicts general support, understanding of the symptomatology and encouragement is sufficient to alleviate acute withdrawal symptoms
  • Symptomatic relief of withdrawal symptoms can be achieved without substitute opiate medication
  • The severity of withdrawal symptoms is not directly related to the quantity of drugs previously consumed
  • When assessing symptoms please identify observable signs rather than subjective symptoms
  • Detoxification may be used in the in-patient wards but methadone must never be given in the Emergency department or CDU.
  • Untreated heroin withdrawal typically reaches its peak 36-72 hours after the last dose and rapidly subside
  • Withdrawal from opiates is associated with a specific withdrawal syndrome

Symptoms and signs of opiate withdrawal

  • Sweating
  • Lacrimation and rhinorrhoea*
  • Yawning*
  • Feeling hot and cold*
  • Anorexia & abdominal cramps*
  • Nausea, vomiting and diarrhoea*
  • Tremor
  • Restlessness*
  • Generalised aches and pains*
  • Tachycardia, hypertension*
  • Gooseflesh
  • Dilated pupils
  • Increased bowel sounds

Only those asterixed in the above list comprise the Opiate Withdrawal Scale (OWS)


Methadone is never to be prescribed for or supplied to patients in the ED


Management

There are now satisfactory non-opiate treatments (such as Lofexidine) for opiate withdrawal. AT CUH, please contact Dr Cassidy's liaison psychiatry team for advice. Drugs that should be considered include.

  • Lofexidine
    • Similar in action to Clonidine, but causes less hypotension
    • It is equally as efficacious as methadone in withdrawal
  • Loperamide hydrochloride (Imodium) or Co-Phenotrope (Lomotil).
    • Use in standard doses for the treatment of diarrhoea
  • Metoclopramide hydrochloride
    • Use to treat nausea and vomiting, may also be useful for treatment of stomach cramps
  • Non-steroidal anti-inflammatory drugs (NSAIDS) – use to alleviate muscular pains and headaches

Methadone is never to be prescribed for or supplied to patients in the ED



Contents (based on UK DoH Drug Misuse& Dependence Publication 1999) by Dr Íomhar O' Sullivan 14/10/2006. Reviewed by Dr ÍOS 13/05/2007. Next review 13/05/2008.