Opioid withdrawal syndrome: Clinical sciences

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Introduction 0:00–2:05

Opioid withdrawal syndrome refers to signs and symptoms that occur after abrupt cessation or dose reduction in individuals who are physically dependent on opioids.
The terms opiates and opioids are sometimes used interchangeably, but they actually refer to different entities. Opiates refer to only naturally occurring compounds derived from the poppy plant like heroin, morphine and codeine, all of which have agonistic effects on the opioid receptor.
On the flip side. Opioids include synthetic and semi synthetic compounds that resemble opiates in structure and their effects on the opioid receptor.
While opioid withdrawal syndrome is not usually life threatening per se, it can cause significant distress and discomfort has the potential to cause complications in individuals with chronic conditions and can significantly interfere with patients receiving care for a medical illness, potentially causing fatalities that way.
Now, based on the severity opioid withdrawal syndrome can be classified as mild, moderate or severe. Of note, it's a common misconception that patients experiencing opioid withdrawal must have an opioid use disorder.
In fact, opioid withdrawal can occur in anyone who develops physical dependence on opioids which occurs at the cellular level and can happen even after one or two weeks of opioid use.
This means that patients who are taking appropriate doses of opioids as prescribed for medical indications could also experience physical dependence and opioid withdrawal syndrome.
Finally, you should anticipate opioid withdrawal syndrome in an opioid dependent individual who receives an opioid antagonist like naloxone or naltrexone.

Unstable 2:05–2:49

Now, if your patient presents with chief concerns, suggesting opioid withdrawal syndrome, first, you should perform an ABCDE assessment to determine whether they're unstable or stable if unstable, stabilize the airway breathing and circulation, which might require endotracheal intubation and mechanical ventilation.
Next, obtain IV access and put your patient on continuous vital sign monitoring including BP, heart rate, pulse oximetry and cardiac telemetry.
Finally, if needed, don't forget to provide supplemental oxygen. All right.
Now that we've addressed unstable patients, let's go back to the ABCDE assessment and discuss stable ones. If your patient is stable, perform a focused history and physical examination, your patient will likely report recent opioid cessation or dose reduction with the development of gastrointestinal symptoms like nausea, vomiting and diarrhea and musculoskeletal symptoms such as body aches and muscle cramps.

Stable 2:49–4:43

Additionally, your patient will often report psychological symptoms including insomnia and anxiety and autonomic symptoms like watery eyes, runny nose chills and yawning.
There might also be a history of acute or chronic pain or substance use disorder. Next, physical examination will reveal signs of sympathetic overactivity such as tachycardia, elevated BP, elevated body temperature, sweating and irritability.
Finally, sympathetic overactivity often results in mydriasis and piloerection. With these findings, you can diagnose opioid withdrawal syndrome.
Here is a clinical pearl opioid withdrawal symptoms typically start within 6 to 12 hours after stopping an opioid. However, the onset of symptoms depends on the formulation taken.
For example, long acting or extended release opioids might take up to 48 hours to induce withdrawal symptoms. Moreover symptoms can persist for a few days to several weeks depending on the dose and duration of opioid use.
Ok. Your next step is to assess the severity of withdrawal using a validated metric such as the clinical opiate withdrawal scale or cows.

Assess the severity 4:43–5:20

For short cows rates, common signs and symptoms of opioid withdrawal including resting pulse rate, pupil size, sweating, restlessness, yawning bone or joint aches, runny nose or tearing, gi upset, tremor, anxiety or irritability and goose bumps.
Each sign or symptom is given a number based on severity and the higher the total score, the higher the severity of withdrawal, let's start with mild withdrawal.

Mild 5:20–10:14

If your patient has a cows score in the mild range. Treatment is typically in an outpatient setting.
If the plan is for opioid continuation, for example, to continue treating chronic pain in a patient without opioid use disorder, who has run out of medication, simply restart the opioid medication.
Alternatively, you could consider switching to buprenorphine or methadone in place of the prior opioid as their pain control method.
On the other hand, if an opioid use disorder is present, buprenorphine or methadone therapy is most appropriate. Buprenorphine is a partial opioid receptor agonist with a long half life, an effective analgesic profile and a strong affinity for the opioid receptor.
Because of these properties, buprenorphine can be considered as an alternative medication option for patients experiencing chronic pain.
Moreover, buprenorphine has a lower potential for misuse when treating opioid withdrawal syndrome. In an individual with opioid use disorder, it has a ceiling effect, preventing the euphoric effects of opioids and decreasing the risk of respiratory depression.
Second, it's commonly formulated with naloxone, an opioid antagonist which further prevents agonistic effects at the opioid receptor.
Keep in mind that naloxone is not absorbed orally. So it's in the formulation as a deterrent for injection.
Finally, due to its binding affinity, buprenorphine can block the action of other opioid agonists at the receptor like other opioids, slowly taper buprenorphine.
If you wanna wean off opioids completely on the flip side, methadone is a full opioid receptor agonist, just like buprenorphine.
Methadone has a long half life and effective analgesic profile and can be used to treat pain syndromes and opioid use disorder.
When utilized for pain management. Methadone can be prescribed just as any other opioid at the lowest effective dose and dispensed for self administration by the patient.
On the other hand, methadone is also often prescribed in patients with opioid use disorder, especially those taking high daily doses of opioids or engaging in high risk behaviors such as intravenous injection unlike buprenorphine, when prescribed for opioid use disorder, methadone has a higher risk of overdose.
So in many locations, laws require that initiation and titration be carried out in carefully controlled settings. Once the patient demonstrates abstinence from illicit opioid use and adherence to an aftercare program, they can sometimes be prescribed methadone for self administration.
Finally, it's important to note that dosing and titration of methadone is not straightforward and some significant potential side effects include QTC prolongation, cardiac arrhythmias and hyperalgesia or increased sensitivity to pain for these reasons.
Methadone is best managed by clinicians with adequate training and experience moving on. If the intent is to wean the patient from a previously therapeutic opioid, initiate a gradual dose tapering schedule usually by reducing the total daily opioid dose by 10% per week.
In most cases, this allows the patient to experience only minimal withdrawal symptoms. But if symptoms are bothersome, implement the dose reduction even more slowly.
One potential drawback to this method is that if the patient is taking a short acting opioid, the dose frequency required to avoid withdrawal might be impractical.
Finally, add non opioid adjunctive medications as needed for withdrawal symptoms. These include alpha two adrenergic receptor agonists such as cloNIDine or lofexidine, which reduce autonomic symptoms.
Antiemetics like promethazine and antidiarrheals such as loperamide. Here's a clinical pearl.
In rare cases, depending on comorbid medical conditions, social factors or patient preference, it might be appropriate for a patient to go through opioid withdrawal, cold turkey, meaning stopping the opioids abruptly without reintroducing opioids to the medication regimen.

Moderate to severe 10:14–11:48

If this route is necessary, it's still important to prescribe non opioid adjunctive medications to minimize uncomfortable symptoms.
All right, let's go back to the cows assessment and discuss patients with scores that fall in the range of moderate, moderately severe and severe.
These individuals are typically best managed in an emergency department or inpatient hospital setting with closer monitoring and supportive care such as IV fluids.
Again, if there is an indication to continue prescribing and the dosage is appropriate restart the previously therapeutic opioid.
On the other hand, if opioid use disorder is a concern, consider starting buprenorphine or methadone. Instead you can initiate an opioid tapering schedule.
If the intention is to wean your patient off opioids completely. Finally add non opioid adjunctive medications as needed.
One last clinical pearl. Any patient presenting with opioid withdrawal syndrome should be evaluated for an underlying opioid use disorder using the DSM five criteria.
This helps determine whether long term maintenance therapy with buprenorphine or methadone is required to maintain abstinence from risky opioid use.

Review11:48–13:08

If your patient does not meet the criteria for diagnosis, reassess their indication for opioid therapy like acute or chronic pain and make a plan to either wean from opioids or maintain them on the minimal effective dose.
All right, as a quick recap opioid withdrawal syndrome is a combination of physical and psychological symptoms that can occur when an opioid dosage is reduced or abruptly stopped.
Use history and physical exam findings to diagnose opioid withdrawal syndrome and proceed with the cows assessment to determine the severity for a mild withdrawal monitor your patient in the outpatient setting while either restarting the previously therapeutic opioid or starting buprenorphine or methadone.
You can initiate an opioid tapering schedule if the intention is to wean your patient off opioids completely. Additionally, don't forget to add non opioid adjunctive therapy for symptomatic treatment on the flip side, treat moderate to severe withdrawal in a hospital setting for additional supportive care and administer the same treatment as for mild withdrawal.
Opioid withdrawal syndrome: Video and Causes | Osmosis