Management of Opioid Withdrawal

Medication Recommendations

The National Comprehensive Cancer Network recommends Prochlorperazine 10 mg orally every 6 hours as needed for antiemetic treatment, and Ondansetron 4-8 mg orally every 8 hours as needed for antiemetic treatment 1
For patients on opioid agonist therapy, the American College of Physicians recommends continuing the usual dose of methadone or buprenorphine, and verifying doses with the patient's maintenance clinic or prescribing physician, with a strength of evidence based on clinical trials 2
Buprenorphine is used for opioid use disorder (OUD) treatment, with a recommended target dose of 16mg daily for most patients, according to the American College of Emergency Physicians 3
The American College of Physicians advises against using mixed agonist-antagonist opioids, such as nalbuphine or butorphanol, as they may precipitate acute withdrawal in patients on opioid agonist therapy 2

A standard taper rate of 10% of original dose every 24-48 hours is recommended, with consideration for slower taper of 10% per month for longer-term use (>14 days) 4, 5
Patients using opioids for less than 7 days can typically discontinue quickly without formal weaning, while those using for 7-14 days may need weaning but can be done more rapidly, and those using for more than 14 days requires a structured weaning protocol 5
For moderate to severe withdrawal, consider reinitiation of buprenorphine at a lower dose followed by a proper taper, as recommended by the American Academy of Pediatrics and the American College of Physicians 4, 2
The Clinical Opiate Withdrawal Scale (COWS) is a validated tool for monitoring withdrawal symptoms, with scores indicating:
Aspect Score
Mild withdrawal 5-12
Moderate withdrawal 13-24
Moderately severe withdrawal 25-36
Severe withdrawal >36

Aspect	Score
Mild withdrawal	5-12
Moderate withdrawal	13-24
Moderately severe withdrawal	25-36
Severe withdrawal	>36

Buprenorphine and methadone are commonly used medications for opioid withdrawal management, with the following characteristics:

Aspect	Buprenorphine	Methadone
Effectiveness	Higher completion rates (89% vs 78%)	Effective but lower completion rates
Safety	Ceiling effect on respiratory depression	No ceiling effect, higher overdose risk
Administration	Sublingual, less frequent dosing	Oral, daily dosing required
Regulations	X-waiver needed for OUD treatment	Restricted to certified OTPs for OUD
Withdrawal profile	Less severe symptoms	Effective but more protracted withdrawal

Methadone can be administered in inpatient settings for up to 72 hours without Opioid Treatment Program involvement, but it has a higher risk of overdose due to no ceiling effect on respiratory depression, with an initial dose of 30-40mg daily, which can be increased in 5-10mg increments if withdrawal persists, as recommended by the American College of Physicians 2, 3

Patients with comorbid pain may benefit from buprenorphine for both withdrawal management and analgesia, as recommended by the Mayo Clinic Proceedings 4
The American College of Obstetricians and Gynecologists recommends that buprenorphine should not be withheld from patients using benzodiazepines, even though methadone may be more appropriate for these patients 8
Opioid agonist/antagonists (e.g., nalbuphine, butorphanol) should be avoided in patients with opioid dependence as they can precipitate withdrawal, according to the American College of Obstetricians and Gynecologists 8

For outpatient Suboxone initiation, start with 2-4 mg sublingually after mild withdrawal symptoms appear, with additional 2-4 mg doses at 2-hour intervals as needed, typically requiring 4-8 mg total on the first day 4
A gradual taper of 10% of the original dose per week is recommended for patients who have been on stimulants, with a standard taper rate of 10% or less reduction per week, as recommended by the Mayo Clinic Proceedings guidelines and the American Society of Addiction Medicine 4, 9

Consider supportive measures during the tapering process, such as short-term use of trazodone or mirtazapine for sleep disturbances, as recommended by the Mayo Clinic Proceedings 4
Non-pharmacological approaches, including regular exercise, stress reduction techniques, adequate sleep hygiene, and cognitive behavioral therapy, can also be used during the tapering process, as recommended by the Mayo Clinic Proceedings 4
The Centers for Disease Control and Prevention advises regularly assessing withdrawal symptoms, monitoring for signs of respiratory depression and sedation, providing overdose prevention education, dispensing take-home naloxone kits, screening for hepatitis C and HIV, and arranging prompt follow-up with addiction treatment services, with a high level of evidence 2
The National Institute on Drug Abuse recommends regular exercise, stress reduction techniques, adequate sleep hygiene, and cognitive behavioral therapy as adjunctive therapies for buprenorphine withdrawal management, with a moderate level of evidence 2