Fentanyl Withdrawal Management

Monitoring Parameters

Continuous monitoring should be performed during the entire time the patient is at risk for withdrawal, with assessments at least once every hour for the first 12 hours, every 2 hours for the next 12 hours, and every 4 hours thereafter 1
Use a standardized scoring system to assess pain, agitation, and respiratory distress 2, 3
Monitor adequacy of ventilation through respiratory rate, depth of respiration, and pattern of breathing 1
Implement continuous pulse oximetry to detect hypoxemia early 1
Consider end-tidal CO2 monitoring (capnography) which can detect respiratory depression earlier than clinical signs or pulse oximetry alone 1
Regularly assess alertness and sedation level using a standardized scoring system 1
Monitor for signs of upper airway obstruction 1
Consider direct arterial pressure monitoring in high-risk patients 1
Document the rationale for giving any dose of comfort medication during withdrawal 3

For continuous intravenous fentanyl (7-14 days duration), calculate the 24-hour fentanyl dose based on current hourly infusion rate, multiply by 100 to calculate equipotent methadone dose, and follow a 5-day tapering schedule 4
For continuous intravenous fentanyl (>14 days duration), calculate the 24-hour fentanyl dose based on current hourly infusion rate, multiply by 100 to calculate equipotent methadone dose, and follow a 10-day tapering schedule 4

Opioid-naïve patients can be started on bolus doses of 2 mg intravenous morphine, titrated to effect 3
For patients receiving continuous infusion of morphine or hydromorphone, provide a bolus dose of 2× the hourly infusion rate every 15 minutes as needed for breakthrough pain or respiratory distress 3
For patients receiving continuous infusion of fentanyl, provide a bolus dose equal to the hourly infusion rate every 5 minutes as needed for breakthrough pain or respiratory distress 2
If a patient receives 2 bolus doses in an hour, double the infusion rate 2, 3
Treat pain or respiratory distress with a bolus dose of opioid followed by an infusion 2
Use sedatives only after pain and dyspnea are treated with opioids 2
Benzodiazepines can be used in combination with opioids during withdrawal 2
For benzodiazepine-naïve patients, start with bolus doses of 2 mg intravenous midazolam, followed by an infusion of 1 mg/h 2

Antinauseants should be ordered as needed with opioids 3
Inhaled epinephrine should be used to treat post-extubation stridor in conscious patients 3
For benzodiazepine dependence, convert intravenous midazolam to oral lorazepam by dividing the 24-hour midazolam dose by 12 6

Have reversal agents (naloxone) available for administration to patients experiencing significant respiratory depression 1
Administer supplemental oxygen to patients with altered level of consciousness, respiratory depression, or hypoxemia 1
Maintain intravenous access if recurring respiratory depression occurs 1
In severe respiratory depression, initiate appropriate resuscitation measures 1
Consider noninvasive positive-pressure ventilation if frequent or severe airway obstruction or hypoxemia occurs 1

Withdrawal symptoms may be underestimated when using assessment tools validated only for traditional opioids 5
Concurrent use of benzodiazepines and opioids can complicate withdrawal management as symptoms overlap significantly 5
Patients may require higher than calculated doses of methadone during conversion from high-dose fentanyl infusions 6