Withdrawal Management (WM) refers to the medical and psychological care of clients who are experiencing withdrawal symptoms as a result of ceasing or reducing use of their drug addiction. 

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Withdrawal Management for Opioid Abuse

​Opioids are drugs such as heroin, opium, morphine, codeine and methadone. Opioid withdrawal can be very uncomfortable and difficult for the patient. It can feel like a very bad flu. However, opioid withdrawal is not usually life-threatening.

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There are some patients who should NOT complete opioid withdrawal:

• Pregnant women: It is recommended that pregnant women who are opioid dependent do not undergo opioid withdrawal as this can cause miscarriage or premature delivery. The recommended treatment approach for pregnant, opioid dependent women is Subutex with approval of your OBGYN. 

 

Opioid withdrawal syndrome

Short-acting opioids (e.g. heroin): Onset of opioid withdrawal symptoms 8-24 hours after last use; duration 4-10 days.

Long-acting opioids (e.g. methadone): Onset of opioid withdrawal symptoms 12-48 hours after last use; duration 10-20 days.

Symptoms include:

• Nausea and vomiting

• Anxiety

• Insomnia

• Hot and cold flushes

• Perspiration

• Muscle cramps

• Watery discharge from eyes and nose

• Diarrhea​

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Observation and monitoring

Patients should be monitored regularly (3-4 times daily) for symptoms and complications. The Clinical Opioid Withdrawal Scale (COWS) is a useful tool for monitoring withdrawal. It should be administered 1-2 times daily. Use the COWS score to select an appropriate management strategy.

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Opioid withdrawal management using buprenorphine

Buprenorphine is the best opioid medication for management of moderate to severe opioid withdrawal. It alleviates withdrawal symptoms and reduces cravings.

Because of its pharmacological action (partial opiate agonist), buprenorphine should only be given after the patient begins to experience withdrawal symptoms (i.e. at least eight hours after last taking heroin).

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Buprenorphine should be used with caution in patients with:

• Respiratory deficiency

• Urethral obstruction

• Diabetes

The dose of buprenorphine given must be reviewed on daily basis and adjusted based upon how well the symptoms are controlled and the presence of side effects. The greater the amount of opioid used by the patient, the larger the dose of buprenorphine required to control symptoms. 

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WITHDRAWAL MANAGEMENT FOR STIMULANT DEPENDENCE

Stimulants are drugs such as methamphetamine, amphetamine and cocaine. Although these drugs vary in their effects, they have similar withdrawal syndromes.

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Stimulant withdrawal syndrome

Symptoms begin within 24 hours of last use of stimulants and last for 3-5 days.

Symptoms include:

• Agitation and irritability

• Depression

• Increased sleeping and appetite

• Muscle aches

People who use large amounts of stimulants, particularly methamphetamine, can develop psychotic symptoms such as paranoia, disordered thoughts and hallucinations. The patient may be distressed and agitated. They may be a risk of harming themselves or others. These symptoms can be managed using anti-psychotic medications and will usually resolve within a week of ceasing stimulant use.

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Observation and monitoring

Patients withdrawing from stimulants should be monitored regularly. Because the mainstay of treatment for stimulant withdrawal is symptomatic medication and supportive care, no withdrawal scale has been included.

During withdrawal, the patient's mental state should be monitored to detect complications such as psychosis, depression and anxiety. Patients who exhibit severe psychiatric symptoms should be referred to a hospital for appropriate assessment and treatment.

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Management of stimulant withdrawal

Patients should drink at least 2-3 liters of water per day during stimulant withdrawal. Multivitamin supplements containing B group vitamins and vitamin C are recommended. Symptomatic medications should be offered as required for aches, anxiety and other symptoms.

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Management of severe agitation

A minority of patients withdrawing from stimulants may become significantly distressed or agitated, presenting a danger to themselves or others.

 

In the first instance, attempt behavioral management strategies for de-escalating the situation. If this does not adequately calm the client, it may be necessary to provide additional medication.

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If agitation persists and the client cannot be adequately de-escalated with oral medication, transfer the patient to a hospital setting for psychiatric care.