Abstract
Background
Important Definitions
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Signs and symptoms of the opioid withdrawal syndrome include yawning, sweating, lacrimation, rhinorrhea, anxiety, restlessness, insomnia, dilated pupils, piloerection, chills, tachycardia, hypertension, nausea/vomiting, cramping abdominal pains, diarrhea, and muscle aches and pains. Unlike withdrawal from alcohol or benzodiazepines, opioid withdrawal is not life threatening. Emergence of withdrawal symptoms varies with half-life of the particular opioid; within 6–12 hours after the last dose of a short-acting drug or 72–96 hours following methadone (see Fast Facts #75, 86). Duration and intensity of withdrawal are related to clearance of the drug such that withdrawal is shorter (5–10 days) and more intense for opioids like morphine and less severe and more protracted with methadone.
Prevention
Opioid withdrawal syndrome should always be prevented. Patients treated with opioids for more than 1 to 2 weeks should be instructed to gradually reduce the opioid before discontinuing use. In general, dose reductions of about 20%–25% every day or two will allow a tapering schedule to prevent signs and symptoms of withdrawal. An alternative recommendation is to give half the previous dose for the first 2 days and then reduce the dose by 25% every 2 days. When the dose reaches the equivalent of approximately 30 mg/d of oral orphine, this dose is given for 2 days, and then the drug is discontinued. It is important to continue to provide around-the-clock opioids to prevent withdrawal in the patient at end-of-life who is no longer able to communicate or take oral opioids.
Treatment
Clonidine 0.1–0.2 mg orally every 4–6 hours as needed or by transdermal patch (clonidine transdermal 0.1 mg per 24-hour patch, which provides 0.1 mg/d for 7 days) can be used to treat autonomic hyperactivity symptoms (however, it will not relieve insomnia). The clonidine patch has a very slow onset and may take 2–3 days to achieve therapeutic levels. The major drawback of clonidine therapy is the tendency to cause hypotension in some patients. Other agents used for control of withdrawal symptoms include: diphenoxylate/atropine (Lomotil®, Pfizer, New York, NY), hydroxyzine, trazodone, and dicyclomine hydrochloride (Bentyl®, Birmingham, AL). For patients still in pain who have abruptly stopped their opioids (because they ran out, lost their prescription, or stopped because of side effects) reinstituting opioid therapy may be appropriate to treat both their withdrawal symptoms and ongoing pain. Depending on how long a patient has been without opioids it may not be safe to reinstate the full opioid dose immediately (especially for long-acting opioids). In this case patients should go through a dose-titration phase with short-acting opioids to safely achieve analgesia.
Footnotes
Acknowledgment
This Fast Fact is adapted with permission from: Gordon D: Pain Care Fast Facts—5 Minute Inservice; University of Wisconsin Pain Team.
Fast Facts and Concepts are edited by Drew A. Rosielle M.D., Palliative Care Program, University of Minnesota Medical Center–Fairview Health Services, and are published by the End of Life/Palliative Education Resource Center at the Medical College of Wisconsin. For more information write to: drosiel1@fairview.org. More information, as well as the complete set of Fast Facts, are available at EPERC: 
Version History: Originally edited by David E Weissman M.D. 2nd Edition published October 2007. Re-copy–edited May 2009. Minor content and reference update May 2011.
Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.