The management of opioid withdrawal

Abstract

To date there has been little consensus on best practice in the management of opioid withdrawal. Regimes involving reducing doses of methadone or the administration of α2-adrenergic agonists such as clonidine and lofexidine are most common, but the use of opioid antagonists to induce withdrawal, and the partial agonist, buprenorphine, are gaining in popularity. This paper reviews 213 published reports of interventions to manage opioid withdrawal. Rates of completion and severity of withdrawal are similar when managed with either α2-adrenergic agonists or reducing doses of methadone but α2-adrenergic agonists, particularly clonidine, are associated with a higher incidence of hypotensive side effects. Vriability in the opioid antagonist treatment regimes prevents the identification of standard approaches. The use of opioid antagonists may increase completion rates, but with the risk of more severe withdrawal. Buprenorphine has considerable promise for the management of opioid withdrawal, being associated with lower withdrawal severity, fewer side effects and similar completion rates to withdrawal managed with α2-adrenergic agonists. Withdrawal in an in-patient setting is associated with higher completion rates than withdrawal in an out-patient setting. Psychological state prior to and during withdrawal may be important in determining withdrawal outcomes. It is currently not possible to determine to what extent the setting and detoxification protocol influences long-term outcomes.