Opioid withdrawal in the emergency setting
- Andrew Stolbach, MD
Andrew Stolbach, MD
- Assistant Professor, Department of Emergency Medicine
- Johns Hopkins University
- Robert S Hoffman, MD
Robert S Hoffman, MD
- Professor of Emergency Medicine
- Director, Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine
- New York University School of Medicine
Opiates, extracted from the poppy plant (Papaver somniferum), have been used recreationally and medicinally for millennia. Opiates belong to the larger class of drugs, the opioids, which include synthetic and semi-synthetic drugs, as well.
The Drug Abuse Warning Network in the United States estimates there were 162,137 heroin-related emergency department visits and 37,007 unspecified opiate-related emergency department visits in 2004 . In addition to opioid overdose, a significant number of these visits related to opioid withdrawal.
This topic review will discuss the clinical features and management of opioid withdrawal in the emergency setting. A summary table to facilitate emergency management is provided (table 1). Discussions of opioid withdrawal during detoxification treatment, opioid intoxication, opioid withdrawal in neonates, and general management of the poisoned patient are found elsewhere. (See "Medically supervised opioid withdrawal during treatment for addiction" and "Acute opioid intoxication in adults" and "Neonatal abstinence syndrome" and "General approach to drug poisoning in adults".)
PHARMACOLOGY AND CELLULAR TOXICOLOGY
Repeated, regular use of opioids produces tolerance that predisposes an individual toward withdrawal. Chronic opioid exposure causes adaptations that increase excitability in neurons in the locus ceruleus, the major noradrenergic center in the brain. The presence of opioids brings these neurons toward their normal firing rates .
The vast number of opioids precludes presenting pharmacokinetic data for each one here. A few clinically important generalizations can be made. The majority of opioids have volumes of distribution of 1 to 10 L/kg, which makes removal of a significant quantity of drug by hemodialysis impossible. They have variable protein binding (from 89 percent for methadone to 7.1 percent for hydrocodone) and are renally eliminated. Many opioids are metabolized to active metabolites. Examples include hydrocodone (metabolized to hydromorphone by Cytochrome [CY] P2D6) and morphine (metabolized to morphine-6-glucuronide). Cytochrome P polymorphisms cause variations in clinical effect.
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- PHARMACOLOGY AND CELLULAR TOXICOLOGY
- CLINICAL FEATURES OF OPIOID WITHDRAWAL
- Physical examination
- DIFFERENTIAL DIAGNOSIS
- LABORATORY EVALUATION
- Withdrawal from interruption in opioid use
- - Opioid agonist therapy
- - Buprenorphine
- Withdrawal due to opioid antagonist and other circumstances not amenable to treatment with opioid agonist
- - Non-opioid adjunctive medications
- Treatment of symptoms
- Ultrarapid opioid detoxification
- ADDITIONAL RESOURCES
- NEONATAL AND PEDIATRIC CONSIDERATIONS
- Neonatal withdrawal
- Pediatric withdrawal
- SUMMARY AND RECOMMENDATIONS