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Opioid withdrawal management during treatment for addiction

INTRODUCTION

Humans have used opiates (substances derived from opium) for pain relief and pleasure for millennia. Opioids include both natural and synthetic agents (eg, heroin) with properties similar to opium. In recent decades, opioid abuse and withdrawal have become a major international public health problem. As the availability and purity of heroin and other opioids has increased, so has the number of emergency department visits for opioid overdose and withdrawal [1,2]. According to the Drug Abuse Warning Network of the United States (US) Federal government, opioids are implicated in more drug-related deaths than any other illicit agent [2].

The diagnosis and management of opioid withdrawal will be reviewed here, focusing on management in the course of treatment for drug addiction. The management of unplanned withdrawal in the emergency department and issues related to chronic opioid abuse and opioid intoxication are discussed separately. (See "Opioid withdrawal in the emergency setting" and "Heroin and other opioids: Management of chronic use" and "Opioid intoxication in adults".)

OPIOID WITHDRAWAL

Symptoms of opiate withdrawal — Tolerance and physical and psychologic dependence on opioids usually occur after three weeks of daily usage. Higher tolerance is created as the user decreases the interval and increases the dose to achieve euphoria. Tolerance does not develop to the miotic effects or constipation.

Although all opioids can cause addiction, heroin has the greatest addictive potential (reinforcement). Heroin provides a "rush" because it easily crosses the blood brain barrier leading to rapidly elevated central nervous system (CNS) levels.

The discontinuation of opioids leads to a constellation of withdrawal symptoms known as the abstinence syndrome (table 1). The severity of its symptoms depends upon the type and frequency of the drug used. The withdrawal syndrome usually occurs if opioid use is discontinued after several months of steady use.
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