Tips for Reducing Opioid Withdrawal Symptoms: A Clinical Commentary

man in dark room depressed
man in dark room depressed
Clinicians are reducing or discontinuing opioid therapy for patients in light of the 2016 guidelines for opioid prescribing by primary care physicians issued by the CDC.

The following article is part of conference coverage from the PAINWeek 2018 conference in Las Vegas, Nevada. Clinical Pain Advisor’s staff will be reporting breaking news associated with research conducted by leading experts in pain medicine. Check back for the latest news from PAINWeek 2018.

LAS VEGAS — When tapering a dependent patient off opioids, it is best to gradually reduce dosages to decrease chances of withdrawal symptoms, but this is not always possible in the clinical setting. During the 2018 PAINWeek conference, held September 4-8, presenters discussed their expert opinions and literature review of beneficial clinical recommendations in dealing with opioid withdrawal symptoms in a realistic medical setting.

Opioid withdrawal symptoms are currently a widespread concern, as many physicians are tapering patients with chronic pain off the drugs. This issue is likely going to increase with the current Center for Disease Control and Prevention guidelines restricting opioid prescriptions by primary care physicians.

Opioid use decreases noradrenaline by inhibiting the production of cyclic adenosine monophosphate in the locus coeruleus. When opioids are discontinued too rapidly, circulating noradrenaline increases quickly, leading to withdrawal symptoms such as anxiety, agitation, nausea, vomiting, and extreme craving for more narcotics. These symptoms can arise 24 to 48 hours after terminating opioid use and can continue up to a week. The Clinical Opiate Withdrawal Scale is used to categorize and evaluate the symptoms.

The authors of this abstract performed a detailed literature review commenting on the current landscape of opioid withdrawal, their professional experience, and real-world clinical recommendations. 

Withdrawal symptoms can be controlled through pharmacological therapy such as clonidine, lofexidine, or specific medication for the particular ailment (ie, anti-inflammatory medications for muscle pain). Nonpharmacological treatments such as transcutaneous electrical stimulation can also be used.  Another withdrawal management theory is to reduce the number of mu-opioid receptors available by using alternative opioids such as buprenorphine or methadone. 

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An opioid maintenance program rotates opioids to slowly taper and wean the patient off the drug and is most effective when it can be tailored to each patient. Psychological and counseling support also play an important function in managing the psychological effects of symptoms, rehabilitation programs, and detoxification protocols.

In conclusion, tapering strategies work best with a variety of therapies, whether pharmacological or nonpharmacological, a support system, and a compliant patient. 

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Pergolizzi J Jr, Rosenblatt M, Mariano D, Colucci R. Clinical tips for managing withdrawal in opioid patients. Abstract 53. Presented at: PAIN Week 2018; September 4-6, 2018; Las Vegas NV. doi: 10.1080/00325481.2018.1512253.

For more coverage of PAINWeek 2018, click here.