Opioid withdrawal (peds) - Revision history

Danbot: Add MedicationDose entries for clonidine, methadone

2026-03-20T21:04:58Z

Add MedicationDose entries for clonidine, methadone

@@ Line 94: / Line 94: @@
 *Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
 *Dose: 10mg IM or 30mg PO
 ==Disposition==

Ostermayer at 20:56, 17 January 2026

2026-01-17T20:56:01Z

← Older revision		Revision as of 20:56, 17 January 2026
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	*Dosing: 0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms		*Dosing: 0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms
	**Major adverse effect is hypotension		**Major adverse effect is hypotension
	*Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release~~{{Citation needed\|reason=Reliable source needed\|date=March 2016}}~~		*Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release

	===[[Lofexidine]]===		===[[Lofexidine]]===

Ostermayer at 20:54, 17 January 2026

2026-01-17T20:54:45Z

← Older revision		Revision as of 20:54, 17 January 2026
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	{{~~PediatricPages~~\|Opioid withdrawal}}		{{PediatricPage\|Opioid withdrawal}}
	==Background==		==Background==
	*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)

Ostermayer at 20:54, 17 January 2026

2026-01-17T20:54:31Z

← Older revision		Revision as of 20:54, 17 January 2026
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	{{~~Peds top~~}} ~~[[Opioid withdrawal]]''~~		{{PediatricPages\|Opioid withdrawal}}
	==Background==		==Background==
	*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)

Rossdonaldson1: Text replacement - "opiod" to "opioid"

2023-10-18T17:24:44Z

Text replacement - "opiod" to "opioid"

← Older revision		Revision as of 17:24, 18 October 2023
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	===Adult Opioid Withdrawal===		===Adult Opioid Withdrawal===
	*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing ~~opiod~~ withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>		*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing opioid withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>
	*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more		*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more
	*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days		*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
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	*'''Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''		*'''Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''
	*'''Altered mental status is also not part of ~~opiod~~ withdrawal signs'''		*'''Altered mental status is also not part of opioid withdrawal signs'''

	==Differential Diagnosis==		==Differential Diagnosis==

Rossdonaldson1 at 19:20, 4 October 2023

2023-10-04T19:20:20Z

← Older revision		Revision as of 19:20, 4 October 2023
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	{{Peds top}} [[Opioid withdrawal ~~(peds)~~]]''		{{Peds top}} [[Opioid withdrawal]]''
	==Background==		==Background==
	*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)		*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)

Rossdonaldson1: Created page with "{{Peds top}} Opioid withdrawal (peds)'' ==Background== Natural derivatives (Opiates): Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS) Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS) *Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine) Olmedo R, Hoffman RS. Withdrawal syndromes...."

2023-10-04T19:19:58Z

Created page with "{{Peds top}} Opioid withdrawal (peds)'' ==Background== *Natural derivatives (Opiates): Heroin, Morphine, Codeine, Hydrocodone, Oxycodone (+ UDS) *Synthetic: Fentanyl, Hydromorphone, Buprenorphine, Methadone, Meperidine, Dextromethorphan (- UDS) *Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes...."

New page

{{Peds top}} [[Opioid withdrawal (peds)]]''
==Background==
*Natural derivatives (Opiates): [[Heroin]], [[Morphine]], [[Codeine]], [[Hydrocodone]], [[Oxycodone]] (+ UDS)
*Synthetic: [[Fentanyl]], [[Hydromorphone]], [[Buprenorphine]], [[Methadone]], [[Meperidine]], [[Dextromethorphan]] (- UDS)
*Opioid withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. [[buprenorphine]]) <ref> Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88. </ref> or as a result of cessation of use
*Symptoms are usually uncomfortable but not life-threatening and manifest with agitation and restlessness but '''does not cause altered mental status'''
*Symptoms may resemble those of [[Influenza]] <ref> Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95 </ref>
**Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
**Withdrawal can be life-threatening in neonates

===Adult Opioid Withdrawal===
*[[Heroin]]: onset 6-12 hours, peak 24-72 hours, duration 7-10 days<ref>Herring, A et al. Managing opiod withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine. 2019.73(5) 481-487</ref>
*[[Methadone]]: onset 24-72 hours, peak 4-6 days, duration 14 days or more
*[[Fentanyl]]: onset 2-5 hours, peak 8-12 hours, duration 4-5 days
*[[Buprenorphine]]: 4-48 hours, peak 96 hours, duration 14-21 days

===Precipitated Withdrawal===
*[[Naloxone]]: onset 1-3 min, duration: 30-60min
*Butorphanol or nalbuphine: 15 min, duration: 90 min
*[[Naltrexone]]: 15-30min, duration 12-24hours
*[[Buprenorphine]]: 10-15min, duration 12-24 hours

===Neonatal Opioid Withdrawal===
*[[Heroin]]: onset within 24hrs
*[[Methadone]]: onset within 2-3 days due to large volume of distribution<ref>Doberczak TM et al. Relationship between maternal methadone dosage, maternal-neonatal methadone levels, and neonatal withdrawal. Obstet Gynecol. 1993. 81:936–940.</ref>
*[[Buprenorphine]]: onset within 2-3 days

==Clinical Features==
Time to peak and duration of symptoms depends on the half-life of the drug involved
===Early symptoms===
*Agitation/restlessness
*[[Anxiety]]
*Muscle aches
*Increased tearing
*Insomnia
*Runny nose
*Sweating
*Yawning
*Skin-Crawling
*May be tachycardic and/or tachypneic but not necessarily

===Late symptoms===
*Abdominal cramping
*[[Diarrhea]]
*Dilated pupils
*Goose bumps
*[[Nausea]]
*[[Vomiting]]

*'''Unlike [[alcohol]] or [[benzodiazepine]] withdrawal, patients rarely have seizures'''
*'''Altered mental status is also not part of opiod withdrawal signs'''

==Differential Diagnosis==
''Differential is largely based on clinical symptoms and history''
*[[Sepsis]]
*[[Influenza]]
*[[Clonidine]] withdrawal
*[[Sympathomimetic]] use

{{Sedative/hypnotic withdrawal types}}

==Evaluation==
*Clinical diagnosis
**Consider [[urine toxicology screen]] and BMP if signs of dehydration
**Clinical Opiate Withdrawal Score ([http://www.mdcalc.com/cows-score-for-opiate-withdrawal/ COWS]) can be used to determine severity

==Management==
''Treatment should include symptomatic treatment as well as discussing medications for opioid use disorder including methadone and buprenorphine. Buprenorphine should be offered to be initiated in the emergency department to patients who are interested and meet criteria for initiation, and linkage to care should be facilitated.'' <ref> Hawk K, Hoppe J, Ketcham E, LaPietra A, Moulin A, Nelson L, Schwarz E, Shahid S, Stader D, Wilson MP, D'Onofrio G. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med. 2021 Sep;78(3):434-442. doi: 10.1016/j.annemergmed.2021.04.023. Epub 2021 Jun 23. PMID: 34172303. </ref>

===Supportive Care===
*PO/IV hydration
*Electrolyte repletion
===Opioid replacement===
*Opioid administration such as [[morphine]] can be given as needed for symptom control

===[[Clonidine]]===
*A central α<sub>2</sub> agonist that does suppress the sympathetic hyperactivity that results during acute withdrawal
*Dosing: 0.1mg PO (or 5mcg/kg PO if SBP >90 mmHg) every 60 minutes as needed for sympathetic symptoms
**Major adverse effect is hypotension
*Clonidine patches are not useful for acute withdrawal due to the 24hr delayed release{{Citation needed|reason=Reliable source needed|date=March 2016}}

===[[Lofexidine]]===
*A newer central alpha<sub>2</sub> agonist

===[[Buspirone]]===
*Generally reserved for outpatient therapy
*Decreases serotonergic activity<ref>Van den Brink W et al. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry 2006; 51:635.</ref>

===[[Benzodiazepines]]===
*Can be added along with with clonidine for adequate sedation
===[[Antihistamines]]===

===[[Methadone]]===
*Consider if withdrawal was precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given
*Dose: 10mg IM or 30mg PO

==Disposition==
*Patients who need long term detoxification can be admitted or transferred to detox facilities
*If patients are going to continue to use opioids then those who are stable can be discharged
*Patients with severe withdrawal requiring sedation and continued monitoring should be admitted

==External Links==

==See Also==
*[[Neonatal abstinence syndrome]]
*[[Opioid toxicity]]
*[[Harbor:Opiate Withdrawal/MAT/BUP]]

==References==
<references/>

[[Category:Toxicology]]