Managing Opioid Withdrawal

Managing Opioid Withdrawal

 

Managing Opioid Withdrawal

Office-based buprenorphine/naloxone is an approach for treating withdrawal without the need for admission to a medical or rehabilitation facility. Before initiating the treatment, the family and the patient must agree and understand the treatment goals. The office-based buprenorphine/naloxone treatment is referred to as induction. The plan is based on The Patient Experience Evidence Research (PEER) guideline for opioid withdrawal treatment. Before starting the induction process, the patient must stay away from opioids for at least 12-24 hours and, if possible 24-36 hours (Korownyk et al., 2019). The plan for the 2-year-old patient will initially involve a 2-day induction program with constant monitoring as follows:

Day 1: Give 4mg/1mg of buprenorphine/naloxone.

Place the patient under monitoring and after 1 hour, evaluate any withdrawal symptoms.

The patient may note feeling better, no change, or worse than before starting the induction. If the patient feels worse, there are three options: stopping the induction and continuing the next day, proceed with the induction, or treating the symptoms with medication (Korownyk et al., 2019). The input of the patient and family will be taken into consideration when making a choice. Respect for the patient’s autonomy is paramount to the success of the treatment. On the other hand, if the patient states no change in withdrawal symptoms, another dose of 4mg/1mg of buprenorphine/naloxone will e given in 1-3 hours with continued observation for side effects. If the patient reports that the withdrawal symptoms have subsided, the treatment will continue on day 2.

Day 2: 4mg/1mg of buprenorphine/naloxone

On day 2, if the patient states that the withdrawal symptoms have persisted, dosage increase will be considered while taking precautions not to exceed 24 mg/6 mg per day. However, if the withdrawal symptoms are absent, the patient will be given the same dose as day 1. During the treatment, if the patient expresses the desire to take a break, he will be allowed.

Psychosocial treatment plan

While Opioid Agonist Therapy is an effective treatment for opioid addiction, psychosocial intervention is always necessary to enhance the effectiveness and sustainability of the treatment outcomes (Ray et al., 2020). For the patient in this scenario, the treatment will incorporate psychosocial interventions. First, the option to integrate psychotherapy will be discussed with the patient and family and agreed upon. The treatment can only be initiated if the patient provides consent and willingness.

The treatment plan will apply cognitive behavioral therapy as the psychotherapy approach to working with the patient. CBT is an evidence-based psychotherapy modality that works with a range of behavioral and mental health issues (Ray et al., 2020). CBT therapy aims to enhance functioning and promote quality of life. CBT helps individuals change their thinking patterns and adopt healthy coping skills to navigate through life’s challenges.

Taper schedule for a patient taking alprazolam

Long-term use of benzodiazepines can lead to adverse health outcomes, including physiologic and psychological dependence leading to tolerance. Withdrawal from the medications also becomes challenging despite reduced effectiveness after long-term use. Patients using short-acting alprazolam encounter rebound symptoms, leading to dose escalation to achieve temporary relief. This results in safety concerns, tolerance, physiologic dependence, and withdrawal (Ogbonna & Lembke, 2017). Abrupt withdrawal of benzodiazepines can present severe health complications. Evidence supports tapering as an effective approach to weaning-off benzodiazepines in patients who have used the medications for an extended period (Ogbonna & Lembke, 2017).

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First, patient education will be necessary to understand the risks and benefits of the continued use of alprazolam. The tapering approach will be replacing alprazolam with a longer-acting equivalent, diazepam (40 mg). The following 15-week schedule coupled with psychological support will be used for the patient.

Week 1		Starting doze of diazepam 35 mg
Week 2	Reduce by 25%	30 mg
Week 3	Reduce by 25%	25 g
Week 4	Reduce by 25%	20 mg
Week 5-6	Same dose	20 g
Week 9	Reduce by 25%	15 mg
Week 10-11	Hold dose	15 mg
Week 12	25%	10 mg
Week 13	25%	5 mg
Week 14	25%	0 mg
Week 15		Wean off

 

 

References

Korownyk, C., Perry, D., Ton, J., Kolber, M., Garrison, S., Thomas, B., . . . Bateman, C. (2019). Managing opioid use disorder in primary care: PEER simplified guideline. Can Fam Physician. Erratum in: Can Fam Physician, 65(5), 321-330.

Ogbonna, C., & Lembke, A. (2017). Tapering Patients Off of Benzodiazepines. Am Fam Physician, 96(9), 606-610.

Ray, L., Meredith, L., Kiluk. BD, Walthers, J., C. K., & Magill, M. (2020). Combined Pharmacotherapy and Cognitive Behavioral Therapy for Adults With Alcohol or Substance Use Disorders: A Systematic Review and Meta-analysis. JAMA Netw Open, 3(6):e208279. https://doi.10.1001/jamanetworkopen.2020.8279.

The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.

Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation.
Include your rationale for each treatment decision
Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions.
Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time.