CURRENT Essentials of Critical Care.pdf

Chapter 16 Toxicology 237■■■Opioid WithdrawalEssentials of Diagnosis• Early symptoms include lacrimation, rhinorrhea, perspiration,yawning; later see restlessness, piloerection, mydriasis, insomnia,nausea, vomiting, abdominal cramps, diarrhea• Can see hyperthermia and hypertension in severe cases• Frequently see intense drug craving• Symptoms develop when opioid stopped or opiate antagonistadministered; timing of symptom onset depends on half-life ofopioid• For heroin, onset of withdrawal symptoms 6 hours after lastdose, peak withdrawal symptoms 36–48 hours after last dose,resolution of withdrawal by 4–5 days• For methadone, onset of withdrawal symptoms 2–3 days afterlast dose, with withdrawal resolution after 2 weeks• Sudden onset of withdrawal can be precipitated by administrationof naloxone to opiate-dependent patientsDifferential Diagnosis• Ethanol withdrawal• Benzodiazepine withdrawalTreatment• IV fluids, particularly if there is vomiting and diarrhea• Control withdrawal symptoms with long-acting opioid such asmethadone, 10 mg intramuscularly initially, which is often adequateto control withdrawal symptoms; additional doses administeredhourly until symptoms subside, usually 20–40 mg• Clonidine, 0.1–0.2 mg every 6 hours can be used to treat mildopioid withdrawal■ PearlPatients with pure opioid withdrawal maintain normal mental status.Therefore, altered mental status should prompt a search for other factorscontributing to the patient’s condition.ReferenceJenkins DH: Substance abuse and withdrawal in the intensive care unit. Contemporaryissues. Surg Clin North Am 2000;80:1033. [PMID: 10897277]