Opioid withdrawal syndrome

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Classification according to ICD-10
F11.3 Withdrawal syndrome from opioids
ICD-10 online (WHO version 2019)

The opioid withdrawal syndrome (inaccurate: opiate withdrawal syndrome ) is defined as a group of symptoms defined, the (complete) by absolute or relative (e.g., by reducing the dosage.) Withdrawal of opioids after prolonged consumption occur. This is a (not absolutely necessary) criterion for diagnosing addiction to opioids .

frequency

It is difficult to estimate how many opioid withdrawals are voluntary “ cold withdrawal ” and how often involuntary withdrawals occur outside of the inpatient area or from correctional facilities . There is also a lack of reliable data on the severity of the symptoms that occur. As a rule, in the latter case, the person concerned will consume more of the substance, provided he has the financial means, or fall back on higher-quality substance if the opportunity exists.

course

When withdrawing from heroin , the symptoms peak 36 to 72 hours after the last dose. Untreated ("cold") withdrawal is only very rarely life-threatening, but there have been reports of serious complications and deaths in connection with various withdrawal techniques ( see : Forced opioid withdrawal under anesthesia ). In addition, patients hospitalized for acute illness (such as endocarditis or psychosis ) may experience complications that require immediate action. In principle, doctors should be able to recognize an impending opioid withdrawal syndrome, also in order to be able to initiate treatments that justify inpatient admission or to prevent the patient from self-discharge from the hospital in a targeted and situation-specific manner.

Withdrawal with the help of buprenorphine is experienced as milder than that of methadone . The consequences for the substitution therapy are that many patients want to switch from methadone to buprenorphine before the final withdrawal or prefer the latter from the outset. However, withdrawal from substances with a long half-life such as methadone or buprenorphine usually takes longer than heroin withdrawal.

Withdrawal manifests itself through flu-like symptoms such as diarrhea , vomiting , cold sweat, dizziness , tremors , bad mood , anxiety , sleep disorders , persistent substance craving and is particularly painful. Often the occurrence of restless legs syndrome is described, which is described as extremely uncomfortable. It can also lead to depression . This condition can last up to 2 weeks, of which the first 3 days are the worst. The desire can persist for up to 6 months and longer. However, this finding can also be observed after withdrawal from other psychotropic substances and is therefore not only opioid-specific. The withdrawal should still be controlled and carried out in a planned manner through consultation with the doctor, addiction counseling center, etc.

The influence of the duration and extent of pre-existing heroin use on the severity of a withdrawal syndrome is stated contradictingly. On the one hand, there are studies that prove a connection, on the other hand, studies that deny a connection or show no influence on the duration of withdrawal treatment.

evaluation

A series of assessment sheets enables the degree of intensity of an opiate withdrawal syndrome to be ascertained by summarizing individual symptoms (objective findings or subjective complaints) by determining a number of points:

Degree Symptoms Hours after the last heroin injection
0 Opiate hunger (“craving”); Anxiety, restlessness 4th
1 Yawning, sneezing, sweating, runny nose, lacrimation 8th
2 Mydriasis , goose bumps , tremors , hot flashes, loss of appetite, muscle and bone pain - especially in the lower extremities and lumbar region 12
3 Pronounced muscle and bone pain. Fever, nausea; Insomnia. Increase in blood pressure , accelerated heartbeat and accelerated breathing 18-24
4th painful muscle spasms; Excessive sweating , vomiting and diarrhea can lead to life-threatening shock symptoms due to pronounced fluid loss and electrolyte imbalance

(to:)

Withdrawal symptoms in substitution treatment

Methadone

Even if the administration of ( racemic ) methadone as part of a substitution treatment is intended to stabilize opioid-dependent patients (and usually also stabilizes it), some show clear withdrawal symptoms towards the end of the 24-hour dosing interval. Relatively small decreases in the methadone concentration in the plasma can lead to a relatively pronounced impairment of mood. The cause could be unintended effects of the S - enantiomer (the right-handed form), so a switch to levomethadone (the left-handed enantiomer) or another alternative should be considered in the case of pronounced symptoms.

Buprenorphine

The same applies to buprenorphine . In contrast to other substitution drugs, treatment with buprenorphine does not allow you to take any other opiates, as buprenorphine as a partial agonist would cause a withdrawal syndrome, which is why you have to wait so long when switching to this drug until the previous opiate no longer works.

Individual evidence

  1. ↑ Steven B. Karch, MD, FFFLM: Addiction and the Medical Complications of Drug Abuse . CRC Press, October 9, 2007, ISBN 978-1-4200-5444-6 , p. 25.
  2. ^ Richard P. Mattick et al: Pharmacotherapies for the Treatment of Opioid Dependence: Efficacy, Cost-Effectiveness and Implementation Guidelines . In: Informa , 2009
  3. ^ Warren K. Bickel, Leslie Amass, Buprenorphine treatment of opioid dependence: A review. In: Experimental and Clinical Psychopharmacology , Volume 3 (4), November 1995, pp. 477-489, doi: 10.1037 / 1064-1297.3.4.477
  4. ↑ Nicholas Seivewright, assisted by Mark Parry: Community Treatment of Drug Misuse: More Than Methadone . Cambridge University Press, 2009
  5. ↑ C. Fundarò, A. Solinas, AM Martino, O. Genovese, G. Noia, GL Conte, G. Segni: Neonatal abstinence syndrome and maternal toxicological profile. In: Minerva pediatrica. Volume 46, Number 3, March 1994, pp. 83-88, PMID 8035762 , ISSN  0026-4946 .
  6. ↑ M. Smolka, LG Schmidt: The influence of heroin dose and route of administration on the severity of the opiate withdrawal syndrome . (PDF; 701 kB) In: Addiction , 1999 Aug, 94 (8), pp. 1191–1198.
  7. ↑ GT Phillips, M. Gossop, B. Bradley: The influence of psychological factors on the opiate withdrawal syndrome . In: Br J Psychiatry , 1986 Aug, 149, pp 235-238, PMID 3779283 .
  8. ↑ A. Glasper, M. Gossop, C. de Wet, L. Reed, J. Bearn: Influence of the dose on the severity of opiate withdrawal symptoms during methadone detoxification . In: Pharmacology . 2008, 81 (2), pp. 92-96, PMID 17952010 . Epub 2007 Oct 19.
  9. ↑ Modified Objective Opiate Withdrawal Scale ( Memento of September 7, 2012 in the Internet Archive ) (PDF)
  10. ↑ Freye: Opioids in Medicine . 8th edition Springer, 2010
  11. ↑ Substitution therapy for opiate addiction . ( Memento of the original from October 4, 2013 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 49 kB) NÖGKK Therapy Tips No. 30, September 2004 @1@ 2Template: Webachiv / IABot / www.noegkk.at
  12. ↑ KR Dyer, JM White, DJ Foster, F Bochner, A Menelaou, AA. Somogyi: The relationship between mood state and plasma methadone concentration in maintenance patients . In: J Clin Psychopharmacol . , 2001 Feb, 21 (1), pp. 78-84, PMID 11199952 .
  13. ↑ Timothy B Mitchell, Kyle R Dyer et al .: Subjective and physiological responses among racemic-methadone maintenance patients in relation to relative (S) - vs. (R) -methadone exposure . In: Br J Clin Pharmacol . , 2004 December, 58 (6), S., PMID 609-617, doi: 10.1111 / j.1365-2125.2004.02221.x , PMC 1884641 (free full text).