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skeller - (7/30/2018 2:08:18 PM)
July 2018: Treating withdrawal symptoms?

Question: Our jail is getting more and more entering who are in withdrawal from opioids. Authorities have reassured us that nobody has ever died withdrawing from opioids so we provide little in the way of medical treatment. Should we be doing more?

Answer #1: Yes, people can and do die in jails across the country from acute opioid withdrawal. As an experienced emergency physician who works in Idaho's jails, Dr. Jeffrey Keller, writes in Jail Medicine:

It is a myth to believe that no one ever dies during withdrawal.” He goes on to describe: “Think of the situation of heroin withdrawal this way: No one disputes that patients can get very sick when going through heroin withdrawal. And maybe young and healthy patients can tolerate being that sick with no lasting problems. But what about someone who isn’t that healthy to begin with? Say someone who has asthma and heart disease? Or maybe they have an underlying sepsis acquired from sharing needles? What if this patient is also malnourished and dehydration from not eating? Could such a person already weakened by these conditions end up dying when the physiological stress of withdrawal is piled on? Of course they could!”[1]

Answer #2: It is also a myth that the pain of cold turkey detox convinces addict not to use again.  The World Health Organization provides some wise guidance in its clinical guidelines for withdrawal management.  The Guidelines begin by stating that while detoxification does not prevent relapse, “providing withdrawal management in a way that reduces the discomfort of patients and shows empathy for patients can help to build trust between patients and treatment staff of closed settings.”

The FDA this year approved the first non-opioid medication for opioid withdrawal called Lofexidine to ameliorate many of the symptoms of withdrawal. Another medication, clonidine, has also been found effective for ameliorating withdrawal symptoms. Following are what research suggests about these medications for withdrawal.

Comparisons of methadone tapering, clonidine, lofexidine, and other medications Twenty-six randomized controlled trials involving 1,728 participants compared alpha2-adrenergic agonists (clonidine, Iofexidine, guanfacine and tizanidine) with a placebo or with methadone tapering. The studies found the agonist medications were significantly more effective than placebo in ameliorating withdrawal in terms of the likelihood of severe withdrawal and completion of treatment was significantly more likely. The research also found insignificant differences in symptom severity in comparison to methadone tapering. Although peak withdrawal severity may be greater with the agonist medications, the signs and symptoms of withdrawal occurred and resolved earlier with these medications than with methadone.  Researchers concluded: “Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone. We detected no significant difference in efficacy between treatment regimens based on clonidine or lofexidine and those based on reducing doses of methadone over a period of around 10 days, but methadone was associated with fewer adverse effects than clonidine, and lofexidine has a better safety profile than clonidine.”[2]