FEATURE
drawal symptoms
(Ref 11: ASAM National Practice Guideline, Part 3,
pg 29)
ii. Consider prescribing prescription medications for
withdrawal (Ref 11: ASAM)
d. If tapering benzodiazepines, do so gradually
i. No more than 25 percent decrease every one to two
weeks
ii. Abrupt benzodiazepine withdrawal can be associated
with rebound anxiety, hallucinations, seizures, delirium
tremens, and, in rare cases, death.
e. Risk mitigation topics (https://bit.ly/2eb0bYe)
i. Discuss with patients undergoing tapering that, be-
cause their tolerance to medications may return to nor-
mal, they are at increased risk for overdose on abrupt
return to previously prescribed higher doses.
ii. Consider offering naloxone when factors that increase
risk for opioid overdose, such as history of overdose,
history of substance use disorder, higher opioid dosages
(≥50 MEDD/day), or concurrent benzodiazepine use,
are present (Ref 12: Opioid Reversal With Naloxone,
NIDA)
REFERENCES:
1. Clinical Opiate Withdrawal Scale https://bit.ly/1UlTHV1
2. Knowing When to Say When: Transitioning Patients from Opioid Therapy
University of Massachusetts Medical School (Massachusetts Consortium) Jeff
Baxter, M.D. April 2, 2014 https://bit.ly/2w7jOHO
3. PEG Scale (Pain, Enjoyment, General Activity) http://https://bit.ly/2MqhB4n
4. Opioid Risk Tool (ORT) https://bit.ly/1Nnwj84, https://bit.ly/2Beoa5M
5. Patient Health Questionnaire (PHQ 4) https://bit.ly/2L05Z3y
6. National Institute on Drug Abuse (NIDA) Sample Informed Consent Form
https://bit.ly/2MOBP4Q
7. National Institute on Drug Abuse (NIDA) Sample Patient Agreement Forms
https://bit.ly/2CF0fJF
8. CDC: Treating Chronic Pain Without Opioids https://bit.ly/2Mk5ZAH
9. CDC: Opioid Factsheet for Patients https://bit.ly/2Ivdez1
Other Patient Education Resources: https://bit.ly/2KTWqDa, https://bit.ly/2n-
FHjnH, https://bit.ly/2nENcS3
10. Calculating Total Daily Dose of Opioids For Safer Dosage (CDC) https://bit.
ly/2eY5bxw
11. American Society of Addiction Medicine National Practice Guideline for the
Use of Medications in the Treatment of Addiction Involving Opioid Use, Part
3: Treating Opioid Withdrawal, Summary of Recommendations (7), page 29.
https://bit.ly/2tbSGcj
The Guideline Committee recommends, based on consensus opinion, the inclusion
of clonidine as a recommended practice to support opioid withdrawal. Clonidine
is not US FDA-approved for the treatment of opioid withdrawal, but it has been
extensively used off-label for this purpose. Clonidine may be used orally or
transdermally at doses of 0.1–0.3 mg every 6–8 hours, with a maximum dose
of 1.2 mg daily to assist in the management of opioid withdrawal symptoms.
Its hypotensive effects often limit the amount that can be used. Clonidine can
be combined with other non-narcotic medications targeting specific opioid with-
drawal symptoms such as benzodiazepines for anxiety, loperamide for diarrhea,
acetaminophen or NSAIDs for pain, and ondansetron or other agents for nausea.
12. Opioid Reversal With Naloxone (NIDA) https://bit.ly/2y0qLgy
ADDITIONAL RECOMMENDED REFERENCES:
a. CDC Checklist for Prescribing Opioids for Chronic Pain https://bit.ly/2Lq3p-
bV
b. Universal Precautions Revisited: Managing the Inherited
Pain Patient by Douglas L. Gourlay, MD, MSc, FRCPC, FASAM,* and Howard
A. Heit, MD, FACP, FASAM. Published in Pain Medicine Volume 10 • Number
S2 • 2009 https://bit.ly/2MMU5vw
c. SAMHSA Behavioral Health Treatment Services Locator
https://findtreatment.samhsa.gov/
d. University of Wisconsin Pain and Policy Studies Database of Statutes,
Regulations, and Other Policies for Pain Management https://bit.ly/2ICIhc8
e. Knowing When to Say When: Transitioning Patients from Opioid Therapy
University of Massachusetts Medical School (Massachusetts Consortium) Jeff
Baxter, M.D. April 2, 2014 https://bit.ly/2w7jOHO
f. The Pain Clinic Closure Survival Guide for Patients and Clinicians
https://bit.ly/2KWq2j5
g. DROPBOX Link for Reference Materials: https://bit.ly/2vMW8Jp
Disclaimer: This is for informational purposes only, does not constitute
medical advice or a patient/provider relationship. It is not meant to
establish a standard of care. I have made every effort to cite references
where applicable, however the opinions expressed are my own and
have not been endorsed by any organization. Links to references or
other materials are taken at your own risk. The content provided
here is not intended to be a substitute for professional medical advice,
diagnosis, or treatment. Always seek the advice of your physician or
other qualified health provider with any questions you may have
regarding a medical condition. Never disregard professional medical
advice or delay in seeking it because of something you have read on
this website. If you think you may have a medical emergency, call your
doctor, go to the emergency department, or call 911 immediately.
James Patrick Murphy, MD, MMM, FASAM is a board-certified pain
medicine and addiction medicine specialist who represents the American
Society of Addiction Medicine on the American Medical Association’s
newly formed Pain Task Force.
SEPTEMBER 2018
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