Treatment for Opioid Withdrawal 'Urgently Needed' to Keep Users Safe

Batya Swift Yasgur, MA, LSW

March 31, 2020

Treatment of opioid withdrawal, specifically, the widespread availability of buprenorphine, is urgently needed to keep users safe.

Investigators at the University of Southern California (USC), Los Angeles, found that opioid withdrawal is significantly associated with syringe sharing as well as nonfatal overdose, after controlling for confounders

"I think we should start treating people with opioid use disorder [OUD] for their frequent withdrawal symptoms rather than waiting until a 'quit attempt,' " lead investigator Ricky Bluthenthal, PhD, associate dean for social justice and professor, Department of Preventive Medicine, Institute for Prevention Research, Keck School of Medicine, USC, told Medscape Medical News.

"This urgently needed treatment should include buprenorphine, which, when made available to this patient population, will ultimately reduce their use of opioids and thereby improve health outcomes," he said.

The study was published online March 18 in Drug and Alcohol Dependence.

Risky Behavior

Individuals who are opioid dependent can experience withdrawal symptoms as soon as 4 to 6 hours after last use, the authors note.

Users may become more focused on obtaining opioids as an effective way to avoid withdrawal. This can result in unsafe practices, such as needle sharing, as well as fatal or nonfatal overdose, the researchers note.

"This study was motivated by the fact that we have known for a long time that people who have OUD experience mild to severe withdrawal symptoms when they stop using even for a short period of time," said Bluthenthal.

There have been "few studies done in community settings investigating how often it happens, how severe the symptoms, and whether they are related to health risks," he added.

The withdrawal symptoms examined in the study were not a consequence of quit attempts but rather the result of the daily challenge of needing to have opioids on board, said Bluthenthal.

The study included 814 injection drug users who reported regular opioid use of at least 12 uses in the past 30 days. Participants reported an average of 20.36 (SD, 14.20) years of use. The mean (SD) frequency of all drug use (injection and noninjection) during the past month was 231 (224.08).

Withdrawal symptoms during the past 6 months were reported by 85% of participants. Symptoms occurred an average of 46.01 (72.47) times.

A little more than a third (36%) of the participants reported experiencing withdrawal symptoms less than once a month; 29% reported monthly to almost weekly symptoms; 35% reported weekly to daily withdrawal symptoms; and more than half (57%) experienced "very painful" or "extremely painful" symptoms.

Younger age was associated with more frequent or severe withdrawal.

"We found that younger people — those under age 50 — were more likely to report withdrawal and that frequency of withdrawal was also associated with age," said Bluthenthal

"One reason may be that as people get older, they are typically better able to manage substance use, perhaps because they have more strategies, but we would need to look at this question more carefully to figure out what is going on to explain the age difference," he added.

Younger age was also associated with more episodes of withdrawal during the past 6 months, greater 30-day injection frequency, greater 30-day drug use, increased odds of weekly (or more frequent) rather than monthly (or less frequent) withdrawal symptoms, and more severe withdrawal pain.

Any opioid withdrawal was associated with syringe sharing and nonfatal overdose (adjusted odds ratio [AOR], 2.75; 95% confidence interval [CI], 1.52 – 5.00; and AOR, 1.71; 95% CI, 1.04 – 2.81, respectively). Weekly or more frequent withdrawal was also associated with nonfatal overdose (AOR, 1.94; 95% CI, 1.26 – 3.00).

In a separate model, "extremely painful" or "very painful" withdrawal symptoms were found to be associated with nonfatal overdose (AOR = 1.53; 95% CI, 1.08 – 2.16).

Impact of COVID-19

"All too often, what people with OUD are told is that they will be treated with buprenorphine only when they are in the process of trying to stop, rather than being told, 'Here's a medication that treats withdrawal, and you should take it when you are experiencing withdrawal,' " said Bluthenthal.

To date, he noted, medications to treat OUD have been more heavily regulated than opioids. He also pointed out that although primary care physicians can prescribe buprenorphine, "they have had to go through a buprenorphine waiver and training and additional paperwork, which have been impediments to making it available."

However, he said, because of the COVID-19 pandemic, the regulations regarding buprenorphine prescribing have been loosened in order to make it more widely available.

Moreover, said Bluthenthal, a new bill that was introduced into the House of Representatives and the Senate proposes removing the requirement of a Drug Enforcement Agency waiver.

"This is a population at elevated risk, since unhoused people cannot engage in the social distancing rules we are all trying to follow, so it is especially important to be able to take the medication home as a way to maintain the pathway to improvement," he said.

The investigators contend that further deregulation of buprenorphine will "make this valuable medication" more widely available to patients with OUD.

Better Health Outcomes

Commenting on the study for Medscape Medical News, Laurence M. Westreich, MD, associate professor of clinical psychiatry, Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School of Medicine, New York City, said that it "makes good sense clinically because the more buprenorphine is available, the better off our patients will be."

Westreich, who is also past president of the American Academy of Addiction Psychiatry, was not involved with the study. He noted that the correlation between opioid withdrawal symptoms and bad health outcomes cannot be regarded as "causal."

However, he agreed "100% with the authors' conclusion that it is important to treat withdrawal with buprenorphine because, once you treat it, you get better health outcomes across the board."

He noted that most clinicians who treat addiction know that "the way to draw people into treatment is to help them with the uncomfortable symptoms of withdrawal and to suggest that if they take buprenorphine for a few months, they won't feel the need to go back to using."

The research was supported by the National Institute on Drug Abuse of the National Institutes of Health. Bluthenthal and coauthors and Westreich have disclosed no relevant financial relationships.

Drug Alcohol Depend. Published online March 18, 2020. Abstract

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