Opioid Withdrawal
Opiod Withdrawal
ICD-10 code: F11.23
DESCRIPTION
The illicit use of prescription medication and opioids in children and adolescents has risen significantly. Behavioural manifestations of withdrawal include anxiety, agitation, insomnia, and tremors. Physiological changes linked to withdrawal include increased muscle tone, nausea, vomiting, diarrhoea, decreased appetite, tachycardia, fever, sweating, and hypertension.
Most patients who take an opioid for less than a week do not experience withdrawal and can have their medication discontinued quickly.
However, a prevention approach is preferred for those exposed for longer than 14 days. These children will usually need to be weaned, by gradually decreasing the opioid dose with time.
The only validated tool to assess withdrawal symptoms in children is the Sophia Observation Withdrawal Symptoms Scale.
MEDICINE TREATMENT
Mild withdrawal may be managed as an outpatient.
Symptomatic treatment:
- Diazepam, oral.
- 6 - 14 years: 2 - 10 mg daily in 2 - 3 divided doses.
- > 14 years: up to 20 mg daily in 2 - 3 divided doses.
- Wean dose from 8 hourly, to 12 hourly, to daily every 3 - 5 days.
For stomach cramps:
- Hyoscine butyl bromide, oral.
- 1 - 3 years: 5 - 10 mg 8 hourly.
- 3 - 6 years: 10 mg 8 hourly.
- 6 - 18 years: 10 - 20 mg 8 hourly.
For diarrhoea:
- Loperamide, oral.
- Over 2 years: initially 1 mg/12.5 kg body mass, followed by 0.5 mg/12.5 kg after each loose stool. Alternatively, 0.08 - 0.24 mg/kg/day in 2 - 3 divided doses.
- 12 - 18 years: initially 4 mg, followed by 2 mg after each loose stool. Maximum dose of 6 mg in 24 hours.
The weaning protocol should take into account the length of opioid exposure and total daily opioid dose. The generally approach is to transition to a longer-acting opioid formulation, such as extended-release morphine. Weaning is usually accomplished by steps of a 10% to 20% decrease in the original dose every 24 to 48 hours.
- Morphine:
- Oral: 0.05 mg/kg/dose 3 hourly.
- IV: 0.02 mg/kg/dose 3 hourly.
Weaning after 48 hours: - Oral: 0.01 mg/kg/dose 3 hourly.
- IV: 0.005 mg/kg/dose 3 hourly.
For CNS disturbances (e.g. seizures):
- Phenobarbitone, oral.
- 5 mg/kg/dose 12 hourly or daily.
OR
- Phenytoin, oral.
- 5 mg/kg/day in 2 - 3 divided doses.
- Maximum dose: 300 mg daily.
- Maintenance dose: 5 - 8 mg/kg/day.
Patients with moderate to severe withdrawal should be admitted.
Substitution treatment is reserved for a specialist rehabilitation centre.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 14: Child & Adolescent Psychiatry, 14.13 Substance Use Disorder, 14.13.3 Substance Withdrawal, 14.13.3.3 Opioid Withdrawal