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Page 33 of 34 Guideline

expectation of abstinence) is ineffective, yet it is still be safely done on an outpatient basis. Principles include
widely used. It has high rates of recurrent opioid use (up gradual decreases in the effects of opiates, either through
to 90% within 1 year), along with a likely sense of failure dose tapering and/or the use of agonists.
or shame in abstinence-focused contexts. Assisted opioid • Mild withdrawal reactions can be managed symptomatically,
withdrawal is often done as an in-patient procedure. with antidiarrhoeal, antinausea, anxiolytic and analgesic
Performing withdrawal management in < 30 days is not medication. Whilst clonidine can be used for its rapid
recommended. Withdrawal management should be adrenergic agonist effects on symptoms, the evidence
75
imbedded within/linked to intensive rehabilitation supporting this regimen is limited. Gradual down-titration of
services to minimise harms should the patient return to the relevant opioid or use of a less potent opioid, can be
use. Ideally, the option to switch a patient to OST should attempted in more severe situations.
be available if the patient is not able to achieve a goal of • Benzodiazepines have been associated with fatal overdoses
abstinence. in people with opioid dependency, and their use in the
• The selection of a substitute opioid is a clinical decision management of withdrawal is discouraged. Risks related
that is made together with the patient after due to return to the use of opioids after detoxification,
consideration of: prior response; medical or mental health particularly amongst people with a history of injecting,
comorbidities; possible drug interactions; side-effect include overdose as well as blood-borne infections.
profile; cost/accessibility; use of other drugs and patient
choice. Management of acute pain in opioid use
• Preparation of the patient for withdrawal symptoms is
important, and they should be motivated to start a disorders
treatment plan, with careful explanations of what they A careful history, physical examination and relevant
may experience. Withdrawal carries little medical risk but diagnostic studies to identify the cause of the acute pain are
can be very unpleasant. Nevertheless, most initiation can the essential first steps.

TABLE 5-A3: Assessment and management of acute pain in opioid use disorders. 82,138
Patients receiving OST Patients who are actively using opioids
• Often require high opioid doses because of tolerance. • The setting of acute pain is not the time to attempt detoxification.
• Patients on methadone maintenance therapy with acute pain should be treated for pain with opioid • Opioid users face stigma and discrimination and may not readily
or non-opioid medications as would be appropriate if they were not on methadone. disclose their opioid use.
• Use a non-judgemental screening tool to assess substance use.
• Baseline quantity of opioids being used may be difficult to ascertain.
Steps: Steps:
1. Confirm the patient’s outpatient daily OST dose and continue this dose. 1. Plan for inpatient opioid withdrawal management and initiate OST
2. Use multimodal analgesia, in appropriate combinations of short-acting opioid (as required), local with patient consent, as outlined earlier.
anaesthesia and adjuvant anti-inflammatory analgesics and paracetamol. 2. Be prepared to titrate opioid doses rapidly if initial doses are
3. Morphine (short-acting opioid) can be used safely. Doses are higher than in opioid-naïve patients and ineffective because of tolerance.
rapid titration may be needed. 3. Arrange outpatient follow-up for OST treatment and pain
4. Short-acting opioid analgesics should be given on a schedule (every 3–4 hours). management.
5. On discharge: Provide last methadone dose verification letter, clear instructions for pain management
and opioid taper (for pain). Encourage follow-up.
OST, opioid substitution therapy.

http://www.sajhivmed.org.za 116 Open Access