opioid withdrawal: a new look at medication options · opioid withdrawal symptoms. 1 other studies...

pioid dose reduction or transition to another opioid therapy often results in uncomfortable signs and symptoms of withdrawal. The sever-ity of these symptoms can fluctuate among patients, even among those with similar body mass index, gender, and dosage.

Several theories have been proposed regarding the contri-bution of noradrenergic pathways in the expression of opioid withdrawal.1 In the central nervous system, the major clus-tering of norepinephrine-producing neurons is in the locus coeruleus (LC). Levels of norepinephrine and its metabolites are altered during opioid dependence, resulting in somatic opioid withdrawal symptoms.1 Other studies have suggested that alterations in the density and sensitivity of alpha and beta adrenergic receptors plays a role.1 Still, others suggest that a mesolimbic dopaminergic system contributes to opioid

withdrawal symptomatology.2

In October, Practical Pain Management featured an article by Hymes et al on the use of percutaneous electrical neu-rostimulation to treat withdrawal symptoms.3 In this arti-cle, the authors examine pharmaceutical ways to attenuate withdrawal symptoms. By taking advantage of alpha- and beta- agonists and antagonist, clincians can provide faster tapers and less withdrawal symptoms—without adding a new medication to patients polytherapy.

Symptoms of Opioid WithdrawalOpioid receptor activation is mediated by 3 different opioid receptors: delta, kappa, and mu. Symptoms of opioid with-drawal may begin 8 to 10 hours after the last dose, depend-ing on the half-life and volume of distribution of the opi-oid (Table 1). The dosage form and route of administration

FEATURE

O

Opioid Withdrawal: A New LookAt Medication OptionsConcomitant use of central adrenergic agonists, and dopaminergic and serotonergic agents can minimize withdrawal symptoms.

Nabeela Ahmed, PharmD PGY-1 Pharmacy ResidentNew York University Langone Medical CenterNew York, New York

Randall Horlacher, BS, PharmDCommunity PracticeHarrisburg, Pennsylvania

Jeffrey Fudin, BS, PharmD, DAAPM, FCCP, FASHPClinical Pharmacy Specialist in Pain Management Director, PGY2 Pain & Palliative Care Pharmacy Pain Residency Samuel Stratton VA Medical CenterAlbany, New York

58 PracticalPainManagement.com | November 2015

can influence a drug’s pharmaco-kinetic parameters and the onset of withdrawal following cessation of the drug.

The majority of opioid withdrawal symptoms reflect increased activity of the autonomic nervous system (ANS). While hyperactivity of noradrenergic neurons within the LC has been asso-ciated with somatic symptoms of opi-oid withdrawal, it is also noteworthy that the LC is involved with various neurophysiologic functions,1 including learning processes and the emotions of anxiety and fear. For these reasons, it is thought that excessive activation of the LC noradrenergic neurons not only induces somatic symptoms of opioid

withdrawal but also causes the cogni-tive and emotional problems associated with withdrawal.

The initial phase of withdrawal includes acute symptoms such as lac-rimation, rhinorrhea, yawning, and sweating that may last 7 to 10 days as well as symptoms that occur later, such as restless sleep, weakness, chills, nau-sea and vomiting, muscle aches, and involuntary movements. The second-ary phase of withdrawal includes symp-toms such as hypotension, bradycardia, hypothermia, mydriasis, and decreased responsiveness of the respiratory sys-tem to carbon monoxide. The sec-ondary phase can last anywhere from 26 to 30 weeks.4

The Clinical Opioid Withdrawal Scale (COWS) is a tool used by cli-nicians to assess the degree of with-drawal a patient is experiencing based on current symptoms.5 The COWS reflects the assessment of 11 symp-toms:, vital signs (pulse), a brief phys-ical exam (pupil size, sweating, rest-lessness, runny nose or eye tearing, achiness, GI distress, tremor, yawn-ing, gooseflesh skin) and mental status (irritability or anxiety).5

These symptoms are then converted into a numeric score based on their severity. These numbers are totaled to form an overall score, from 0 (indicat-ing no withdrawal symptoms) to 48 (the maximum degree of withdrawal

Table 1: Opioid Half-Life and Volume of Distribution

Opioid Half-life, h Volume of Distribution, L/Kg

Buprenorphine (buccal) 16.4-27.5 430

Buprenorphine (sublingual) 37 430

Buprenorphine (injection) 1.7-7.2 430

Buprenorphine (transdermal) 26 430

Cocaine (smoking) 1-1.5 1.5-2

Codeine 3 3-6

Fentanyl (buccal) 3.22-6.43 4

Fentanyl (injection) 3.65 4

Fentanyl (sublingual tablet) 5.02-13.5 4

Fentanyl (transdermal) 16-25 3-8

Heroin 3.38-4.16 minutes 96

Hydrocodone 3.8 3.3-4.7

Hydromorphone 2.5 4

Methadonea 8 - 59 (up to 190) 1-8

Morphine (IR) 2-4 2.7-5.3

Oxycodone (IR) 3.2 2.6

Oxymorphone (IR) 2.85-12.79 3

Tramadol 6.3 2.6-2.9a Large range in variable half-life due to polymorphisms.

h, hour; IR, immediate release

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Opioid Withdrawal: A New Look at Medicat ion Options

November 2015 | Pract icalPainManagement.com

symptoms). These scores typically are used to determine whether buprenor-phine induction is appropriate, with mild to moderate withdrawal symp-toms being the ideal time to begin buprenorphine therapy.7

Treatment of Withdrawal There are myriad agents that can be used to support clinicians in their treat-ment of patients experiencing opioid withdrawal. The following is a sum-mary of agents that can attenuate with-drawal symptoms (Table 2).

Alpha-1 Antagonists Administration of the alpha-1 antag-onists phentolamine,6 phenoxyben-zamine (Dibenzyline, others),6 and pra-zosin (Minpress, others)7 can decrease the occurrence of somatic symptoms associated with opioid withdrawal.

Trazodone (Oleptro, others) is a tri-azolopyridine derivate that is used as an antidepressant.8 Trazodone acts as a 5-serotonin (HT)2 receptor antag-onist at high doses and inhibits the reuptake of serotonin at the presynap-tic membrane. Trazodone also weakly inhibits alpha-2 adrenergic receptors and strongly inhibits postsynaptic alpha-1 receptors. Due to its ability to inhibit alpha-1 adrenergic receptors, we postulate that it has a role in opi-oid withdrawal. Interestingly, trazo-done has been shown to bind to opi-oid receptors as well, but only at high concentrations.8

When studied in mice, trazodone was found to induce potent mu-1 and mu-2 opioid receptor–mediated pain relief. Schreiber et al evaluated the effects of trazodone on opioid with-drawal symptoms in morphine-depen-dent mice who were receiving a high dose of naloxone.9 They evaluated the intensity of withdrawal symptoms using 3 different behavioral measure-ments: rearing, jumping, and groom-ing and found that adding trazodone

to naloxone in morphine-dependent mice effectively decreased opioid- withdrawal intensity.9

Alpha-2 AgonistsAnother agent that is commonly used to attenuate opioid withdrawal is clonidine (Catapres, Kapvay, oth-ers). The use of clonidine for opioid withdrawal originally was proposed by DeStefano et al.10 In addition, studies have revealed that clonidine plays a role in reducing the negative motivational aspects of opioid withdrawal.11

A recent review article by Gowing et al evaluated the evidence for alpha-2 adrenergic agonists in the management of withdrawal symptoms in people who are physically dependent on opioids.12 The review evaluated 25 random-ized control trials consisting of 1,668 opioid-dependent patients who were being treated with either clonidine, lofexidine, guanfacine (Tenex, Intuniv, others), or tizanidine (Zanaflex, oth-ers). Twelve studies compared alpha-ad-renergic agonists with decreasing doses of methadone (Dolophine, Methadose, others), 5 studies compared alpha-2 agonists with placebo, 4 studies com-pared the study drug with drugs used for specific symptom control in with-drawal, and 5 studies compared differ-ent alpha-2 adrenergic agonists to each other. Treatment duration averaged 1 to 2 weeks (shortest duration was 3 days, and longest duration was 30 days).

The review showed no difference in opioid withdrawal symptoms between those receiving central alpha-2 adren-ergic agonists and those treated with decreasing doses of methadone.12 The chance of completing treatment also was similar with alpha-2 adrener-gic agonists and decreasing doses of methadone. However, the duration of treatment was longer with methadone. There were fewer adverse effects with methadone withdrawal signs and symp-toms occurred earlier in patients taking

alpha-adrenergic agonists. Of note, clonidine and lofexidine were more effective than placebo in managing withdrawal from heroin or methadone and were more likely to be associated with treatment completion than pla-cebo. The studies conclude that alpha-2 adrenergic agonists may be an alterna-tive in treating opioid withdrawal.12

Sos et al evaluated the effects of the alpha-2 adrenergic agonist tizani-dine in patients suffering from opioid addiction.13 In this study, 26 intrave-nous heroin users were divided into 2 groups; each group had the usual detoxification treatment, but patients in the experimental group were given tizanidine 8 mg three times daily. A subjective scale was used to deter-mined severity of withdrawal using 7 key withdrawal symptoms (sweat-ing, nervousness, insomnia, tremor, diarrhea, muscle pain, and drug crav-ing). The results of the study showed that tizanidine treatment decreased the intensity of withdrawal symptoms and may have potential benefit in treating opioid withdrawal.13

Although there are no studies to sug-gest that methyldopa is useful in the prevention of withdrawal, because it is a centrally acting alpha-2 agonist we could postulate that it would provide some benefit in this setting.12

Beta-1 Antagonists And Beta-2 AntagonistsPropranolol (Inderal, InnoPran XL, others) and atenolol (Tenormin, others) have been reported to reduce somatic signs of spontaneous opioid withdrawal and naloxone-precipitated opioid absti-nence.14 It is theorized that beta block-ers can have these effects because they block the noradrenergic hyperactiv-ity associated with supersensitive beta- adrenergic receptors that result from adaptive changes induced by chronic opioid exposure.19-21 Somatic symp-toms, including jumping and wet dog

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Table 2. Summary of Agents That Attenuate Opioid Withdrawal

Class Drug Mechanism of Action Evidence

Alpha-1 Antagonists

Phentolamine

Blocks alpha-1 receptors, thus inhibiting the release of NE during noradrenergic hyperactivity (which occurs as a result of opioid withdrawal)

Yes6

Phenoxybenzamine (Dibenzyline, others) Yes6

Prazosin (Minpress, others) Yes7

Trazodone (Oleptro, others) Yes8.9

Alpha-2Agonists

Clonidine (Catapres, Kapvay, others)

Stimulates central alpha-2 receptors that inhibit the release of NE during noradrenergic hyperactivity (which occurs as a result of opioid withdrawal)

Yes10

Lofexidine Yes12

Guanfacine (Tenex, Intuniv, others) Yes12

Tizanidine (Zanaflex, others) Yes13

Methyldopa No12

Beta-AdrenergicAntagonists

Propranolol (Inderal, InnoPran XL, others)

Blocks beta-1 and beta-2 receptors (which become supersensitive as a result of adaptive changes induced by chronic opioid exposure) that inhibit release of NE during noradrenergic hyperactivity

Yes14-16

Atenolol (Tenormin, others) Yes14-16

Metoprolol (Lopressor, Toprol XL, others) No

Nadolol (Corgard, others) No

Carvedilol (Coreg, others) No

Labetalol No

NMDA Receptor Antagonists

Dextromethamphetamine

Blocks NMDA receptors that may have a role in increasing the release of beta endorphins, thus attenuating withdrawal symptoms

Yes20

Ketamine (Ketalar, others) Yes20

Memantine (Namenda, others) Yes21

Amantadine Yes22

Dextromethorphan Yes23-25

Orphenadrine (Norflex, others) No26

Serotonergic and Norepinephrine

Reuptake Inhibitors

Venlafaxine (Effexor, others)Blocks the reuptake of serotonin, which may have a role in decreasing the release of NE centrally, but further studies are warranted to determine the role of serotonin in opiate withdrawal.

Mirtazapine increases release of dopamine by inhibiting alpha-2 adrenoceptors in the cerebral cortex and by blocking 5-HTc2 receptors, which generally block prefrontal cortex release of DA.

Mirtazapine increases the release of dopamine, which may have a role in reducing acute withdrawal symptoms and inhibiting opioid cravings

Yes27-29

Mirtazapine (Remeron, others) Yes30

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shakes, were both blocked by beta-1 antagonists, whereas beta-2 antagonists have been shown to suppress the inci-dence of wet dog shakes only.14

Propranolol and atenolol have been shown to reduce withdrawal-induced anxiety in animals.15,16 Addicts have reported that anxiety associated with opioid withdrawal often returns when they are in an environment that is associated with drug use. Harris and Aston-Jones conducted a study to investigate whether propranolol and atenolol reduced somatic symptoms and whether the medications reduced place aversion in opioid-abstinent rats.15,16 The most common somatic symptoms included wet dog shakes, teeth chatter, writhing, and vocalization upon touch. Place aversion was tested by injecting the rats with naloxone in one area of the cage and then observ-ing whether the rats avoided that area. The investigators found that beta-ad-renergic antagonists reduced somatic symptoms and alleviated withdraw-al-induced anxiety.

Beta receptors have a role in pro-moting consolidation and retrieval of memory; thus, in theory, blocking this

pathway with a beta-adrenergic antag-onist would prevent such memories from forming.17 Animal studies have suggested that propranolol can disrupt memory reconsolidation that previ-ously had been associated with reward-ing medications such as morphine.17-19 Such results imply that by preventing the memory of the rewarding effects of the medication, propranolol could be effective for preventing relapse in addicts.

Although a prior study by Robinson et al showed that propranolol disrupted memory reconsolidation associated with morphine,18 when they tested this theory in rats, they found that in a setting of exposure to high doses of morphine, propranolol was not able to disrupt memory reconsolidation.19 This study indicates that chronic expo-sure to morphine markedly alters the effects of propranolol as a reconsolida-tion blocking treatment.19

NMDA Receptor AntagonistsSome evidence suggests that another mechanism responsible for tolerance to and withdrawal from opioids involves activation of N-methyl-D-aspartase

(NMDA) receptors. Thus, it has been theorized that NMDA antagonists may decrease withdrawal symptoms.20

Bisaga et al demonstrated that the NMDA-receptor antagonist meman-tine (Namenda, others) decreased naloxone-induced symptoms of with-drawal in heroin-addicted patients.21 Amantadine, another NMDA antag-onist with dopaminergic, adrenergic, and serotonergic properties (MAO-A inhibition), also has been theorized to have efficacy in the treatment of opioid-withdrawal symptoms. Amiri et al found that amantadine plus clon-idine was superior to clonidine alone in controlling opioid-withdrawal symptoms for a duration of 3 days in a study involving 69 patients.22 The mechanism of action may be due to NMDA-receptor inhibition and MAO inhibition, which cause an increase in beta-endorphins. Amiri et al showed a trend for increased withdrawal symp-toms on day 3; thus, studies done with amantadine for a longer duration are warranted.

The antitussive dextrometho-rphan is another agent that, theoret-ically, can provide benefit for patients

Table 2. Summary of Agents That Attenuate Opioid Withdrawal

Dopaminergic Agonists

Levodopa

Increases the release of dopamine, which may have a role in reducing acute withdrawal symptoms and inhibiting opioid cravings. L-dopa increased aggression during opioid withdrawal, while quinpirole decreased aggression.

Levels of dopamine increases acutely during opioid administration and then decreases after opioid withdrawal; thus, it has been hypothesized that a decrease in dopaminergic neurotransmission may be associated with some of the unpleasant subjective symptoms associated with drug withdrawal.

No33

Quinpirole Yes36

SKF82958 Yes36

Dopaminergic Antagonists

Haloperidol (Haldol, others)Unknown

Yes37

Droperidol Yes38

Miscellaneous Buproprion (Aplenzin, Buproban, others)

Inhibits reuptake of dopamine, and, thus, may have a role in reducing acute withdrawal symptoms and inhibiting opioid cravings

Yes39

DA, dopamine; NE, norepinephrine; NMDA, N-methyl-D-aspartase

(Continued)

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experiencing opioid withdrawal, based on its ability to inhibit NMDA recep-tors. Dextromethorphan is metabolized to dextrophan, the pharmacologic activ-ity of which is primarily at the NMDA receptor. (Dextromethorphan binds to NMDA binding sites with a 10-fold lower affinity than dextrophan.)23

In a randomized clinical trial involving 48 heroin addicts, dex-tromethorphan showed benefit in attenuating withdrawal symptoms. Dextromethorphan combined with diazepam (Valium, others) had greater efficacy compared with diazepam and chlorpromazine combined.24

However, Rosen et al found that oral dextromethorphan (60 mg, 120 mg, or 240 mg) did not attenuate withdrawal symptoms in 11 subjects who expe-rienced naloxone-precipitated with-drawal after being stabilized on oral methadone 25 mg per day.23 Subjects received challenges with 0.4 mg of intramuscular naloxone on 3 different days and were randomized to receive either dextromethorphan or placebo. Patients taking dextromethorphan showed no difference in withdrawal symptoms compared with patients tak-ing placebo.23

Bisaga et al showed beneficial data for withdrawal with dextrometho-rphan in 6 male patients who were daily heroin users.25 The patients in this trial were hospitalized during the study, and all received 75 mg of dex-tromethorphan 5 times per day (no other medications were given besides hydroxyzine [Vistaril, others], acet-aminophen [Tylenol, others], and ibu-profen [Advil, Motrin, others]). Two patients dropped out of the study, but the 4 patients who completed the study reported a subjective difference from previous detoxification with metha-done; they all had a rapid and thor-ough decrease in signs, symptoms, and craving associated with opioids by the fourth day of treatment. Patients

received treatment for an average of 6 days and were discharged after being free from medication for 1 day. Results of this trial indicate that dextrometho-rphan may be an inpatient treatment option in patients suffering from opi-oid withdrawal.25

Of note, efficacy in treating opioid withdrawal symptoms can be expected from dextromethorphan due to its NMDA-antagonist properties, not due to its effects as an opioid agonist. Dextromethorphan’s binding affinity to mu opioid receptors is 6,000 times less than that of morphine; thus, we would not see much efficacy to dimin-ish withdrawal symptoms due to its mu opioid–receptor activity.

Orphenadrine (Norflex, others), a commonly used muscle relax-ant, is an anticholinergic medication with NMDA-antagonist properties. Theoretically, orphenadrine can be used for opioid withdrawal due to its ability to inhibit NMDA receptors.26 Although there have been no studies conducted to substantiate the role of orphenadrine in opioid withdrawal, anecdotal reports have noted benefit from its use to mitigate such symptoms.

Serotonergic and Norepinephrine Reuptake Inhibitors Venlafaxine (Effexor, others) is a novel antidepressant that blocks reuptake of norepinephrine and serotonin. It has been postulated to mitigate opioid with-drawal due to its serotonin reuptake–blocking properties. In a study by Lu et al, rats treated with chronic mor-phine were pretreated with venlafaxine or not given anything before admin-istration of naloxone.27 Pretreatment significantly attenuated the rats’ symp-toms of morphine withdrawal, includ-ing jumping, writhing, shaking, explor-ing, lacrimation, piloerection, irrita-bility, and diarrhea. Venlafaxine also attenuated morphine-induced reacqui-sition of conditioned place preference

in these rats. However, because there is limited evidence to suggest that the serotonergic system is involved in opi-oid withdrawal, more studies are war-ranted to determine if the serotoner-gic properties of venlafaxine contrib-ute to the attenuation of withdrawal symptoms.

Although there is limited evidence for the role of serotonergic neurotrans-mission in opioid dependence and withdrawal, the selective serotonin reuptake inhibitors (SSRI) fluvoxam-ine and sertraline (Zoloft, others) have been shown to decrease the intensity of physical signs of naloxone-induced opioid withdrawal.28 In an experiment conducted by Gray, naloxone increased norepinephrine levels in the hippocam-pus of morphine-dependent rats 20 minutes after administration, and with-drawal-induced physical behaviors were apparent 5 minutes after injection.28 Study animals were given either flu-voxamine or sertraline, either acutely (after discontinuation of 8 days of ther-apy with morphine and right before naloxone administration) or chron-ically (after daily morphine doses for 8 days). Chronic administration of both SSRIs reduced the severity of naloxone- precipitated opioid withdrawal syn-drome and prevented naloxone-precip-itated increases in hippocampal levels of norepinephrine.

However, acute administration did not prevented naloxone-precipitated increases in norepinephrine in the hippocampus. Acute administration of SSRIs only reduced the intensity of physical symptoms of naloxone-precip-itated opioid withdrawal.28 The prin-cipal finding of the study was that flu-voxamine given once daily following morphine prevented an increase in norepinephrine levels and the phys-ical behaviors of opioid withdrawal, and reduced levels of norepinephrine in the hippocampus of morphine- dependent rats.28

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Theories about the ability of SSRIs to ameliorate symptoms of opioid with-drawal suggest that increased serotonin in the synaptic cleft can increase the inhibitory tone of the LC, causing lower levels of noradrenergic activity within the LC.28 Another hypothesis suggests that SSRIs may be involved in increasing endogenous opioid lev-els, which can cause a decrease in nor-epinephrine levels.28,29

Mirtazapine (Remeron, others) is an antidepressant with noradrenergic and serotonergic properties. More spe-cifically, mirtazapine is a potent pre-synaptic alpha-2 receptor antagonist, 5-HT1 receptor agonist, and 5-HT2 and 5-HT3 antagonist. A study con-ducted by Kang et al tested the acute and chronic effects of mirtazapine on rats that were given morphine for 10 days.30 The acute effects of mirtazap-ine were observed by administering mirtazapine 15 minutes before nalox-one. The chronic effects of mirtazap-ine were tested by administering mir-tazapine 15 minutes before daily doses of morphine. The experiment recorded 8 behaviors (wet dog shakes, digging, teeth chattering, rearing, grooming, chewing, scratching, and escape atten-dance) over a period of 30 minutes.

Overall, the results of the study showed that chronic mirtazapine can reduce the severity of withdrawal symp-toms, inhibit the craving for morphine, and may decrease the rewarding effects of morphine in rats.30 Also, mirtazapine caused pronounced elevation in dopa-mine levels. Kang et al proposed that mirtazapine increases levels of dopa-mine by inhibiting alpha-2 adreno-ceptors in the cerebral cortex and by blocking 5-HTc2 receptors that gen-erally block prefrontal cortex release of dopamine. The rise in dopamine is the suggested neurobiological mecha-nism of mirtazapine’s action for reduc-ing acute withdrawal symptoms and inhibiting opioid craving in rats. More

studies are warranted to explore the role of mirtazapine in the treatment of opioid dependence and withdrawal in humans.30

Dopaminergic Agonists And Antagonists There are contradictory data on the role of dopamine agonists and antagonists in morphine withdrawal.31,32 For exam-ple, amphetamine, apomorphine, and levodopa have been shown to increase aggression in rats undergoing morphine withdrawal33,34 but quinpirole decreases aggression associated with morphine withdrawal. Furthermore, Harris and Aston-Jones found that activation of D2 dopaminergic receptors within the NAc prevented some of the somatic symptoms of opioid withdrawal.35

Radhke and Gewirtz examined the effects of dopamine agonists on with-drawal-induced anxiety following spon-taneous withdrawal from acute mor-phine exposure.36 They examined the effects of intracerebrally infused dopa-mine-receptor agonists on the poten-tiation of acoustic startle reflex, which likely represent the anxiety-like compo-nent of withdrawal. The experiments used 2 dopamine receptor agonists, SKF82958 (D1 receptor agonist) and quinpirole (D2 receptor agonist), and randomly injected either medication during morphine withdrawal in rats. The study found that activation of D1- and D2-like receptors attenuated opi-oid withdrawal–induced anxiety and, thus, support the theory that dimin-ishing activity at both D1- and D2-like receptors have a role in the expression of opioid withdrawal.36

From a pharmacologic perspec-tive, since opioid withdrawal is asso-ciated with a reduction in the release of dopamine along the mesolimbic path-way, dopamine agonists have shown some benefit for opioid withdrawal. Counterintuitive to this is the fact that some dopamine antagonists, in

particular the butyrophenones haloper-idol (Haldol, others) and droperidol, have some benefit in withdrawal too.37 Both butyrophenone antipsychotics block postsynaptic mesolimbic dopa-minergic D2 receptors in the brain and reduce dopaminergic neurotransmis-sion in the 4 dopaminergic pathways.

Haloperidol has been shown to markedly decrease morphine withdraw-al-induced aggression.37 Rodriguez-Arias et al revealed that aggressive behavior in rats decreased when they were administered haloperidol during either naloxone-precipitated or spon-taneous withdrawal. This study sug-gested that anti-aggressive effects of haloperidol were more pronounced in naloxone-precipitated withdrawal than in spontaneous withdrawal.37

Sivolap and Savenkov examined 197 patients who were treated with haloper-idol and droperidol following opioid withdrawal.38 They found that with-drawal-induced psychosis was relieved with droperidol and haloperidol, and these 2 agents were especially help-ful in the acute phase of withdrawal. Although the exact mechanism through which these agents attenuate symptoms of withdrawal are unclear, it is evident that these agents have some benefit in opioid withdrawal.38

Miscellaneous Bupropion (Aplenzin, Buproban, oth-ers), a norepinephrine and dopamine reuptake inhibitor, has shown some benefit in opioid withdrawal. Joshi et al studied the effects of bupropion on morphine tolerance and dependence in mice.39 They gave mice bupropion ther-apy (2 or 5 mg/d) with morphine for 10 days. When naloxone was adminis-tered, the mice treated with bupropion had less withdrawal-induced jumps. Furthermore, acute administration of bupropion on day 10 decreased the incidence of naloxone-precipitated withdrawal jumps without causing

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tolerance to the analgesic effect. The results of this study suggest that bupro-prion may have potential in opioid withdrawal.

Although the exact mechanism for bupropion’s efficacy in opioid with-drawal is unknown, its ability to decrease reuptake of dopamine may contribute to attenuation of withdrawal symptoms.

Summary A person’s ability to tolerate a rapid opi-oid taper and substantial dose reduc-tions when converting to other opi-oids can, in large part, depend on their concomitant medical therapies. These therapies, which may have been pre-scribed for any number of disorders, can directly or indirectly affect the sym-pathetic and parasympathetic nervous systems. All of these factors should be carefully considered when tapering or switching opioids.

Authors’ Bios: At the time of this writ-ing, Dr. Nabeela Ahmed was a PharmD Candidate, 2015 at the Albany College of Pharmacy and Health Sciences. She is currently a PGY-1 Pharmacy Resident at New York University Langone Medical Center in New York City.

At the time of this writing, Dr. Randall Horlacher was a PharmD Candidate,

2015 at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences. He is currently in community practice in Harrisburg, Pennsylvania.

Jeffrey Fudin, BS, PharmD, DAAPM, FCCP, FASHP, is Adjunct Associate Professor of Pharmacy Practice & Pain Management, Western New England University College of Pharmacy, in Springfield, Massachusetts, He also is Adjunct Assistant Professor of Pharmacy Practice, University of Connecticut School of Pharmacy, in Storrs, Connecticut, and Clinical Pharmacy Specialist and Director, PGY2 Pain & Palliative Care Pharmacy Residency at the Stratton VA Medical Center, in Albany, New York.

Dr. Fudin graduated from the Albany College of Pharmacy & Health Sciences with his Bachelors Degree and his PharmD. He was awarded and completed an American Cancer Society Sponsored Fellowship in Oncology/Hematology at SUNY/Upstate Medical Center shortly after his undergraduate work.

Dr. Fudin practices as a Clinical Pharmacy Specialist and Director, PGY-2 Pharmacy Pain Residency Programs at the Stratton Veterans Administration Medical Center. He is an Adjunct Associate Professor of Pharmacy Practice at Western New England University College of Pharmacy; Adjunct Assistant Professor of Pharmacy Practice at Albany College of Pharmacy; Adjunct Assistant Professor

of Pharmacy Practice at the University of Connecticut School of Pharmacy; and has several other academic affiliations including and the University at Buffalo School of Pharmacy and Pharmaceutical Sciences. He has been an Instructor of Pharmacology at SAGE Graduate School of Nursing for several years. He is a Clinical Pharmacy Consultant to Homedical Associates, an innovative home-based academic patient care ser-vice dedicated to treating medically com-plex patients in their homes.

He is a Diplomate of the American Academy of Pain Management, a Fellow of the American College of Clinical Pharmacy, and a member of several other professional organizations. Dr. Fudin is a Section Editor for Pain Medicine, the official journal of AAPM. He is Founder/Chairman of Professionals for Rational Opioid Monitoring & Pharmacotherapy (PROMPT), a group that advocates in favor of safe opioid prescribing by encour-aging clinician education, proactive risk stratification, and appropriate therapeu-tic monitoring.

Drs. Fudin, Ahmed, and Horlacher disclosed that their involvement with this article was not prepared as part of their official government duties.

Practical Pain Management read-ers will recognize Dr. Fudin as one of the codevelopers of the PPM Opioid Calculator.

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