Traditional Buprenorphine/ Induction: Medications to Minimize Withdrawal Symptoms

Adjunct medications can be used to provide short-term relief for withdrawal symptoms during a traditional buprenorphine/naloxone induction. To help reduce discomfort associated with withdrawal symptoms, consider providing one or more of the medications discussed in the table below prior to the first dose or during the first few doses of buprenorphine/naloxone in anticipation of withdrawal symptoms. Consult the 24/7 Medicine Consult Line if needed.

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24/7 Clinician Support Line Phone: 778-945-7619 (available 24 hours a day, 7 days per week)

Considerations Dimenhydrinate Acetaminophen

Prevent or relieve Relieve diarrhea Relieve muscle aches, Relieve muscle aches, Reduce opioid nausea or vomiting joint , or headache joint pain, or headache withdrawal symptoms such as sweating, diarrhea, vomiting, abdominal cramps, anxiety, and irritability

Note: RNs and RPNs can only prescribe Therapeutic clonidine in the context of useª

Footnotes a. Therapeutic use during a traditional buprenorphine/naloxone induction.

Traditional Buprenorphine/naloxone Induction: Medications to Minimize Withdrawal Symptoms: Page 1 Considerations Dimenhydrinate Loperamide Acetaminophen Ibuprofen Clonidine

• Hypersensitivity to • Hypersensitivity to • History of or • Allergic reaction or • Heart rate less than dimenhydrinate, its loperamide or any skin reaction with hypersensitivity to 60 beats per minute components, or any component of the acetaminophen non-steroidal anti- component of the formulation inflammatory • Blood pressure less formulation or any component than 90/60 mmHg • Acute dysentery of the formulation, • Concurrent use or acetylsalicylic acid • Allergy or of or use within • Acute ulcerative hypersensitivity to 14 days following colitis • Prescribed: clonidine or any therapy with • components of the , • Bacterial • product , or enterocolitis • Indomethacin • • Diarrhea not • • Narrow angle associated with • glaucoma opioid withdrawal • • • Chronic pulmonary • Bloody or black stool • disease

• Prostatic Contraindications hypertrophy

Traditional Buprenorphine/naloxone Induction: Medications to Minimize Withdrawal Symptoms: Page 2 Considerations Dimenhydrinate Loperamide Acetaminophen Ibuprofen Clonidine

• Central nervous • Do not use when • A high number of • Should be avoided • Orthostatic system (CNS) peristalsis inhibition overdoses occur during depression should be avoided with acetaminophen due to potential risk due to potential for of miscarriage and • Use with caution in • May have ileus, megacolon, or • If patient is using birth defects patients with chronic hallucinogenic and toxic megacolon more than 81mg renal impairment euphoric effects acetylsalicylic • Can cause increased • Discontinue acid daily, avoid risk of serious • Pregnancy • Use with caution promptly if use of additional cardiovascular with CNS , non-steroidal anti- thrombotic events • abdominal pain, inflammatory drugs • This risk may occur abdominal early in treatment • These desensitize • Hepatic impairment distension, blood • Advise use of and may increase alpha-2 in stool, or ileus caution with with duration of adreno-receptors; • Elderly may be more develop or over the use should be stopped sensitive to effects counter products 3 weeks prior to • Seek medical that may contain use of clonidine care promptly if acetaminophen • Medications known experiencing: to increase the risk of gastrointestinal • Severe dizziness • Use with caution in patients with hepatic bleeding Precautions • Angina impairment or active and • Tachycardia disease cautions • Abdominal heartbeat • Warfarin

• Severe pain and nausea • Abdominal pain or edema • Constipation • Bloating • Black or bloody stools •

Traditional Buprenorphine/naloxone Induction: Medications to Minimize Withdrawal Symptoms: Page 3 Considerations Dimenhydrinate Loperamide Acetaminophen Ibuprofen Clonidine

• 50–100mg by mouth • 2–4mg by mouth • 325–1000mg by • 400mg by mouth • If patient weighs less (maximum 16mg/ mouth (maximum (maximum 2,400mg/ than 90kg, 0.1mg by • Can be decreased day) 4,000mg/day; day) mouth to 25mg by mouth 2,000mg/day for the for older adults, elderly or those with • If patient weighs adults under 45kg, liver impairment) 90kg or more, 0.2mg or based on clinical by mouth judgment

Administration Dose interval: Dose interval: Dose interval: Dose interval: Dose interval: dose As needed, Every 6 hours Every 4 to 6 hours Every 4 hours 4 to 6 hours following loose stools

• Can dispense up to • Can dispense up to • Can dispense • Can dispense up to • 0.4–0.8mg 4–8 dimenhydrinate 8 loperamide 2mg up to 4,000mg 2,400mg ibuprofen 50mg tablets tablets at a time acetaminophen at a at a time time

Dispensing doseb

When prescribing adjunct medications for use during a traditional buprenorphine/naloxone induction, prescribe enough for 24 hours.

Footnotes b. Per approved organizational pathway/process for dispensing

Traditional Buprenorphine/naloxone Induction: Medications to Minimize Withdrawal Symptoms: Page 4 Considerations Dimenhydrinate Loperamide Acetaminophen Ibuprofen Clonidine

• Can take 1–2 tablets • Take 2 tablets after • Take acetaminophen • Take ibuprofen • Take a test dose by mouth every first loose stool and 325mg to 1,000mg 400mg by mouth • 0.1mg or 0.2mg 6 hours, as needed one tablet after each by mouth every every 4 hours clonidine subsequent loose 4 to 6 hours depending on • Stay hydrated stool (maximum • Administer with patient weight 16mg/day) • Overdose can food, milk, or occur with antacids to decrease • If the medication • Take with plenty acetaminophen. gastrointestinal is helping, repeat of clear fluids to Ensure patient is adverse effects every 4 to 6 hours prevent dehydration informed of the maximum dose • Stop medication Patient if experiencing symptoms of instructions dizziness or postural hypotension

Consult as per Advise patient to Consult as per Consult as per organizational pathway connect with care organizational pathway organizational pathway if vomiting persists, team for assessment if: if: unable to keep fluids by a nurse practitioner • Ongoing pain • Ongoing pain down, or dehydrated or physician management with management with and discontinue medications is medications is loperamide if diarrhea required required persists greater than • Pain is determined • Pain is determined 2 days, symptoms to be moderate to to be moderate to worsen, or abdominal severe severe swelling or bulging develops Follow-up care

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