(75) Advancing Clinician-Informed, Symptom-Specific Approaches to Opioid Withdrawal Care

Background & Introduction: Opioid withdrawal syndrome (OWS) is a predictable and distressing consequence of opioid cessation in individuals with opioid use disorder (OUD). Although rarely life-threatening, poorly managed withdrawal can lead to treatment dropout, return to use, and loss of trust in care systems. Effective withdrawal management is therefore critical to patient engagement, stabilization, and recovery.

While medications for opioid use disorder (MOUD) such as methadone and buprenorphine are first-line treatments, patients frequently experience breakthrough withdrawal during transitions in care or when MOUD is delayed, inaccessible, or declined. In these settings, non-opioid medications are often used to target specific symptoms; however, evidence-based, symptom-specific guidance remains limited. Nurses and frontline staff frequently rely on institutional habits or individual provider preference rather than standardized protocols, contributing to inconsistent care experiences.

To address this gap, we surveyed addiction medicine and psychiatry specialists to identify the most commonly used non-opioid medications for specific withdrawal symptoms. Findings will inform the development of a practical job aid that links common withdrawal symptoms to recommended non-opioid medications to enhance clinical consistency, empower nursing staff, and support patient autonomy within trauma-informed, person-centered models of addiction care.

Methods: We conducted a cross-sectional survey of addiction medicine and psychiatry clinicians in the Pacific Northwest to identify commonly used non-opioid medications for managing opioid withdrawal symptoms. The survey aimed to characterize medication classes, specific agents within each class, and their use across common symptom domains of opioid withdrawal.

The survey, developed by a multidisciplinary team with expertise in addiction medicine and withdrawal management, included both closed- and open-ended questions about ordering practices. Clinicians identified medication classes used for withdrawal, specific agents within each class, and preferred medications for individual symptoms (e.g., anxiety, nausea, diarrhea, muscle pain, insomnia). Frequency of use was rated on a four-point Likert scale (“often” to “never”). Participants were also asked about contextual factors influencing medication choice, patterns of scheduled versus as-needed prescribing, and perceptions of how effectively nurses and patients identify and communicate withdrawal symptoms in care settings.

Eligible participants included physicians and advanced practice providers with clinical experience managing OWS. Recruitment occurred through direct email outreach, and participation was voluntary and anonymous. Quantitative data were summarized descriptively, and qualitative responses were analyzed thematically to identify rationale and contextual influences on medication selection.

Results: Thirty addiction-trained clinicians completed the survey. Most identified as attending physicians (80%), followed by fellows (13.3%) and advanced practice providers (6.7%). Clinical experience varied: 43.3% had five or more years, 43.3% one to four years, and 13.3% less than one year. The majority practiced in academic medical centers (76.7%), with others affiliated with community hospitals (23.3%) or working in detoxification facilities, carceral settings, or Veterans Administration environments.

Clinicians reported frequent use of alpha agonists (100%), antiemetics (97%), sleep aids (83%), and non-opioid analgesics (80%) to manage opioid withdrawal symptoms. Clonidine, ondansetron, trazodone, and acetaminophen were the most common agents within these classes, with nearly all respondents selecting them. Other medications were used less consistently, including beta blockers (33%) and memantine (7%). Insomnia and anxiety/irritability were treated with the broadest range of medications, whereas runny nose and tearing were least often addressed.
All respondents primarily prescribed non-opioid medications on an as-needed basis, yet 88% also reported utilizing scheduled dosing for certain medications, most commonly clonidine (64%), gabapentin (55%), and tizanidine (27%). Scheduled dosing was typically used during the initial days of withdrawal, for particularly severe symptoms, or when patients were unlikely to request PRN medications, with conditional parameters such as blood pressure and sedation applied.

Prescribing was frequently modified for co-occurring medical conditions, including QTc prolongation (88%), renal insufficiency (84%), liver disease (60%), and pregnancy (76%). Adjustments included avoiding or minimizing certain agents, dose modifications, and consulting pharmacy colleagues or clinical references.

In acute care settings, clinicians were more likely to “agree” or “strongly agree” than to “disagree” or “strongly disagree” that nurses could effectively assess and manage opioid withdrawal symptoms; however, this difference was not statistically significant (p = .834). In contrast, patients were often perceived as unable to communicate their symptoms effectively to staff (p = .033). There was no significant consensus regarding whether patients consistently received appropriate treatment for withdrawal symptoms (p = .532).

Conclusion & Discussion: Few studies have systematically characterized real-world prescribing practices for non-opioid medications used to manage opioid withdrawal. This survey addressed that gap by examining how addiction-trained clinicians use these medications, with the goal of informing development of a symptom-targeted job aid for acute care and detoxification settings. Clonidine, tizanidine, ondansetron, loperamide, hydroxyzine, acetaminophen, and trazodone were most frequently used, while antipsychotics, benzodiazepines, and gabapentinoids showed variable use, reflecting reliance on provider preference rather than standardized, evidence-based protocols. FDA-approved lofexidine and other potentially effective agents, such as memantine and mirtazapine, were rarely used.

Scheduled non-opioid medications were reported in about one-third of cases, typically applied when PRN dosing was insufficient due to nursing inexperience, patient communication barriers, or severe symptoms. Clinicians frequently adjusted prescribing for co-occurring conditions, underscoring the need for context-aware guidance. Although most believed nurses could manage withdrawal effectively, many perceived that patients struggled to communicate their symptoms, highlighting a key barrier to adequate treatment and the need for structured, symptom-specific assessment tools.

Despite the small, regionally limited sample, these findings offer insight into current practices and opportunities to standardize symptom-targeted, evidence-based non-opioid management to improve safety, consistency, and patient-centered care.

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