As detailed below, this guideline recommends against withdrawal management alone. For patients who expressly wish to pursue withdrawal management, slow outpatient opioid agonist tapers should be considered, followed by long-term psychosocial OUD treatment for relapse prevention.
Recommendations 10. Withdrawal management alone
Withdrawal management alone (including rapid opioid agonist tapers) without transition to opioid agonist treatment is not recommended.
Quality of Evidence: Moderate
Strength of Recommendation: STRONG
Remarks:
Withdrawal management alone (i.e., without transition to opioid agonist treatment or continuing substance use disorder care) is not effective; the vast majority of patients who undergo withdrawal management relapse soon after treatment completion, which increases their risk of HIV and hepatitis C transmission, morbidity, and mortality.
Patients who request withdrawal management alone should be provided with clear, concise information about these risks, and be engaged in supportive, constructive discussion about safer treatment options.
Recommendation 11. Setting and duration of withdrawal management
If the patient chooses to pursue withdrawal management (e.g., slow opioid agonist taper), this should be conducted in an outpatient setting, followed by a collaboratively developed relapse prevention plan and referral to long-term psychosocial treatment and support.
Quality of Evidence: Moderate
Strength of Recommendation: STRONG
Remarks:
When discharged from a highly structured inpatient withdrawal management setting and returned to familiar environment where cravings may be high and unregulated opioids easily available, individuals may be particularly vulnerable to opioid-related harms—including fatal overdose.
Outpatient withdrawal management programs permit a slower, more flexible, and individualized approach to tapered agonist reduction compared to inpatient withdrawal management, while still allowing for dose readjustment and stabilization if withdrawal symptoms, cravings, or relapse to unregulated opioid use occur.
Outpatient withdrawal management is also less disruptive to the patient’s daily routine.
Consider initiating opioid agonist treatment to address withdrawal symptoms and slowly tapering under outpatient supervision. The risks of withdrawal management alone and the benefits of being maintained on OAT should be periodically revisited in the course of the taper while respecting patient autonomy.
Patients undergoing withdrawal management should be offered referral to psychosocial treatment interventions and community-based supports.
In order to reduce the risk of fatal overdose among patients who decline long-term opioid agonist treatment, patients and families should also be advised to undergo take-home naloxone training, a safe and effective intervention to prevent fatal overdose.
