Given that withdrawal management alone is not recommended, it is the consensus of the committee that, in cases where it is preferred, most individuals with opioid use disorder should be offered community-based, outpatient withdrawal management as opposed to rapid inpatient withdrawal management. This is consistent with the American Society of Addiction Medicine placement criteria that emphasize meeting a patient’s clinical needs with the most appropriate and least restrictive care setting and intensity.103 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 in the event that withdrawal symptoms, cravings, or relapse to unregulated opioid use occur. Outpatient withdrawal management is also less disruptive to the patient and their family, and offers the opportunity to continue with their normal routine of daily living, providing a more realistic environment for the development of coping strategies and support systems on reduction or cessation of opioid use.

Traditional assumptions that certain treatment modalities can be delivered only in a particular setting may not be applicable or valuable to patients. Many of the traditional placement criteria that favour inpatient rather than community-based withdrawal management services (e.g., individuals with comorbid mental health issues) should not necessarily apply in the case of opioid use disorder. In these cases, rapid inpatient opioid withdrawal may leave individuals even more vulnerable to opioid-related harms—including fatal overdose—when discharged from a highly structured treatment setting and returned to their home environment where cravings and desire to use may be high and unregulated opioids easily obtained, particularly if no follow-up substance use disorder care is provided.313,314 Instead, like all patients without serious comorbidities, these patients can be referred to long-term inpatient or outpatient addiction services, where possible and appropriate, rather than short-term inpatient withdrawal management.315

Withdrawal management alone (i.e., without transition to opioid agonist treatment) is not effective and often leads to high rates of relapse rapidly post-treatment, which, increases the risk of HIV and hepatitis C transmission, morbidity, and mortality.79,167,301 As the first point of engagement in clinical care, opioid withdrawal management can serve an important role as a bridge to treatment, but is not recommended unless a strategy is in place for referral to ongoing OUD treatment, given the risks associated with withdrawal management alone.

Specifically, a meta-analysis found higher HIV incidence among individuals undergoing withdrawal management alone as compared with individuals receiving no treatment.167 Other past research has shown that individuals who have received inpatient opioid withdrawal management are at increased risk of death from drug overdose compared to those who received no treatment.301 This phenomenon is believed to be due to loss of tolerance to opioids and is consistent with the increased risk of fatal opioid overdose observed following release from incarceration.316 Furthermore, relapse to opioid use is common among patients undergoing withdrawal management alone, as evidenced by a large US-based observational cohort (n=990) that reported significantly lower rates of sustained abstinence at six-years follow-up for outpatient detoxification (12%) compared to other treatment approaches (18–21%).308,317 

For individuals who choose withdrawal management over long-term agonist treatment, including those with high opioid tolerance, consider initiating buprenorphine/naloxone treatment to address withdrawal symptoms and slowly tapering under outpatient supervision. Individuals who are unsuccessful with this approach may be offered ongoing opioid agonist treatment. 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.318,319 As individuals experience reduced tolerance following cessation of opioid use, clinicians should offer further information on vitural overdose prevention services, such as the Lifeguard app, and in-person overdose prevention sites. For more information on take-home naloxone and other harm reduction strategies please refer to Harm Reduction Programs and Services.