Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts.
Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island.
J Emerg Med. 2020 Feb;58(2):245-253. doi: 10.1016/j.jemermed.2019.12.015. Epub 2020 Jan 28.
Precipitated opioid withdrawal (POW) after opioid antagonist administration can be challenging to manage in the emergency department (ED), particularly if caused by a long-acting opioid antagonist such as naltrexone. There are no evidence-based guidelines to assist in safely and efficiently managing patients with this syndrome.
To review current practice on the treatment of long-acting antagonist POW and make recommendations on the treatment of this complex disease process.
A literature search of opioid withdrawal cases precipitated by naltrexone was done using PubMed. One of the authors screened all the results of this search by title and abstract, leading to a final count of 27 articles that were reviewed in full by all authors. English language cases that involved precipitated opioid withdrawal from a long-acting opioid antagonist were included. Data were extracted, including the precipitant involved and dose, severity of opioid withdrawal, treatments rendered, and response to treatment. In all cases where symptoms and signs were described, a Clinical Opiate Withdrawal Scale score was calculated based on the information available.
Twenty-seven papers were included. Naltrexone alone was the primary antagonist reported in 19 of the papers, extended-release naltrexone in two, naltrexone-morphine combination in two, and nalmefene in four. Treatment most commonly included fluid replacement, benzodiazepines, antiemetics, and clonidine. Full opioid agonist treatment, although often suggested, was poorly described. Buprenorphine successfully reduced the severity and duration of withdrawal in several cases. No standardized response scale was used, and response to treatment ranged from 3 to 48 h prior to resolution of clinical effects.
Management of POW from long-acting antagonists is a complex problem with little formal evaluation of treatment options. There is not currently a sufficiently robust body of literature to support an evidence-based guideline. However, use of intravenous fluids, antiemetics, and benzodiazepines is commonly reported as successful and seems to be a reasonable approach until this process is better studied. A treatment strategy using partial agonists such as buprenorphine is emerging and may represent a safe and effective treatment pathway for these patients.
在急诊科（ED）中，阿片类拮抗剂给药后出现沉淀性阿片戒断（POW）可能难以处理，特别是如果由纳曲酮等长效阿片拮抗剂引起。目前尚无循证指南来协助安全有效地管理此类综合征患者。
回顾目前对长效拮抗剂 POW 治疗的实践，并就这种复杂疾病过程的治疗提出建议。
使用 PubMed 对纳曲酮引发的阿片类戒断病例进行文献检索。其中一位作者通过标题和摘要筛选了该搜索的所有结果，最终确定了 27 篇全文进行审阅的文章。纳入的英语病例涉及由长效阿片拮抗剂引发的沉淀性阿片戒断。提取数据，包括涉及的催瘾剂和剂量、阿片类戒断的严重程度、给予的治疗以及对治疗的反应。在所有有症状和体征描述的病例中，根据可用信息计算临床阿片戒断量表评分。
纳入 27 篇论文。19 篇论文报告的主要拮抗剂为纳曲酮，2 篇为纳曲酮缓释剂，2 篇为纳曲酮-吗啡组合，4 篇为纳美芬。最常见的治疗方法包括补液、苯二氮䓬类、止吐药和可乐定。尽管经常建议使用完全阿片类激动剂，但描述较差。丁丙诺啡在数例中成功降低了戒断的严重程度和持续时间。没有使用标准化的反应量表，治疗反应范围为 3 至 48 小时，直至临床效果消退。
长效拮抗剂引起的 POW 管理是一个复杂的问题，对治疗选择的正式评估很少。目前，没有足够丰富的文献支持循证指南。然而，静脉补液、止吐药和苯二氮䓬类药物的使用常被报道为成功，在这一过程得到更好研究之前，这似乎是一种合理的方法。使用部分激动剂（如丁丙诺啡）的治疗策略正在出现，可能代表这些患者安全有效的治疗途径。
