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Stabilization priorities
Immediate threats
Airway compromise from emesis or sedation
Lateral positioning and suction readiness
Consider naloxone only if ongoing opioid toxicity suspected
Severe dehydration
Persistent vomiting
Profuse diarrhoea
Hemodynamic instability
Hypotension from volume loss or alpha-2 agonists
Tachyarrhythmia from withdrawal or stimulants
Hyperthermia
Consider stimulant intoxication or sepsis if marked
Monitoring and environment
Cardiorespiratory monitoring for severe symptoms
Continuous pulse oximetry
Cardiac monitoring if QT prolongation risk or methadone use
Intravenous access when moderate to severe withdrawal or poor oral intake
Crystalloid rehydration targets guided by vitals and urine output
High risk features needing escalation
Altered mental status not explained by withdrawal
Consider head injury, infection, metabolic, co-ingestants
Chest pain or dyspnea
Consider ACS, PE, pneumonia, stimulant toxicity
Severe abdominal pain
Consider withdrawal mimics and surgical pathology
Pregnancy
Obstetric consultation trigger for moderate to severe withdrawal
Polysubstance withdrawal risk
Alcohol withdrawal history
Benzodiazepine dependence history
Key concepts
Core physiology
Opioid withdrawal is adrenergic hyperactivity after mu receptor downregulation
Autonomic symptoms predominate
Symptoms are rarely life-threatening but complications can be
Opioid withdrawal severity correlates with dependence level and opioid half-life
Short-acting opioids earlier onset
Long-acting opioids later onset
Time course patterns
Short-acting opioids
Onset 6-12 hours after last use
Peak 24-72 hours
Duration 5-10 days
Long-acting opioids and methadone
Onset 24-48 hours or longer
Peak 3-5 days
Duration 10-20 days
Buprenorphine cessation
Delayed onset
Prolonged lower-grade symptoms
Initial decision points
Syndrome classification
Withdrawal versus intoxication
Withdrawal findings
Mydriasis
Diaphoresis
Piloerection
Tachycardia
Intoxication findings
Miosis
Bradypnea
Sedation
Withdrawal versus mimic
Gastroenteritis
Fever or infectious exposure
Sepsis
Persistent hypotension
Thyrotoxicosis
Tremor with weight loss and goitre
Treatment pathway choice
Opioid agonist pathway preferred for OUD and significant withdrawal
Buprenorphine based initiation
Methadone based initiation when buprenorphine not feasible
Non-opioid symptomatic pathway
Alpha-2 agonist
Supportive medications
Micro-induction pathway
High fentanyl exposure
Prior precipitated withdrawal history
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.