The Curbsiders Internal Medicine Podcast #498 Opioid Withdrawal with Dr. Ashish Thakrar
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Sep 15, 2025 Join Dr. Ashish Thakrar, an internist and addiction medicine specialist from the University of Pennsylvania, as he provides invaluable insights on managing opioid withdrawal amid the fentanyl crisis. Discover the intricacies of choosing between methadone and buprenorphine, and learn about the importance of personalized treatment approaches. The conversation dives into the challenges posed by adulterants in the drug supply and emphasizes the critical role of empathetic care in breaking the cycle of addiction. Don’t miss these essential strategies for effective management!
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Opioid Withdrawal Is Multi‑Dimensional
- Opioid withdrawal has objective signs (dilated pupils, tachycardia, yawning) and subjective symptoms (nausea, anxiety, muscle pain, craving).
- Fentanyl withdrawal often peaks later (2–3 days) and can last longer than heroin withdrawal.
Start With A Foundation Medication
- Use a long‑acting opioid (methadone or buprenorphine) as the foundational treatment for opioid withdrawal in hospital.
- Pair that with an alpha‑2 agonist (clonidine or lofexidine), symptom‑targeted PRNs, and add short‑acting opioids if needed.
Safer Buprenorphine Inductions
- Prevent buprenorphine precipitated withdrawal by waiting for objective withdrawal signs and at least 12 hours after last fentanyl use before induction.
- Start low and titrate (2mg → 2mg → 4mg over 1–2 hours) to reach ~8mg quickly.