Menu Search Donate
Child Health Guideline Identifier

Weaning of Opioids and Benzodiazepines

This document is only valid for the day on which it is accessed. Please read our disclaimer.

This guideline is not intended for use in infants born to drug dependant mothers. In this instance, please refer to the Newborn Services Neonatal Abstinence Syndrome Guideline

Background

Patients receiving opioid analgesia and/or benzodiazepine sedation for longer than 5-7 days may display clinical signs and symptoms of withdrawal if these medicines are stopped abruptly. Weaning reduces the likelihood of withdrawal symptoms.

Determining if medication weaning is required

Table 1. Does the patient requires medication weaning?

Days on Medicine WAT-1 Scoring Dose Reduction %* Rate of Reduction Medicine Discontinuation
 < 5 Days  - Immediate 
 5 - 10 Days 1. Stop medicines and begin WAT-1
    scoring for 72 hours
 -  -  Scoring only
- immediate
2. If WAT-1 score > 3 on 2 consecutive
    occasions begin 20% withdrawal
    programme
 20% Every 24 hours  20% reduction
programme
- Day 6 
 > 10 Days  tick 10% Every 24 hours   Day 11


If medication weaning is required:

  • Prescribe weaning medicine/s on Paediatric Weaning and Assessment Prescription Form (CR8993)
  • Instigate Withdrawal Assessment Tool - 1 (WAT-1) observation tool for signs and symptoms of withdrawal (located on the CR8993)

Prescribing of weaning medicine/s

Prescribing guidance algorithm 

weaning algorithm

Notes:
- If pain not well controlled DO NOT WEAN OPIOID
- Use paracetamol and NSAIDs if pain is an on-going issue
- When enteral route is not available wean benzodiazepine/opioid infusions in a similar manner
  • Convert medicines to equivalent 24 hour oral (if tolerating enteral feed) doses of opioid or diazepam and divide into 4 or 6 hourly dosing as indicated. (See medicine information and calculating equipotent doses below)
  • If enteral route not available wean IV infusions in same manner as above
  • Prescribe daily doses and PRN rescue doses on Paediatric Weaning and Assessment Prescription Form CR8993 following the Prescribing Guidance algorithm above
  • Patients may require weaning from more than one medicine:
    - Reduce opioid and benzodiazepine by the same rate at the same time
    - If there are signs or symptoms of withdrawal during weaning process, reduce one medicine at a time in the following order:
      • Morphine, oxycodone, fentanyl or methadone (unless on long-term opioid use)
      • Midazolam or diazepam
      • Chloral hydrate
      • Clonidine
  • Clonidine (oral or IV) 1-2 micrograms/kg TDS may be added as a weaning adjunct in patients who are difficult to wean. It may be given as a transdermal (patch) release formulation (See medicine information and calculating equipotent doses below )
  • Use paracetamol and Non-Steroidal Anti Inflammatory Drugs (NSAIDS) if pain is an ongoing issue. Weaning opioids may result in pain. This is NOT WITHDRAWAL and will require the primary team to review the appropriateness of initiating reduction of analgesia
  • If any concerns or the following arise please contact and discuss with the Paediatric Pain Service
    - A WAT-1 Score <1 for greater than 48 hours (may allow for a more rapid wean)
    - If not weaning according to the prescribing guidance algorithm (repeated episodes of withdrawal)
    - Requires ≥ 2 doses of rescue medicine in 24 hours (acute withdrawal)

Medicines information and calculating equipotent doses

Opioids

  •  The preferred opioid weaning agent is oral/enteral morphine
  • Calculate the total dose of opioid administered in the last 24 hours and convert to appropriate opioid equivalent (see table 2 below)
  • Divide 24hr dose into age appropriate dosing regimen
  • If appropriate a long acting morphine derivative may be used and dosed every 12 hours e.g. m-Eslon. NB: These capsules cannot be crushed so are only suitable for children who are old enough to swallow capsules
  • Do not wean opioids until pain is adequately controlled
  • Do not use PRN rescue doses as analgesic doses
  • Treat breakthrough pain with other analgesics where possible, if opioids required for analgesia, review appropriateness of initiation of weaning process

Maximum Dose for oral morphine  = 15 mg/dose
Maximum dose of oral oxycodone = 10 mg/dose

Table 2. Opioid equivalence table

From To Conversion Frequency Example
        From To
Morphine
IV 
(mg)
Morphine
oral
 (mg) 
X 3 Q4H>1yr
Q6H<1yr
Morphine IV 3mg/24 hr Morphine oral 9mg/24hrs
Fentanyl
IV 
(microgram)
Morphine
oral
 (mg)
X 0.2  Q4H>1yr
Q6H<1yr
Fentanyl IV 30 microgram/24 hr Morphine oral 6mg/24 hrs

Morphine
oral 
(mg) 
Methadone
oral (mg)
 
X 0.25  Q12H Morphine oral 10mg/24hr  Methadone oral 2.5mg/24hr
 
Oxycodone
IV 
(mg) 
Oxycodone
oral (mg)
X 1.25  Q6H>1yr
Q8H<1yr
Oxycodone IV 4mg/24 hr  Oxycodone oral 5mg /24hr 

Fentanyl
IV 
(microgram) 
Oxycodone
oral (mg)
 
X 0.1  Q6H>1yr
Q8H<1yr
Fentanyl IV 40mg/24hr  Oxycodone oral 4mg/24hr


Benzodiazepines (Midazolam / Diazepam)

  • The preferred benzodiazepine weaning agent is oral/enteral diazepam
  • If remaining on an intravenous midazolam infusion the dose can be decreased as per Prescribing Guidance Algorithm above
  • Calculate the total dose of benzodiazepine administered in the last 24 hours and convert to benzodiazepine equivalent (see Table 3 below)
  • Divide 24 hour dose into age appropriate dosing regime

Table 3. Benzodiazepine equivalence table

From To Conversion Frequency Example
        From To
Midazolam
IV (mg)
Diazepam oral (mg) ÷ 3 Q4H>1yr
Q6H<1yr
Midazolam IV 27mg/24hrs Diazepam oral 9mg/24hrs
Diazepam
IV
 (mg)
Diazepam oral (mg) Equivalent  Q4H>1yr
Q6H<1yr
Diazepam IV  9mg/24 hrs Diazepam oral 9mg/24hrs
  • When converting from intravenous midazolam infusion to oral/enteral diazepam, halve infusion rate by 50% after 1st dose of diazepam.
  • Cease intravenous midazolam infusion with 2nd dose of oral/enteral diazepam.

Chloral Hydrate

Table 4. Chloral hydrate weaning table

Chloral hydrate WAT-1 score Managing withdrawal
More than 5-7 days ≥ 3 Oral diazepam 0.1 mg/kg every six hours (and follow benzodiazepine weaning flowchart)

Clonidine

  • During weaning of clonidine the patient should have their blood pressure monitored and documented every 6 hours and the WAT-1 score completed 12 hourly. The patient must continue to have 6 hourly blood pressure recording until 24 hours after the last dose of clonidine or post transdermal patch removal.
  • If the mean blood pressure increases by more than 50% over 24 hours, contact the primary team registrar for review and cease the weaning of clonidine.
  • Elimination of clonidine is decreased in patients with renal impairment.

Table 5. Clonidine weaning table

Clonidine duration Clonidine dose Weaning
Less than 7 days ≤ 4microgram/kg/day Stop without weaning
Less than 7 days ≥ 4 microgram/kg/day Reduce by 50% every 24 hrs for 3 days then cease
More than 7 days   Reduce by 1 microgram/kg/dose every 24 hrs until dose reaches 1 microgram/kg/dose.
Continue until other medicines being weaned are ceased, then reduce clonidine by
50% every 24hrs for 3 days then cease
  •  Clonidine can also be used as an adjunct when weaning opioids or benzodiazepines
    -  Standard dose is 1-2 micrograms/kg/PO or IV every 4-6 hours OR
    -  as an infusion at doses up to 2 micrograms/kg/hour OR
    -  as a transdermal patch

Use of a Clonidine Patch

  • Choose a patch size that delivers 5-18 micrograms/kg/24 hours
  • Do not exceed 18 micrograms/kg/24 hours
  • Patches should never be cut
  • Patches come in the following concentrations and are effective for 7 days:
    -  100 micrograms/24 hours (TTS 1)
    -  200 micrograms/24 hours (TTS 2)
    -  300 micrograms/24 hours (TTS 3)
  • If a patch has been used and is no longer required, remove patch and score for withdrawal for 72 hours

Dexmedetomidine (PICU only)

Dexmedetomidine is a selective alpha-2 agonist similar to clonidine with a much greater receptor affinity. It produces a state of sedation and analgesia without depressing respiration. Patients may be rapidly weaned from benzodiazepines and opioids while on a dexmedetomidine infusion. The majority of the drug is metabolised by the liver and therefore clearance is not affected by renal impairment.

Table 6. Dexmedetomidine weaning table

Dexmedetomidine IV Dose Rate of infusion
Load 0.5-1 microgram/kg Over 15 minutes
Then Titrate to effect 0.1-1 microgram/kg/hr

To achieve adequate effect occasionally requires a dose of up to 1.5 microgram/kg/hour in infants. After prolonged use (>24 hours) stopping the infusion abruptly can cause withdrawal. Main side effects are bradycardia and hypotension.

Treatment of medicine withdrawal

WITHDRAWAL SYNDROME = WAT-1 score ≥ 3
  • Treat as per the treatment of withdrawal algorithm below
  • Consider the use of Clonidine as a weaning adjunct if withdrawal episodes continue despite using the treatment of withdrawal algorithm. Do not add weaning adjuncts early - there are only a small number of patients who will require weaning adjuncts to facilitate weaning. Contact the Paediatric Pain Service for advice if this is required.

Treatment of Withdrawal Algorithm

withdrawal algorithm

Notes:
If at any time the WAT-1 ≥ 3 or is trending upwards then:
   Eliminate alternative diagnoses
   Treat as per the treatment of withdrawal algorithm (above)

Patient observation requirements and considerations

Medication withdrawal is highly variable and patients need to be observed closely for signs and symptoms during the weaning and cessation of opioids and benzodiazepines.

Optimising non-pharmacological measures can support the weaning process and reduce withdrawal. These include reducing environmental stimuli, ensuring adequate hydration, regular feeds for infants, and optimising patient position should be considered when planning care.

Assess patients to ensure that these signs and symptoms are not due to another cause - WITHDRAWAL is a DIAGNOSIS of EXCLUSION.

The WAT-1 scoring tool is the tool used in Starship Child Health to assess for withdrawal signs and symptoms.

  • WAT-1 scoring should be completed:
    -  Early in each nursing shift - minimum 12 hourly
    -  Anytime if clinically indicated
    -  According to instructions given on the Paediatric Weaning and Assessment Prescription Form (CR8993)
  • If there has been evidence of withdrawal and rescue medicine was required repeat WAT-1 scoring 1 hour post rescue medicine dose. Higher scores indicate withdrawal symptoms; lower scores indicate minimal/no withdrawal symptoms
  • Interpretation is based on scoring trend over time. A score that is increasing, e.g. from 1 to 3, may be an indication to alter weaning plan before patient shows overt signs of withdrawal
  • A total score greater than or equal to 3 can indicate withdrawal symptoms - assess the patient and initiate treatment of withdrawal algorithm above
  • Patients need to be assessed for signs and symptoms of medicine withdrawal for 72 hours minimum (using the WAT-1 scoring tool) once the medicine(s) are ceased

Patient review

Patients undergoing weaning of analgesia or sedation in the ward will have this reviewed and managed daily by the primary team and will not be routinely reviewed by the Paediatric Pain Service.

The Paediatric Pain Service will be informed of all patients going to the ward from the Paediatric Intensive Care Unit (PICU) on a weaning plan. If a patient is commenced on a weaning plan outside of PICU the Paediatric Pain Service is unlikely to know about the patient. Contact the Acute Pain Service by calling the anaesthesia registrar on 021 938 273 for advice.

References

  1. ANAND KJS, ARNOLD JH. (1994) Opioid tolerance and dependence in infants and children. Critical Care Medicine. 22;2; 334-342.
  2. ANAND KJS, INGRAHAM J (1996). Tolerance, Dependence and Strategies for Compassionate Withdrawal of Analgesics and Anxiolytics in the Pediatric ICU. Critical Care Nurse. 16;6; 87-93.
  3. ANAND KJS. et al. (2010). Tolerance and Withdrawal from Prolonger Opioid Use in Critically Ill Children. Pediatrics. 125;5; 1208-25.
  4. BADDIGAM K. et al (2005). Dexmedetomidine in the treatment of withdrawal syndromes in cardiothoracic surgery patients. Journal of Intensive Care Medicine. 20, 118-23.
  5. BIRCHLEY, G. (2009). Opioid and benzodiazepine withdrawal syndromes in the paediatric intensive care unit: a review of recent literature. Nursing in Critical Care. 14;1; 26-37.
  6. FINKEL JC. et al (2005). The use of dexmedetomidine to facilitate acute discontinuation of opioids after cardiac transplantation in children. Critical Care Medicine, 33, 2110-2.
  7. FINKEL JC et al. (2004). The use of dexmedetomidine to facilitate opioid and benzodiazepine detoxification in an infant. Anesthesia & Analgesia, 98, 1658-9.
  8. FRANCK LS. et al (2012) Validity and generalizability of the Withdrawal Assessment Tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain 153;1; 142-8.
  9. FRANCK LS et al (2008) The Withdrawal Assessment Tool-1 (WAT-1): An assessment instrument for monitoring opioid and benzodiazepine withdrawal symptoms in pediatric patients. Pediatr Crit Care Med 9;6; 573-580.
  10. GALINKIN J et al Recognition and Management of Iatrogenically Induced Opioid Dependence and Withdrawal in Children. Pediatrics 133; 152-155
  11. HONEY et al (2009). Alpha-2 Receptor Agonists for Treatment and Prevention of Iatrogenic Opioid Abstinence Syndrom in Critically Ill Patients. The Annals of Pharmacotherapy 43;1506-1511
  12. HUDAK ML et al (2012) Neonatal Drug Withdrawal. Pediatrics 129;e540-e560.
  13. PUNTILLO K. et al. (1997) Opioid and benzodiazepine tolerance and dependence: Application of theory to critical care practice. Heart & Lung The Journal of Acute & Critical Care. 26;4; 317-324.
  14. TOBIAS JD. (2000) Tolerance, withdrawal and physical dependency after long-term sedation and analgesia of children in the pediatric intensive care unit Critical Care Medicine 28(6), 2122-2132.
  15. YASTER M et al (1996) The Management of Opioid and Benzodiazepine Dependence in Infants, Children, and Adolescents. Pediatrics 98;135-140.

Did you find this information helpful?

Document Control

  • Date first published: 19 July 2017
  • Date last published: 01 August 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit, Paediatric Pain Service, ADHB Pharmacy
  • Editor: Greg Williams
  • Review frequency: 2 years

More From Starship