Why We Use Clonidine for Opioid Withdrawal

A little doctor humor

A little doctor humor

 

Clonidine has been used for decades as a blood pressure medication. It’s cheap and effective, but has some unpleasant side effects: sedation, dry mouth, and constipation. Because newer blood pressure medications have fewer side effects, clonidine is used less today than in the past to treat high blood pressure.

However, it is at least moderately effective at treating many of the symptoms of opioid withdrawal.

Among many other places in the central nervous system, opioids act on a part of the brain called the locus ceruleus. The locus ceruleus, which in Latin means the “blue place,” is part of the system that controls the autonomic nervous system. When locus ceruleus neurons are stimulated, norepinephrine is released into the brain, and this causes overall stimulation of the brain.

Opioids slow the firing of these neurons in the locus ceruleus, reducing the release of norepinephrine. When the body gets opioids regularly from an outside source, the locus ceruleus makes adjustments to make up for extra opioids. Then if the supply of opioids is suddenly stopped, the locus ceruleus becomes unbalanced, and releases an overabundance of norepinephrine. The heart rate and blood pressure increase, along with other symptoms: runny nose, yawning, tearing of the eyes, diarrhea, and nausea.

Since clonidine works by calming the locus ceruleus, clonidine reduces many of these unpleasant opioid withdrawal symptoms.

So how effective is clonidine? Most patients say that it helps somewhat, but they still feel withdrawal symptoms. My impression from what patients have described is that clonidine is mildly to moderately effective.

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3 responses to this post.

  1. We used clonidine for years, going back to 1981, in conjunction with valium. The affect, during the acute phase of withdrawal provided some mitigation of the physiological and some of the psychological affects that typify this phase. Our problem consisted, primarily, of the post acute withdrawal that, often, continued for many months to over a year. We began to call the opiate dependent patients “whiners” because while the alcoholic, meth addict, etc. had gotten on with their recovery, the opiate dependent patients consistently complained of a lack of energy, purpose, pleasure or joy. They lacked the enthusiasm, that typified the hope, most found in early recovery.
    Unfortunately, we didn’t know that their brains had changed at the Mu and kappa receptor sites and that more prayer, meetings, grief recovery etc. didn’t make fix this deficit. With the advent of buprenorphine, in 2004, we found that we had found an agent that would return their brains to a state of homeostasis or balance. Now, they could again feel the promise of a life in recovery. From that difficult transition, we have found that our treatment program is now abstinence based Medication assisted Treatment. Our outcomes, retention and family involvement have soared while each patient’s treatment is individualized to meet their specific brain’s response, while addressing any psychiatric and/or chronic pain conditions.
    In retrospect, the acute phase was easy, it was the six to eighteen months of anhedonia that proved the trigger to a relapse and, often, death by overdose.
    Just another anecdotal experience over thirty years.

    Reply

    • Posted by Steve S on June 1, 2016 at 2:09 am

      Couldn’t agree with you more regarding abstinence based MAT but many of our colleagues would say that, that term is an oxymoron and many pts agree. I had a patient ask me today if she was cheating by using buprenorphine to maintain a stable recovery.
      However, I find that many of my alcohol pts also have a protracted phase of anhedonia also which is improved somewhat by gabapentin.
      I agree with Dr Burson that clonidine is only mildly to moderately effective but increasing the dosage seems to help but greatly increases sedation.

      Reply

  2. Too bad all of those patients that could have benefited from Methadone for all those years. 😦

    Reply

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