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Managing Opioid Withdrawal: Symptoms and Solutions
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Opioid withdrawal occurs when you abruptly stop taking opioids without a proper taper. Symptoms like muscle aches, nausea, and anxiety are uncomfortable but not life-threatening and can be managed medically.
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Opioid withdrawal symptoms usually start within 4 hours, peak in 48–72 hours, and subside in about a week for opioids like oxycodone. Withdrawal symptoms for opioids like methadone may last for more than a week. Medication-assisted treatment (MAT) can help manage these symptoms during the process.
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Medications like buprenorphine, methadone, and lofexidine are FDA-approved to ease withdrawal. A medically supervised detox and ongoing treatment are crucial for managing opioid use disorder and preventing relapse.
Opioid withdrawal refers to a set of symptoms that occur when a person abruptly stops using opioids or reduces their dosage after taking them daily for more than two weeks, especially if it exceeds three months. Withdrawal symptoms occur because the body gets used to having opioids in the system, and when the drugs are no longer there, it causes certain withdrawal symptoms during the adjustment period. A hallmark sign of opioid dependence is the appearance of withdrawal symptoms when the drug is withheld.
Examples of opioid drugs include prescription opioid painkillers such as morphine, codeine, oxycodone, hydrocodone, oxymorphone, hydromorphone, fentanyl, and tramadol. Other slow-acting opioids used for the treatment of opioid use disorder include methadone and buprenorphine. The illicit drug heroin is also an opioid.
In most cases, opioid withdrawal symptoms are not life-threatening. However, they can be severely uncomfortable. Healthcare providers can manage symptoms with medications. Following detoxification, counseling, and psychotherapy can help a person with opioid use disorder stop taking opioid medicine or using illicit drugs again. Continue reading to learn more about opioid withdrawals.
Is It A Physical Dependence or An Opioid Addiction?
Opioid withdrawal syndrome occurs in people with a physical dependence on opioid drugs. A physical dependence on opioids is different from an opioid addiction. Opioid addiction refers to compulsive substance abuse (opioid abuse). The medical term for an opioid addiction is Opioid Use Disorder (OUD). Physical dependence refers to when the body is physically reliant on a substance, and withdrawal symptoms appear when drug use is stopped or reduced. A person can have physical dependence on opioids, opioid use disorder (OUD), or both together.
Read Next: What Are the Most Addictive Drugs You Can Be Prescribed?
Causes and Triggers for Opiate Withdrawal
The main cause of opioid withdrawal symptoms is a physical dependence on opioids. Opioid withdrawal syndrome occurs in opioid-dependent patients, including those who have been taking prescription opioid medication from a healthcare provider as well as those with opioid misuse or abuse (OUD).
What Are The Withdrawal Symptoms Associated With Opioids?
Common symptoms of opiate withdrawal include agitation, anxiety, sleep problems, hot and cold flushes, muscle aches, sweating, runny nose, nausea, vomiting, diarrhea, and cravings. However, there is a long list of potential symptoms someone can experience during opioid withdrawal, including:
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Flu-like symptoms (fever, chills)
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Muscle aches and pains
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Agitation
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Anxiety
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Stomach cramps
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Nausea
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Vomiting
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Diarrhea
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Loss of appetite
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Dilated (widened) pupils
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Rapid heart rate
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Increased breathing rate
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Excessive sweating
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Insomnia
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Tearing or crying
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Yawning
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Gooseflesh
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Tremors
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Muscle twitching
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Severe drug cravings
Managing Serious Withdrawal Symptoms
Opioid withdrawal symptoms are not life-threatening. However, they can be very uncomfortable. Severe withdrawal symptoms can trigger a relapse, causing a person to return to drug use for relief from withdrawal symptoms. Opioid misuse can put the individual at risk of overdose and death, especially after a period of abstinence that led to withdrawal.
That’s why it’s important to undergo a medically supervised opioid withdrawal (also called detoxification). During opioid detoxification, healthcare providers can prescribe medications to reduce the severity of withdrawal symptoms and thereby lower the risk of relapse.
Clinical Opiate Withdrawal Scale
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale used by healthcare providers to rate the common signs and symptoms of opiate withdrawal and monitor their severity over time. The total score on COWS helps clinicians determine a patient’s level of physical dependence on opioids and the severity of opiate withdrawal. The items that are scored on the Clinical Opiate Withdrawal Scale include:
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Resting pulse rate
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Restlessness
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Sweating
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Pupil size
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Runny nose or tearing
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Bone pain or joint pain
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Gastrointestinal upset
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Tremor
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Anxiety or irritability
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Yawning
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Gooseflesh
Save On Your Withdrawal Management Medications
Managing Withdrawal Symptoms
Medications Used To Manage Opiate Withdrawal Symptoms
Treatment for opioid withdrawal symptoms consists of managing specific symptoms. Some of the medicines used to manage symptoms include:
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Stomach cramps and diarrhea: Clonidine (Catapres) and over-the-counter anti-diarrhea medicines are used to manage stomach cramps and diarrhea. Clonidine also helps in controlling high blood pressure. The usual dose is 0.1 mg to 0.2 mg every 4-6 hours.
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Diarrhea: Loperamide (Imodium).
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Nausea and vomiting: Metoclopramide (Reglan), ondansetron (Zofran ODT), and prochlorperazine (Compazine).
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Insomnia: Antidepressants such as mirtazapine (Remeron), trazodone (Desyrel), and doxepin (Silenor).
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Muscle spasms: Muscle relaxants such as baclofen (Ozobax).
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Muscle aches and pains: Over-the-counter pain relievers such as acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil) and naproxen (Aleve).
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Opioid cravings: Methadone (Dolophine, Methadose), buprenorphine (Subutex), or buprenorphine and naloxone (Zubsolv, Suboxone). Compare opioid addiction treatments.
Clinical Guidelines For Withdrawal Management
Opioid withdrawal management can be of the following types:
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Cold turkey (no treatment, just allowing the opioid withdrawal to run its course).
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Opioid substitution with buprenorphine or methadone.
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Use of medications such as clonidine to relieve opioid withdrawal symptoms.
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Long-term support and naltrexone use.
As mentioned, while a moderately severe opioid withdrawal syndrome can be very uncomfortable, it is self-limited and not life-threatening. Most people going through opioid withdrawal can be managed in an outpatient setting unless they have comorbid medical or mental health conditions requiring hospitalization.
Rapid and Ultrarapid Protocols for Opioid Withdrawal
Fast withdrawal from opioids can be achieved with rapid and ultrarapid protocols using a combination of drugs.
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Rapid protocols: These involve the use of naloxone, nalmefene, naltrexone, or buprenorphine to induce opioid withdrawal and clonidine and other drugs to manage opioid withdrawal symptoms.
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Ultrarapid protocols: These involve large doses of naloxone and diuretics (water pills) to rapidly remove opioids from the body. They are done with the patient under general anesthesia. However, ultrarapid protocols are not recommended because they carry a high risk of complications and have no major benefit in opioid withdrawal management. Learn about over-the-counter naloxone options.
Learn more about using nalmefene for opioid and alcohol dependence.
FDA-Approved Treatments for Opioid Withdrawal
It’s important to understand that opioid withdrawal management is not the only treatment for opioid use disorder. It is the first step and has to be followed by an ongoing addiction treatment program which includes medications and counseling.
The U.S. Food and Drug Administration (FDA) has approved the following drugs for medication-assisted treatment of opioid use disorders:
Buprenorphine
Buprenorphine is a partial opioid agonist. It is given sublingually (placed under the tongue) during opioid withdrawal. The usual dose of buprenorphine to control severe withdrawal symptoms is 8 mg to 16 mg per day with a maximum of 32 mg per day. This dose may be tapered (gradually reduced) over several weeks as the body adjusts to the absence of opioids in the system. However, some people receive long-term buprenorphine maintenance treatment.
A medication called naloxone is added to buprenorphine to reduce the potential for misuse. When taken as directed, buprenorphine effects predominate and control withdrawal symptoms. But if buprenorphine is misused (crushed and injected), naloxone effects predominate and cause withdrawal symptoms. The combination, therefore, reduces the risk of drug misuse.
Methadone
Methadone is an FDA-approved drug for opioid withdrawal syndrome. It is used in certified opioid treatment programs. Methadone is given by mouth at initial doses ranging from 10 mg to 30 mg. The maintenance dose is usually between 60 mg and 120 mg per day.
Once a person stabilizes, the methadone dose can be slowly decreased by 10-20% every day. However, some people receive long-term methadone maintenance treatment. Coming off methadone can cause methadone withdrawal with anxiety and other symptoms. A gradual taper may be necessary in patients who have been on higher doses (100 mg/day or more) or long-term treatment with methadone.
Note: Methadone has been linked to serious side effects such as QTc prolongation and cardiac arrhythmias like torsades de pointes. This medication should, therefore, be used with caution and with close monitoring by a healthcare provider.
Lofexidine Hydrochloride
The FDA has approved a non-opioid drug, lofexidine hydrochloride (Lucemyra), to manage withdrawal symptoms after the abrupt discontinuation of opioid drugs. This is an oral selective alpha 2-adrenergic receptor agonist. It works by stopping the release of norepinephrine in the autonomic nervous system, which is believed to mediate many of the symptoms of opioid withdrawal.
Lucemyra can lessen the severity of withdrawal symptoms but does not completely prevent them. The maximum treatment duration with Lucemyra is 14 days. It is not the only treatment for opioid use disorder (OUD) but can be used as part of the overall treatment plan.
What is the Timeline For Opioid Withdrawal?
The timeline for opioid withdrawal (onset of withdrawal symptoms and duration of withdrawal syndrome) depends on the specific opioid and its half-life (how long it stays in the body). For example, oxycodone withdrawal symptoms or heroin withdrawal symptoms may last for 4-5 days because these are fast-acting opioids. On the other hand, methadone withdrawal symptoms may last a week because it is a longer-acting opioid. Illicit fentanyl also has a long duration of action, so withdrawal symptoms may not start until 24 to 48 hours after stopping use and may last a week.
Generally, the timeline for opiate withdrawal symptoms is as follows:
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Early symptoms of opioid withdrawal can appear 4 hours after the last dose of an opioid drug.
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Peak withdrawal symptoms occur in 48 to 72 hours.
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Most opiate withdrawal symptoms subside in about one week.
Preventing Opioid Withdrawal
It may not be possible to prevent opioid withdrawal if you have a physical dependence on opioid drugs. However, seeking medical care and undergoing a medically supervised detoxification can help to manage the symptoms, keep you as comfortable as possible during opioid withdrawal, and lower the risk of relapse to drug use.
Find out what other drugs can cause withdrawal symptoms.
Who Is Most At Risk For Withdrawal?
Some of the risk factors for severe opioid withdrawal syndrome include:
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Larger amounts of daily opioid use.
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Longer duration of opioid use.
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Use of other drugs.
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Pre-existing mental health symptoms (anxiety and depression).
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Lower pain tolerance.
Long-Term Health Considerations
When you suddenly stop using opioids, it takes your body time to adjust. This is what causes opioid withdrawal symptoms. As noted, these symptoms are short-lived and typically disappear in about one week. Clonidine and other medicines can be used to manage withdrawal symptoms.
Many people are fearful of opioid withdrawal. However, it is an important first step in treating an opioid use disorder (OUD). OUD is a chronic condition, which if left untreated, can lead to serious health complications, including overdose and death.
Educative Resources And Support Systems
Treatment Centers and Resources
Role of Healthcare Professionals In Managing Withdrawal
Healthcare professionals play a vital role in managing withdrawal from opioids. While it is possible to quit opioid drug use cold turkey (stop suddenly), this carries a risk of relapse due to severe withdrawal symptoms.
Medically supervised detoxification and opioid withdrawal management can help you stay as comfortable as possible during the withdrawal process. A team of health care providers, including a physician with expertise in addiction medicine, a registered nurse, a counselor, a pharmacist, and others, can help to manage withdrawal symptoms.
Educational Insights on Withdrawal Management
Here are some links for further reading and educational insights on opioid withdrawal:
Frequently Asked Questions About Opioid Withdrawal
How Long Does Withdrawal Fatigue Last?
The precise duration of withdrawal fatigue depends on a number of factors, including the type of substance use disorder and the severity of physical dependence. Depending on individual factors, it can take several days, weeks, and even up to 6 months for complete resolution of all opioid withdrawal symptoms, including withdrawal fatigue.
When Does Brain Chemistry Normalize After Opioids?
Research suggests that it takes 4-8 weeks for brain chemistry to return to normal after stopping opioid use. Once opioids are removed from the body, opioid receptor sensitivity returns to normal gradually over several weeks.
What Are Withdrawal Symptoms?
Early opioid withdrawal symptoms include anxiety, drug cravings, fast respiratory rate, and sweating. Other symptoms can include tearing, yawning, widened pupils, and stomach cramps.
Later, symptoms like gooseflesh, muscle twitching, tremors, fast heartbeat, high blood pressure, fever, chills, loss of appetite, nausea, vomiting, and diarrhea can develop.
How Long Does A Withdrawal Take?
Withdrawal from opioids typically takes one week. Symptoms of opioid dependence with withdrawal start about 4 hours after the last dose, peak in 48-72 hours, and go away in about a week.
What Are The Other Types of Withdrawals?
Other substances that can result in withdrawal symptoms after abrupt discontinuation include:
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Alcohol
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Benzodiazepines
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Cannabis
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Opioids
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Stimulants
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Nicotine
What Is The Most Serious Form Of Withdrawal?
The most serious form of withdrawal is a severe form of alcohol withdrawal called delirium tremens or DTs. It can be life-threatening and requires immediate care in the emergency department.
References:
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https://my.clevelandclinic.org/health/diseases/opioid-withdrawal
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https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/opioids
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https://www.uptodate.com/contents/opioid-withdrawal-clinical-features-assessment-and-diagnosis
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https://nida.nih.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf
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https://www.sciencedirect.com/science/article/pii/S0740547221001124#:~
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https://steverummlerhopenetwork.org/recovery/science-of-mat/#:
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