Opioid withdrawal
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]
Overview
Opioid withdrawal occurs due to the cessation of opioids or the administration of an opioid antagonist following a heavy or prolonged use of opioids. Symptoms of withdrawal from opiates include, but are not limited to, depression, aggression and irritability, leg cramps, abdominal cramps, vomiting, diarrhea, insomnia, and cravings for the drug itself. Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days.
Historical Perspective
- Opium and its derivatives have been used as medical therapies since 5,000 years ago.[1]
- In the United States, in the early 20th century, opiates were over-the-counter drugs and were commonly used in medical therapy of various disorders.[1]
- In the early 1900s, the federal restrictions on opioid access caused suffering and death since there were no effective treatments for the opioid withdrawal symptoms that happened with sudden discontinuation of opioids.[1]
Classification
The onset and duration of opioid withdrawal depends on the half-life of the consumed opioid:[2][1][3][4][5]
| Half-lives of Opioids | Onset of Withdrawal Symtoms | Duration of the syndrome |
|---|---|---|
Short half-lives
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Within 12 h of last use | eg, heroin withdrawal lasts 4–5 days |
Long half-lives
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1–3 days after last use |
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`Pathophysiology
Causes
Opioid withdrawal may be caused by discontinuation of repeated use of an opioid.[6]
Differentiating opioid withdrawal from other diseases and conditions
Opioid withdrawal must be differentiated from:[6]
- Sedative-hypnotic withdrawal
- Hallucinogen intoxication
- Stimulant intoxication
- Opioid-induced depressive disorder
| Disease | Prominent clinical features | Investigations |
|---|---|---|
| Hyperthyroidism | The main symptoms include:
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| Essential hypertension | Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: | JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:
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| Generalized anxiety disorder | According to DSM V, the following criteria should be present to fit the diagnosis of generalized anxiety disorder:
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| Menopause | The perimenopausal symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication etc may be associated with the hormone withdrawal process.
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| Opioid withdrawal disorder | According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:
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| Pheochromocytoma | The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:
Please note that not all patients with pheochromocytoma experience all classical symptoms. |
Diagnostic lab findings associated with pheochromocytoma include:
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Epidemiology and Demographics
Prevalence
The prevalence of opioid withdrawal is 6,000 per 100,000 (60%) of the population that have used heroin one or more time in the prior 12 months.[6]
Risk Factors
Opioid withdrawal may be caused by discontinuation of repeated use of an opioid in any setting such as:[6]
- Medical therapy of pain
- Opioid agonist therapy for opioid use disorder
- Recreational use
- Self-treating the symptoms of mental disorders
Screening
Natural History, Complications and Prognosis
Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days. The user, upon returning to the environment where they usually used opiates, can experience environmentally implied physical withdrawal symptoms well-after regaining physical homeostasis - or the termination of the physical withdrawal phase by synthesis of endogenous opioids (endorphins) and upregulation of opioid receptors to the effects of normal levels of endogenous opioids. These implied symptoms are often just as distressing and painful as the initial withdrawal phase.
Detoxification is best conducted in an in patient facility that provides a controlled environment. Patients who are isolated and exposed solely to care givers and other patients in this environment have a better rate of staying clean then those who detox out-patient.
Diagnosis
Diagnostic Criteria
DSM-V Diagnostic Criteria for Opioid Withdrawal[6]
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AND
AND
AND
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History and Symptoms
The most common symptoms of opioid withdrwal include :[7][8]
- Anxiety
- Anxiety
- Restlessness
- Irritability
- Insomnia
- Hot flashes
- Chills
- Sweating
- Pupillary dilatation
- Heart pounding
- Lacrimation
- Rhinorrhea
- Yawning
- Gooseflesh
- Nausea, vomiting
- Abdominal cramps
- Diarrhea
- Aches, pain
- Muscle spasms, twitching
- Tremor
Physical Examination
Common physical examination findings of opioid withdrwal include:[7][8][1]
- Anxiety
- Restlessness
- Irritability
- Hypertension
- Tachycardia
- Mydriasis
- Piloerection (such as goose bumps)
- Lacrimation
- Rhinorrhea
- Yawning
- Nausea, vomiting
- Diarrhea
- Sweating
- Muscle spasms, twitching
- Tremor
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography or Ultrasound
CT Scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Medications used in opioid withdrawal include:
- Methadone
- Methadone is a long-acting agonist at the μ-opioid receptor
- Dose:
- Methadone is the most commonly used medication, but patients require adjunctive drugs for nausea, vomiting, diarrhea, and stomach cramps
- Clonidine
- Buprenorphine
- Buprenorphine is a partial μ-opioid agonist
Surgery
Primary Prevention
Primary Prevention
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Kosten TR, Baxter LE (2019). "Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment". Am J Addict. 28 (2): 55–62. doi:10.1111/ajad.12862. PMC 6590307 Check
|pmc=value (help). PMID 30701615. - ↑ Srivastava AB, Mariani JJ, Levin FR (2020). "New directions in the treatment of opioid withdrawal". Lancet. 395 (10241): 1938–1948. doi:10.1016/S0140-6736(20)30852-7. PMC 7385662 Check
|pmc=value (help). PMID 32563380 Check|pmid=value (help). - ↑ Kosten TR, O'Connor PG (2003). "Management of drug and alcohol withdrawal". N Engl J Med. 348 (18): 1786–95. doi:10.1056/NEJMra020617. PMID 12724485.
- ↑ Kleber HD (2007). "Pharmacologic treatments for opioid dependence: detoxification and maintenance options". Dialogues Clin Neurosci. 9 (4): 455–70. PMC 3202507. PMID 18286804.
- ↑ Kreek MJ, Borg L, Ducat E, Ray B (2010). "Pharmacotherapy in the treatment of addiction: methadone". J Addict Dis. 29 (2): 200–16. doi:10.1080/10550881003684798. PMC 2885886. PMID 20407977.
- ↑ 6.0 6.1 6.2 6.3 6.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
- ↑ 7.0 7.1 Wesson DR, Ling W (2003). "The Clinical Opiate Withdrawal Scale (COWS)". J Psychoactive Drugs. 35 (2): 253–9. doi:10.1080/02791072.2003.10400007. PMID 12924748.
- ↑ 8.0 8.1 Vernon MK, Reinders S, Mannix S, Gullo K, Gorodetzky CW, Clinch T (2016). "Psychometric evaluation of the 10-item Short Opiate Withdrawal Scale-Gossop (SOWS-Gossop) in patients undergoing opioid detoxification". Addict Behav. 60: 109–16. doi:10.1016/j.addbeh.2016.03.028. PMID 27124502.