Opioid withdrawal

Clinical Presentation

• Onset of symptoms depends on time from last dose and the half-life of the opioid
  • Short-acting opioids (heroin, morphine, hydrocodone, immediate-release oxycodone): 12 to 16 hours from last dose
  • Intermediate-acting opioids (slow-release oral morphine, controlled-release hydromorphone, sustained-release oxycodone): 17 to 24 hours from last dose
  • Long-acting opioids (methadone): 24 to 48 hours from last dose
• Symptoms progress over time, and vary with the patient, their health status, their frequency, duration, and amount of use, and any concurrent substance use
  • Within the first 6 to 12 hours: cravings, anxiety, anorexia, irritability, tachypnea, hypertension, sweating, yawning, lacrimation, rhinorrhea, piloerection, tremor, and dilated pupils
  • Within 24 to 48 hours: nausea, vomiting, insomnia, tachycardia, abdominal cramps, and involuntary muscle spasms and limb movements
• Persistent symptoms usually resolve over 5 to 7 days
• However, cravings, depression, irritability, and dysphoria may persist for weeks to months

Precipitated withdrawal

• Occurs when buprenorphine or another partial opiate agonist is started while there is a full agonist still active

Diagnosis

• Clinical opioid withdrawal scale (COWS)
• Subjective opioid withdrawal scale (SOWS)