Opioid Withdrawal


Opioid is an umbrella term for any substance that binds to opioid receptors in the body’s central nervous system.1,2 The body’s natural opioids are endorphins, which are involved in regulating our response to both pain and pleasure.1,4 Medications like morphine, oxycodone, and hydrocodone, which are prescribed to treat moderate to severe pain, are opioid analgesics (i.e., painkillers).1,2 Heroin is an illegal opioid drug with no medicinal use.1,3

Opioids are very effective in producing analgesia, in other words, they are good at reducing the ability to feel pain. Along with other short-term and long-term effects, opioids also induce a sense of euphoria, or pleasure. Prescription medications may be misused, and heroin is typically used, for this purpose. This makes opioids, both prescription-only and illicit heroin, have a high potential for abuse and both are tightly controlled by the U.S. Drug Enforcement Agency and the use and regulation of medicinal opioids are overseen by the U.S. Food and Drug Administration.5,6

According to the 2018 National Survey on Drug Use and Health, an estimated 10.3 million people aged 12 or older misused opioids in the past year, including 9.9 million prescription pain reliever misusers and 808,000 heroin users. Approximately 506,000 people misused both prescription pain relievers and heroin.7 Opioids were involved in 46,802 drug overdose deaths in 2018 (69.5% of all overdose deaths).8

Opioid Dependence and Addiction

Chronic use of opioids leads to dependence, which means users will experience withdrawal symptoms.9,10 Dependence may occur even when a medication is taken as prescribed and a physical dependence to opioids can develop quickly, as little as 4-8 weeks.9 Withdrawal symptoms can range from mild to severe and may even be debilitating.10 Symptoms are uncomfortable and distressing, but they are rarely life-threatening.10,11

A person who is dependent on opioids is at risk of becoming addicted to opioids, also known as opioid use disorder.9 An opioid use disorder is characterized by continued misuse of opioids despite health problems and failing to meet responsibilities at work, school, or home.2,9

A person who is dependent on opioids or who has an opioid use disorder not only experiences severe withdrawal symptoms but also strong cravings to use opioids.9-11 Preventing withdrawal and stopping drug cravings lead many people to relapse to drug use.10,11

How Long Does Opioid Withdrawal Take?

The duration and severity of opioid withdrawal, as well as the symptoms that someone will experience, varies from person to person and is dependent on the type of opioid taken, the dose taken, and the duration of opioid use.11,12

Withdrawal from opioids begins 8-24 hours after last use and lasts anywhere from 5 days to 2 weeks.13-15 More specific withdrawal timelines based on the type of opioid taken are below:

  • Heroin: First symptoms arrive within 12 hours of last use, peak within 1-3 days, then gradually resolve over the course of 5-7 days.13,14
  • Short-acting opioid medications (immediate-release morphine, hydromorphone, oxycodone, hydrocodone, oxymorphone, codeine, fentanyl): First symptoms arrive 8-24 hours after last use. Fully developed withdrawal begins 1-3 days after last use with the total duration of withdrawal being 7-10 days.15
  • Long-acting opioid medications (methadone, levorphanol, and extended-release/sustained-release/controlled-release formulations of short-acting opioids): First symptoms arrive up to 36 hours after last use with fully developed withdrawal 72-96 hours after last use. The total duration of withdrawal is 14 days or more.15

Symptoms of Opioid Withdrawal

Symptoms of opioid withdrawal may include:9,10,12

  • Generalized aches/pains.
  • Muscle spasms/twitching/tension/cramps.
  • Tremor or shaking.
  • Abdominal cramps and/or nausea/vomiting/diarrhea.
  • Anxiety/restlessness and/or irritability.
  • Yawning and/or insomnia, or trouble sleeping.
  • Hot flashes, sweating, chills and/or gooseflesh.
  • Tearing up of the eyes.
  • Runny nose.
  • Dilated pupils.
  • Heart pounding.

Intense cravings and a strong desire to use opioids typically accompany withdrawal, especially for those with an opioid use disorder.9,12 Cravings, along with other psychological and physiological symptoms, may continue even after acute withdrawal and detoxification.16 Extended symptoms that may continue for several weeks and up to six months include:16

  • Insomnia or sleep disturbances.
  • Fatigue, anhedonia, or dysphoria (inability to feel pleasure or feeling emotionally blunted).
  • Decreased cognitive abilities.
  • Inability to focus.
  • Cravings.
  • Increased sensitivity to physical pain.

Management of Opioid Withdrawal

People who have developed physical dependence to opioids or who have been diagnosed with an opioid use disorder may benefit from medically supervised opioid withdrawal management. Studies have shown that without medical supervision, many people are unable to complete discontinuation of opioids, as avoiding withdrawal symptoms often becomes a driving force for continuing use.12

Medically managed detoxification can make the withdrawal experience more comfortable, as doctors can prescribe medications to help reduce the severity of symptoms. In many cases, medical management of opioid withdrawal is an important first step for those overcoming an addiction to opioids and serves as a bridge to longer-term treatment of opioid use disorder.11-13 In these cases, an opioid maintenance medication, such as buprenorphine or methadone, is often started during withdrawal in an effort to eliminate completely or reduce the severity of withdrawal symptoms.11,12,15 Buprenorphine and methadone help significantly in reducing a person’s cravings for opioids, and these medications are usually continued through long-term treatment, which will also include psychosocial counseling (e.g., individual and/or group therapy) as well as self-help, or mutual-help, groups.11-16

References

  1. Lyden, J., & Binswanger, I. A. (2019). The United States opioid epidemicSeminars in Perinatology43(3), 123–131.
  2. National Institute on Drug Abuse. (2020). DrugFacts: Prescription Opioids.
  3. National Institute on Drug Abuse. (2019). DrugFacts: Heroin.
  4. Sprouse-Blum, A. S., Smith, G., Sugai, D., & Parsa, F. D. (2010). Understanding endorphins and their importance in pain management. Hawaii Medical Journal, 69(3), 70–71.
  5. U.S. Drug Enforcement Agency. (2019). Drug Scheduling.
  6. U.S. Food and Drug Administration. (2020). Opioid Medications.
  7. Center for Behavioral Health Statistics and Quality. (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD.
  8. Centers for Disease Control and Prevention. (2020). Drug Overdose Deaths.
  9. American Psychiatric Association. (2018). Opioid Use Disorder.
  10. Shah, M., & Huecker, M. R. (2020). Opioid Withdrawal. In StatPearls. StatPearls Publishing.
  11. The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med. 2020;14(2S Suppl 1):1-91.
  12. Kosten, T. R., & Baxter, L. E. (2019). Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatmentThe American Journal on Addictions, 28(2), 55–62.
  13. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington D.C.: American Psychiatric Association.
  14. Substance Abuse and Mental Health Treatment Services Administration. (2015). TIP 45: Detoxification and Substance Abuse Treatment.
  15. Substance Abuse and Mental Health Treatment Services Administration. (2020). TIP 63: Medications for Opioid Use Disorder.
  16. Miller, S. C., Fiellin, D. A., Rosenthal, R. N., & Saitz, R. (2019). The ASAM Principles of Addiction Medicine, Sixth Edition. Philadelphia: Wolters Kluwer.


About The Contributor

Ryan Kelley, NREMT
Ryan Kelley, NREMT

Medical Editor, American Addiction Centers

Ryan Kelley is a nationally registered Emergency Medical Technician and the former managing editor of the Journal of Emergency Medical Services (JEMS). During his time at JEMS, Ryan developed Mobile Integrated Healthcare in Action, a series... Read More


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