E) A and B are correct
This patient is experiencing opioid withdrawal, and both heroin (A) and opioid analgesic pills (B) are opioids that cause identical withdrawal syndromes.
Clinical Presentation Analysis
The constellation of symptoms presented is pathognomonic for opioid withdrawal 1:
- Mydriasis (dilated pupils) - hallmark sign
- Lacrimation and rhinorrhea - autonomic hyperactivity
- Sweating - despite being afebrile
- Yawning - classic withdrawal symptom
- Sleep deprivation - insomnia is universal in withdrawal
- Persistent cough - respiratory symptom of withdrawal
- Drug-seeking behavior - requesting cough syrup (which contains codeine, an opioid)
The guideline explicitly states that acute opiate withdrawal includes: "sweating, piloerection, mydriasis, lacrimation, rhinorrhea, vomiting, diarrhea, abdominal cramping, tachycardia, hypertension, fever, tachypnea, yawning, restlessness, irritability, myalgias, increased sensitivity to pain, and anxiety" 1.
Why Both A and B Are Correct
There is no clinical distinction between heroin withdrawal and prescription opioid withdrawal - they produce identical symptoms because they act on the same opioid receptors. The guideline makes no differentiation between illicit opioids (heroin) and prescription opioids when describing withdrawal symptoms 1.
The patient's request for cough syrup is particularly revealing - codeine-containing cough syrups are well-documented as substances of abuse among opioid users 2, 3. This behavior suggests the patient is attempting to self-medicate withdrawal symptoms with another opioid source.
Why Other Options Are Incorrect
Cannabis (C): Does not cause mydriasis; typically causes conjunctival injection (red eyes) and miosis or normal pupils. Withdrawal is mild and does not produce this symptom cluster.
Hallucinogens/LSD (D): While LSD causes mydriasis, it does not cause the autonomic symptoms (lacrimation, rhinorrhea, sweating, yawning) or withdrawal syndrome described. LSD does not produce physical dependence.
Critical Clinical Pitfall
Do not be misled by the absence of fever - while fever can occur in opioid withdrawal, it is not required for diagnosis 1. The mydriasis is the key distinguishing feature, as most other withdrawal syndromes (alcohol, benzodiazepines) do not cause pupillary dilation.
The onset of symptoms can occur within 12 hours of opioid discontinuation 1, making this a medical urgency requiring appropriate management with opioid replacement or symptomatic treatment to prevent complications and reduce morbidity.