From the Guidelines
Mild opiate withdrawal typically presents with flu-like symptoms including runny nose, teary eyes, yawning, sweating, muscle aches, restlessness, anxiety, and insomnia, and management focuses on supportive care and symptom relief, with the goal of reducing morbidity, mortality, and improving quality of life. The symptoms of mild opiate withdrawal can be assessed using tools such as the Clinical Opiate Withdrawal Scale (COWS) 1, which evaluates various symptoms including resting pulse rate, GI upset, sweating, restlessness, pupil size, anxiety, bone or joint aches, and runny nose or tearing.
Symptoms of Mild Opiate Withdrawal
- Flu-like symptoms
- Runny nose
- Teary eyes
- Yawning
- Sweating
- Muscle aches
- Restlessness
- Anxiety
- Insomnia
Management of Mild Opiate Withdrawal
- Supportive care
- Symptom relief
- Over-the-counter medications such as ibuprofen (400-600mg every 6 hours) or acetaminophen (500-1000mg every 6 hours) for pain and fever
- Loperamide (4mg initially, then 2mg after each loose stool, maximum 16mg daily) for diarrhea
- Diphenhydramine (25-50mg at bedtime) for insomnia
- Clonidine, a prescription medication, can reduce multiple withdrawal symptoms at doses of 0.1-0.2mg every 6 hours 1
- Staying hydrated, maintaining proper nutrition, and getting light exercise are important supportive measures
- Creating a calm environment and practicing relaxation techniques can help manage anxiety
According to the most recent and highest quality study, the Clinical Opiate Withdrawal Scale (COWS) is a useful tool for assessing the severity of withdrawal symptoms 1. The study also notes that buprenorphine should be administered only to patients in active opioid withdrawal, and that particular care is required when transitioning from methadone to buprenorphine due to the risk of severe and prolonged precipitated withdrawal 1.
In terms of prevention, decreasing the dose of opioid over time rather than abruptly discontinuing the medication can help prevent withdrawal symptoms 1. Additionally, physical dependence can lead to a desire to avoid withdrawal symptoms, and a strong patient drive to maintain an opioid prescription, but this can be managed with slow tapering of the drug 1.
Overall, the management of mild opiate withdrawal should prioritize supportive care, symptom relief, and the use of tools such as the COWS to assess the severity of withdrawal symptoms, with the goal of reducing morbidity, mortality, and improving quality of life.
From the FDA Drug Label
If buprenorphine hydrochloride is abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur, typically characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis Other signs and symptoms also may develop, including irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate
The symptoms of mild opiate withdrawal may include:
- Restlessness
- Lacrimation
- Rhinorrhea
- Perspiration
- Chills
- Myalgia
- Mydriasis
- Irritability
- Anxiety
- Backache
- Joint pain
- Weakness
- Abdominal cramps
- Insomnia
- Nausea
- Anorexia
- Vomiting
- Diarrhea
- Increased blood pressure
- Increased respiratory rate
- Increased heart rate 2
From the Research
Symptoms of Mild Opiate Withdrawal
- Opiate withdrawal has been described as akin to a moderate to severe flu-like illness 3
- Symptoms classically include severe muscle cramps, bone aches, autonomic symptoms, anxiety, restlessness, insomnia, and temperature dysregulation 4
- Other symptoms may include aches, yawning, mydriasis, tremor, nausea, and mild anxiety 5
- Itching, jitteriness, depression, craving, vomiting, diarrhea, and anorexia are also common symptoms of opioid withdrawal 6
Management of Mild Opiate Withdrawal
- Alpha2-adrenergic agonists, such as clonidine and lofexidine, are effective in ameliorating withdrawal symptoms and can be used to manage opioid withdrawal 7
- Buprenorphine is also effective in managing opioid withdrawal and has been shown to be less severe than clonidine 5
- Mirtazapine, a noradrenergic and specific serotonergic receptor antagonist, has been proposed as a one-drug strategy to treat the variety of symptoms of opioid withdrawal, including nausea, vomiting, itching, craving, diarrhea, anxiety, and insomnia 6
- Reducing doses of methadone can also be used to manage opioid withdrawal, but may be associated with more adverse effects than alpha2-adrenergic agonists 7