What are the symptoms of opioid withdrawal?

Opioid Withdrawal Symptoms

Opioid withdrawal presents with a constellation of behavioral, autonomic, gastrointestinal, and musculoskeletal symptoms that typically begin 2-3 half-lives after the last opioid dose, peak at 48-72 hours, and resolve within 7-14 days. 1

Behavioral and Psychological Symptoms

Behavioral changes are often the primary manifestation of withdrawal and include: 2

• Anxiety and agitation 2, 3
• Insomnia 2, 3
• Irritability and dysphoria 3
• Restlessness 4
• Intense craving for opioids 3
• Tremors (can range from subtle to gross muscle twitching) 2

Autonomic Symptoms

The autonomic nervous system dysregulation produces: 3

• Tachycardia and hypertension 2
• Fever and sweating (perspiration) 2, 4
• Piloerection (gooseflesh/"cold turkey") 2, 3
• Lacrimation (tearing) and rhinorrhea (runny nose) 2, 3, 4
• Mydriasis (pupil dilation) 4
• Yawning 2

Gastrointestinal Symptoms

GI disturbances are prominent and include: 3

• Nausea and vomiting 2
• Abdominal cramps 3, 4
• Diarrhea 2
• Decreased appetite/anorexia 2, 4

Musculoskeletal Symptoms

Pain and muscle-related symptoms manifest as: 3

• Increased muscle tone 2
• Myalgias (muscle aches) and body aches 3, 4
• Backache and joint pain 4

Temporal Pattern and Clinical Course

Symptoms begin 2-3 half-lives after the last opioid dose (for example, with oxycodone having a 3-4 hour half-life, symptoms would start after 6-12 hours). 2, 1

Peak symptom intensity occurs at approximately 48-72 hours, with acute symptoms resolving within 7-14 days, though variability depends on the specific opioid dose, speed of taper, and duration of use. 2, 1

Protracted Withdrawal Syndrome

A secondary abstinence syndrome can persist for up to 6 months after opioid cessation, characterized by: 1

• General malaise and fatigue 2, 1
• Decreased sense of well-being 1
• Poor tolerance to stress 2, 1
• Persistent opioid cravings 2, 1

This protracted phase represents a prolonged neuroadaptive recovery period distinct from acute withdrawal. 1

Critical Clinical Pitfalls

Rule out other causes of these symptoms, particularly infection and sepsis, as many withdrawal symptoms overlap with serious medical conditions. 2, 3

Anxiety can significantly enhance perceived withdrawal severity or cause anxiety symptoms to be misinterpreted as withdrawal—when masked patients on long-term opioid treatment were given placebo for 60 hours, only 3 out of 10 had actual withdrawal symptoms. 2, 1

Voice changes are NOT part of opioid withdrawal syndrome—if present, investigate alternative causes unrelated to withdrawal. 3

Assessment Tools

Use validated scales to objectively measure withdrawal severity: 2, 1

• Clinical Opiate Withdrawal Scale (COWS): Clinician-administered, scores 5-12 indicate mild withdrawal, 13-24 moderate, 25-36 moderately severe, and >36 severe 2, 1
• Subjective Opiate Withdrawal Scale (SOWS): Patient self-rated, detects symptoms earlier than observer-rated scales 2, 3