From the Guidelines
Opiate withdrawal presents with flu-like symptoms including muscle aches, runny nose, excessive tearing, sweating, diarrhea, nausea, vomiting, abdominal cramping, insomnia, anxiety, and intense cravings, while alcohol and benzodiazepine withdrawal can be medically dangerous and potentially fatal. The signs and symptoms of opiate withdrawal, as described in the study by 1, include cravings, abdominal cramping, nausea, vomiting, diarrhea, agitation, anxiety, feelings of hopelessness, dysphoria, piloerection, and myalgias. In contrast, alcohol withdrawal, as discussed in the study by 1, can lead to more severe symptoms such as tremors, anxiety, insomnia, high blood pressure, tachycardia, sweating, hallucinations, and potentially seizures or delirium tremens. Benzodiazepine withdrawal, as mentioned in the study by 1, can also be delayed and prolonged, especially with long-acting medications.
The timeline for withdrawal varies by substance:
- Opiate withdrawal begins within 8-24 hours and peaks at 48-72 hours, as noted in the study by 1
- Alcohol withdrawal starts 6-24 hours after the last drink with risk of seizures at 24-48 hours, as discussed in the study by 1
- Benzodiazepine withdrawal can be delayed and prolonged, especially with long-acting medications, as mentioned in the study by 1
- Stimulant withdrawal begins quickly after use ends, typically causing profound depression, fatigue, increased appetite, and intense cravings, as described in the study by 1
- Cannabis withdrawal is milder, featuring irritability, anxiety, sleep disturbances, and decreased appetite, as noted in the study by 1
The severity of withdrawal depends on the substance used, duration of use, dosage, individual factors like genetics and health status, and whether multiple substances were used simultaneously. It is essential to note that while opiate withdrawal is rarely life-threatening, it can be extremely uncomfortable, and treatment may involve symptomatic relief with medications such as α2-adrenergic agonists, antiemetics, and buprenorphine or methadone, as discussed in the study by 1 and 1.
From the FDA Drug Label
The opioid abstinence or withdrawal syndrome is characterized by some or all of the following: restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis Other 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. Acute withdrawal signs and symptoms associated with benzodiazepines have included abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions (e.g., nausea, vomiting, diarrhea, weight loss, decreased appetite), headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor
Signs and symptoms of withdrawal from different substances are:
- Opiates (e.g. methadone): restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, mydriasis, irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate 2
- Benzodiazepines (e.g. lorazepam): abnormal involuntary movements, anxiety, blurred vision, depersonalization, depression, derealization, dizziness, fatigue, gastrointestinal adverse reactions, headache, hyperacusis, hypertension, irritability, insomnia, memory impairment, muscle pain and stiffness, panic attacks, photophobia, restlessness, tachycardia, and tremor 3
- Alcohol: not explicitly listed in the provided drug labels, but may be inferred to have similar symptoms to benzodiazepines due to their similar mechanisms of action as CNS depressants.
- Other substances: not explicitly listed in the provided drug labels.
From the Research
Signs and Symptoms of Opiate Withdrawal
- Opiate withdrawal symptoms can be managed with medications such as buprenorphine and methadone 4
- Buprenorphine is associated with less severe withdrawal symptoms and higher treatment completion rates compared to clonidine or lofexidine 4
- Methadone and buprenorphine appear to be equally effective in managing opioid withdrawal, but data are limited 4
Comparison to Alcohol Withdrawal
- Sedative-hypnotic drugs, including alcohol, can cause a life-threatening withdrawal syndrome 5
- Benzodiazepines, phenobarbital, and other GABA agonists can effectively control symptoms of withdrawal from alcohol and other GABAergic agents 5
Comparison to Benzodiazepine Withdrawal
- Buprenorphine may be more effective for the treatment of opiate-benzodiazepine codependent patients, with less severe withdrawal symptoms and higher treatment completion rates 6
- Sedative-hypnotic drug withdrawal syndrome, including benzodiazepine withdrawal, requires a patient-specific approach and can be managed with adjunctive therapies such as alpha agonists, beta blockers, and anticonvulsants 5
Comparison to Withdrawal from Other Substances
- Psychostimulant withdrawal, including methamphetamine and cocaine, can be managed with medications such as mirtazapine, naltrexone, and bupropion, as well as repetitive transcranial magnetic stimulation 7
- Topiramate shows mixed evidence of efficacy for cocaine withdrawal 7
- Antidepressant withdrawal can occur after discontinuation of antidepressant drugs and may be associated with behavioral toxicity 8