What are the signs of opioid withdrawal in an adult with a history of chronic opioid use?

Opioid Withdrawal Signs in Adults with Chronic Opioid Use

Opioid withdrawal produces a constellation of gastrointestinal, autonomic, musculoskeletal, and psychological symptoms that are subjectively severe but objectively mild, comparable to a moderate to severe flu-like illness. 1, 2

Core Clinical Manifestations

Gastrointestinal Symptoms

• Abdominal cramps, nausea, vomiting, and diarrhea are hallmark features of opioid withdrawal 1, 3
• Multiple episodes of diarrhea or vomiting indicate more severe withdrawal 1

Autonomic Symptoms

• Piloerection (goosebumps), sweating, lacrimation (tearing), and rhinorrhea (runny nose) result from supranormal noradrenaline release after opioid discontinuation 1, 3
• Tachycardia, hypertension, and fever occur due to autonomic overreactivity 1, 3
• Mydriasis (pupil dilation) is a classic objective sign 1

Musculoskeletal Symptoms

• Myalgias (muscle aches), body aches, increased muscle tone, and tremors are prominent features 1, 3
• Bone or joint aches with patients rubbing affected areas and unable to sit still 1

Psychological Symptoms

• Anxiety, agitation, dysphoria, irritability, and insomnia are universal 1, 3
• Intense craving for opioids drives continued use 3, 4
• Restlessness with frequent shifting or inability to sit still 1

Additional Observable Signs

• Yawning (three or more times during assessment indicates moderate withdrawal) 1
• Tremor ranging from palpable to grossly observable 1

Timing of Symptom Onset

The onset of withdrawal depends critically on the opioid's half-life:

• Short-acting opioids (heroin, oxycodone): Symptoms begin 6-24 hours after last use, typically within 12 hours 5, 6
• Long-acting opioids (methadone): Onset delayed 24-72 hours, occasionally up to 5-7 days 3, 6
• Buprenorphine: Peak withdrawal at 40 hours, most severe symptoms at 70 hours 3

Objective Assessment Tools

Use the Clinical Opiate Withdrawal Scale (COWS) to quantify withdrawal severity and guide treatment decisions. 1, 5

The COWS assesses 11 parameters with numerical scoring:

• Resting pulse rate (0-4 points)
• Sweating (0-4 points)
• Restlessness (0-5 points)
• Pupil size (0-5 points)
• Bone/joint aches (0-4 points)
• Runny nose or tearing (0-4 points)
• GI upset (0-5 points)
• Tremor (0-4 points)
• Yawning (0-4 points)
• Anxiety/irritability (0-4 points)
• Piloerection (0-5 points) 1

COWS Score Interpretation:

• 5-12: Mild withdrawal
• 13-24: Moderate withdrawal
• 25-36: Moderately severe withdrawal

• 36: Severe withdrawal 1

Critical Clinical Pitfalls

Pain during withdrawal may be a withdrawal symptom itself, not simply exacerbation of chronic pain. Descending pain facilitatory tracts show increased firing during early abstinence, amplifying pain perception 1

Fentanyl withdrawal differs from heroin withdrawal with more frequent, painful, and faster onset of symptoms, making management more challenging 4

Protracted withdrawal syndrome can persist for months after opioid elimination, manifesting as dysphoria, irritability, insomnia, anhedonia, or vague malaise that must be anticipated and addressed 1

Fever from opioid withdrawal must be distinguished from infectious causes, particularly in critically ill patients where withdrawal may not be immediately apparent from the history 3

Buprenorphine can precipitate severe withdrawal if given before the patient is in active withdrawal due to its high receptor binding affinity and partial agonist properties 5, 7

Subjective Assessment Alternative

The Subjective Opiate Withdrawal Scale (SOWS) includes 16 self-reported symptoms rated 0-4 by the patient, providing complementary information to objective assessment 1, 8