What are the symptoms of opioid (narcotic) withdrawal?

From the Guidelines

Opiate withdrawal should be managed with a combination of medications and supportive care, prioritizing buprenorphine or methadone to alleviate withdrawal symptoms and initiate medication for addiction treatment (MAT) for Opioid Use Disorder (OUD). The treatment approach should focus on reducing morbidity, mortality, and improving quality of life. According to the most recent and highest quality study 1, opioid withdrawal may be very uncomfortable but is rarely directly life-threatening as a sole condition. However, patients are often motivated to avoid these distressing symptoms through continued hazardous opioid use.

Symptoms and Treatment

The common signs and symptoms of opioid withdrawal include cravings, abdominal cramping, nausea, vomiting, diarrhea, agitation, anxiety, feelings of hopelessness, dysphoria, piloerection, and myalgias. Treatment of opioid withdrawal may be symptomatic, often involving the use of α2-adrenergic agonists such as clonidine or lofexidine as well as antiemetics, atypical antipsychotics, and other medications targeting the withdrawal symptoms.

• Buprenorphine is a preferred medication for acute withdrawal, with initial dosing serving to initiate medication for addiction treatment (MAT) for OUD.
• Methadone can also be used to alleviate withdrawal symptoms, with careful titration.
• Clonidine (0.1-0.2mg every 6 hours) helps with autonomic symptoms.
• Loperamide (4mg initially, then 2mg after each loose stool) addresses diarrhea.
• Ondansetron (4-8mg every 6 hours) can relieve nausea.
• NSAIDs or acetaminophen can manage pain.

Long-term Treatment

Long-term treatment should include medication-assisted treatment with either buprenorphine/naloxone maintenance, methadone maintenance, or naltrexone, combined with counseling and support groups. These medications work by either partially activating opioid receptors to prevent withdrawal without causing significant euphoria (buprenorphine), providing controlled opioid receptor stimulation (methadone), or blocking opioid receptors to prevent relapse (naltrexone) 1.

Physical Dependence and Addiction

It's essential to distinguish between physical dependence and addiction, as physical dependence is an expected response for patients treated with opioids over an extended period, but these symptoms typically resolve quickly (3–7 days) 1. However, physical dependence can lead to a desire to avoid withdrawal symptoms and a strong patient drive to maintain an opioid prescription.

From the FDA Drug Label

Physical dependence is manifested by withdrawal symptoms after abrupt discontinuation of a drug or upon administration of an antagonist Physical dependence is expected during opioid agonist therapy of opioid addiction. 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.

Opiate withdrawal symptoms are characterized by a range of physical and psychological symptoms, including restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia, and mydriasis, as well as irritability, anxiety, backache, joint pain, weakness, abdominal cramps, insomnia, nausea, anorexia, vomiting, diarrhea, or increased blood pressure, respiratory rate, or heart rate 2.

• Key symptoms of opiate withdrawal include:
  • Restlessness
  • Lacrimation
  • Rhinorrhea
  • Yawning
  • Perspiration
  • Chills
  • Myalgia
  • Mydriasis
  • Irritability
  • Anxiety
  • Backache
  • Joint pain
  • Weakness
  • Abdominal cramps
  • Insomnia
  • Nausea
  • Anorexia
  • Vomiting
  • Diarrhea
  • Increased blood pressure, respiratory rate, or heart rate.

From the Research

Opiate Withdrawal Management

• Opiate withdrawal management is a crucial step in treating opioid use disorder (OUD) and can be achieved through various medications and strategies 3, 4, 5, 6.
• Buprenorphine is a commonly used medication for managing opioid withdrawal and has been shown to be effective in reducing withdrawal symptoms and improving treatment outcomes 3, 4, 5.
• A study comparing buprenorphine to clonidine found that buprenorphine was superior in alleviating subjective and objective opiate withdrawal symptoms 4.
• Buprenorphine has also been compared to methadone, with some studies suggesting that they are equally effective in managing opioid withdrawal, although more research is needed to confirm this 3.

Treatment Strategies

• Medications such as methadone and buprenorphine can be used to manage opioid withdrawal and initiate maintenance treatment for OUD 5, 6.
• A novel low-dose approach to buprenorphine induction, also known as "microinduction," may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids 5.
• Non-opioid medications such as alpha 2 agonists, benzodiazepines, and antiemetics can also be used to manage withdrawal symptoms 5.
• Harm reduction strategies and relapse prevention are also important components of opioid withdrawal management 5, 6.

Clinical Challenges

• Discontinuing opioid agonist treatment, such as methadone or buprenorphine, can be challenging and requires careful consideration of the patient's individual needs and circumstances 7.
• Clinicians should use a patient-centered approach to care and consider factors such as "recovery capital" when making decisions about discontinuing opioid agonist treatment 7.
• Shared decision making between the clinician and patient is also important in determining the best course of treatment 7.