Opioid withdrawal: Clinical manifestations, course, assessment, and diagnosis
- Kevin Sevarino, MD
Kevin Sevarino, MD
- Assistant Clinical Professor of Psychiatry
- Yale University School of Medicine
Spontaneous opioid withdrawal occurs when a patient who is physiologically dependent upon opioids reduces or stops opioid use abruptly. Precipitated opioid withdrawal can occur when a patient who is physiologically dependent upon opioids and who has or recently had opioids in his/her system is administered an opioid antagonist (naloxone, naltrexone, or nalmefene) or an opioid partial agonist (buprenorphine). Signs and symptoms of opioid withdrawal include drug craving, anxiety, restlessness, gastrointestinal distress, diaphoresis, and tachycardia. Untreated opioid withdrawal frequently results in relapse to opioid use.
Patients in opioid withdrawal or seeking to stop an opioid to which they are physiologically dependent can undergo medically supervised opioid withdrawal (also known as detoxification), in which medication is used to reduce the severity of withdrawal symptoms .
This topic describes the clinical manifestations, course, assessment and diagnosis of opioid withdrawal. Medically supervised opioid withdrawal as the first step in treatment of opioid use disorder is described separately. The management of unplanned withdrawal in the emergency department is also described separately, as is opioid withdrawal in adolescents. Pharmacotherapy and psychosocial interventions for opioid use disorder are also discussed separately. (See "Medically supervised opioid withdrawal during treatment for addiction" and "Opioid withdrawal in the emergency setting" and "Opioid withdrawal in adolescents" and "Pharmacotherapy for opioid use disorder" and "Psychosocial interventions for opioid use disorder".)
Patients presenting for opioid withdrawal management include those with untreated opioid use disorders, those on methadone or buprenorphine maintenance who are ending this treatment voluntarily or not, and those ending chronic opioid treatment for pain management. Supervised opioid withdrawal uses medication to reduce the severity of withdrawal symptoms.
Supervised withdrawal alone is unlikely to result in sustained abstinence from opioids , nor does it address reasons the patient became dependent on opioids or the damage that the addiction has done to relationships, employment, finances, and the mental, physical, and spiritual health of the patient. Without successful transition to follow-up treatment – most typically, medication-assisted therapy (buprenorphine, methadone, extended-release naltrexone) – supervised withdrawal alone is associated with many harms, including elevated rates of death, incarceration, and infectious disease transmission [3,4].
- Diaper AM, Law FD, Melichar JK. Pharmacological strategies for detoxification. Br J Clin Pharmacol 2014; 77:302.
- Mattick RP, Hall W. Are detoxification programmes effective? Lancet 1996; 347:97.
- Evans E, Li L, Min J, et al. Mortality among individuals accessing pharmacological treatment for opioid dependence in California, 2006-10. Addiction 2015; 110:996.
- Degenhardt L, Bucello C, Mathers B, et al. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction 2011; 106:32.
- Farrell M. Opiate withdrawal. Addiction 1994; 89:1471.
- Kanof PD, Aronson MJ, Ness R. Organic mood syndrome associated with detoxification from methadone maintenance. Am J Psychiatry 1993; 150:423.
- Mackie SE, McHugh RK, McDermott K, et al. Prevalence of restless legs syndrome during detoxification from alcohol and opioids. J Subst Abuse Treat 2017; 73:35.
- Teoh Bing Fei J, Yee A, Habil MH. Psychiatric comorbidity among patients on methadone maintenance therapy and its influence on quality of life. Am J Addict 2016; 25:49.
- Fareed A, Eilender P, Haber M, et al. Comorbid posttraumatic stress disorder and opiate addiction: a literature review. J Addict Dis 2013; 32:168.
- Rosen D, Smith ML, Reynolds CF 3rd. The prevalence of mental and physical health disorders among older methadone patients. Am J Geriatr Psychiatry 2008; 16:488.
- Goldner EM, Lusted A, Roerecke M, et al. Prevalence of Axis-1 psychiatric (with focus on depression and anxiety) disorder and symptomatology among non-medical prescription opioid users in substance use treatment: systematic review and meta-analyses. Addict Behav 2014; 39:520.
- Martins SS, Fenton MC, Keyes KM, et al. Mood and anxiety disorders and their association with non-medical prescription opioid use and prescription opioid-use disorder: longitudinal evidence from the National Epidemiologic Study on Alcohol and Related Conditions. Psychol Med 2012; 42:1261.
- Jordan KD, Okifuji A. Anxiety disorders: differential diagnosis and their relationship to chronic pain. J Pain Palliat Care Pharmacother 2011; 25:231.
- Sullivan MD, Edlund MJ, Steffick D, Unützer J. Regular use of prescribed opioids: association with common psychiatric disorders. Pain 2005; 119:95.
- Asmundson GJ, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. Depress Anxiety 2009; 26:888.
- Scherrer JF, Salas J, Copeland LA, et al. Prescription Opioid Duration, Dose, and Increased Risk of Depression in 3 Large Patient Populations. Ann Fam Med 2016; 14:54.
- Sullivan MD, Edlund MJ, Zhang L, et al. Association between mental health disorders, problem drug use, and regular prescription opioid use. Arch Intern Med 2006; 166:2087.
- Wasan AD, Butler SF, Budman SH, et al. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain 2007; 23:307.
- Center for Substance Abuse Treatment. Substance abuse treatment for persons with co-occurring disorders. Treatment Improvement Protocol (TIP) Series 42, Publication no. SMA-053992. Substance Abuse and Mental Health Services Administration; Department of Health and Human Services, Rockville, MD 2005.
- Mannelli P, Wu LT, Peindl KS, Gorelick DA. Smoking and opioid detoxification: behavioral changes and response to treatment. Nicotine Tob Res 2013; 15:1705.
- Stein MD, Kanabar M, Anderson BJ, et al. Reasons for Benzodiazepine Use Among Persons Seeking Opioid Detoxification. J Subst Abuse Treat 2016; 68:57.
- Kuramoto SJ, Chilcoat HD, Ko J, Martins SS. Suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and presence of prescription opioid disorders among U.S. adults. J Stud Alcohol Drugs 2012; 73:178.
- Vaughan BR, Kleber HD. Opioid detoxification, chap. 20. In: American Psychiatric Press Textbook of Substance Abuse Treatment, 5th ed, Galanter M, Kleber HD, Brady KT (Eds), American Psychiatric Publishing, Washington DC 2015.
- Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998; 13:204.
- Fishman M. Precipitated withdrawal during maintenance opioid blockade with extended release naltrexone. Addiction 2008; 103:1399.
- ASAM: The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related and Co-Occurring Conditions, 3rd ed, Mee-Lee D, Shulman GD, Fishman MJ, et al (Eds), The Change Companies, Carson City 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- CLINICAL MANIFESTATIONS
- Co-occurring conditions
- Initial evaluation
- - Substance use history
- - Psychiatric status, history, mental status exam
- - Medical history and physical exam
- - Laboratory and other testing
- - Withdrawal symptoms
- - Naloxone challenge test
- - Level of care determination
- SUMMARY AND RECOMMENDATIONS