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].
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- 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