Opioid Withdrawal

If you’re experiencing opioid dependence, you may experience some withdrawal symptoms after reducing or stopping opioid use. The severity and duration of your symptoms can be impacted by several factors, including how often you use opioids, how much you use them, the types of opioids you take, and how long you’ve been using. Withdrawal symptoms for short-acting opioids (such as heroin) typically appear within eight to 24 hours of last use. Contrarily, individuals taking long-acting opioids (such as methadone) typically begin having symptoms around 12 to 48 hours after last use.

Early symptoms of opioid withdrawal, such as those of heroin withdrawal, may include:

• Flu-like symptoms, including headache and body aches 
• Sweating
• Muscle pain
• Restlessness 
• Insomnia 
• Yawning
• Agitation and irritability
• Runny nose
• Anxiety

Late symptoms may include: 

• Profuse sweating
• Hypertension and heart arrhythmias
• Dilated pupils
• Chills and goosebumps
• Gastrointestinal symptoms, such as nausea, vomiting, and diarrhea 
• Intense opioid cravings 
• Abdominal cramping
• Mood swings
• Panic
• Depression
• Hallucinations (rare)

People recovering from opioid dependence may experience psychological symptoms of withdrawal that persist for weeks to months after detoxification. These symptoms are referred to as post-acute withdrawal symptoms (PAWS) and include: 

• Anxiety
• Low mood or depression
• Heightened stress sensitivity and irritability 
• Sleeping difficulty
• Difficulty maintaining relationships 
• Cynicism, apathy, and a pessimistic outlook
• Memory problems
• Mild opioid cravings

Not everyone experiences all symptoms of opioid withdrawal, and the duration of symptoms can vary. In general, symptoms of opioid withdrawal tend to start mildly and become more intense over time, peaking around 48 to 72 hours after the last dose. Opioid use tends to slow down the respiratory system—a factor contributing to overdose risk. When opioid use is stopped abruptly, the risk of complications like heart attacks and strokes can rise. Additionally, severe dehydration resulting from vomiting and diarrhea can be life-threatening if left untreated. To reduce these risks, it’s recommended that opioid withdrawal be managed in a medical setting. 

When you take opioids repeatedly, the brain may respond by adjusting its production of chemicals, effectively creating a new state of balanced functioning. This response creates opioid tolerance, meaning an individual requires more of the drug to experience the same effect, often driving opioid dependence. If a person has opioid dependence, not taking opioids may lead to a state of chemical imbalance, resulting in opioid withdrawal symptoms. 

Anyone who uses opioids, whether taken as prescribed by a doctor, taken differently than prescribed (misuse), or taken without a prescription, may be at risk of developing opioid dependence and subsequent opioid withdrawal syndrome. The following can increase the risk of experiencing severe withdrawal symptoms: 

• Use of high doses of opioids (over 100 morphine milligram equivalents [MME])
• Cessation of opioids abruptly
• Use of certain types of opioids
• Inability to obtain medical care
• Use of other substances 
• The presence of underlying health conditions
• Factors like age and body weight
• A history of severe opioid withdrawal symptoms

To help the brain adjust to the absence of opioids, it may help to slowly taper their usage under the supervision of a doctor and medical team. In some cases, tapering can eliminate withdrawal symptoms. 

Opioid withdrawal symptoms can increase the risk of relapse. However, there are treatment options available that can reduce symptom severity, symptom duration, and the likelihood of relapse, including the following. 

Medication

Medications are often used in cases of moderate to severe opioid withdrawal and in the long-term management of opioid use disorder. Below are a few medications that might be used: 

• Clonidine: This medication is a supportive (non-opioid) medication that may be prescribed to relieve symptoms such as diarrhea, vomiting, cramping, sweating, chills, insomnia, and anxiety. 
• Methadone: Methadone is an opioid often used to reduce withdrawal symptoms. It may be given every four to six hours by a medical professional as needed to address withdrawal symptoms. By the third day of withdrawal, methadone is often tapered (reduced) to an acceptable maintenance dose. Some people may become tolerant to the pain relief of methadone, in which case they may be given non-opioid pain relievers. When taken after withdrawal is complete, methadone can reduce the risk of relapse. CBT can be used to reduce the rate of relapse for individuals on a methadone maintenance treatment plan. 
• Buprenorphine: In some cases, buprenorphine is prescribed instead of methadone for people with opioid dependence. It’s a partial-opioid agonist, meaning that its effects aren’t as strong as those of drugs like morphine and fentanyl, and it has a lower risk of overdose than methadone. Like methadone, buprenorphine is an opioid that healthcare providers can prescribe to substitute for opioids used by the patient. The dose of buprenorphine is slowly tapered, and it can effectively reduce withdrawal symptom severity.
• Naltrexone: Naltrexone is sometimes used as a long-term medication to reduce relapse risk, but it can only be prescribed if all other opioids have been fully detoxified from the system. When a person uses naltrexone in combination with opioids, withdrawal symptoms may begin immediately. 

Additional medications are often helpful in managing other symptoms of opioid withdrawal. Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis. 

Other treatment options

Other treatment options may include the following: 

• Tapering: If you’ve been taking opioid medications for more than two weeks, you may be advised by your doctor to taper your medications. A doctor can create a medication withdrawal plan to gradually reduce opioid use while routinely monitoring for signs of severe symptoms. 
• Support groups: Groups like Narcotics Anonymous (NA) may support individuals going through the mental and physical challenges of opioid withdrawal.
• Medication-assisted treatment (MAT): MAT can be an effective, individualized approach to treatment that combines pharmacotherapy (like methadone), talk therapy, and other treatment options to manage withdrawal and reduce the risk of relapse.  

Self-care 

Self-care strategies that may be beneficial when withdrawing from opioids include the following: 

• Promote healing: Getting enough rest, drinking fluids, getting light exercise, and eating nutritious foods may help your body and mind recover. 
• Develop a relaxing routine: Reading, journaling, meditating, stretching, and practicing mindfulness and yoga may reduce anxiety and stress during the withdrawal period and beyond. 
• Emphasize positive self-talk: When experiencing pessimistic thoughts, it may help to tell yourself a positive mantra, such as “I will get through this” or “These symptoms won’t last forever.” 

There are resources available to manage withdrawal symptoms and promote long-term recovery,³ including but not limited to: 

• Support groups: Narcotics Anonymous (NA) is an organization that offers free online, hybrid, and in-person support groups that follow a 12-step process. You can find a local NA group on the NA website. You can also connect with support groups, treatment options, and helpful resources on opiate withdrawal through the Substance Abuse and Mental Health Services’ website, SAMHSA.gov.
• CDC resources: The Centers for Disease Control and Prevention (CDC) provides resources for providers, patients, and their loved ones to learn more about opioid use and available support. For example, the CDC site offers information on buprenorphine and methadone programs near you, information on pain management, and fact sheets on substance use disorder⁴ insurance benefits.  
• Group sessions: You can find group sessions through online therapy platforms like BetterHelp.These platforms can offer valuable support and diverse perspectives, enabling participants to share experiences and learn from others facing similar challenges in a structured environment.

For help with substance use, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357).

Standard medications used for medication-assisted treatment of opioid dependence are methadone and buprenorphine. While these medications may be effective, they themselves are opioids that can result in serious side effects and overdose when misused. Alternatives for withdrawal symptom management may reduce these risks. In 2018, the Food and Drug Administration (FDA) approved a medication called Lucemyra (lofexidine hydrochloride) to reduce withdrawal symptom severity for up to 14 days. Unlike methadone and buprenorphine, lofexidine is not an opioid, and the side effects are milder than those of clonidine (another non-opioid withdrawal medication). 

Naltrexone is a medication that is sometimes prescribed to reduce the risk of relapse. Unlike methadone and buprenorphine, it’s not listed as a scheduled substance, so it may be easier to find a provider who can prescribe it. However, due to a high risk of severe withdrawal, it cannot be used in conjunction with opioid medications like methadone. Since lofexidine is not an opioid, it can be combined with naltrexone to achieve better treatment outcomes. In one study, a combination of naltrexone and lofexidine resulted in significantly lower dropout rates and opioid craving. Talk to your doctor when considering medications. 

Below are several key statistics on opioid withdrawal syndrome: 

• In a study of 814 people who regularly use opioids, 85% reported experiencing opioid withdrawal symptoms within the last 12 months, and 35% reported at least weekly symptoms. 
• An estimated 75% of people in the United States whose opioid use disorder began in the 2000s report first being introduced to opioids through prescription drugs. 
• More than 60% of people with opioid use disorder also have an anxiety disorder.