Opioid Withdrawal: Symptoms of Dependence

In the U.S. and around the world, opioid use continues to cause great harm to those consuming the drug. The misuse or abuse of both legal and illicit opioids can have significant mental and physical health consequences, and both can result in a fatal overdose.

Opioid addiction is all-consuming and the effects can be devastating to your health, your lifestyle, and to those who love you. Quitting can save your life, but the withdrawal can be difficult. This is why so many people trying to overcome opioid addiction seek professional help as they withdraw from the drug.

Opioid Dependence and Misuse

Opioids cover a long list of drugs including legal, prescription medications like hydrocodone, fentanyl, and oxycodone and illegal substances like heroin.¹ These opioids are everywhere—sales of prescription opioids quadrupled from 1999 to 2014.² In 2016, there were about 11.5 million people who reported misusing prescription pain medications within the previous year.³ Plus, there were almost 1 million people who reported using heroin within the same time period.³

Opioids are widely abused for their euphoric high. When opioids reach the brain, they bind to and activate opioid receptors to elicit their painkilling properties. This receptor interaction is also associated with a release of a neurotransmitter known as dopamine in key brain pathways.⁴ The surge of dopamine is responsible for the rewarding or pleasurable feelings—such as relaxation and euphoria—that are linked to opioid use.⁴ Other opioid-induced changes in neurotransmitter activity are responsible for the slowed breathing, low blood pressure, and increased sleepiness common to all opioid highs.⁵

Opioid Dependence and Addiction

It doesn’t take long for a person’s body to adapt to opioids, though. In time, the receptors become less reactive to the consistently elevated levels of circulating opioids. As the receptors adapt, their repeated activation results in less of a dopamine-mediated sense of pleasure.⁵ The decreasing response to the opioid is referred to as tolerance; basically, the normal dose just won’t do it anymore.

You’ll need to use more of the drug or use it more often (or both) in order to get the effects you’re used to. Most opioid addicts find they never get that first high back, even when they increase their dose over and over again. Constantly seeking to overcome tolerance with more and more opioids can lead you to a deadly overdose situation.

The consistent use of ever-increasing doses of these drugs will lead to the inevitable development of physical dependence, wherein you grow to rely on a steady supply of opioids in your system just to function normally.⁵ Without the opioid, you will feel sick and may suffer some psychological distress as well. This is known as withdrawal.

Just how quickly dependence will develop fully in an individual is hard to determine. A person increases the risk and speed of developing dependence, as well as addiction, by misusing opioids.

Although people sometimes use the terms interchangeably, physical dependence and addiction are not the same. As mentioned, dependence is a physical response as the body adapts to the consistent presence of opioids. Addiction development reflects more of a psychological change and may entail intense cravings and an increase in compulsive drug-seeking behaviors and uncontrollable drug use.⁵

You will know you’re physiologically dependent when you go through withdrawal (see symptoms below) after trying to stop or cut down, but it can be harder to know if you’re really addicted. Here are some additional indicators of an opioid use disorder, or addiction:⁶

• You spend significant amounts of time getting, using, and recovering from the drug.
• You continue using even when your physical and mental states are in danger.
• You struggle to fulfill your duties at home, school, or work.
• You experience more conflict with friends and loved ones.
• You shift your interests and activities to focus on drug use.
• You make unsuccessful attempts to reduce your opioid intake or quit altogether.

Symptoms of Opioid Withdrawal

In many cases, the signs and symptoms of opioid withdrawal are quite the opposite of the happy, relaxed state produced by opioid intoxication.

Physical effects of opioid withdrawal include:^6,7

• Fast pulse.
• High blood pressure.
• Quicker breathing.
• Increased sensitivity to pain.
• Nausea.
• Vomiting.
• Diarrhea.
• Aching muscles.
• Runny nose and watery eyes.
• Goosebumps.
• Excessive sweating.
• Dilated pupils.
• Yawning.
• Fever.
• Muscle twitches.
• Insomnia.

The signs and symptoms of opioid withdrawal are quite the opposite of the happy, relaxed state produced by opioid intoxication. Withdrawal symptoms for opioids like heroin and OxyContin feel like a really awful flu and can be severe enough to pose an extreme relapse risk for people trying to quit. If you’re in opioid withdrawal, you might also experience some troublesome changes in mood, thinking, and behavior that also may make it hard to continue all the way through the detox process. These could include: ⁶

• Depression.
• Irritability.
• Restlessness.
• Agitation.

Opioid withdrawal does have a commonly experienced set of symptoms, but each person’s experience will be unique. Withdrawal symptoms and severity will vary slightly based on things like:⁷

• How long you used.
• Which drugs you used and your regular dose.
• Whether you’ve had serious withdrawal symptoms before.
• Whether you have any preexisting mental and medical health disorders.

How Long Will Opioid Withdrawal Last?

Withdrawal symptoms begin as the substance leaves,⁶ but different types of opioids stay in the body for different amounts of time. Heroin, for instance, is a relatively short-acting opioid that produces effects quickly and leaves the body quickly. Heroin withdrawal symptoms can begin just 6 hours after the last dose, peak between days 1 and 3, and generally conclude within a week. ⁶

Longer-acting drugs like methadone or buprenorphine may not produce withdrawal symptoms until 2-4 days have passed since last use.⁶ Symptoms can then last for as many as 20 days.⁸

The symptoms that arise shortly after use and last for a brief period are called acute withdrawal symptoms. They last through the acute, or most intense, a period of withdrawal. Some symptoms may last beyond this period, and these are known as post-acute withdrawal syndrome, or PAWS.⁹

In the case of opioids, these lasting symptoms might include:⁹

• Problems sleeping.
• Fatigue.
• Irritability.
• Consistently poor mood.
• Increased anxiety.
• Continued depression.
• Poor focus.
• Decreased ability to make decisions.

The post-acute withdrawal symptoms for opioids may last for many months following the last time you used.⁹

Potential Risks of Opioid Withdrawal

Opioid withdrawal can be uncomfortable and difficult to endure, but for the most part, the symptoms are more painful than dangerous. Other withdrawal syndromes, like those of alcohol and benzodiazepines, are much more medically threatening.⁷ Still, detoxing from opioids can produce some significant issues like: ⁷

• Dehydration. The vomiting and diarrhea associated with withdrawal can lead to severe dehydration and electrolyte imbalance.
• Aspiration. Aspiration occurs when vomited material is inhaled into the lungs, leading to respiratory issues and pneumonia.
• Cardiac dangers. Withdrawal’s ability to increase heart rate and blood pressure may trigger hazards to people with preexisting heart conditions.
• Anxiety. Many people will suffer some degree of anxiety during withdrawal, but those with a preexisting anxiety disorder may have even worse anxiety which may escalate to panic symptoms.
• Depression and suicide. Similarly, the depression and mood problems linked to acute and post-acute withdrawal could increase suicidal thoughts or behaviors.

The most obvious and pressing risk, however, is the risk of relapse. During withdrawal, the individual will have strong cravings for more opioids and will need support to avoid turning back to opioids to relieve their symptoms. ⁸ Supervised detox programs can provide this support as well as an environment where drugs aren’t readily available.

Relapse after a period of sobriety is especially dangerous. The reason for this is that tolerance decreases during this time. Someone who returns to using their normal dose could be giving themselves a now dangerously large amount that overwhelms their system and triggers an overdose.⁸

Medications for Opioid Withdrawal

A number of prescription medications are used to treat withdrawal and maintain sobriety. It’s an unfortunately widely held belief that taking one of these drugs is replacing one addiction for another. In reality, these drugs help to break the cycle of addiction and promote improved well-being.¹⁰

There are many medications used to treat opioid dependence and addiction during and after the acute withdrawal period. These include: ^7,8,10,11

• Methadone – a long-acting, opioid medication that alleviates withdrawal and lowers cravings. When carefully and consistently dosed, methadone’s stable effects contrast the fast and intense high of other opioids like heroin.
• Buprenorphine – a “partial opioid agonist” that has a ceiling effect, meaning after a certain point, taking more won’t do anything. Buprenorphine can reduce cravings and has a lower risk of overdose compared to full opioid agonists like methadone.
  • Suboxone – a branded version of buprenorphine that is mixed with an opioid blocker called naloxone to discourage misuse.
  • Probuphine – a form of buprenorphine implanted under the skin to offer a steady, low dose of the drug. One implant will provide 6 months of treatment. With the implant, there is no risk of forgetting or losing the medication. It also eliminates the possibility of diverting, or selling, the medication.
• Naltrexone – Naltrexone, an opioid blocker that prevents opioids from attaching to receptors in the brain and creating a high. Vivitrol is the name for an intramuscular injectable form of naltrexone that lasts for a month. Naltrexone is effective but must not be given until after withdrawal is complete to avoid worsening symptoms. Your prescriber will let you know how many days you must wait before beginning the medication (generally, 7-14 days).¹²
• Clonidine – a safe, nonaddictive drug used to help temper some withdrawal symptoms. It will not treat all symptoms, but clonidine may reduce sweating, vomiting, diarrhea, and tremors.

Other medications and over-the-counter products used in opioid withdrawal include:⁷

• Benadryl, trazodone, or hydroxyzine (Vistaril) to improve sleep.
• Acetaminophen, aspirin, or ibuprofen for headaches and pain.
• Mylanta, Pepto-Bismol, or milk of magnesia for gastric complaints.

The path to sobriety is a challenging and complex road. Achieving this incredibly important goal starts with managing withdrawal in a safe and effective way. To ensure your success, be sure to consult with an addiction treatment program or a medical expert today. Your recovery and well-being are too valuable to gamble.

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