Opioid addiction

What are the symptoms of opioid dependence?

Addictions: Loss of control over substance use with compulsive continued use despite harm

Dependence: A state of adaptation resulting in drug class-specific withdrawal symptoms upon abrupt dose reduction, decreasing drug level or antagonist administration.

Tolerance: Decreasing effect of drug over time.


What are the symptoms of opioid withdrawal?

Symptoms of opioid withdrawal can be classified to three groups:

Stage 1, up to 8 hours: 

  • Fear of withdrawal
  • Anxiety
  • Drug cravings

Stage 2, 8-24 hours:

  • Insomnia
  • Restlessness
  • Anxiety
  • Yawning
  • Stomach cramps
  • Lacrimation
  • Rhinorrhea
  • Diaphoresis
  • Mydriasis

Stage 3, up to 3 days :  

  • Vomiting
  • Diarrhea
  • Fever
  • Chills
  • Muscle spasms
  • Tremor
  • Tachycardia
  • Piloerection
  • Hypertension
  • Seizures

Physical exam

  • Check vital signs: Blood pressure, pulse rate, temperature, O2 saturation
  • Pupils size: should show small pupils
  • Sweating and wet skin
  • Chills-hots
  • Tachycardia
  • Agitation
  • Irritability

Laboratory work up

  • Urine drug screening (amphetamines, benzodiazepines, cocaine, opioids, fentanyl, oxycodone, cannabinoids, barbituate, TCA, …)
  • Methadone metabolites
  • Buprenorphine
  • Urinalysis
  • Alcohol or EtG


Muscle spasms: Cyclobenzaprine 5-10 mg TID
Nausea: Gravol 25-50 mg Q4-6hr

Diarrhea: Imodium 4 mg stat, followed by 2 mg after each loose bowel movement, maximum 16 mg daily

Aches: Iboprofen 200-400 mg po Q4-6hr, maximum 2400 mg daily

Insomnia: Trazodone 25-50 mg po hs

Sympathetic activation: Clonidine 0.1 to 0.3 mg Q2-4 hr within 24 hours, maximum 1.2 mg/day

Methadone or suboxone taper: severity of symptoms and signs of opioid withdrawal is affected by a variety of factors such as amount of opioid used, half life of drugs, purity of drugs, route of administration, and opioid type. People who experience severe withdrawal symptoms would benefit from a taper program where a standard dose of methadone or suboxone is initiated and the dose is reduced in a daily basis.

Methadone or Buprenorphine maintenance program: to reduce the risk of relapse after detoxification, some individuals would need to be on replacement therapy where methadone or buprenorphine is prescribed for a longer period of time.

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