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Withdrawal from opioids

WFeb 18 05

Alternative names 
Opiate withdrawal; Dopesickness

Definition

Opiate withdrawal is caused by stopping, or dramatically reducing, opiate use after heavy and prolonged use (several weeks or more).

Opiates include heroin, morphine, codeine, Oxycontin, Dilaudid, methadone, and others. The reaction frequently includes sweating, shaking, headache, drug craving, nausea, vomiting, abdominal cramping, diarrhea, inability to sleep, confusion, agitation, depression, anxiety, and other behavioral changes.

Causes, incidence, and risk factors

About 5% of the population is believed to misuse opiates, including illegal drugs like heroin and prescribed pain medications such as Oxycontin.

These drugs can cause physical dependence. This means that there is a reliance on the drug to prevent symptoms of withdrawl. Over time, greater amounts of the drug become necessary to produce the same effect.

The time it takes to become physically dependent varies with each individual.

When the drugs are stopped, the body needs time to recover, and withdrawal symptoms result. Withdrawal from opiates can occur whenever any chronic use is discontinued or reduced.

Some people even withdraw from opiates after hospitalization for painful conditions without realizing what is happening to them. They think they have the flu, and because they don’t know that opiates would fix the problem, they don’t crave the drugs.

Symptoms

The symptoms of withdrawal are often the reverse of intoxication. Withdrawal includes dilated pupils, diarrhea, runny nose, goose bumps, and abdominal pain.

Signs and tests

A physical exam and clinical history are often sufficient to diagnose opiate withdrawal. A urine or serum drug screen can verify the existence of opiates and any other drugs of abuse.

Treatment

Treatment of withdrawal includes supportive care and medications. The most commonly used medication, clonidine, primarily reduces physical symptoms.

Another detox method is to use a slowly tapered dose of methadone to reduce the intensity of withdrawal symptoms. This can be effective in inpatient programs, but outpatient methadone detox programs are ineffective.

Methadone maintenance involves ongoing use of methadone. This is the most effective treatment for opiate addiction, according to the Institutes of Medicine.

The FDA is expected to approve a new medication for use in the treatment of opiate withdrawal very soon. This medication, called buprenorphine, may help both physical and mental withdrawal symptoms. It may also be used for long-term maintenance like methadone.

This will have significant advantages over methadone because it will be obtainable from general practitioners, not just specialized clinics with rigid attendance requirements.

Some drug treatment programs have widely advertised treatments for opiate withdrawal called detox under anesthesia or rapid opiate detox. This involves anesthetizing the patient and injecting large doses of opiate-blocking drugs, with hopes that this will speed up the transition to normal opioid system function.

There is no evidence that these programs actually reduce time spent suffering withdrawal. In some cases, they may reduce the intensity of symptoms. However, there have been several deaths associated with the procedure, particularly when it is performed outside a hospital.

Because opiate withdrawal produces vomiting, and vomiting during anesthesia significantly increases death risk, many specialists think the risks of this procedure significantly outweigh potential (and unproven) benefits.

Support Groups
Support groups, such as Narcotics Anonymous and SMART Recovery, can be enormously helpful to people suffering opiate addiction.

Expectations (prognosis)

Withdrawal from opiates is painful, but not life-threatening.

Complications

The biggest complication is return to drug use. Most opiate overdose deaths occur in people who have just withdrawn or detoxed. Because withdrawal reduces a previously-developed tolerance, recently withdrawn addicts can overdose on a much smaller dose than they used to take daily. Addicts should be warned about this possibility.

Longer term treatment is recommended for most addicts following withdrawal. This can include self-help groups, like Narcotics Anonymous or SMART Recovery, outpatient counseling, intensive outpatient treatment (day hospitalization), or in-patient treatment.

Addicts withdrawing from opiates should be assessed for depression and other mental illnesses. Appropriate treatment of such disorders can reduce the risk of relapse, and antidepressant medications should NOT be withheld under the assumption that the depression is only related to withdrawal and not a pre-existing condition.

Treatment goals should be discussed with the patient and recommendations for care made accordingly. If an opiate addict has withdrawn repeatedly only to relapse repeatedly, methadone maintenance is strongly recommended.

Calling your health care provider

Call your doctor if you are using or withdrawing from opiates.

Johns Hopkins patient information

Last revised: December 5, 2007
by David A. Scott, M.D.

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