Opioid withdrawal


  • Withdrawal can be precipitated with administration of antagonist (e.g. naloxone) or partial agonist (e.g. buprenorphine). [1]
  • Symptoms are usually uncomfortable but not life-threatening
    • Catecholamine surge during withdrawal may cause a level of hemodynamic instability that may not be tolerated by patients with co-morbid conditions
    • life-threatening in neonates

Clinical Presentation

  • Onset: within hours of cessation
  • Symptoms resemble severe case of influenza [2]

Early symptoms

  • Agitation/restlessness
  • Anxiety
  • Muscle aches
  • Increased tearing
  • Insomnia
  • Runny nose
  • Sweating
  • Yawning
  • Skin-Crawling
  • May be tachycardic and/or tachypneic but not necessarily

Late symptoms

  • Unlike alcohol or benzo withdrawal, unlikely to have seizures
    • Typically normal mental status despite agitation


  • Time to peak and duration of symptoms depends on the half-life of the drug involved.
    • Heroin: onset 6-12 hours, peak 36-72 hours, duration 7-10 days
    • Methadone: onset 30 hours, peak 72-96 hours, duration 14 days or more
  • If naloxone-induced withdrawal, typically symptom duration < 1 hour


  • Normally a clinical diagnosis


  • Clinical Opiate Withdrawal Score (COWS)
    • Can be used to determine severity

Differential Diagnosis


  1. PO/IV hydration PRN
  2. Clonidine
    • Mild opioid withdrawal - 0.1 - 0.3 mg PO
      • Monitor heart rate and blood pressure and may titrate to effect
    • 5mcg/kg PO (as long as SBP >90)
  3. Benzodiazepines (e.g. diazepam 10-20mg IV)
    • Can add with clonidine for adequate sedation
  4. Antihistamines
  5. Antiemetics
  6. Antidiarrheals

For select cases:

  • Buprenorphine
    • Partial agonist, may induce withdrawal in opioid intoxicated patients
  • Methadone 10mg IM or 20mg PO
    • Consider if withdrawal precipitated by interruption in opioid use, NOT if antagonist (e.g. narcan) was given

See Also


  1. Olmedo R, Hoffman RS. Withdrawal syndromes. Emerg Med Clin North Am. 2000;18(2):273–88.
  2. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med 2003;348:1786-95
  • Tintinalli