What is Opioid Withdrawal?
Opioid withdrawal syndrome is a serious condition that can occur when a person who regularly uses opioids, a type of drug used to manage severe pain, suddenly stops taking them. Opioids, which include drugs like morphine, heroin, oxycontin, codeine, methadone, and hydromorphone hydrochloride, are also often used for their mind-altering effects. These drugs can provide relaxation, pain relief, and a sense of intense happiness.
However, long-term use of opioids can lead to dependence, which can be highly debilitating for users. This dependence not only affects the individual but also puts a considerable financial strain on society by leading to higher healthcare costs, increase in unemployment, absenteeism from work, and early death. Some studies have shown that these consequences can account for as much as 0.2% to 2.0% of a country’s total economic output or gross domestic product.
What Causes Opioid Withdrawal?
Opioids work by interacting with three types of receptors, or ‘docking stations’, in your body: mu, delta, and kappa. These receptors are like switches that can turn off certain actions inside the body. When opioids bind to these receptors, they stop an enzyme (namely adenyl cyclases) in various tissues in the body, causing a decrease in a substance called cyclic adenosine monophosphate. The mu receptor is particularly important in how opioids work.
Withdrawal from opioids can happen when someone who has been taking these drugs for awhile suddenly reduces the dosage or stops taking them completely. Withdrawal can also occur if someone has opioids in their system and then they receive certain other drugs which only partly act like opioids (these are called opioid partial agonists) such as buprenorphine, or drugs that block the action of opioids (these are called opioid antagonists) like naloxone or naltrexone.
The reason why withdrawal happens is complex. Research conducted on animals in lab settings have suggested that withdrawal symptoms are closely related to ‘overexcitation’ in the central nervous system. This is triggered by an overactive enzyme known as adenylyl cyclase.
Risk Factors and Frequency for Opioid Withdrawal
Heroin and prescription opioids are often misused, not just in the United States, but also in Asia, Europe, and Oceania. In fact, the use of these substances is quickly rising around the world. There are about 15.6 million people globally who use these substances illegally, and this number goes up each year.
- In 2016, about 11.5 million Americans at least 12 years old misused opioid pain medications.
- Of these, 1.8 million developed a substance use disorder because of these prescribed pain medications.
- From 2000 to 2015, approximately 500,000 people passed away from opioid overdoses.
- In 2012, the number of opioid prescriptions written by doctors was 259 million, enough for every adult in the United States.
Signs and Symptoms of Opioid Withdrawal
The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) outlines various signs and symptoms that indicate opioid withdrawal. These include:
- Tearing up or runny nose
- “Goose flesh” or skin that resembles the skin of a plucked goose
- Muscle aches
- Diarrhea
- Nausea or vomiting
- Dilated pupils
- Sensitivity to light
- Insomnia
- Increased body functions like rapid breathing, enhanced reflexes, fast heartbeat, sweating, high blood pressure, high body temperature
- Yawning
Testing for Opioid Withdrawal
To check for the possibility of withdrawal from opioids or any other drugs, urine tests are usually performed. These tests can detect the presence of drugs like morphine, heroin, codeine, oxycodone, and propoxyphene within 12 to 36 hours from the time of usage. However, other opioids such as methadone, buprenorphine, and LAAM (a type of drug used for treating opioid addiction) are not usually detected by standard opiate tests, and therefore need to be tested separately. Urine tests can also help identify other common drugs of abuse including marijuana, cocaine, benzodiazepines, and amphetamines, which might be present among opioid users. Several other tests like an ECG, a Complete Blood Count (CBC), a blood alcohol level test, and a Basic Metabolic Panel (BMP) should also be done as a part of the evaluation.
The severity of opioid withdrawal is typically determined by a test known as the Clinical Opioid Withdrawal Scale (COWS). This test evaluates 11 common signs and symptoms of opioid withdrawal. The scores, which range from 0 to 47, are used to classify the severity of withdrawal into different levels. Scores of 5 to 12 indicate mild withdrawal symptoms, 13 to 24 indicate moderate symptoms, 25 to 36 point to moderate-severe symptoms, and a score above 37 is indicative of severe opioid withdrawal. This type of assessment has become particularly important as the prescription of buprenorphine, a drug used to treat opioid withdrawal, can actually lead to withdrawal symptoms in opioid-dependent patients who are not yet showing any signs of withdrawal.
Treatment Options for Opioid Withdrawal
When signs of opioid withdrawal, such as anxiety, restlessness, and body aches, are present, medication is needed to help manage these discomforts. Two common medications used for long-term treatment of opioid addiction include methadone and buprenorphine. Both these drugs help reduce cravings and withdrawal symptoms associated with opioid addiction.
Methadone, a type of medication, is usually given in a hospital or treatment center setting to control withdrawal symptoms. It’s given on a strict schedule, and over time, doses are adjusted to best support the patient’s recovery.
Buprenorphine, another option, can also be used for treatment, but there are important guidelines for its initiation to avoid worsening of withdrawal symptoms. It must be started around 12 to 18 hours after the last use of short-acting opiates like heroin, or 24 to 48 hours after long-acting ones like methadone.
There are additional medications that can help manage specific symptoms of opioid withdrawal. Loperamide can help control diarrhea, promethazine can aid in reducing nausea and vomiting, and ibuprofen can help with muscle aches. Clonidine can be given to lower blood pressure.
The U.S government has introduced the Mainstreaming Addiction Treatment (MAT) Act to make opioid addiction treatment more accessible. This Act allows all health care providers with a controlled substance license to prescribe buprenorphine for opioid use disorder. This move was made to reduce stigma around opioid use disorder treatment and encourage its integration into regular healthcare.
As of December 2022, changes in regulation have made it easier for healthcare providers to prescribe buprenorphine under the MAT Act. The requirements and patient limits tied to prescribing buprenorphine have been lifted. The intention is to broaden access to this effective treatment option. Pharmacy staff are now able to fill prescriptions for buprenorphine using the standard issuing authority. However, state laws may still impose certain limits for the treatment of patients with opioid use disorder, and healthcare providers must adhere to these rules.
What else can Opioid Withdrawal be?
When treating a patient showing signs of opioid withdrawal, according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), doctors need to rule out several other conditions before confirming the diagnosis. These include:
- Opioid-Induced Mental Disorders: This refers to mental health issues that commonly occur alongside opioid drug use. These can include feelings of depression, long-term depressive disorder (dysthymia), and opioid-induced depressive disorder. These disorders differ from opioid withdrawal in that the symptoms of these disorders overshadow potential withdrawal symptoms, and they require further investigation for diagnosis.
- Other Substance Intoxication: Intoxication from substances like alcohol, sedatives, or anxiety relieving drugs might present similar symptoms to opioid intoxication, thus it’s necessary to rule out this possibility before confirming opioid withdrawal.
- Other Withdrawal Disorders: Withdrawal symptoms from sedative and hypnotic drugs can resemble those of opioid withdrawal. However, symptoms such as excessive tear production, runny nose, and widened pupils are typical of opioid withdrawal. Other substances like hallucinogens and stimulants can also cause widened pupils, but lack other typical symptoms of opioid withdrawal such as nausea, diarrhea, vomiting, and a runny nose.
Having a clear understanding of these similar conditions helps doctors arrive at an accurate diagnosis.
What to expect with Opioid Withdrawal
The chances of recovery and the risks involved with opioid addiction varies depending on many factors related to an individual’s family life, society, environment, genetics, and friends circle. As per the DSM-5, which is a manual for mental health diagnosis, genetics can directly and indirectly influence the situation.
Those suffering from opioid addiction are likely to have a better recovery outcome if they have a strong support system and good self-control capabilities. It’s also beneficial if their genetics are somewhat resistant to the disease. Moreover, patients who consistently visit their psychiatrist or detoxification programs for follow-up care are also more likely to recover successfully.
Possible Complications When Diagnosed with Opioid Withdrawal
According to the DSM-5, using drugs increases the risk of contracting infectious diseases. Around 80% to 90% of people who use injection opioids test positive for Hepatitis A, B, and C. HIV, another infectious disease, is also highly common in this population. In fact, in certain parts of the United States and Russia, the HIV rates for injection opioid users can be as high as 60%. However, this rate can drop to as low as 10% in other areas. Liver function tests may also indicate possible liver damage due to the toxic substances that can be mixed with opioids or a previous hepatitis infection.
Even though they are rare, diseases like tetanus and Clostridium botulinum are serious complications for opioid users. These individuals are also at a higher risk for tuberculosis, especially if heroin is their drug of choice. Tuberculosis infections are often symptomless and are usually indicated by a positive tuberculin skin test.
People who snort heroin or other opioids experience issues with their nasal mucosa, which can sometimes lead to perforation of the nasal septum. Sexual side effects are also commonly experienced: male users often experience erectile dysfunction and irregular reproductive patterns are seen in female users.
Possible side effects:
- Increased risk of infectious diseases
- Damage to the liver
- Potential risk for tetanus and Clostridium botulinum
- Higher risk of TB
- Nasal mucosa irritation and nose perforation
- Sexual wellness issues
- Physiological disturbances
- Low birth weight in infants born to opioid users
Children born to women who use opioids can also experience physiological disturbances and a lower birth weight.
Recovery from Opioid Withdrawal
People who have been using opioids for a long period often need recovery care once their initial withdrawal symptoms are under control. It’s also necessary for them to regularly meet with a psychiatrist outside of the hospital or clinic setting for further check-ups and support.
Preventing Opioid Withdrawal
It’s important for patients to understand the potential dangers of using opioids. They should also be made aware that stopping the use of opioids suddenly can lead to harmful effects. If a patient wishes to stop taking opioids, they should seek advice from a doctor for a medically-guided detoxification process. This way, they can safely and effectively reduce their dependence on these drugs.
