At least 3 of the following developing within minutes to several days after Criterion A:

1. Dysphoric mood
2. Nausea or vomiting
3. Muscle aches
4. Lacrimation or rhinorrhea
5. Pupillary dilation, piloerection, or sweating
6. Diarrhea
7. Yawning
8. Fever
9. Insomnia

Course

• The speed and severity of withdrawal depends on the half-life of the opioid used.
  • Short-acting opioids:
    • Heroin users can have withdrawal symptoms within 6-12 hours after the last dose.
    • Symptoms usually peak within 1-3 days and gradually subside over a period of 5-7 days
  • Long-acting opioids:
    • Methadone, LAAM (L-alpha-acetylmethadol), and buprenorphine users may take up to 2 to 4 days for withdrawal symptoms to occur.
• For both long-acting and short-acting opioids, less acute withdrawal symptoms (e.g. - anxiety, dysphoria, anhedonia, and insomnia) can persist for weeks to months.

Management

• Non-specific symptoms of acute opioid withdrawal can be managed with the following medications:
  • Anxiety
    • Clonidine 0.1 to 0.2 mg q4h (max 1.2 mg/24h)PRN[7]
  • Anti-emetics/anti-diarrheals
    • Ondansetron (Zofran®) 8-16 mg PO/SL q8h PRN for nausea and vomiting
    • Dimenhydrinate 50-100 mg q4-6h PRN (max 400 mg/24 h) for nausea and vomiting
    • Loperamide 4 mg PO once then 2 mg PO after each loose stool (max 16 mg/day)
  • Muscle cramps or pain
    • Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, ketorolac, naproxen
  • Dyspepsia
    • Rabeprazole 20mg qAM PRN
• However, these medications are not a long term treatment for opioid use disorder, and initiating an opioid replacement therapy is the most important.