Is Suboxone treatment a fit for you?
Find it now

Managing Opioid Withdrawal

No items found.
September 7, 2021

The first step in discontinuing an opioid use disorder (OUD) is the withdrawal period. Opioid withdrawal can be extremely difficult to tolerate. Effective treatment of withdrawal is crucial to the success of staying abstinent long term. An array of treatment options are available: opioid medications, non-opioid adjunctive medications, and a host of non-pharmacologic therapies including nutrition, exercise, and alternative modalities. 

Understanding withdrawal

When an individual stops taking opioids (e.g., heroin), withdrawal symptoms typically begin 8-24 hours after the last use, and can persist for 4-10 days. After curtailing use of a long-acting opioid (e.g., methadone), withdrawal symptoms begin 12-48 hours after last use and can persist for 10-20 days. Symptoms include nausea and vomiting, anxiety, insomnia, hot and cold flashes, perspiration, muscle cramps, watery discharge from eyes and nose, and diarrhea.

The severity and duration of opioid withdrawal symptoms vary greatly from person to person, and are affected by multiple factors that are hard to predict. 

Treating withdrawal

Opioid based medications

Regardless of the ultimate treatment goal, management of acute opioid withdrawal symptoms is the first step during opioid discontinuation or dose reduction.

Of the three principal types of opioid-based medication assisted treatment (MAT) for opioid use disorder — methadone, buprenorphine/naloxone (Suboxone) and naltrexone — Suboxone is often preferred because it can be prescribed by licensed medical provider in any treatment setting, whereas in the U.S., methadone is strictly regulated and can only be provided through federally licensed treatment centers.

Prior to starting Suboxone, the individual should be experiencing mild-to-moderate withdrawal symptoms from the opioid (e.g., heroin) that they were taking previously—in order to prevent precipitated withdrawal.

This first phase of Suboxone treatment is called the initiation phase. During this period, effective treatment of withdrawal symptoms is a crucial first step on the pathway to successful OUD treatment because the distress in the first few days after discontinuation can be severe. Without adequate treatment, many patients are unable to sustain abstinence from opioids (2019 clinical review).

Non-opioid/adjunct medications

Evidence for the effectiveness of treatment of withdrawal symptoms with opioid medications (MAT) is by far the best. The evidence for non-opioid medications in treating withdrawal is not as strong. However, these medications can be good adjunctive, or additional, medications to use, or good substitutions if MAT is not available or tolerable. Some adjunctive, non-opioid medications include:

  • a-2 adrenergic agonists can be useful in treating the symptoms of anxiety, tremors, and restlessness. Clonidine is the medication most commonly prescribed for this purpose. However, there are a few others: The FDA approved lofexidine in May 2018 and it is the first non-opioid medication indicated for treatment of opioid withdrawal symptoms in the U.S. One clinical review paper concludes that “Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone [as] no significant difference in efficacy between treatment regimens based on Clonidine or lofexidine and those based on reducing doses of methadone [were detected] over a period of around 10 days; but methadone was associated with fewer adverse effects than Clonidine, and lofexidine has a better safety profile than Clonidine.”
  • Loperamide, an anti-diarrheal, can be used to treat GI upset and diarrhea symptoms. 
  • Bentyl, an antispasmodic, can be used to assist with stomach cramping. 

The following chart lists many of the most commonly experienced opioid withdrawal symptoms, and the corresponding non-opioid medications that can provide relief adjunctive to MAT. Talk to your doctor if you have questions about whether any of these medications are right for you. You can learn more about managing withdrawal symptoms here.

Symptom Prescription medications OTC medications
Abdominal cramps dicyclomine (Bentyl); propantheline
Agitation and anxiety diphenhydramine or hydroxyzine; benzodiazepines can be used with caution, and those with less abuse potential (e.g., clonazepam, oxazepam) are preferred.
Dehydration electrolytes
Diarrhea loperamide (Imodium); Bismuth (Pepto Bismol)
Insomnia eszopiclone, zolpidem, or low doses of doxepin or trazodone
Muscle aches Nonsteroidal anti-inflammatory drugs (such as ibuprofin); acetaminophen; topical agents (Bengay, Tiger Balm)
Muscle spasms Anti-spasmodics (Bentyl)
Nausea ondansetron, prochlorperazine, metoclopramide Pepto Bismol, Kaopectate
Restless leg syndrome Clonidine
Sweating Clonidine
Vomiting Clonidine Increased hydration
Watery eyes, Sneezing diphenhydramine (Benadryl)

Nutrition, hydration and exercise

Depending on the severity of the addiction, patients with OUD are often going long periods of time without adequate nutrition and are often malnourished. Opioids also affect the gastrointestinal system in numerous ways. Constipation is a common symptom of opioid use, and conversely, withdrawal often causes the opposite symptom of diarrhea, nausea and vomiting. This can all lead to nutrient losses, imbalance of electrolytes, and dehydration, that can further exhaust a person as their body goes through withdrawal.

Thus, adequate hydration and nutrition are really essential as the body undergoes withdrawal. Eating balanced meals, maintaining a high-fiber diet with plenty of complex carbohydrates (such as whole grains, vegetables, peas, and beans), maintaining adequate hydration and increasing dietary intake of protein can all help to strengthen the body as it goes through the withdrawal process. Zinc can help to improve immune system and proper brain function, and calcium and magnesium deficiencies are the major factors of pain and nervous/muscular disorders among addicts. Vitamin B and vitamin C supplements are often recommended as well.

Light exercise is encouraged as endorphins released by physical movement can improve mood and pain tolerance. Endorphins themselves are natural opioids. 

Psycho-social support

Psycho-social support from both professionals and loved ones is essential during withdrawal. Families are encouraged to create a judgment-free, loving environment. If you are concerned about a loved one’s recovery process, speak up! For more information on how to have this conversation, here are several helpful websites/resources:

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.


Elena Hill, MD, MPH

Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.
Elena Hill, MD; MPH received her MD and Masters of Public Health degrees at Tufts Medical School and completed her family medicine residency at Boston Medical Center. She is currently an attending physician at Bronxcare Health Systems in the Bronx, NY where she works as a primary care physician as well as part time in pain management and integrated health. Her clinical interests include underserved health care, chronic pain and integrated/alternative health.

Citations

Articles related

No items found.

Bicycle Health Online Suboxone Doctors

Safe, confidential, & affordable treatment for opioid use disorder.