Opioid Withdrawal Timeline: The Three Stages of Withdrawal Explained

January 11, 2021

M.M. is a 24 year-old male who was in a motor vehicle accident 3 years ago and sustained a severe whiplash injury. His doctor prescribed him several month’s worth of oxycodone to treat his neck pain. After his doctor stopped the medication abruptly, M.M started buying oxycodone “off the street.” He found it not only helped his pain but also improved his mood, and he would “pop a pill” when he felt depressed or anxious. He switched to heroin (which was laced with fentanyl) since it was cheaper than oxycodone and he could feel the effects faster. One day, when he called his usual dealer and was unable to reach him, M.M. ended up going over 12 hours without heroin and he started to feel awful--shaky, agitated, his muscles started to ache, and his nose started running.

J.R. is a 56 year-old male who recently injured his back while lifting cement bricks at his job. His doctor gave him vicodin for the pain. After he returned to work and resumed heavy lifting, J.R. felt an exacerbation of his back pain and started to take extra pills for a few days in row. Toward the end of the month, he ran out of his vicodin early, and after a few days without it, he started to get nauseas, began vomiting, running to the bathroom with diarrhea, and felt intense stomach cramps.

L.D. is a 42 year old female who works at the post-office, is married with two young kids. She has been in recovery for opioid addiction for over 10 years and takes buprenorphine/naloxone (Suboxone) every day to prevent cravings, prevent overdose, and help her feel “normal” so she can work and take care of her kids. Over her kids’ spring break, her family decided to go camping. While setting up camp, her backpack got flung open and her medications, including her buprenorphine/naloxone (Suboxone), spilled out. Two days later, while her family was getting ready to pack up, she started feeling flu-like symptoms - body aches, chills with “gooseflesh” skin, and was very nauseous.

All of these people were experiencing opioid withdrawal.

So, what is opioid withdrawal and why does it happen?

Opioid withdrawal is a natural physiological process that can occur in anyone whose body becomes used to having opiates in their system 24 hours a day.

Think about it this way: imagine that throughout your body, you have neurological opioid receptors. For most people, it is normal for these opioid receptors to occasionally be stimulated when you do something pleasurable, like eat a piece of cake, have sex, or go for a run and feel a ‘runner’s high.’ Again, for most people, these receptors are empty and only occasionally activated.

But if your doctor gives you a prescription for an opioid, like oxycodone or if you were to get illicit opioids like fentanyl off the street, and you take these every day for longer than 5 days, your body starts to feel used to always having your opioid receptors stimulated.(1)

Now, if you abruptly stop taking these opioids or no longer have access to them, your brain’s opioid receptors feel “naked” and you will experience the complete opposite of that happy/”high” feeling -- what we call opioid withdrawal.(2)

Patients describe opioid withdrawal like a severe form of the flu -- you will feel body aches, chills, GI symptoms like abdominal cramps, nausea, vomiting, diarrhea, and agitation and tremulousness.

Symptoms of opioid withdrawal (3)

  • Restlessness
  • Heavy yawning 
  • Enlarged pupils
  • Runny nose 
  • Body aches 
  • Tremors/twitching 
  • Chills or sweating 
  • Anxious or irritable 
  • “Goose pimples” on your skin
  • Stomach cramps, nausea, vomiting or diarrhea

How soon can opioid withdrawal occur?

The timing of opioid withdrawal symptoms depends on the opioid being consumed. Some opioids are shorter-lasting so leave the body sooner, and the person can experience opioid withdrawal symptoms fairly quickly. Others are longer-lasting so opioid withdrawal occurs later. 

How soon withdrawal symptoms can occur after the last dose of opioid was taken (4):

Short-action opioids: heroin, Percocet, oxycodone, Vicodin, Dilaudid

  • After 10-12 hours

Long-acting opioids: fentanyl, Oxycontin, MS Contin

  • After 24 hours

Very long-acting opioids: methadone

  • After 48-72 hours

Is opioid withdrawal DANGEROUS?

Dr. Brian Clear, Chief Medical Officer of Bicycle Health, a tele-health company that supports patients with opioid addiction by providing evidence-based MAT (medication for addiction treatment), explains, “Opioid withdrawal is definitely UNCOMFORTABLE-- no one likes to feel like they have the flu. But, it is NOT deadly. Patients will not die from opioid withdrawal.”

Additionally, it is necessary to briefly go through opioid withdrawal in order to start life-saving medications that treat opioid addiction, like buprenorphine/naloxone (Suboxone), methadone and naltrexone (AKA Vivitrol). If your body is used to taking oxycodone or fentanyl, for example, you actually need to wait to feel withdrawal symptoms after stopping these drugs before you start treatment medications. If you take the treatment medications (like Suboxone) too soon, you can actually cause a faster, more severe form of withdrawal, called precipitated withdrawal.

Dr. Clear explains how Bicycle Health helps start patients on their buprenorphine/naloxone (Suboxone) based on these principles. “When you are starting Suboxone at Bicycle Health, we ask you what was the last opioid you took and when did you take it. We use that to figure out when your withdrawal symptoms are likely to occur. Once you start feeling at least three of these symptoms, then we start you on Suboxone, which will make you start to feel better.”

Many patients are concerned about that window between taking their last opioid and starting medication for treating opioid addiction. So, what can be done?In order to help patients tolerate the period of withdrawal symptoms, doctors often prescribe “comfort” medications to help treat feelings of agitation, nausea and vomiting, diarrhea, stomach cramps and body aches.

Dr. Clear explains how Bicycle Health also uses Clinical Support Specialists to help patients when they are starting buprenorphine/naloxone (Suboxone). “Our team is available to patients when they’re preparing to start Suboxone and are experiencing withdrawal symptoms to make sure they are doing okay, understand the plan developed with their provider, and are staying on track to a successful start.”

Is it worth it to go through all of this?

Certainly!

We know that abstinence-only programs do not work for most patients. This means that if someone wants to detox and come off opioids--like oxycodone and fentanyl-- if they do NOT start medication for opioid addiction treatment, relapse rates and overdose death rates are very high--up to 90% of patients will relapse after 3 months of not being on medication treatment. To learn more about the effectiveness of medications to treat opioid addiction, read more on the common misconceptions around treatment.

Dr. Clear explains the resounding benefits of starting medications to treat opioid addiction.

“We have seen outstanding rates of success here at Bicycle Health, and we know these align with national trends, suggesting that, after starting buprenorphine: at one month 97% of patients are still taking their medications and at 6 months 56% of patients are taking their medications. That means patients remain in recovery much longer than if they detoxed and subsequently did not start buprenorphine.”

Possibility of Relapse?

Patients often ask if they have to be on medications for opioid addiction treatment, like buprenorphine/naloxone (Suboxone), for the rest of their lives.

“What we know is that coming off these medications poses high risk of relapse. I like to tell my patients that if things are working out for them-- they are working, fulfilling their responsibilities, developing meaningful relationships with their friends and family and are taking better care of their health- like going to doctor’s appointments, getting back into exercising and eating healthy-- because they are taking these medications, there is certainly NO rush or need to ever come off them.”  

To learn more about. how addiction is a chronic disease and has relapse rates similar to other chronic disease (like diabetes and asthma), click here.

But what if I want to come off? How do I taper?

Because buprenorphine/naloxone (Suboxone) is a partial opioid agonist, meaning it partially activates the opioid receptors, coming off this medication too abruptly can cause opioid withdrawal symptoms.

“If patients really want to come off Suboxone, we of course work with them to safely taper off these medications, though it will take awhile--usually a minimum of 6 months-- and is generally not encouraged.”

Patients desiring to come off buprenorphine/naloxone (Suboxone) should work with their prescribing doctors to develop a long-term plan. This involves very gradual tapering and frequent check-ins to reassess how the tapering process is going to minimize withdrawal symptoms.

Dr. Clear also offers this “checklist” as a way to truly assess if a patient may be ready.

He explains, “the more questions you can honestly answer as ‘YES,’ the greater the likelihood that you may be able to taper off Suboxone and maintain your recovery. Consider that each ‘NO’ response represents an area that you probably need to work on to increase the odds of a successful taper and recovery.”

  • Have you been abstaining from illegal drugs such as heroin/fentanyl, cocaine, and speed?
  • Do you think you are able to cope with difficult situations without using drugs?
  • Are you employed or in school?
  • Are you staying away from contact with users and illegal activities?
  • Have you gotten rid of your “works”/ “outfit?”
  • Are you living in a neighborhood that does not have a lot of drugs and are you comfortable there?
  • Are you living in a stable family relationship?
  • Do you have non-user friends that you spend time with?
  • Do you have friends or family that would be helpful during a taper?
  • Have you been participating in counseling that has been helpful?
  • Does your counselor think you are ready to taper?

Dr. Clear reiterates an important message about helping patients with opioid addiction. “We know that this is a life-long disease and patients do well in recovery on scientifically-proven treatment medications like Suboxone. There is definitely no rush to come off, and I generally discourage tapering off Suboxone because there is a high rate of relapse associated with it.”

Bicycle Health

Bicycle Health helps patients struggling with addiction to opioids. We help support patients in starting on buprenorphine/naloxone (Suboxone) (minimizing uncomfortable opioid withdrawal symptoms) and maintaining on buprenorphine/naloxone (Suboxone) so they can get back on track of living a meaningful life in recovery.

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.

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

(1) Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing. N Engl J Med. 2019. https://doi.org/10.1056/NEJMp1904190.

(2) Wise RA, Bozarth MA. Brain mechanisms of drug reward and euphoria. Psychiatr Med. 1985;3(4):445-60. PMID: 2893431.

(3) Wesson DR, Ling W. 2003. The clinical opiate withdrawal scale (COWS). Journal of Psychoactive Drugs 35:253–259.

(4) O’Connor PG. Methods of detoxification and their role in treating patients with opioid dependence. JAMA 2005;294:961-963

O’Brien CP. Drug addiction. In: Brunton L, Chabner B, Knollman B, eds. Goodman & Gilman’s the pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill, 2011:649-666.

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