A typical opioid withdrawal episode begins within a few hours of the last drug use, and it can persist for several days. When it starts, and how long it lasts, depends on the type of drug used.
A typical opioid withdrawal timeline may look like the following:[6]
- Short-acting opioids (like heroin): Symptoms begin within 8 to 24 hours and last for 4 to 10 days.
- Long-acting opioids (like methadone): Symptoms begin within 12 to 48 hours and last between 10 and 20 days.
Entering a treatment program can change these timelines. For example, using medications like buprenorphine could mean experiencing few symptoms after the first day or two. Treatment programs can also keep you safe as your body adjusts to sobriety.
What Does Opioid Withdrawal Feel Like?
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 months 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 a 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 and 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.
What is Opioid Withdrawal?
Opioid withdrawal is a natural physiological process that can occur in anyone whose body becomes used to having opioids in their system regularly.
Opioids work by latching to dedicated receptors located in the brain and spinal cord. When they’re connected, opioids block pain signals and trigger the release of the neurotransmitter dopamine.[8]
The brain naturally releases dopamine in response to pleasurable activities, so we remember them and are encouraged to repeat them. Large bursts of dopamine triggered by drugs can stimulate the brain to seek out drugs at the expense of everything else.[9]
At the same time, the brain responds by producing fewer neurotransmitters—even when the person is engaged in something pleasurable. In time, people may only feel content while using drugs. The cravings can be powerful and overwhelming.[9]
When people try to quit opioids, parts of the brain, like the amygdala, send out distress signals.[9] Feelings like anxiety and insomnia begin. In time, they can worsen into gastrointestinal distress, severe vomiting and bone pain.
Symptoms of Opioid Withdrawal
Symptoms of opioid withdrawal include the following:[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
When Does Opioid Withdrawal Start & Stop?
The timing of opioid withdrawal symptoms depends on the opioid being consumed. Some opioids are shorter-lasting, so they leave the body sooner, and the person can experience opioid withdrawal symptoms fairly quickly. Others are longer-lasting so opioid withdrawal occurs later.
This chart can help you understand how opioid withdrawal works with various opioid types:[6,7]
| Type of Opioid | When Do Symptoms Start? | How Long Do Symptoms Last? |
| Short-acting opioids (codeine, hydrocodone, oxycodone, morphine) | 8-24 hours after last use | 4-10 days |
| Long-acting opioids (methadone, hydromorphone, fentanyl, buprenorphine) | 12-48 hours after last use | 10-20 days |
Is Opioid Withdrawal Dangerous?
Experts define opioid withdrawal as a life-threatening condition caused by opioid dependence.[10] Without proper treatment, dehydration caused by relentless vomiting and diarrhea can lead to serious consequences. People may also relapse to drugs before the withdrawal ends.
In a treatment program including a medication like Suboxone, mild withdrawal is required. If you take the treatment medications 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 use disorder (OUD). 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.”
Why Should I Consider Treatment?
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 a 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 diseases (like diabetes and asthma), click here.
Understanding the Taper Process
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 a while–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.
By 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 ... Read More
- Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing. N Engl J Med. 2019. https://doi.org/10.1056/NEJMp1904190.
- Wise RA, Bozarth MA. Brain mechanisms of drug reward and euphoria. Psychiatr Med. 1985;3(4):445-60. PMID: 2893431.
- Wesson DR, Ling W. 2003. The clinical opiate withdrawal scale (COWS). Journal of Psychoactive Drugs 35:253–259.
- 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.
- Withdrawal management. World Health Organization. Published 2009. Accessed January 17, 2024. https://www.ncbi.nlm.nih.gov/books/NBK310652/
- Rapid onset opioids in palliative medicine. Annals of Palliative Medicine. 2012;1(1). https://apm.amegroups.org/article/view/101/106
- Prescription opioids Drug Facts. National Institute on Drug Abuse. Published June 2021. Accessed January 17, 2024. https://nida.nih.gov/publications/drugfacts/prescription-opioids
- Drugs and the brain. National Institute on Drug Abuse. Published June 2020. Accessed January 17, 2024. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
- Shah M, Huecker M. Opioid withdrawal. StatPearls. Published July 21, 2023. Accessed January 17, 2024. https://www.ncbi.nlm.nih.gov/books/NBK526012/
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