Overview & timeline

Onset and duration depend on the opioid: short‑acting opioids (heroin) cause withdrawal 6–24 hours after last use, peaking at 48–72 hours and improving over 5–10 days. Long‑acting opioids (methadone) onset is 24–72 hours, peaking later and lasting longer.

Common withdrawal symptoms

• Autonomic: sweating, piloerection, tachycardia, hypertension.
• Gastrointestinal: nausea, vomiting, diarrhoea, abdominal cramps.
• Neuro‑behavioural: anxiety, restlessness, insomnia, yawning, muscle aches.
• Less common: yawning, lacrimation, rhinorrhoea; severe complications are rare but include dehydration and electrolyte disturbances from vomiting/diarrhoea.

Assessment & scoring

1. Scale Use: Clinical Opiate Withdrawal Scale (COWS) is widely used — score from mild to severe (0–36+); use to titrate medications like buprenorphine induction decisions.
2. History: confirm opioid type, last use, quantity, route, prior withdrawal severity, comorbidities (psychiatric, cardiac, pregnancy), and social supports.
3. Examination: vitals, pupils, signs of dehydration, injection sites, and mental state including suicidality.

Management goals

• Relieve symptoms and prevent complications (dehydration, electrolyte imbalance).
• Provide a tolerable pathway into evidence‑based treatment: buprenorphine or methadone maintenance where appropriate.
• Engage patients with psychosocial support and harm reduction (naloxone supply, education).

Pharmacological options

Opioid agonist treatments (preferred when aiming for long‑term treatment)

• Buprenorphine induction: initiate when patient in moderate withdrawal (COWS ≥8). Typical starting dose 2–4 mg SL, repeat and titrate to effect (max initial 8–16 mg in first day depending on protocol) then maintain (8–24 mg/day commonly).
• Methadone: used for withdrawal or maintenance; initial supervised dosing required (typical 20–30 mg once daily with careful titration), often used when buprenorphine is not suitable.

Non‑opioid symptomatic treatments

• Alpha‑2 agonists: clonidine (oral or transdermal) or lofexidine reduce autonomic symptoms — monitor blood pressure and sedation.
• Antiemetics (ondansetron/metoclopramide), antidiarrheals (loperamide), NSAIDs for myalgia, and sleep aids where appropriate.
• Adjuncts: gabapentin or pregabalin may help some patients with anxiety/insomnia but have misuse potential; use cautiously.

Buprenorphine micro‑induction & precipitated withdrawal

• Standard induction requires moderate withdrawal to avoid precipitated withdrawal when buprenorphine displaces full agonists.
• Micro‑induction (very small buprenorphine doses while continuing full agonist) is an alternative in specialist settings — requires local protocol and monitoring.
• If precipitated withdrawal occurs, provide symptomatic care and consider returning to low‑dose buprenorphine titration under supervision.

Outpatient vs inpatient care

• Most uncomplicated withdrawals can be managed outpatient with clear plan, medications, and close follow‑up.
• Admit for inpatient care if severe comorbidity, pregnancy, inability to take oral meds, lack of safe environment, severe psychiatric comorbidity, or suspected complications (dehydration, severe vomiting/diarrhoea).

Special populations

• Pregnancy: avoid abrupt withdrawal; consider methadone or buprenorphine maintenance — coordinate obstetric care (neonatal abstinence risk exists).
• Adolescents: family involvement, child/adolescent services, and careful consideration before OAT initiation — specialist input recommended.
• Patients on high‑dose methadone or with cardiac disease: require specialist oversight for any changes and inpatient induction may be safer.

Practical resources

• COWS scoring sheet (add to patient notes) and local buprenorphine induction protocol.
• Withdrawal medication checklist: clonidine/lofexidine, antiemetics, loperamide, NSAIDs, buprenorphine starter packs.
• Contact pathways for urgent addiction specialist advice and inpatient detox beds.

Key takeaways

• Use COWS to guide management and buprenorphine induction; aim to relieve symptoms and engage patients into ongoing treatment.
• Alpha‑2 agonists and symptomatic treatments reduce suffering when OAT is not immediately available.
• Tailor care to patient context — most can be managed outpatient with clear follow‑up; escalate for dehydration, severe psychiatric risk or comorbidity.