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==Overview==
==Overview==
Opioid withdrawal occurs due to the cessation of opioids or the administration of an opioid antagonist following a heavy or prolonged use of opioids.  Symptoms of [[withdrawal]] from opiates include, but are not limited to, [[clinical depression|depression]], aggression and irritability, leg cramps, abdominal cramps, vomiting, diarrhea, insomnia, and cravings for the [[medication|drug]] itself.  Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days.
Opioid withdrawal occurs due to the cessation of opioids or the administration of an opioid antagonist following a heavy or prolonged use of opioids.  Symptoms of [[withdrawal]] from opiates include, but are not limited to, [[clinical depression|depression]], aggression and irritability, leg cramps, abdominal cramps, vomiting, diarrhea, insomnia, and cravings for the [[medication|drug]] itself.  Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days.


==Historical Perspective==
==Historical Perspective==
* [[Opium]] and its derivatives have been used as medical therapies since 5,000 years ago.<ref name="pmid30701615">{{cite journal| author=Kosten TR, Baxter LE| title=Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. | journal=Am J Addict | year= 2019 | volume= 28 | issue= 2 | pages= 55-62 | pmid=30701615 | doi=10.1111/ajad.12862 | pmc=6590307 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30701615  }} </ref>
* In the United States, in the early 20th century, [[opiates]] were [[over-the-counter]] drugs and were commonly used in [[medical therapy]] of various disorders.<ref name="pmid30701615">{{cite journal| author=Kosten TR, Baxter LE| title=Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. | journal=Am J Addict | year= 2019 | volume= 28 | issue= 2 | pages= 55-62 | pmid=30701615 | doi=10.1111/ajad.12862 | pmc=6590307 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30701615  }} </ref>
* In the early 1900s, the federal restrictions on [[opioid]] access caused suffering and death since there were no effective [[treatments]] for the [[opioid]] withdrawal symptoms that happened with sudden discontinuation of [[opioids]].<ref name="pmid30701615">{{cite journal| author=Kosten TR, Baxter LE| title=Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. | journal=Am J Addict | year= 2019 | volume= 28 | issue= 2 | pages= 55-62 | pmid=30701615 | doi=10.1111/ajad.12862 | pmc=6590307 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30701615  }} </ref>


==Classification==
==Classification==
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==Causes==
==Causes==
[[Opioid]] withdrawal may be caused by discontinuation of repeated use of an [[opioid]] in any setting such as:<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
[[Opioid]] withdrawal may be caused by discontinuation of repeated use of an [[opioid]].<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
* [[Medical therapy]] of [[pain]]
* [[Opioid]] agonist therapy for [[opioid use disorder]]
* [[Recreational]] use
* Self-treating the symptoms of [[mental disorders]]


==Differentiating opioid withdrawal from other diseases and conditions==
==Differentiating opioid withdrawal from other diseases and conditions==
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==Risk Factors==
==Risk Factors==
[[Opioid]] withdrawal may be caused by discontinuation of repeated use of an [[opioid]] in any setting such as:<ref name=DSMV>{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
* [[Medical therapy]] of [[pain]]
* [[Opioid]] agonist therapy for [[opioid use disorder]]
* [[Recreational]] use
* Self-treating the symptoms of [[mental disorders]]


==Screening==
==Screening==
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* Muscle [[spasms]], twitching
* Muscle [[spasms]], twitching
* [[Tremor]]
* [[Tremor]]


===Laboratory Findings===
===Laboratory Findings===
Line 218: Line 220:
===Primary Prevention===
===Primary Prevention===
===Primary Prevention===
===Primary Prevention===


==References==
==References==

Revision as of 13:34, 25 November 2020



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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Opioid withdrawal occurs due to the cessation of opioids or the administration of an opioid antagonist following a heavy or prolonged use of opioids. Symptoms of withdrawal from opiates include, but are not limited to, depression, aggression and irritability, leg cramps, abdominal cramps, vomiting, diarrhea, insomnia, and cravings for the drug itself. Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days.

Historical Perspective

  • Opium and its derivatives have been used as medical therapies since 5,000 years ago.[1]
  • In the United States, in the early 20th century, opiates were over-the-counter drugs and were commonly used in medical therapy of various disorders.[1]
  • In the early 1900s, the federal restrictions on opioid access caused suffering and death since there were no effective treatments for the opioid withdrawal symptoms that happened with sudden discontinuation of opioids.[1]

Classification

Pathophysiology

Causes

Opioid withdrawal may be caused by discontinuation of repeated use of an opioid.[2]

Differentiating opioid withdrawal from other diseases and conditions

Opioid withdrawal must be differentiated from:[2]

Disease Prominent clinical features Investigations
Hyperthyroidism The main symptoms include:
Essential hypertension Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:
Generalized anxiety disorder According to DSM V, the following criteria should be present to fit the diagnosis of generalized anxiety disorder:
  1. The presence of sense of apprehension or fear toward certain activities for most of the days for at least 6 months
  2. Difficulty to control the apprehension
  3. Associated restless, fatigue, irritability, difficult concentration, muscle tension or sleep disturbance (only one of these manifestations)
  4. The anxiety or the physical manifestations must affect the social and the daily life of the patient
  5. Exclusion of another medical condition or the effect of another administered substance
  6. Exclusion of another mental disorder causing the symptoms
-
Menopause The perimenopausal symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication etc may be associated with the hormone withdrawal process.
  • B-HCG should always be done first to rule out pregnancy especially in women under the age of 45 years
  • FSH can be measured but it can be falsely normal or low
  • TSH, T3 and T4 to rule out thyroid abnormalities
  • Prolactin can be measured to rule out prolactinoma as a cause of menopause
Opioid withdrawal disorder According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:
  1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer) or administration of an opioid antagonist after a period of opioid use.
  2. Development of three or more of the following criteria minutes to days after cessation of drug use: dysphoric mood, nausea or vomiting, muscle aches, Lacrimation or rhinorrhea, pupillary dilation, piloerection, or sweating, diarrhea, yawning, fever, and insomnia.
  3. The signs or symptoms mentioned above must cause impairment of the daily functioning of the patient.
  4. The signs or symptoms mentioned above must not be attributed to other medical or mental disorders.
  • Urine drug screen to rule out any other associated drug abuse
  • Routine blood work such as electrolytes and hemoglobin to rule out any associated disease explaining the symptoms
Pheochromocytoma The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:
  • Palpitations especially in epinephrine producing tumors.
  • Anxiety often resembling that of a panic attack
  • Sweating
  • Headaches occur in 90 % of patients.
  • Paroxysmal attacks of hypertension but some patients have normal blood pressure.
  • It may be asymptomatic and discovered by incidence screening especially MEN patients.

Please note that not all patients with pheochromocytoma experience all classical symptoms.

Diagnostic lab findings associated with pheochromocytoma include:

Epidemiology and Demographics

Prevalence

The prevalence of opioid withdrawal is 6,000 per 100,000 (60%) of the population that have used heroin one or more time in the prior 12 months.[2]

Risk Factors

Opioid withdrawal may be caused by discontinuation of repeated use of an opioid in any setting such as:[2]

Screening

Natural History, Complications and Prognosis

Depending on the quantity, type, frequency, and duration of opioid use, the physical withdrawal symptoms last for as little as 5 days and as much as 14 days. The user, upon returning to the environment where they usually used opiates, can experience environmentally implied physical withdrawal symptoms well-after regaining physical homeostasis - or the termination of the physical withdrawal phase by synthesis of endogenous opioids (endorphins) and upregulation of opioid receptors to the effects of normal levels of endogenous opioids. These implied symptoms are often just as distressing and painful as the initial withdrawal phase.

Detoxification is best conducted in an in patient facility that provides a controlled environment. Patients who are isolated and exposed solely to care givers and other patients in this environment have a better rate of staying clean then those who detox out-patient.

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Opioid Withdrawal[2]

  • A. Presence of either of the following;
  • 1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer).
  • 2. Administration of an opioid antagonist after a period of opioid use.

AND

  • B. Three (or more) of the following developing within minutes to several days after Criterion A:

AND

  • C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

  • D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

History and Symptoms

The most common symptoms of opioid withdrwal include :[3][4]

Physical Examination

Common physical examination findings of opioid withdrwal include:[3][4][1]

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography or Ultrasound

CT Scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Primary Prevention

References

  1. 1.0 1.1 1.2 1.3 Kosten TR, Baxter LE (2019). "Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment". Am J Addict. 28 (2): 55–62. doi:10.1111/ajad.12862. PMC 6590307 Check |pmc= value (help). PMID 30701615.
  2. 2.0 2.1 2.2 2.3 2.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  3. 3.0 3.1 Wesson DR, Ling W (2003). "The Clinical Opiate Withdrawal Scale (COWS)". J Psychoactive Drugs. 35 (2): 253–9. doi:10.1080/02791072.2003.10400007. PMID 12924748.
  4. 4.0 4.1 Vernon MK, Reinders S, Mannix S, Gullo K, Gorodetzky CW, Clinch T (2016). "Psychometric evaluation of the 10-item Short Opiate Withdrawal Scale-Gossop (SOWS-Gossop) in patients undergoing opioid detoxification". Addict Behav. 60: 109–16. doi:10.1016/j.addbeh.2016.03.028. PMID 27124502.

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