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Opiate Withdrawal Timeline

Medically Reviewed By: Benjamin Caleb Williams RN, BA, CEN

Written By: Phillippe Greenough

Article Updated: 01/24/2021

Number of References: 25 Sources

Opiates have become massively popular in America over the last two decades, and with that popularity comes the subsequent awareness of the horror of opiate withdrawal. This can be so painful as to be the main motivator for many opiate addicts to keep using their opiate of choice. The symptoms of opiate withdrawal can include insomnia, anxiety, depression, diarrhea, and pain in the muscles, joints, and bones. Depending on the particular opiate, these symptoms may last around a week. Here we will look at some specific opiates, the causes and symptoms of opiate withdrawal, the timeline involved, and the physical and mental effects which arise from withdrawal.

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There are many different types of opiates used today and while they are used for the same purpose, all of them have unique characteristics. There are 3 major classes of opiates which encompasses every opiate drug:

  • Natural Opiates: Like morphine, thebaine, and codeine.
  • Semi-Synthetic Opiates: Such as heroin, oxycodone, hydrocodone, and oxymorphone.
  • Fully Synthetic Opiates: Including methadone, buprenorphine, meperidine, and fentanyl (including fentanyl analogs).

Also referred to these days as opioids, all of these drugs produce very similar effects through very similar mechanisms of action. They all work on the opioid system of the brain through opioid receptors. Some opiate drugs have a greater affinity for certain types of receptors, and this, along with the specifics of their metabolism in the body produces the difference in the effects of these drugs.

Some of the most commonly used and abused opiates drugs include:

Opiate Withdrawal Symptoms

The acute phase is the first phase of opiate withdrawal, and while not very long-lasting, it may be extremely uncomfortable or even painful. This may result in withdrawal symptoms appearing within 4 to 8 hours of the last opiate use and persisting for around a week. This depends on the specific opiates used of course. There is some variability between people as to how long opiate withdrawal will last, but the early stages are identical for the most part. Within hours of the last opiate use, symptoms will appear and begin to escalate. Physical symptoms will appear first and then psychological symptoms will join them, resulting in a truly miserable experience.

A general overview of the timeline of opiate withdrawal may look something like this:

Week 1

Within 8 to 24 hours of the last time someone used opiates, physical symptoms will begin to appear. Sweating and chills are commonly the first to emerge, joined shortly after by anxiety and a deepening depression. Shaking may begin shortly afterward, and then an aching in the muscles or joints. On the second day of withdrawal, diarrhea and muscle cramps should begin and insomnia will be increasingly prominent as yawning, tossing, and turning becomes frequent. Anxiety and depression will have been escalating all the while and will continue to do so over the first week. The physical symptoms will usually peak around the 3rd or 4th day after withdrawal symptoms begin, and begin a gradual reduction from that point forward. Sweating, chills, diarrhea, and joint pain are commonly the last to resolve, typically persisting until 5 to 7 days after withdrawal initially began.

Some symptoms of opiate withdrawal that may be expected during the first week may include:

  • Intense Cravings for Opiates
  • Diaphoresis (excessive sweating)
  • Rhinorrhea (extremely runny nose)
  • Piloerection (goosebumps)
  • Repeated Yawning
  • Hot Flashes and Chills
  • Pain in the Muscles, Joints, and Bones
  • Allodynia (perception of pain from a normally not painful stimulus)
  • Insomnia
  • Lack of Appetite
  • Extreme Restlessness
  • Tremor and Shaking
  • Severe Anxiety and Irritability
  • Deep Depression
  • Stomach Cramps and Frequent Diarrhea
  • Tachycardia (rapid heart rate)
  • Hypertension (elevated blood pressure)
  • Dilated Pupils

These symptoms may reach their maximum within three or four days of their appearance, and acute withdrawal is commonly described as “agonizing” by opiate addicts. This is frequently one of the main reasons for users to continue opiate use; withdrawal avoidance. This phase may last around a week, give or take, depending on the person and their use habits and is an extremely unpleasant experience. Medications may help reduce the symptoms and give someone a better chance of making it through acute withdrawal. It is very highly recommended for someone to seek medical help if they are experiencing acute withdrawal.

Week 2

The beginning of the second week may show some significant improvement in the physical symptoms. If they are not totally resolved by this time, they are usually very close to total resolution by this time. The psychological symptoms of depression, anxiety, and insomnia will still be very much present as well as profound fatigue and lethargy, with someone feeling totally drained of energy and motivation. Appetite may begin to return to normal during the second week, and sleep may become a little easier, although it will still be a challenge. The yawning, while still present may begin to subside somewhat during this time as well.

  • Diaphoresis (excessive sweating)
  • Piloerection (goosebumps)
  • Repeated Yawning
  • Strong Cravings for Opiates
  • Minor Hot Flashes and Chills
  • Aches in the Muscles, Joints, and Bones
  • Allodynia (perception of pain from a normally not painful stimulus)
  • Mild Insomnia
  • Reduced Appetite
  • Restlessness
  • Anxiety and Irritability
  • Deep Depression
  • Diarrhea

These physical symptoms should improve throughout the course of the second week and are usually fully resolved by week’s end. The psychological symptoms, however, may persist throughout the week. As the physical symptoms resolve, the psychological symptoms may become more noticeable, since the physical symptoms are no longer able to distract someone.

Weeks 3 & 4

While insomnia and yawning may be much improved by this time, depression, anxiety, and extremely low energy levels will be the main features of the third and fourth weeks of opiate withdrawal. These may improve somewhat throughout the course of the third week, but should still be expected to be very fairly intense. Energy levels may improve more than the other symptoms, but someone will still be quite lethargic and fatigued. The fourth week of opiate withdrawal will show continued improvement in symptoms.

  • Repeated Yawning
  • Minor Insomnia
  • Restlessness
  • Cravings for Opiates
  • Anxiety and Irritability
  • Deep Depression
  • Minor Stomach Issues

These mood issues can be expected for some time, but they will gradually resolve over the course of the next few weeks or months. Medications and therapy have proven very effective at treating symptoms in the weeks after opiate use ceases, and these may greatly improve someone’s state of mind during this time.

Post-Acute Withdrawal Symptoms

The post-acute phase of withdrawal, while much less intense than acute withdrawal, can be extremely long-lasting. This phase differs greatly in duration between individuals but is commonly several months long. The symptoms are strictly psychological in nature, but that does not mean it is an easy phase to endure. The hopelessness, depression, and anxiety can severely impact someone’s daily life and cause them to withdraw into isolation.

Some of the most commonly reported symptoms of post-acute withdrawal include:

  • Depression
  • Fatigue and Lethargy
  • Anxiety (particularly social anxiety)
  • Insomnia
  • Cravings for Opiates

These symptoms will be most intense early on and will gradually subside over weeks or months. This phase is associated with a high risk of relapse, as depression and anxiety may seem unending and permanent. The memory of the “good times” provided by opiates may seem more attractive as the pain and misery of acute withdrawal become more distant over time. Medications and therapies have been very successful in treating symptoms of post-acute withdrawal and it is highly recommended for someone to seek help during this time.

More About Opiate Addiction

To get a better idea of the experience of opiate withdrawal, it will be helpful to know a little more about how opiates work. The main mechanism of opiate action is through the endogenous opioid system of the brain and body. “Endogenous” simply refers to the fact that these opioids are produced by the body and are in contrast to “exogenous” opioids which are introduced from outside the body. This is a network of opioid receptors that are present all throughout the body but found in particularly large numbers in the brain and gastrointestinal tract. Imbalances in the opioid system produced through opiate addiction is directly responsible for the symptoms of opiate withdrawal. While the body produces its own opioid peptides that interact and regulate this system, opiate drugs will stimulate this system to a much higher degree than our natural opioid peptides are capable of doing.

The main way that opiates interact with this system is through the μ (Mu), κ (Kappa), and δ (Delta) opioid receptors. The main euphoric and painkilling effects of opiates are mainly produced through interactions with the μ-opioid receptors. These are present in the brain where they help to regulate the perception of pain (analgesia), heart function, and mood. These receptors are also present in the gut in large numbers where they help to slow and synchronize intestinal muscle contractions. The κ and δ also contribute to opiate drug effects, with the κ receptors affecting analgesia and mood while the δ influence analgesia and intestinal function.

Through chronic opiate use, this natural opioid system undergoes changes that reduce the sensitivity of these receptors through a process known as downregulation. This is the brain and body’s attempt to maintain balance and efficient function while also protecting against neurotoxic overstimulation. This process is initially responsible for tolerance, as the reduction in receptor sensitivity means that more opiate drugs are needed to produce the same effects. If opiate use continues, physical dependence will be the result, with the body’s own opioid peptides being unable to stimulate this system to the degree necessary for healthy function. Opiate withdrawal is the result, and the longer someone uses opiates, the more uncomfortable this experience will be.

Opiate withdrawal can be separated into two distinct phases, the acute and post-acute phases. The acute phase is characterized by physical symptoms, while the post-acute is more of a mental struggle. While the symptoms differ between these two phases, the discomfort in acute withdrawal is a product of opioid receptor downregulation which results from chronic opiate use, and the subsequent cessation of opiates. The symptoms of post-acute withdrawal arise from structural changes the brain makes in response to prolonged downregulation, and these changes can take time to reverse.

The Importance of Detox

Opiate withdrawal is an extremely uncomfortable and sometimes painful process, and medical help is often recommended. In an average healthy person, there are minimal risks to their life, although if someone had underlying or preexisting medical conditions, they may be at increased risk of serious complications or even death. Likewise, if someone has had a drug or opiate problem and tried to quit on their own but failed, then an opiate detox center is highly recommended.

Opiate Detox Centers

Article References (In addition to 5 in-article references)

  1. 1 Neuropharmacology: Fentanyl, Fentanyl Analogs and Novel Synthetic Opioids - A Comprehensive Review
  2. 2 Premier Biotech: Fentanyl Analogs - Danger Defined
  3. 3 Stanford School of Medicine: Opioid Conversion Equivalency Table
  4. 4 Western Australia Department of Health: Opioid Conversion Guide
  5. 5 Psychopharmacology: Intravenous Oxycodone, Hydrocodone and Morphine in Recreational Opioid Users - Abuse Potential and Relative Potencies
  6. 6 American Academy of Pain Medicine: Clinical Pharmacology of Oxymorphone
  7. 7 Addiction Biology: Pharmacodynamic Effects of Oral Oxymorphone - Abuse Liability, Analgesic Profile, and Direct Physiological Effects in Humans
  8. 8 Palliative Drugs: Methadone Guidelines
  9. 9 World Health Organization: Tramadol - Update Review Report
  10. 10 Neuropsychopharmacology: Gamma-Hydroxybutyric Acid for Treatment of Opiate Withdrawal Syndrome
  11. 11 Patient Safety Network: Dependence vs Pain
  12. 12 American Society of Addiction Medicine: Clinical Opiate Withdrawal Scale (COWS)
  13. 13 StatPearls: Physiology - Opioid Receptor
  14. 14 Neuropsychopharmacology: Untangling the Complexity of Opioid Receptor Function
  15. 15 British Journal of Anaesthesia: Cardiac M-Opioid Receptor Contributes to Opioid Induced Cardioprotection in Chronic Heart Failure
  16. 16 Cardiovascular Research: Opioid Peptides and the Heart
  17. 17 World Health Organization: Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings
  18. 18 Frontiers in Psychiatry: Craving in Opioid Use Disorder - From Neurobiology to Clinical Practice
  19. 19 Alcohol and Alcoholism: GABAergic Mechanisms Of Opiate Reinforcement
  20. 20 The Journal of Neuroscience: Increased Opioid Inhibition of GABA Release in Nucleus Accumbens during Morphine Withdrawal

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