Opioid withdrawal

Essential (Required) Features:

• The presence of a clinically significant cluster of symptoms, behaviours, and/or physiological features that occurs upon cessation or reduction in the use of opioids in individuals who have developed dependence on opioids or have used opioids for a prolonged period or in large amounts. Note: Opioid Withdrawal can occur when prescribed opioids (e.g., oxycodone, morphine) have been used in standard therapeutic doses.
• Presenting features of Opioid Withdrawal may include depressed or dysphoric mood, craving for an opioid, anxiety, nausea or vomiting, abdominal cramps, muscle aches, yawning, perspiration, hot and cold flashes, hypersomnia (typically in the initial phase) or insomnia, diarrhoea, piloerection, and pupillary dilation.
• The severity and time course of Opioid Withdrawal is influenced by many factors that include the type of opioid taken, its half-life and duration of action, the amount, frequency and duration of opioid use before cessation or reduction of use, prior experience of opioid withdrawal, and expectations of the severity of the syndrome.
• The symptoms are not better accounted for by another medical condition or another mental disorder.

Additional Clinical Features:

• Opioid Withdrawal from short-acting opioids such as injected heroin or morphine typically begins within 4 to 12 hours of cessation of use and lasts for 4 to 10 days.
• Opioid Withdrawal from longer-acting opioids such as codeine and oxycodone and similar pharmaceutical agents may not be evident for 2 to 4 days and may last for 1 to 2 weeks.
• The withdrawal state from long-acting drugs such as methadone may persist for up to 2 months after cessation of use.
• Opioid Withdrawal occurs in phases. The early phase typically includes lacrimation, rhinorrhoea and yawning. This is followed by hot and cold flashes, muscle aching and abdominal cramps, nausea and vomiting and diarrhoea; piloerection and pupillary dilatation may also occur. The later phase is dominated by craving for opioids.
• Recurrence or worsening of pain may occur if the opioid was used to manage chronic pain.
• Serious medical complications of Opioid Withdrawal are rare. Fluid depletion may occasionally lead to renal impairment. Death during Opioid Withdrawal is very uncommon.
• Characteristic features of Opioid Withdrawal are opposite to the acute pharmacological effects of opioids.
• Opioid Withdrawal symptoms become more severe with repeated episodes of withdrawal (termed ‘kindling’), with aging, or in the presence of comorbid medical conditions.

Boundary with Normality (Threshold):

• Opioid Withdrawal should only be diagnosed when symptoms are consistent with those recognized as occurring upon cessation or reduction in use of opioids. Recent cessation or reduction of use and the presence of various non-specific transient symptoms is not sufficient to make the diagnosis of Opioid Withdrawal.
• Withdrawal symptoms should be differentiated from the transient physiological aftereffects of intoxication (‘hangover effect’).
• Some individuals who have previously had Opioid Dependence may experience symptoms similar to those of Opioid Withdrawal months after the last use of the substance, particularly when the individual encounters stimuli (e.g., drug paraphernalia) and contexts (e.g., location where use was frequent) previously associated with past opioid use. These symptoms are more transient than those observed during Opioid Withdrawal and occur exclusively when in contact with associated stimuli and contexts. A diagnosis of Opioid Withdrawal should not be assigned under these circumstances.

Course Features:

• Opioid Withdrawal is time-limited. Factors that influence the features and time course of Opioid Withdrawal include: (1) the severity of Opioid Dependence, if present, (2) the dose, frequency of use, and duration of opioid use prior to cessation or reduction of that use, (3) the half-life and duration of action of opioids, and (4) the presence of comorbid medical conditions (e.g., metabolic disturbances).

Culture-Related Features:

• Symptoms of withdrawal depend largely on the psychotropic characteristics of opioids. However, specific cultures may emphasize certain symptoms of withdrawal over others, making it more difficult to conduct a differential diagnosis. In addition, vernacular terms for withdrawal vary greatly.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Opioid Dependence: Many individuals with Opioid Dependence develop Opioid Withdrawal upon cessation or reduction in the amount of the substance. In such cases, both Opioid Dependence and Opioid Withdrawal should be diagnosed. However, Opioid Withdrawal can be diagnosed in the absence of a diagnosis of Opioid Dependence, for example in response to cessation of medically appropriate treatment with opioid analgesics (e.g., oxycodone, morphine), when the other Essential Features of Substance Dependence are not present.
• Boundary with Opioid Intoxication: The onset of Opioid Intoxication occurs immediately or shortly after the consumption of opioids. In contrast, Opioid Withdrawal occurs upon cessation or reduction in the amount of opioids in the context of Opioid Dependence or when opioids have been taken for a prolonged period or in large amounts. For opioids, the intoxication and withdrawal syndromes are typically distinct.
• Boundary with Opioid-Induced Delirium: Delirium is characterized by disturbances in attention, orientation, and awareness that develop within a short period of time with symptoms that are transient and may fluctuate depending on the underlying etiology. Delirium often includes disturbance of behaviour and emotion, and may include impairment in multiple cognitive domains. Disturbance of the sleep-wake cycle may also be present. Delirium may occur as an aspect of Opioid Withdrawal, particularly during later stages of withdrawal. In such cases, diagnoses of both Substance Withdrawal and Opioid-Induced Delirium should be assigned.
• Boundary with other Opioid-Induced Mental Disorders: Mental or behavioural symptoms that arise during Opioid Withdrawal should only be used as a basis for diagnosing an Opioid-Induced Mental Disorder if the intensity or duration of the symptoms is substantially in excess of those that are characteristic of the Opioid Withdrawal and the symptoms are sufficiently severe to warrant specific clinical attention. In such cases, if the withdrawal syndrome is ongoing, diagnoses of both Opioid Withdrawal and an Opioid-Induced Mental Disorder may be assigned.
• Boundary with other mental disorders: Various symptoms associated with Opioid Withdrawal overlap with those that are characteristic of other mental disorders (e.g., depressive and anxiety symptoms). Symptoms of Opioid Withdrawal occur in specific temporal relationship to the cessation of use of opioids and diminish with the passage of time. Evidence supporting a mental disorder diagnosis would include the symptoms preceding the onset of opioid use, the symptoms persisting for a substantial period of time after cessation of opioids or withdrawal (e.g., 1 month or more, depending on the substance), or other evidence of a pre-existing mental disorder (e.g., a history of prior episodes not associated with opioid use).
• Boundary with other medical conditions: It may be difficult to distinguish between various symptoms associated with Opioid Withdrawal (e.g., nausea or vomiting, abdominal cramps, diarrhea, pupillary dilation, sleep disruption) and those that are characteristic of other medical conditions. Symptoms of Opioid Withdrawal occur in specific temporal relationship to the cessation of use of opioids and diminish with the passage of time.
• Boundary with Foetus or Newborn Affected by Maternal Use of Tobacco, Alcohol, or Other Drugs of Addiction: The ICD-11 chapter on Certain Conditions Arising During the Perinatal Period contains categories for ‘Foetus or newborn affected by maternal use of tobacco, alcohol, and other drugs.’ A neonate exhibiting signs of Opioid Withdrawal may also be Opioid Withdrawal diagnosis in order to guide treatment together with appropriate diagnosis from the chapter on Certain Conditions Originating in the Perinatal Period.