Key Takeaways
- Opioid withdrawal usually lasts at least a week, reaches its peak around the third day, and becomes tolerable after a week or two, though cravings can continue for months or even years.
- Some people have a prolonged form, post acute withdrawal syndrome, or PAWS, in which symptoms come and go for months, and those symptoms do become less intense and less frequent with time.
- Unlike alcohol withdrawal, opioid withdrawal is usually not life-threatening, yet few people get through it alone without taking opioids again just to stop feeling sick.
- Street fentanyl can delay the start of withdrawal by days and make it last longer than withdrawal from other opioids.
- Medication can make the symptoms more tolerable, but it does not shorten the withdrawal timeline.
- Buprenorphine (Suboxone) and methadone relieve withdrawal because they are opioids themselves, so a person who later stops either of them will have a withdrawal of their own.
- A person who has become physically dependent on prescribed opioids for pain is not necessarily addicted, and medical treatment of the physical withdrawal syndrome can help in that situation too.
- Whether or not you choose ongoing treatment with buprenorphine or methadone, the decision is yours, and a doctor can still prescribe medication to ease withdrawal and talk you through it.
Why do opioid withdrawal symptoms make opioid detox so difficult?
Opioid withdrawal is difficult because the symptoms are intense and do not even peak until about the third day: chills, cramps, crawling skin, sweating, nausea, vomiting, anxiety, and depression, along with a powerful craving for the drug. While it is usually not life-threatening, most people who try to get through it alone end up taking opioids again just to stop feeling sick.
When a person who is addicted to opioids is told that they must quit taking opiate or opioid drugs, their first thought is often about the physical sickness of opioid withdrawal. In fact, many people continue taking opioids, not to get high, but to feel normal without getting too sick from withdrawal.
In the beginning, opioid use helps to stop the pain of living with past traumas. Opioids are effective at treating physical pain, but people who take them discover that they are also effective at covering up emotional pain. Unfortunately, opioids are very addicting for some people, so continued use leads to addiction and physical dependence.
Opioid withdrawal symptoms last for a long time. Even when the symptoms subside after a few days, for the lucky people who do not have prolonged or protracted opioid withdrawal, those few days are very difficult.
A person who is admitted to a residential opioid addiction treatment program will benefit from medical and social support while experiencing opiate withdrawal symptoms. For a person quitting opioids at home, without support or medication assisted treatment, it is often very difficult to get through the opioid withdrawal process.
People who drink coffee regularly are often familiar with physical withdrawal from a drug, even if they have never used legal, illegal or prescription drugs. Caffeine, the drug found in regular coffee, creates a physical dependence. The coffee drinker who stops drinking coffee cold turkey may experience physical caffeine withdrawal syndrome.
Caffeine withdrawal lasts about a day for most people. It is characterized by fatigue and headaches. The headaches are persistent and hard to overcome, until the withdrawal symptoms wear off by the next day, or until the person gives in, and has another cup of coffee.
A coffee drinker finds it challenging to get through even one day without a cup of coffee, for fear of suffering from a caffeine headache. Imagine an intense drug withdrawal, many times more unpleasant than caffeine withdrawal, that does not even peak in intensity until the third day.
Opioid withdrawal typically lasts at least a week, with the worst symptoms, and the greatest intensity of symptoms, appearing around 72 hours. At that time, there are chills, cramps, crawling skin, involuntary limb movements, anxiety, depression, sweating, nausea, vomiting, upset stomach, and much more.
Add to the withdrawal symptoms a powerful craving for opioids, and you can see why many people do not make it through opioid withdrawal without relapsing. The person who makes it to day three, withdrawing from opioids on their own without support, will very likely give in, and take more opioids, just to stop feeling sick.
Unlike alcohol withdrawal, opioid withdrawal is typically not life-threatening. However, going through an opiate detox without medical treatment or support is not easy for anyone.
How long is the opiate withdrawal timeline for most people?
For many people, the opioid withdrawal nightmare will begin to subside after about a week or two. The worst of the symptoms become tolerable, as the person who has quit opioids enters a phase where withdrawal symptoms wax and wane.
Unfortunately, if a person detoxes from opioids and gets to the stage where they are past physical opiate withdrawal symptoms, they may still have opioid cravings for months, or even years, to come. Returning to active opioid addiction is a risk as long as cravings persist.
Cravings for a person with opioid use disorder can be very subtle. Sometimes a craving can be a simple thought, such as what will you do if you have to go to the dentist or get surgery. Won’t it be fine to take a prescription opioid if it is necessary, after a medical procedure?
Unfortunately, relapse is a part of addiction. Relapse, meaning going back to self-harming drug use, occurs for many people who have recovered from opioid addiction.
In order to make relapse less likely, it helps to have a support system of people who understand and are willing to listen when times are tough. Opioid addiction is not easy to overcome. Some people find that support in a recovery group, and that choice is theirs. Meetings are not medical treatment, and they are not required.
Therapy, counseling, and coaching can be helpful as well. A person in recovery can learn to identify and avoid dangerous triggers that may lead back to active addiction.
In some cases, the physical withdrawal symptoms may last for an extended period, which is known as post acute withdrawal syndrome, or PAWS. Where you might typically expect symptoms to mostly subside after a week or two, with PAWS, the withdrawal symptoms may persist for months, or even beyond a year.
Even with PAWS, there is hope to get beyond the uncomfortable symptoms and get back to feeling normal again. Symptoms do improve over time, becoming less intense, and less frequent.
Focusing on physical activity, creative endeavors, mindfulness, and meditation can make PAWS more tolerable. Of course, returning to opioid use can be a major setback for people who may be predisposed to PAWS.
How long does fentanyl opioid withdrawal last?
Pharmaceutical fentanyl, which is found in the Duragesic Patch, the Actiq lollipop for cancer pain, and IV vials for surgery, is a short-acting opioid. The drug wears off fairly quickly, and the withdrawal from fentanyl will last a similar amount of time to any other opioid withdrawal, depending on the person and the amount and time period of fentanyl use.
Fentanyl bought on the streets, as heroin, or in fake pills, is not the pharmaceutical product, and it often behaves differently from the FDA approved fentanyl used in surgery and prescription drugs.
Any heroin addiction treatment program must be aware that much of the heroin on the streets contains fentanyl. In fact, much of the street heroin is pure fentanyl, and contains no actual heroin.
Street fentanyl often stays in the body for much longer than would be expected. Why it lingers is not well understood.
Typically, with “real” fentanyl, we expect the drug to wear off and withdrawal to start within less than 24 hours. With street fentanyl analogs, withdrawal may not start for days, and it may last longer than expected.
Because street fentanyl lingers, it is more difficult to quit than other, more traditional opioids. People who use street opioids tend to find quitting difficult because fentanyl has infiltrated all forms of them, from heroin to fake pressed oxycodone pills.
Methadone maintenance is one treatment option for street fentanyl addiction. The advantage of methadone is that it can be started immediately, on the same day that the person has taken their final dose of street fentanyl.
For people using street fentanyl, starting Suboxone, ZubSolv, or another buprenorphine-based medication is more problematic, because if these drugs are started while the patient still has significant fentanyl levels in their system, they will experience precipitated withdrawal, which is unpleasant and traumatic. Naltrexone, another medication-assisted treatment drug, has the same problem, in that it can cause precipitated withdrawal if taken too soon.
Because street fentanyl lingers and is so potent, starting buprenorphine after fentanyl takes more care than it once did. When fentanyl is involved, Dr. Leeds starts with a low-dose induction when it is needed, so that the first doses do not set off precipitated withdrawal.
A methadone program is the other route, and the choice between the two is made with the patient.
Can opioid withdrawal treatment drugs shorten the opioid withdrawal course?
Currently, there is only one drug on the market that is approved to treat opioid withdrawal symptoms. This drug is named Lucemyra, or lofexidine.
Technically, there are two other drugs to treat opiate withdrawal, which are buprenorphine (Suboxone), and methadone. While these drugs will help to get rid of withdrawal symptoms, they are both opioids, so the patient will eventually have withdrawal symptoms when they stop using either of them.
Lucemyra was originally studied as a blood pressure medication. It is chemically related to clonidine, an older blood pressure medication.
Clonidine is known as an alpha agonist, and lowers blood pressure due to its effects in the brain. It is not a very popular blood pressure drug due to side effects.
Yet, it is often used off-label for opioid withdrawal symptoms. As an alpha agonist, it reduces excitation of the sympathetic nervous system, which is the reason it is used for opioid withdrawal.
However, the main problem with clonidine is that it lowers blood pressure, so it is of limited usefulness. Patients can only take it several times daily, and they must be careful of the risk of their blood pressure dropping too much.
While Lucemyra failed as a blood pressure medication, because it did not lower blood pressure much at all, it went on to be approved for easing opioid withdrawal symptoms. It works similarly to clonidine, and its own label still warns of low blood pressure, slow heart rate, and fainting, so the dose is reduced or held when blood pressure or pulse drop too far.
Unfortunately, Lucemyra will not relieve all opioid withdrawal symptoms. However, it can make the symptoms more tolerable by reducing their severity.
While Lucemyra will make opioid detox more tolerable, it will not necessarily shorten the course of withdrawal. The opioid withdrawal timeline remains about the same, whether the patient takes Lucemyra or not.
Does Suboxone withdrawal last longer than other opioid withdrawals?
One major concern about taking Suboxone is that when a person decides to taper off of Suboxone, they will experience opioid withdrawal symptoms. Common symptoms may include anxiety, depression, upset stomach, muscle cramps, chills, and restless leg syndrome or similar movement disorders. Suboxone is, after all, a type of opioid drug, so withdrawal symptoms often occur as the dosage is lowered.
The last dose of Suboxone should be as low as possible, well below even 0.5 mg, and your prescriber can arrange doses small enough to reach that point. The experience of Suboxone withdrawal will vary from one person to another.
Some people describe feeling back to normal within a week or two of quitting Suboxone, and others describe withdrawal symptoms for months after stopping Suboxone or ZubSolv. In Dr. Leeds’ experience, many patients finish a buprenorphine taper without major difficulty. Sometimes, patients complain during this process that they wish they had never started buprenorphine treatment in the first place.
Of course, hearing a person complaining that they regret starting Suboxone therapy is concerning to both doctors who prescribe Suboxone, and patients who are considering starting Suboxone therapy. Is it worth starting Suboxone, if it will be difficult to quit it in the future?
It is important for doctors to keep this issue in mind when discussing Suboxone therapy with patients. It is important to provide informed consent, explaining to the patient the risks, benefits and alternatives, relating to buprenorphine treatment.
While some people have a prolonged withdrawal after stopping Suboxone, doctors and patients must also consider the life-saving benefits of Suboxone. Medication-assisted treatment with Suboxone is the gold standard for opioid dependence.
So, if a patient is currently misusing pain pills or using street opioids, putting them at high risk of deadly overdose, and they are at risk of losing their children, marriage, job, money, or their health, Suboxone can reduce risk and allow the person to return to normal functioning.
For a patient who is misusing opioids, but is still working effectively, they may be able to continue work, supporting their lifestyle and their family, with minimal interruption, by starting Suboxone therapy. There are many benefits of buprenorphine treatment, in spite of the withdrawal that can follow tapering and quitting.
Additionally, patients who have chronic pain issues may benefit from the pain relieving attribute of Suboxone. As a partial agonist of the opioid receptors, buprenorphine is often an effect analgesic, which can help to reduce the severity of chronic pain.
How can an addiction treatment doctor help with opioid withdrawal?
For a patient quitting opioids, whether it is a patient completing pain management, or a patient quitting street opioids, or prescription opioid misuse with an opioid medication, there are medical detox treatment plans which an experienced doctor can provide. Even for the patient in pain management, who has become physically dependent on opioids, but not necessarily addicted, medical treatment of the physical opioid withdrawal syndrome can help.
While Lucemyra is the only FDA approved medication for treating opioid withdrawal symptoms, there are other medications that doctors may prescribe off-label to improve opioid withdrawal symptoms. Which ones, if any, are used is a patient-specific decision made with the prescribing doctor.
Patients considering quitting opioids should see a doctor for help in addressing opioid withdrawal symptoms. By getting treatment for opioid withdrawal, they will have a better chance at being successful in quitting opioids and staying opioid-free for the long term.
If a patient chooses to not go forward with methadone maintenance or Suboxone treatment, it is their choice. While their doctor may strongly recommend one of these highly effective therapies, the decision is ultimately in the patient’s hands.
For a person who chooses not to go forward with medication-assisted treatment, and simply quit opioids, cold turkey, they may still ask their doctor for prescription medication to make opioid withdrawal more tolerable. Their doctor may also provide support by talking them through the withdrawal process, giving them hope for the future, knowing that, as uncomfortable as withdrawal can be, it will eventually subside, as the patient’s brain and body goes through a progressive healing process.
Frequently asked questions
Is opioid withdrawal dangerous?
Unlike alcohol withdrawal, opioid withdrawal is usually not life-threatening. However, it is unpleasant enough that few people get through it on their own, and the common outcome of trying is giving in and taking more opioids just to stop feeling sick. If anything during withdrawal feels unsafe, call 911 or go to the emergency room.
When is opioid withdrawal at its worst?
The symptoms build over the first days and reach their peak around 72 hours after the last dose, with chills, cramps, crawling skin, involuntary limb movements, sweating, nausea, vomiting, anxiety, and depression. Fortunately, after about a week or two, the worst of it becomes tolerable, and the symptoms then wax and wane.
Street fentanyl is the exception. Because it lingers in the body, withdrawal may not start for days, and it may last longer than expected.
Can any medication shorten opioid withdrawal?
Not really. A doctor can prescribe medication that reduces the severity of the symptoms and makes withdrawal more tolerable, but the timeline stays about the same with or without it.
Buprenorphine (Suboxone) and methadone relieve withdrawal because they are opioids themselves. They are a treatment in their own right rather than a shortcut through withdrawal, and a person who later stops either of them will go through withdrawal from that medication too, which is why it is tapered.
Is Suboxone withdrawal worse than heroin withdrawal?
Some people say so. In Dr. Leeds’ view it is more myth than fact, the word on the street rather than a reliable description, and there is no need to scare people who would benefit from the medication. In his experience, multiple patients have tapered and completed buprenorphine treatment without it being a major issue.
Still, the experience does vary from one person to another, and the last dose before stopping should be as low as possible to keep the withdrawal mild.
How long do cravings last after opioid withdrawal?
Cravings can continue for months, or even years, after the physical symptoms have passed, and they can be subtle. Sometimes a craving is nothing more than a passing thought, such as wondering whether it would be fine to accept an opioid prescription after dental work or surgery.
A return to opioid use is a risk for as long as cravings persist, which is why it helps to have people around who understand and are willing to listen when times are tough.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
