Recognizing Opioid Withdrawal

In many patients, you will able to identify opioid withdrawal by observing the patient and through physical exam.

Look for the following signs and symptoms of withdrawal:

  • drug craving
  • anxiety
  • drug-seeking behavior
  • yawning
  • sweating
  • lacrimation
  • rhinorrhea
  • mydriasis
  • gooseflesh
  • muscle twitching
  • anorexia
  • insomnia
  • increased pulse, respiratory rate, and blood pressure
  • abdominal cramps
  • vomiting
  • diarrhea
  • weakness

You may wish to use the Clinical Opioid Withdrawal Scale (COWS), or one of the other opioid withdrawal scales listed below, to assess a patient's level of withdrawal. Many clinicians use this assessment tool with patients during the first stages of buprenorphine induction.

Buprenorphine Withdrawal

Buprenorphine's high affinity and low dissociation contribute to its long therapeutic half-life and relatively mild withdrawal syndrome.

Related Resources: 

DSM-5 Criteria for Opioid Withdrawal

Description: 
Lists DSM-5 Criteria for Opioid Withdrawal

Opioid withdrawal occurs in opioid-dependent individuals who reduce or stop their opioid use or who take an opioid antagonist (precipitated withdrawal). Because of its high affinity but low activity at opioid receptors, buprenorphine can act as an antagonist in some patients.

DSM-5 Criteria for Opioid Withdrawal


A. Either of the following:

  • cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)
  • administration of an opioid antagonist after a period of opioid use


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

  • dysphoric moods
  • nausea or vomiting
  • muscle aches
  • lacrimation or rhinorrhea
  • pupillary dilation, piloerection, or sweating
  • diarrhea
  • yawning
  • fever
  • insomnia

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

D. The signs or symptoms are not due to another medical condition and are not better accounted for by another mental disorder, including intoxication or withdrawal from another substance.

The ICD-10-CM code with moderate of severe opioid use disorder is F11.23. (Do not use withdrawal code with mild opioid use disorder.) The ICD-9 CM code was 292.0.

(Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. Copyright © 2000 American Psychiatric Association.). Updated to: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Description: 
This PDF Document contains the Clinical Opioid Withdrawal Scale (COWS), a common instrument used to assess a patient's opioid withdrawal severity.
Source: 
California Society of Addiction Medicine (CSAM)
field_vote: 
Patient Handouts: 
Description: 
The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater.
Source: 
Reprinted from Handelsman, L., Cochrane, K. J., Aronson, M. J., et al. (1987) Two new rating scales for opiate withdrawal. American Journal of Drug and Alcohol Abuse, 13 (3), 293–308. By courtesy of Marcel Dekker, Inc.
field_vote: 
Patient Handouts: 
Tags: 
Description: 
The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely).
Source: 
Reprinted from Handelsman et al. 1987, p. 296, by courtesy of Marcel Dekker, Inc.
field_vote: 
Patient Handouts: 
Tags: