Last reviewed: 23 Dec 2021
Last updated: 06 Oct 2020



History and exam

Key diagnostic factors

  • presence of risk factors
  • maladaptive pattern of opioid use
  • high Addiction Severity Index (ASI) score
  • blunting of pleasurable opioid effects
  • miosis
  • dilated pupils
  • shallow/slow respirations or apnoea
  • needle marks, scars, or necrosis on skin near veins
  • unconsciousness
  • pulse <40 bpm

Other diagnostic factors

  • chronic constipation
  • weight loss
  • nausea/vomiting
  • sedation
  • restless sleep/insomnia
  • memory impairment
  • sneezing
  • yawning
  • abdominal cramps
  • diarrhoea
  • backache/muscle spasms
  • hot and cold flashes
  • hypotension
  • sedation
  • confusion
  • slurred speech
  • aggressive behaviour
  • excess perspiration or lacrimation
  • rhinorrhoea
  • restlessness
  • piloerection
  • tachypnoea
  • hypertension
  • arrhythmias
  • seizures

Risk factors

  • male sex
  • young age
  • history of mental illness
  • history of substance abuse
  • long-term opioid therapy
  • family history of substance abuse

Diagnostic investigations

1st investigations to order

  • urine drug screen
  • gas chromatography-mass spectroscopy (GC-MS)
  • serum electrolytes
  • FBC
  • urea/creatinine
  • LFTs
  • rapid plasma reagent
  • hepatitis serology
  • HIV serology
  • PPD skin test
  • blood cultures
  • beta-hCG

Treatment algorithm



Ashwin A. Patkar, MD, MRCPsych

Associate Professor

Medical Director

Duke Addictions Program

Department of Psychiatry and Behavioral Sciences

Duke University Medical Center




AAP is a consultant/member of the advisory board for Cubist Pharma, Biodelivery Sciences (BDSI), Kaleo, Forest Research Institute, and Titan Pharma; is on the speaker’s bureau and received honoraria from Otsuka, Alkermes, Sunovion, and BDSI; and is a shareholder in Ironwood Sciences LLC and Patkar Medical Consultants. AAP's institution has received grant support from National Institutes of Health (NIDA, NIAAA), SAMHSA, AstraZeneca, Bristol-Myers Squibb, Cephalon, Daiichi Sankyo, Envivo Pharma, Forest, J & J, Jazz Pharmaceuticals, Lundbeck, Merck, Organon, Pfizer, Sunovion, Shire, and Titan. AAP holds unpaid positions on the Board of Directors of Southlight Inc, the Board of Advisors of People's Medical Care, the Executive Committee of Triangle Indian American Physicians Society, and also as President of Indo American Psychiatric Association.

Jonathan C. Lee, MD

Medical Director

The Farley Center at Williamsburg Place



Affiliate Assistant Professor

Department of Psychiatric Medicine

East Carolina University



Community Assistant Professor

Department of Family Medicine

Eastern Virginia Medical School




JCL is a full-time employee at The Farley Center at Williamsburg Place.

Douglas M. Burgess, MD

Assistant Professor

Department of Psychiatry

University of Missouri - Kansas City

Medical Director

Outpatient Behavioral Health

Truman Medical Centers

Kansas City



DMB declares that he has no competing interests.


Dr Ashwin A. Patkar, Dr Jonathan C. Lee, and Dr Douglas M. Burgess would like to gratefully acknowledge Dr Kamal Bhatia and Dr Srilakshmi Musham, previous contributors to this monograph. KB declares that he has received grant support from National Institutes of Health, Lundbeck Pharmaceuticals, Pfizer, and Titan Pharmaceuticals. SM declares that she has received grant support from Pfizer, Titan Pharmaceuticals, Shire Pharmaceuticals, and the Forest Research Institute.

Peer reviewers

Andrew Stolbach, MD

Assistant Professor

Department of Emergency Medicine

Johns Hopkins University Hospital




AS declares that he has no competing interests.

F. Gerard Moeller, MD


Department of Psychiatry and Behavioral Sciences

University of Texas

Health Science Center




FGM declares that he has no competing interests.

Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD

Consultant Psychiatrist and Honorary Senior Lecturer

Institute of Psychiatry

King's College London




CK declares that he has no competing interests.

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