Summary
Definition
History and exam
Key diagnostic factors
- maladaptive pattern of opioid use
- high Addiction Severity Index (ASI) score
- blunting of pleasurable opioid effects
- miosis
- dilated pupils
- shallow/slow respirations or apnea
- 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
- diarrhea
- backache/muscle spasms
- hot and cold flashes
- hypotension
- sedation
- confusion
- slurred speech
- aggressive behavior
- excess perspiration or lacrimation
- rhinorrhea
- restlessness
- piloerection
- tachypnea
- hypertension
- arrhythmias
- seizures
Risk factors
- young age
- history of a mental health disorder
- history of substance use
- long-term opioid therapy
- childhood trauma
- family history of substance use
Diagnostic tests
1st tests to order
- urine or saliva drug screen
- gas chromatography-mass spectroscopy (GC-MS)
- serum electrolytes
- CBC
- BUN/creatinine
- LFTs
- hepatitis serology
- HIV serology
- purified protein derivative (PPD) skin test
Tests to consider
- rapid plasma reagin
- blood cultures
- beta human chorionic gonadotropin (beta-hCG)
Treatment algorithm
nonpregnant adults in inpatient/outpatient detoxification program
nonpregnant adolescents in inpatient/outpatient detoxification program
pregnant women in inpatient/outpatient detoxification program
nonpregnant adults after detoxification program
nonpregnant adolescents after detoxification program
pregnant women after detoxification program
Contributors
Authors
Ashwin A. Patkar, MD, MRCPsych
Associate Professor
Medical Director
Duke Addictions Program
Department of Psychiatry and Behavioral Sciences
Duke University Medical Center
Durham
NC
Disclosures
AAP has received payments for being Consultant to Radeas Labs that performs drug testing and is a member of the Speakers Bureau for Janssen Pharmaceuticals, manufacturer of Spravato, and Otsuka Pharmaceuticals, manufacturer of Rexulti. AP is a stockholder in Generys Biopharmaceuticals that has compounds in development for drug addiction.
Jonathan C. Lee, MD
Medical Director
The Farley Center at Williamsburg Place
Williamsburg
Community Assistant Professor
Department of Family Medicine
Eastern Virginia Medical School
Norfolk
Assistant Clinical Professor
Department of Psychiatry
Virginia Commonwealth University
Richmond
VA
Affiliate Assistant Professor
Department of Psychiatric Medicine
East Carolina University
Greenville
NC
Disclosures
JCL declares that he has no competing interests.
Douglas M. Burgess, MD
Assistant Professor
Department of Psychiatry
University of Missouri - Kansas City
Medical Director
Outpatient Behavioral Health
Truman Medical Centers
Kansas City
MO
Disclosures
DMB declares that he has no competing interests.
Acknowledgements
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 topic.
Disclosures
KB declares that he has received grant support from National Institutes of Health, Lundbeck, Pfizer, and Titan Pharmaceuticals. SM declares that she has received grant support from Pfizer, Titan Pharmaceuticals, Shire, and the Forest Research Institute.
Peer reviewers
Christos Kouimtsidis, MBBS, MSc, MRCPsych, PhD
Consultant Psychiatrist and Honorary Senior Lecturer
Institute of Psychiatry
King's College London
London
UK
Disclosures
CK declares that he has no competing interests.
George E. Woody, MD
Emeritus Professor
Department of Psychiatry
Perelman School of Medicine
University of Pennsylvania
Philadelphia
PA
Disclosures
GEW declares that he has no competing interests. GEW is an author of a number of references cited in this topic.
References
Key articles
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed, text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.
World Health Organization. International statistical classification of diseases and health related problems (ICD). 11th revision. Jan 2022 [Internet publication].Full text
Substance Abuse and Mental Health Services Administration. Federal guidelines for opioid treatment programs. Mar 2015 [internet publication].Full text
National Institute for Health and Care Excellence. Drug misuse in over 16s: opioid detoxification. Jul 2007 (reaffirmed 2019) [internet publication].Full text
Gowing L, Ali R, White JM, et al. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017 Feb 21;2(2):CD002025.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Alcohol intoxication
- Sedative intoxication
- Anticholinergic intoxication
More DifferentialsGuidelines
- Diagnostic and statistical manual of mental disorders, 5th edition, text revision
- Screening and intervention for mental health disorders and substance use and misuse in the acute trauma patient
More GuidelinesPatient information
Opioid-use disorder
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