DSM-III

For more information, see Withdrawal

Diagnostic Criteria

A. Prolonged, heavy use of an opioid (or administration of a narcotic antagonist following a briefer period of use).

B. At least four of the following symptoms due to the recent cessation of or reduction in opioid use:

  1. lacrimation
  2. rhinorrhea
  3. pupillary dilation
  4. piloerection
  5. sweating
  6. diarrhea
  7. yawning
  8. mild hypertension
  9. tachycardia
  10. fever
  11. insomnia

Differential Diagnosis

Influenza

Influenza is remarkably similar in its clinical picture to Opioid Withdrawal.

Other substances

Other substance withdrawals and mixed withdrawals, especially Barbiturate or Similarly Acting Sedative or Hypnotic Withdrawal, can be differentiated from Opioid Withdrawal by testing of blood and urine and by taking a careful history, bearing in mind that individuals giving such a history are often unreliable. Third-party confirmation is extremely valuable.

DSM-IV

For more information, see Substance Withdrawal

The essential feature of Opioid Withdrawal is the presence of a characteristic withdrawal syndrome that develops after the cessation of (or reduction in) opioid use that has been heavy and prolonged (Criterion A1). The withdrawal syndrome can be also precipitated by administration of an opioid antagonist (e.g., naloxone or naltrexone) after a period of opioid use (Criterion A2). Opioid Withdrawal is characterized by a pattern of signs of symptoms that are opposite to the acute agonist effects. The first of these are subjective and consist of complaints of anxiety, restlessness, and an "achy feeling" that is often located in the back and legs, accompanied by a wish to obtain opioids ("craving") and drug-seeking behavior, along with irritability and increased sensitivity to pain. Three or more of the following must be present to make a diagnosis of Opioid Withdrawal: dysphoric mood; nausea or vomiting; muscle aches; lacrimation or rhinorrhea; pupillary dilation, piloerection, or increased sweating; diarrhea; yawning; fever; and insomnia (Criterion B). Piloerection and fever are associated with severe withdrawal and are not often seen in routine clinical practive because individuals with Opioid Dependence usually obtain substances before withdrawal becomes that far advanced. These symptoms of Opioid Withdrawal must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D).

In most individuals who are dependent on short-acting drugs such as heroin, withdrawal symptoms occur within 6-24 hours after the last dose. Symptoms may take 2-4 days to emerge in the case of longer-acting drugs such as methadone or LAAM (L-alphacetylmethadol). Acute withdrawal symptoms for a short-acting opioid such as heroin usually peak within 1-3 days and gradually subside over a period of 5-7 days. Less acute withdrawal symptoms can last for weeks to months. These more chronic symptoms include anxiety, dysphoria, anhedonia, insomnia, and drug craving.

Diagnostic Criteria

A. Either of the following:

  1. cessation of (or reduction in) opioid use that has been heavy and prolonged (several weeks or longer)
  2. 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:

  1. dysphoric mood
  2. nausea or vomiting
  3. muscle aches
  4. lacrimation or rhinorrhea
  5. pupillary dilation, piloerection, or sweating
  6. diarrhea
  7. yawning
  8. fever
  9. insomnia

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

D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

DSM-5

Diagnostic Criteria

A. Presence of either of the following:

  1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e., several weeks or longer).
  2. 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:

  1. Dysphoric mood.
  2. Nausea or vomiting.
  3. Muscle aches.
  4. Lacrimation or rhinorrhea.
  5. Pupillary dilation, piloerection, or sweating.
  6. Diarrhea.
  7. Yawning.
  8. Fever.
  9. Insomnia.

C. The signs or 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 attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Note: Opioid withdrawal can only occur in the presence of a moderate or severe opioid use disorder. It is not permissible to record a comorbid mild opioid use disorder with opioid withdrawal.

Differential Diagnosis

Other withdrawal disorders

The anxiety and restlessness associated with opioid withdrawal resemble symptoms seen in sedative-hypnotic withdrawal. However, opioid withdrawal is also accompanied by rhinorrhea, lacrimation, and pupillary dilation, which are not seen in sedative-type withdrawal.

Other substance intoxication

Dilated pupils are also seen in hallucinogen intoxication and stimulant intoxication. However, other signs or symptoms of opioid withdrawal, such as nausea, vomiting, diarrhea, abdominal cramps, rhinorrhea, and lacrimation, are not present.

Other opioid-induced disorders

Opioid withdrawal is distinguished from the other opioid-induced disorders (e.g., opioid-induced depressive disorder, with onset during withdrawal) because the symptoms in these latter disorders are in excess of those usually associated with opioid withdrawal and meet full criteria for the relevant disorder.

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