4.7. Dependence and withdrawal
Prolonged use of opioids can cause psychological and physical dependence1. Opioids are abused2 for their euphoriant effect. However, concerns about dependence should not lead to withholding of an opioid for managing opioid-responsive pain. pain.
Dependent individuals have a strong urge to keep taking the opioid so as to prevent unpleasant withdrawal symptoms. Development of tolerance3 leads to a need for increasing doses.
Withdrawal symptoms begin within a few hours of abrupt discontinuation of an opioid and are usually at their worst within 36–72 hours, followed by gradual diminution of the effects. Withdrawal effects, some of which resemble ’flu-like symptoms, include:
nausea | vomiting | diarrhoea |
sweating | anxiety | agitation |
restlessness | yawning | insomnia |
dilated pupils | increased tear production | rhinorrhoea |
bone and muscle pain | abdominal cramps | gooseflesh |
Factors which increase risk
Chronic opioid use, especially when the opioid is no longer necessary to relieve pain can lead to dependence.
The risk of opioid addiction4 is raised in vulnerable individuals such as those with a history of substance abuse. History of anxiety and depression might also increase the risk of opioid dependence.
Opioid withdrawal effects, though very unpleasant, are not generally life-threatening, but they may have more serious consequences in debilitated or frail individuals.
Risk-reduction measures
In the management of acute pain, reduce the opioid dose as pain diminishes. If an opioid is no longer required to treat pain, withdraw it gradually.
Generally avoid a sustained-release opioid product for managing acute pain or for fluctuating pain intensity.
An opioid should not be continued if the pain does not respond to opioid treatment.
Treatment
The patient should be committed to the withdrawal programme.
For gradual opioid withdrawal, consider switching to a long-acting opioid such as buprenorphine or methadone. The doses of these drugs can be reduced gradually over several days or even weeks; opioid withdrawal symptoms in addicts can be protracted and take several months to gradually disappear.
Some withdrawal symptoms may be alleviated by specific pharmacological treatment.
Activity 5
Some formulations of buprenorphine are licensed as substitution treatment for opioid dependence5, including treatment of individuals who have not undergone opioid withdrawal. In what circumstances might buprenorphine itself induce withdrawal reactions?
- Dependence is a state that develops as a result of repeated use of a certain chemical substance (eg alcohol, benzodiazepine, opioid, or even medicines for reducing blood pressure). It represents the resetting of homeostasis because of the persisting presence of the chemical substance↩
- Any use of an illegal drug or use of a medicine for a non-therapeutic purpose (eg to alter state of consciousness or to seek a ‘high’)↩
- Tolerance follows repetitive exposure to a drug, leading to a reduction of the pharmacological effect of that drug↩
- Addiction is compulsive substance-seeking behaviour, sometimes also termed ‘substance abuse’; it can involve impaired control over drug use, craving, compulsive use, and continued use despite harm from the substance. Addiction, which can involve genetic, psychosocial and environmental factors, is quite distinct from physical and psychological dependence↩
- Dependence is a state that develops as a result of repeated use of a certain chemical substance (eg alcohol, benzodiazepine, opioid, or even medicines for reducing blood pressure). It represents the resetting of homeostasis because of the persisting presence of the chemical substance↩