Opiate Use Disorder & The Detox Process
Written by: Benjamin Gift, CADC I
Reviewed by: Candice Watts, Clinical Director CADC II
Opiate use disorder (OUD) represents a significant public health challenge, affecting millions of Americans and causing substantial personal, social, and economic harm. Despite recent encouraging trends showing declines in overdose deaths, opioid misuse remains a leading cause of death for Americans aged 18-44. This article explores the diagnostic criteria for OUD, signs and symptoms of opiate abuse, the detoxification process, and available treatment options.
Neurobiology of Opioid Addiction
Opioids, including prescription painkillers (e.g., oxycodone), heroin, and synthetic opioids (e.g., fentanyl), exert their effects primarily through μ-opioid receptors (MORs) in the brain’s reward circuitry. The mesolimbic pathway-comprising the ventral tegmental area (VTA) and nucleus accumbens (NAc)-is central to addiction. Opioids inhibit GABAergic interneurons in the VTA, disinhibiting dopamine neurons and causing a surge of dopamine in the NAc, which reinforces drug-seeking behavior10. Chronic use disrupts glutamate and GABA balance, impairing prefrontal cortex (PFC) regulation of impulse control and decision-making10.
ΔFosB, a transcription factor, accumulates in the NAc with repeated opioid exposure, promoting long-term synaptic changes that sustain cravings and compulsive use10. These neuroadaptations explain why OUD often persists despite negative consequences and repeated quit attempts.
Understanding Opiate Use Disorder
Addiction is defined as "a chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long-lasting changes in the brain"2. It is considered both a complex brain disorder and a mental illness. Opiate use disorder specifically refers to problematic patterns of opioid use that lead to clinically significant impairment or distress.
According to the National Institute on Drug Abuse (NIDA), addiction is the most severe form of a full spectrum of substance use disorders and is a medical illness caused by repeated misuse of a substance or substances2. The financial impact is staggering-use of and addiction to alcohol, nicotine, and illicit drugs cost the nation more than $740 billion annually in healthcare, crime, and lost productivity2.
Diagnostic Criteria for OUD
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides specific criteria for diagnosing OUD. A diagnosis requires at least two of eleven criteria occurring within a 12-month period11719:
Opioids are often taken in larger amounts or over a longer period than intended
Persistent desire or unsuccessful efforts to cut down or control opioid use
A great deal of time spent obtaining, using, or recovering from opioids
Craving or strong desire to use opioids
Recurrent use resulting in failure to fulfill major role obligations (work, school, home)
Continued use despite persistent social or interpersonal problems
Important activities given up or reduced because of opioid use
Recurrent use in physically hazardous situations
Continued use despite knowledge of physical or psychological problems likely caused by opioids
Tolerance (need for increased amounts or diminished effect with same amount)
Withdrawal symptoms when opioid use is reduced or stopped
The severity of OUD is classified based on the number of criteria met18:
Mild: 2-3 criteria
Moderate: 4-5 criteria
Severe: 6 or more criteria
Commonly Abused Opiates
Heroin – An illegal, highly addictive street drug derived from morphine.
Morphine – A powerful prescription painkiller often used in hospitals.
Codeine – Found in some prescription cough syrups and pain medications.
Hydrocodone (e.g., Vicodin, Norco) – Commonly prescribed for moderate to severe pain.
Oxycodone (e.g., OxyContin, Percocet) – Frequently misused for its euphoric effects.
Fentanyl – A synthetic opioid 50–100 times more potent than morphine; often linked to overdose deaths.
Oxymorphone (e.g., Opana) – A potent painkiller with high potential for abuse.
Hydromorphone (e.g., Dilaudid) – Typically used for severe pain but highly addictive.
Methadone – Used in medication-assisted treatment but can be misused.
Buprenorphine (e.g., Subutex, Suboxone) – Used in treatment but sometimes diverted or misused.
Signs and Symptoms of Opiate Abuse
Recognizing the signs and symptoms of opiate abuse can help identify potential problems before they escalate to severe addiction.
Physical Signs
Physical indicators of opiate abuse may include5:
Small pupils
Decreased respiratory rate
Non-responsiveness or drowsiness
Loss or increase in appetite
Weight loss or weight gain
Intense flu-like symptoms (nausea, vomiting, sweating, shaky hands or feet)
Wearing long-sleeves or hiding arms (potentially to conceal injection sites)
Behavioral Signs
Behavioral changes can also signal opiate misuse56:
Changes in attitude and/or personality
Avoidance of contact with family and friends
Changes in friend groups, hobbies, activities, and/or sports
Declining grades or work performance
Isolation and secretive behavior
Moodiness, irritability, nervousness, or giddiness
Tendency to steal
Dr. Jonathan D. Morrow from the University of Michigan notes that "if you're using more and more of a drug, yet your daily functioning is getting worse instead of better, that's a sign of addiction"6. Additionally, using for longer than prescribed or for reasons other than prescribed-such as for depression, anxiety, or boredom-puts individuals at high risk for addiction.
Advanced Warning Signs
More advanced indicators of opiate abuse may include5:
Missing medications
Burnt or missing spoons and/or bottle caps
Presence of syringes
Small bags with powder residue
Missing shoe laces and/or belts (potentially used as tourniquets)
The Detoxification Process
What is Detoxification?
Medically supervised withdrawal or "detoxification" is the process of removing physiological dependence on opioids while managing withdrawal symptoms7. The term is increasingly called "medically supervised withdrawal management" to destigmatize the process.
Importantly, detoxification alone is not a treatment for OUD. When not followed by medications for opioid use disorder (MOUD), detoxification increases an individual's risk for relapse, overdose, and death7.
Approaches to Detoxification
While it might seem intuitive to start OUD treatment with detoxification and complete cessation of opioids, this is not always the best approach. Research indicates that people who complete detox soon after stopping illicit opioid use have a very high chance of returning to opioid use-in some studies, more than 90% relapsed over the next few months7.
Several approaches to detoxification exist:
Medication-Assisted Detoxification:
Methadone
Methadone is a full μ opioid receptor agonist usually taken as an oral liquid9. For detoxification, doses can be reduced to zero in approximately 12 weeks, by reducing the dose by 2–5 mg every 1–2 weeks. Some studies suggest less craving and withdrawal discomfort with slower tapering9. Methadone is a long-acting opioid medication used to treat opioid addiction by reducing withdrawal symptoms and cravings without producing the intense high associated with drugs like heroin or prescription painkillers. It works by binding to the same receptors in the brain as other opioids, but in a controlled and steady way that helps stabilize individuals in recovery. Methadone is typically given once daily in liquid or tablet form at licensed opioid treatment programs (OTPs), where patients receive it under medical supervision. Over time, methadone can help people focus on rebuilding their lives, engaging in counseling, and addressing the root causes of their addiction. It is especially effective for individuals with severe or long-term opioid use, and when used properly as part of a comprehensive treatment plan, it can greatly reduce the risk of relapse and overdose.
Buprenorphine
Buprenorphine is a partial μ opioid receptor agonist with less risk of respiratory depression than methadone9. It can be reduced more quickly than methadone, typically by 2–4 mg every 2 weeks. Suboxone, a combination of buprenorphine and naloxone, discourages misuse by causing withdrawal symptoms if the tablet is crushed and injected or snorted9. Buprenorphine can be used in conjunction with other drugs such as clonidine. Managing symptoms effectively is crucial during opioid detox, and understanding the appropriate opiate withdrawal clonidine dose can make a significant difference in patient comfort and safety. Clonidine is a non-opioid medication commonly used to ease withdrawal symptoms such as anxiety, sweating, muscle aches, and agitation. While the exact dosage can vary based on individual needs and medical supervision, it’s typically administered in small, controlled amounts to minimize side effects like low blood pressure or dizziness. Consulting a healthcare provider is essential when determining the right opiate withdrawal clonidine dose, as improper use can lead to complications. When used correctly, clonidine can be a valuable part of a medically supervised detox plan.
α2-Adrenoceptor Agonists
Medications like lofexidine can help limit the noradrenergic "storm" during detoxification9. They can be used alongside methadone and buprenorphine or alone for detoxification if the dependence is mild or if rapid detoxification is requested.
Naltrexone/Naloxone
Naltrexone is a μ opioid receptor antagonist that blocks the effects of opioids9. Treatment is typically recommended for 3 months but can continue as needed. Side effects like dysphoria, depression, and insomnia can lead to poor compliance. Naltrexone and naloxone are two important medications used to support recovery from opioid addiction, but they work in different ways. Naloxone (commonly known by the brand name Narcan) is used in emergencies to quickly reverse the effects of an opioid overdose. It works by blocking the opioids in the brain, helping someone start breathing again if they've stopped or slowed down due to an overdose. It's often given as a nasal spray and can be used by friends, family, or first responders. Naltrexone, on the other hand, is used after someone has detoxed from opioids and is ready to focus on staying sober. It helps prevent relapse by blocking the "high" opioids produce, making it less likely a person will want to use again. Naltrexone can be taken as a daily pill or a monthly shot (called Vivitrol), and it’s not addictive. Both medications are safe and effective tools that support long-term recovery when used alongside counseling, coaching, and other supportive services.
Withdrawal Symptoms
Acute Withdrawal
Opioid withdrawal syndrome is a life-threatening condition resulting from opioid dependence14. Symptoms typically appear within 6 to 12 hours after the last dose of short-acting opioids (e.g., heroin, oxycodone) and within 24 to 30 hours for longer-acting opioids (e.g., methadone)8.
Common symptoms include14:
Lacrimation (tearing) or rhinorrhea (runny nose)
Piloerection ("goose flesh")
Myalgia (muscle pain)
Diarrhea and nausea/vomiting
Pupillary dilation and photophobia
Insomnia
Autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension)
Yawning
These symptoms generally peak within 72 hours and can last for several days or even weeks8.
Post-Acute Withdrawal Syndrome (PAWS)
After acute withdrawal subsides, many individuals experience post-acute withdrawal syndrome (PAWS), which refers to more emotional and psychological symptoms during the second stage of withdrawal15. Approximately 90% of people in early recovery from opioid use disorder will experience PAWS.
Common PAWS symptoms include15:
Foggy thinking or trouble remembering
Urges and cravings
Irritability or hostility
Sleep disturbances, including insomnia or vivid dreams
Fatigue
Issues with fine motor coordination
Stress sensitivity
Anxiety or panic
Depression
Lack of motivation
Reduced ability to focus
Mood swings
PAWS is normal and temporary but can increase the risk of relapse if not properly managed. Drug use changes the brain and its ability to deal with stress. Addiction experts describe PAWS as the brain's way of correcting the chemical imbalances that occur during active addiction15.
Treatment Options Beyond Detox
Detoxification is only the beginning of treatment for OUD. Long-term recovery typically requires additional interventions.
Medication for Opioid Use Disorder (MOUD)
Three FDA-approved medications are used to treat OUD12:
Methadone: A long-acting opioid agonist that reduces withdrawal symptoms and cravings
Buprenorphine: A partial opioid agonist that reduces withdrawal symptoms with less risk of overdose
Naltrexone: An opioid antagonist that blocks the effects of opioids
Despite their effectiveness, these medications remain underutilized. According to CDC data from 2022, while 3.7% of US adults needed OUD treatment, only 25.1% of those received medications for OUD11.
Behavioral Therapies and Support Services
Behavioral therapies often used in conjunction with medications include cognitive-behavioral therapy, contingency management, and motivational interviewing. Additional support services like peer support groups, recovery housing, and employment services can facilitate recovery.
Recent Developments and Statistics
Recent data from the CDC indicates encouraging trends in the fight against opioid overdose deaths. Provisional data shows about 87,000 drug overdose deaths from October 2023 to September 2024, down from around 114,000 the previous year-a nearly 24% decline3.
More recent data indicates there were an estimated 107,543 drug overdose deaths in the United States during 2023-a decrease of 3% from 2022, marking the first annual decrease in drug overdose deaths since 201816. Overdose deaths involving opioids specifically decreased from an estimated 84,181 in 2022 to 81,083 in 202316.
"It is unprecedented to see predicted overdose deaths drop by more than 27,000 over a single year," said Allison Arwady, MD, MPH, Director of CDC's National Center for Injury Prevention and Control. "That's more than 70 lives saved every day."3
While this national decline is encouraging, overdose remains the leading cause of death for Americans aged 18-44, highlighting the continued importance of prevention and treatment efforts.
After Detox: The Importance of Ongoing Treatment
Detox is only the first step in recovery. While it addresses physical dependence, it does not treat the underlying addiction or the psychological and behavioral aspects of Opiate use disorder12. Without further treatment, relapse rates are high-up to 80% within the first month post-detox if no ongoing support is provided12.
If you or someone you know is struggling with opiate use, seek help as soon as possible. Warning signs that professional intervention is needed include:
Inability to stop using despite repeated attempts94
Neglect of personal, work, or family responsibilities94
What to Do:
Contact a healthcare provider: Addiction specialists or mental health professionals can assess the situation and recommend treatment84.
Call a helpline: National helplines provide free, confidential support and referrals.
Reach out to local resources: Community health centers, hospitals, and nonprofit organizations often provide addiction treatment services.
Inpatient vs. Outpatient Rehabilitation
Inpatient (Residential) Rehab: Provides structured, immersive treatment for those with severe addiction or unstable home environments12
Outpatient Rehab: Allows individuals to receive treatment while maintaining work, school, or family responsibilities1218
Ongoing Therapy and Support
Individual counseling: Addresses personal triggers, trauma, and co-occurring mental health issues12
Family therapy: Improves communication and healing within the family system12
12-step programs (e.g., Cocaine Anonymous): Offers peer support and accountability912
Sober living homes: Provide a drug-free, supportive environment during early recovery12
Relapse Prevention
Relapse is common in addiction recovery but does not signify failure9. Effective relapse prevention includes:
Identifying triggers: Stress, social situations, or emotional distress912
Developing coping skills: Stress management, mindfulness, and healthy hobbies12
Building a support network: Friends, family, therapists, and peer groups912
Regular follow-up: Ongoing check-ins with healthcare providers12
Conclusion
Opiate use disorder is a complex condition that requires a comprehensive approach to treatment. Detoxification, while an important step, is just the beginning of the recovery process. Understanding the signs of abuse, withdrawal symptoms, and available treatment options can help individuals and their loved ones navigate the path to recovery.
If you or a loved one is seeking compassionate, professional support on the journey to recovery, Solace Health offers personalized addiction services—from detox coordination to sober coaching—tailored to meet your unique needs. Let our experienced team help guide you toward lasting healing and freedom.
Sources:
American Society of Addiction Medicine. "DSM-5 Criteria for Diagnosis of Opioid Use Disorder." https://www.asam.org/docs/default-source/education-docs/dsm-5-dx-oud-8-28-2017.pdf
National Institute on Drug Abuse (NIDA) and Substance Abuse and Mental Health Services Administration (SAMHSA). "Substance Use Disorder defined by NIDA and SAMHSA." https://wyoleg.gov/InterimCommittee/2020/10-20201105Handoutfor6JtMHSACraig11.4.20.pdf
Centers for Disease Control and Prevention. "CDC Reports Nearly 24% Decline in U.S. Drug Overdose Deaths." February 25, 2025. https://www.cdc.gov/media/releases/2025/2025-cdc-reports-decline-in-us-drug-overdose-deaths.html
Substance Abuse and Mental Health Services Administration. "Locating Data on Risk Factors for Opioid Overdose." https://www.samhsa.gov/sites/default/files/sptac-locating-data-on-risk-factors-for-opioid-overdose.pdf
New York State Department of Health. "Opioids: Recognizing the Signs." https://www.health.ny.gov/community/opioid_epidemic/signs.htm
Michigan Medicine. "Signs of Opioid Abuse: How To Tell If Someone is Addicted to Opiates." https://www.michiganmedicine.org/health-lab/how-spot-signs-opioid-addiction
Providers Clinical Support System. "Medically Supervised Withdrawal (Detoxification) from Opioids." https://pcssnow.org/courses/detoxification-from-opioids/
Lake County Indiana. "Opioid Withdrawal: Understanding the Challenges and Symptoms of Recovery." https://lakecountyin.gov/departments/health/Nursing-Clinic/Prevention/Opioids/opioid-withdrawal-understanding-the-challenges-and-symptoms-of-recovery
PMC. "Pharmacological strategies for detoxification." https://pmc.ncbi.nlm.nih.gov/articles/PMC4014033/
Substance Abuse and Mental Health Services Administration. "Protracted Withdrawal." https://library.samhsa.gov/sites/default/files/sma10-4554.pdf
Centers for Disease Control and Prevention. "Treatment for Opioid Use Disorder: Population Estimates." https://www.cdc.gov/mmwr/volumes/73/wr/mm7325a1.htm
Substance Abuse and Mental Health Services Administration. "TIP 63: Medications for Opioid Use Disorder." https://library.samhsa.gov/product/tip-63-medications-opioid-use-disorder/pep21-02-01-002
Substance Abuse and Mental Health Services Administration. "National Helpline for Mental Health, Drug, Alcohol Issues." https://www.samhsa.gov/find-help/helplines/national-helpline
National Center for Biotechnology Information. "Opioid Withdrawal - StatPearls." https://www.ncbi.nlm.nih.gov/books/NBK526012/
WebMD. "Post-Acute Withdrawal Syndrome and Opioids." https://www.webmd.com/mental-health/addiction/opioids-post-acute-withdrawal-syndrome
Centers for Disease Control and Prevention. "U.S. Overdose Deaths Decrease in 2023, First Time Since 2018." https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2024/20240515.htm
McSTAP. "DSM-5 Checklist of Diagnostic Criteria: Opioid Use Disorder." https://www.mcstap.com/docs/DSM%20Checklist.pdf
Centers for Disease Control and Prevention. "Opioid Use Disorder: Diagnosis." https://www.cdc.gov/overdose-prevention/hcp/clinical-care/opioid-use-disorder-diagnosis.html
Oregon Pain Guidance. "DSM-5 Criteria for Opioid Use Disorder." https://www.oregonpainguidance.org/wp-content/uploads/2019/07/DSM-5-Criteria-OPG-form.pdf
