Early Signs of Opioid Withdrawal: What You Should Expect

You may notice the early signs of opioid withdrawal within hours of your last dose. Recognizing these initial symptoms—such as anxiety, muscle aches, sweating, runny nose, and cramping—can help you decide when to seek medical support and plan a safer detox process [1]. By understanding what to expect in the first stages of opioid withdrawal, you can reduce discomfort, avoid complications, and connect with professional treatment at the right time.

Understanding opioid withdrawal

What causes withdrawal

When you use opioids regularly, your brain and body adapt to the drug’s presence. Over time, nerve cells in regions like the locus coeruleus increase noradrenergic activity to compensate for opioid effects, so when opioids suddenly stop, your system becomes hyperactive. This shift triggers the physiological and psychological symptoms known as opioid withdrawal syndrome [2].

Why early recognition matters

Catching withdrawal symptoms early gives you a chance to manage discomfort and reduce the risk of complications. If you wait until severe symptoms set in—dehydration from uncontrollable vomiting or dangerous cardiovascular responses—you may need more intensive care. Noticing the first signals of withdrawal empowers you to seek medical detox, adjust medications, or tap into counseling resources before symptoms escalate.

Recognizing early symptoms

Physical signs

The first physical indicators of opioid withdrawal can appear as soon as 6 to 12 hours after your last heroin dose or within 30 hours after stopping Buprenorphine/Naltrexone [1]. Early signs include:

• Lacrimation (tearfulness) or rhinorrhea (runny nose)
• Piloerection (“goose flesh”)
• Muscle aches (myalgia) and cramping
• Excessive yawning
• Sweating and chills
• Dilated pupils and photophobia
• Diarrhea, nausea, and vomiting
• Insomnia or restlessness
• Autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia)

Emotional and psychological signs

Beyond physical discomfort, you may also experience:

• Anxiety and panic
• Irritability or agitation
• Mental fog or difficulty concentrating
• Restlessness and trouble sitting still
• Intense drug cravings

These psychological symptoms can be as distressing as physical ones and often lead people to resume opioid use to relieve discomfort.

Withdrawal timeline by substance

Heroin withdrawal

Heroin withdrawal typically begins 6 to 12 hours after your last use, peaks around 24 to 48 hours, and gradually subsides over about five days, though some symptoms may linger longer [3]. For a detailed day-by-day breakdown, see heroin withdrawal day by day.

Buprenorphine/Naltrexone withdrawal

Because Buprenorphine/Naltrexone has a longer half-life, withdrawal onset may occur 30 hours or more after your last dose. Symptoms tend to develop more gradually but often last longer than with short-acting opioids. You might experience mild early signs that persist for up to two weeks before tapering.

Fentanyl and other opioids

Fentanyl withdrawal may start as early as 8 to 12 hours after your last dose if you use short-acting formulations. Early-stage symptoms mirror those of other opioids—muscle aches, sweating, anxiety—but can escalate quickly given fentanyl’s potency. For more on early fentanyl symptoms, visit fentanyl withdrawal symptoms early stages. Prescription opioids like oxycodone and hydrocodone follow similar patterns, generally within 8 to 24 hours.

How severity is measured

Clinical opioid withdrawal scale

Clinicians use the Clinical Opioid Withdrawal Scale (COWS) to assess withdrawal severity. It scores 11 signs—such as resting pulse rate, sweating, restlessness, pupil size, bone or joint aches, gastrointestinal upset, and anxiety—on a scale from 0 to 4 or 5. Total scores fall into four categories:

A score of 6 or more often justifies initiation of buprenorphine (Suboxone®) to alleviate symptoms safely [3].

Managing early withdrawal symptoms

Medications to ease discomfort

Medications can help you transition through early withdrawal more comfortably:

• Buprenorphine/Naltrexone or buprenorphine: Partial agonists that stabilize opioid receptors when started 12 to 18 hours after short-acting opioid use to avoid precipitated withdrawal [2].
• Clonidine: Reduces anxiety, agitation, sweating, muscle aches, and nasal runniness by lowering blood pressure; it does not curb cravings.
• Symptomatic treatments:
• Loperamide for diarrhea
• Promethazine for nausea and vomiting
• Ibuprofen for muscle pain
• Sleep aids for insomnia

Non-pharmacological support

In addition to medication, you can ease early symptoms by:

• Staying hydrated and replacing electrolytes
• Eating small, nutrient-dense meals throughout the day
• Resting and pacing activities to conserve energy
• Practicing relaxation techniques like deep breathing or guided imagery
• Seeking peer or professional counseling to address cravings and stress

Combining medical and holistic approaches often yields the best outcomes and reduces your risk of complications.

When to seek professional help

Warning signs

While many withdrawal symptoms are uncomfortable, they are rarely life-threatening if managed properly. You should seek immediate medical attention if you experience:

• Severe dehydration from persistent vomiting or diarrhea
• Rapid, irregular heart rate or blood pressure spikes
• Confusion, hallucinations, or seizures
• Uncontrolled psychiatric symptoms (suicidal thoughts or severe agitation)
• Complications from co-occurring medical conditions

For a full list of red-flag symptoms, see withdrawal symptoms that require medical care.

Medical detox vs home detox

Detoxing at home may seem convenient but carries risks, especially if you have:

• Polysubstance use or co-occurring mental health disorders
• History of severe withdrawal complications
• Limited social support or unstable living conditions

Professional medical detox provides:

• 24/7 monitoring by trained staff
• Access to emergency care if needed
• Tailored medication protocols
• Counseling and peer support

Learn why you should not detox alone at home and signs you need medical supervision in withdrawal at why you should not detox at home and signs you need medical detox.

Preparing for detox or rehab

Signs you need medical detox

Consider inpatient or outpatient medical detox if you have:

• Moderate to severe opioid dependence with a COWS score above 12
• Significant physical or psychiatric comorbidities
• Previous unsuccessful or complicated quit attempts
• Concurrent use of alcohol or benzodiazepines
• Concern for relapse in an unsupervised setting

What to expect in treatment

A structured detox or rehab program typically includes:

1. Intake assessment: Medical history, physical exam, COWS evaluation, and urine toxicology to rule out other substances.
2. Stabilization phase: Administration of Buprenorphine/Naltrexone, buprenorphine, or clonidine to manage withdrawal safely.
3. Therapeutic support: Individual and group counseling to address triggers, coping strategies, and relapse prevention.
4. Aftercare planning: Transition to outpatient therapy, peer support groups, or medication-assisted maintenance to sustain recovery.

By preparing ahead—assembling medical records, arranging supportive contacts, and clarifying insurance coverage—you can focus on healing when you arrive at your treatment center.

Recognizing and managing the early signs of opioid withdrawal can help you navigate detox with fewer complications, greater comfort, and a clearer path to recovery. With timely intervention and professional support, you can reduce the physical and emotional toll of withdrawal and transition into lasting treatment and healing.

References

1. (MedlinePlus)
2. (NCBI)
3. (SA Health)