Post-acute withdrawal after opiates

SAMHSA’s advisory says that symptoms such as anxiety, depression and sleep problems can last for weeks or months after opioid withdrawal. It also lists tiredness, irritability, and feeling down or emotionally flat.

Sleep

Trouble falling asleep and waking often are among the most common complaints. Poor sleep then makes everything else feel worse.

Mood

Many people describe a gray, joyless stretch where things that used to feel good do nothing. There is a word for this: anhedonia. SAMHSA describes it as a reduced ability to feel pleasure that can follow long-term substance use.

Cravings

Cravings can come in waves, sometimes out of nowhere and sometimes set off by a place, a person or stress. World Health Organization guidelines note that strong cravings in this phase often lead people back to opioid use.

Thinking and focus

Some people find it harder to concentrate, remember things or make decisions for a while.

Not everyone gets these symptoms. SAMHSA notes that some people have none, some have them from the start, and some feel fine for a month or two before symptoms appear.

There is no reliable number, and we will not invent one. SAMHSA deliberately gives no timeframe for protracted withdrawal, because the research is too thin.

What public sources do say is this. SAMHSA says weeks or months for opioids. WHO guidelines describe a protracted phase lasting up to six months. The National Institute on Drug Abuse notes that some people show persistent withdrawal signs for many months after heroin.

The symptoms tend to fade gradually, with good days and bad days mixed together. SAMHSA’s message to people in recovery is that these symptoms do not last forever and can be managed.

These suggestions come from SAMHSA’s guidance. None is a cure. Together they make this stretch more bearable.

• Keep a sleep routine. Go to bed and get up at the same times, cut back on caffeine, and avoid late afternoon naps.
• Stay active. Physical activity, earlier in the day, improves sleep and mood and takes your mind off symptoms.
• Use lists and routines. If your memory or focus is off, write things down and keep your days predictable.
• Do less, not more. People often try to make up for lost time and end up overloaded. Looking after your recovery is enough for now.
• Find people who get it. Mutual support groups are linked with longer recovery. If you take medication, look for a group that accepts that.
• Talk to someone. Counseling can help with cravings, stress and low mood.

Be careful with sleeping pills or sedatives. Take them only if a prescriber who knows your history recommends them.

This phase is when many people return to opioids, often to get relief from exactly these symptoms. It is also when tolerance is low and overdose risk is high.

Medication changes that picture. SAMHSA advises clinicians to consider methadone or buprenorphine for people whose lingering symptoms are too strong and whose risk of returning to use is high.

If you already take one of these medicines, this is a good reason to keep taking it. NIDA reports that people treated with methadone or buprenorphine are less likely to overdose or die. Our medication treatment and aftercare pages explain what ongoing care looks like.

If you are not in treatment, it is not too late to start. The treatment directory lists providers by state. A slip during this time is common, and the page on relapse explains what to do next.

Some of what feels like lingering withdrawal may be depression or anxiety that needs its own treatment. SAMHSA tells clinicians to check for this as recovery goes on.

Tell your prescriber or counselor if your mood is getting worse instead of slowly better, or if you feel hopeless most days. That is useful information, not a complaint.

If you have thoughts of suicide, call or text 988 at any hour. Call 911 if someone is not breathing or cannot be woken. For free referral to treatment, SAMHSA’s National Helpline is 1-800-662-4357.

For how this phase fits with the earlier ones, see the main guide to opiate withdrawal.