Opioid Withdrawal on the NCLEX
COWS scoring, symptoms vs alcohol withdrawal, MAT with methadone and buprenorphine.
Opioid withdrawal feels terrible and looks dramatic. It is rarely fatal. That contrast is the test point.
Symptoms
Yawning, lacrimation, rhinorrhea, dilated pupils, piloerection (gooseflesh), sweating, muscle and bone aches, abdominal cramping, nausea, vomiting, diarrhea, anxiety, restlessness, insomnia. Onset depends on the opioid: hours for short-acting, 1-2 days for methadone.
COWS basics
Clinical Opiate Withdrawal Scale. 11 items: pulse, sweating, restlessness, pupil size, aches, GI upset, tremor, yawning, anxiety, gooseflesh. 5-12 mild, 13-24 moderate, 25+ severe. Guides timing of buprenorphine induction.
Uncomfortable vs deadly
Opioid withdrawal is miserable but rarely life-threatening in an otherwise healthy adult. Alcohol and benzodiazepine withdrawal can kill (seizures, DTs). The NCLEX loves this comparison. Watch for dehydration from vomiting and diarrhea, the main physical risk.
Medication for opioid use disorder (MAT)
Methadone: full agonist, daily dosing at a licensed program. Buprenorphine: partial agonist. Start only after withdrawal is established (moderate COWS), or it precipitates withdrawal by displacing the full agonist. Naltrexone: antagonist, relapse prevention, requires 7-10 days opioid-free. Clonidine treats autonomic symptoms but is not MAT. Comfort meds: antiemetics, loperamide, NSAIDs.
Frequently asked
Pupils in withdrawal vs overdose?
Withdrawal: dilated. Overdose: pinpoint with respiratory depression. Opposite findings.
Why wait to start buprenorphine?
As a partial agonist it displaces full agonists from receptors. Given too early it triggers sudden precipitated withdrawal.
Quick check
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