When an addict misses his first shot, he senses mild withdrawal distress ('feels his habit coming on') but this is probably more psychological than physiological, for fear plays a considerable role in the withdrawal syndrome. At this stage a placebo may give relief. During the first 8-16 h of abstinence the addict becomes increasingly nervous, restless and anxious; close confinement tends to intensify these symptoms. Within 14 h (usually less) he will begin to yawn frequently; he sweats profusely and develops running of the eyes and nose comparable to that accompanying a severe head cold.
These symptoms increase in intensity for the first 24 h, after which the pupils dilate and recurring waves of goose-flesh occur. Severe twitching of the muscles (the origin of the term 'kick the habit') occurs within 36 h and painful cramps develop in the backs of the legs and in the abdomen; all the body fluids are released copiously; vomiting and diarrhoea are acute; there is little appetite for food and the subject is unable to sleep. The respiratory rate rises steeply. Both systolic and diastolic blood pressure increase moderately to a maximum between the third and fourth day; temperature rises an average of about 0.5°C, subsiding after the third day; the blood sugar content rises sharply until the third day or after; the basal metabolic rate increases sharply during the first 48 h.
These are the objective signs of withdrawal distress which can be measured; the subjective indications are equally severe and the illness reaches its peak within 48-72 h after the last dose of the opioid, gradually subsiding thereafter for the next 5-10 days. The withdrawal syndrome proper is self-limiting and most addicts will survive it with no medical assistance whatever (this is known as kicking the habit, 'cold turkey'). Abrupt withdrawal is inhumane, but with the use of such drugs as methadone, it is possible to reduce the distress of withdrawal very considerably.29
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