Psychotic symptoms following synthetic opioid withdrawal: A case report

Psychosis during opioid withdrawal is rare but clinically significant and may complicate detoxification and delay accurate diagnosis, particularly with synthetic opioids such as tramadol. We report the case of a 41-year-old married male with no prior personal or family psychiatric history who developed acute psychotic symptoms following abrupt cessation of tramadol. The patient had a 25-year history of alcohol dependence but had been in sustained remission for 3.5 years. After stopping tramadol, he initially developed classical opioid withdrawal symptoms, followed several days later by second-person auditory hallucinations and persecutory delusions. On admission, the Clinical Opioid Withdrawal Scale (COWS) score was 25/60, indicating moderate to severe withdrawal. He was managed with opioid agonist substitution, benzodiazepines, and short-term antipsychotic therapy, resulting in rapid resolution of both withdrawal and psychotic symptoms. The patient was discharged symptom-free on day 11 and remained asymptomatic without recurrence during four weeks of follow-up. This case highlights tramadol withdrawal–induced psychosis as an uncommon but important clinical entity and underscores the importance of careful substance use history, close monitoring during withdrawal, and appropriate short-term antipsychotic use to avoid misdiagnosis as primary psychosis or delirium. • Psychosis can rarely emerge during withdrawal from synthetic opioids like tramadol. • Case shows persecutory delusions and auditory hallucinations after opioid cessation. • Symptoms resolved rapidly with codeine tapering and short-term antipsychotics. • Chronic alcohol history may heighten vulnerability to withdrawal-related psychosis. • Early recognition avoids misdiagnosis as primary psychosis and guides treatment.