FOR PATIENTS CONSIDERING OPIATE WITHDRAWAL

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The following is an overview of the clinical appoach to office-based opiate detoxification. 

 

The chronic use of opiates causes abnormalities in the ways our body and brain work.  Opiate withdrawal refers to the physical and emotional symptoms we experience as these drugs leave our body and these abnormalities reverse.  Opiate withdrawal can be expected to peak between two to four days.  The symptoms of this include muscle aches and spasms, irritability and anxiety, sweating, runny nose and eyes, yawning, stomach cramps and diarrhea, gooseflesh and difficulty sleeping.  There is also an elevation of the blood pressure and pulse, temperature and persistent vomiting when severe.  This is caused by over-activity in certain areas of the brain as well as in the intestinal tract.  Treatment is tailored to reduce activity in the affected parts of the brain as well as relieve some of the more distressing symptoms.

 

The initial part of the treatment is the first three or four days.  Buprenorphine (Subuxone) is substituted for the specific opiate that you are coming off of.  It is administered underneath the tongue.  Whatever is swallowed is wasted. Depending upon the patient and their degree of tolerance, this initial period may be associated with mild withdrawal or no withdrawal.  If your primary goal is to detox, I prefer to keep the use of Subuxone as short as possible.  The longer one stays on it, the more difficult it will be to eventually discontinue it

 

When the Subuxone is stopped, there will be a secondary withdrawal.  It will have all of the characteristics of typical drug withdrawal but it will usually be much less intense.  Some patients do not experience any withdrawal but they are the minority.  It is easy to panic when you experience the milder withdrawals.  They will remind you of a cold turkey withdrawal.  Such a panic will than magnify the actual intensity of the withdrawal symptoms.  In fact, usually the withdrawal symptoms remain mild and will resolve within a week.  Typically, they are described as “not as bad as I expected.”

 

After the acute withdrawal period is over, psychiatric symptoms last from weeks to months. Sometimes these symptoms are treated with psychiatric medication but sometimes they do not respond well to treatment.   Sometimes the best alternative is to shorten this delayed withdrawal syndrome via the use of naltrexone.  There are even recent studies to suggest that the naltrexone can be started before the Subuxone is withdrawn.

 

OTHER MEDICATIONS USED DURING PROTOCOL

 

There are medications that are helpful.  They can be used during the initial few days if withdrawal symptoms are too difficult.  They may be needed during the secondary Subuxone withdrawal.  Some of them may even be useful during the early abstinence period that can last one or two months.

 

 

1-Elavil (amitriptyline), Trazadone- These are anti-depressants that are quite sedating.  I use them as sleeping pills.  I regularly give it out for one to two months.  It can be used indefinitely without risk of addiction

 

2-Clonidine- The medicine reduces activity in the locus coeruleus, the area responsible for a great deal of physical withdrawal symptoms.  Increased activity in this area causes most symptoms of physical withdrawal.  So, the clonidine is able to reduce the intensity of withdrawal.  Unfortunately, it can lower blood pressure significantly and cause sedation and/or dry mouth.  A certain amount of lightheadedness (especially when standing up) is normal.  If lightheadedness is severe, the medicine should be reduced.  Suddenly stopping the medication from a high dose to nothing may cause an elevation in pressure so the medicine will need to be tapered.  The pill is started four times daily.  It may be increased or decreased during the detox.  This medication may not be necessary during the first few days but should be started if any withdrawal is being experienced.

 

3-Zofran- (please see article elsewhere on site) This is a useful medication for relieving all types of mental irritability as well nausea and other types of stomach upset.

4-Baclofen- This is a muscle relaxer that helps muscle aches.  It was studied as an aid to withdrawal years ago and found to be effective.  Yet, it is rarely used.  It also works as a mild sedative and reduces the intensity of other withdrawal symptoms in addition to muscle spasms.  It also has anti-craving effects.  This medication may not be necessary initially, but like clonidine, should be used if there is mild to moderate withdrawal

 

5-Phenobarbital- this is a sedative medication used for symptoms such as anxiety, irritability and inability to sleep, which are not adequately treated by the Subuxone, Clonidine, and Baclofen.  Side effects include sedation but it otherwise well tolerated.  I have used this medication because, of all the sedatives, this is the safest one in terms of addictive potential.  I have yet to see anyone get into trouble with it.

 

6-Motrin (Ibuprofen)- Muscle aches are extremely common and helped with this medication.  It may cause stomach problems and should not be used if there is a history of ulcers.  Taking the medication with food makes it easier to tolerate.

 

7-Neurontin, Depakote, Topamax- This are medications that Dr. Wasser has found useful in treating the symptoms of early abstinence.  They are used in just a small percentage of patients who are trying to detox quickly.  There seems to be evidence that chronic opiate use can sensitize certain areas of the brain and spinal cord.  This results in increased pain and irritability.  This effect may be blocked to some extent by these drugs. like Neurontin.  They are safe medications that have no addictive potential.  Since it reduces irritability and anxiety, I will use these medications for extended periods, several months if necessary.  These medications can cause stomach upset, fatigue and a fuzzy head in some patients.  I have to stop it in abut 20- 25% of the patients.   

 

8-Bentyl (dicyclomine)-This is an effective medication for relief of stomach cramps.

 

9-Imodium- If diarrhea is a real problem, this over the counter medication will usually relieve symptoms. 

 

10-Nutritional Supplements- For those patients, who are unable to eat during this time, the use of nutritional drinks may improve their sense of well-being.  This should be used as needed.

 

11-Vitamins- while vitamin therapy is unlikely to affect the withdrawal procedure, the use of a multi-vitamin is helpful in maintaining optimal health over the next few weeks to months

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