(Read Part 1 at this link.)
Prevention of withdrawal symptoms:
Before we discuss strategies for withdrawing from opiates,
let’s discuss how to help to mitigate the inevitable onset of tolerance and
dependence to begin with.
If your doctor feels that you will need to be prescribed
opiates for longer than 1-2 weeks, then ask that they prescribe a long acting
opiate right from the start. Long acting opiates smooth out the highs and lows
of the medication in your system which decreases the development of tolerance
and abuse. With short acting opiates the body gets a high dose and then quickly
switches to a lower dose after just a few hours. Your pain level with increase
with each low that occurs, potentially making you feel like you need a higher
and higher dose to keep you comfortable. In this case you don’t need a higher
dose but a formulation that smooths out the highs and lows, so you stay in a
steady state of pain relief over time. This also makes it much easier to
withdraw when it is time to discontinue the use of opiates.
In my view, the only time short acting medication is
appropriate is if you need only a few pills to get over an acute pain (e.g. a minor
surgery or injury). For any pain that is likely to last longer than 1-2 weeks
you are best prescribed a long acting opiate.
Also, ask your physician to be prescribed NeuDexta. It is an
uncompetitive antagonist (blocker) of NMDA receptors and may help decrease the
overall amount of opiates needed to relieve pain. NeuDexta contains
Dextramethorphan which is a weak opiate in itself and it can be the last
medication that is withdrawn. Some pain physicians even keep patients on
Neudexta permanently for pain relief.
Withdraw slowly:
After 1-2 weeks of continuously taking opiates, they should generally
be discontinued slowly. The longer you have been taking opiates, the more gradually
you might need to discontinue them in order to try to avoid severe discomfort.
Generally withdrawing from opiates should be done at a rate of approximately 10-20%
every 2 weeks. For each drop-in dose of opiates your body needs time to start
ramping up its own endogenous opiates before you drop to the next level.
In order to withdraw at this rate, you will need to be on a
formulation that has decreasing dosages that do not cause too much of a
drop. If you are not using such a
formulation, then your doctor can change your opiate prescription to one that
allows a lowering of the dose in small incremental changes. For example, this
might involve a compounded prescription with smaller and smaller doses over
time. Your physician can order doses of the medication that allows you to
withdraw slowly. So, for example, if you are taking 20 mg a day of Percocet
(hydrocodone) your doctor could switch you to a compounded extended release version
of hydrocodone as 5 mg and 3 mg capsules. With these doses you can withdraw
from 20 mg a day to 17, 15, 13, 10, 8, 6, and 3 mg by taking the appropriate
combination four times per day. Once you get to a low enough dose you can start
to spread out the doses to 3 times per day and then 2 times and finally one
time at bedtime. If you are on high dose opiates, then a switching to a Fentanyl
patch, that specifically can be cut up (see below for manufacturers) into
smaller and smaller pieces, can be very helpful. Alternatively, the ultra-long
acting opiate Methadone can be used in lower and lower doses.
Another option for withdrawing from opiates is called Rapid
Detox. This is a very fast approach that uses medications to rapidly alter the
bodies biochemistry to allow you to discontinue opiates. This approach is done
intravenously and must be done under the supervision of a physician. Drugs that
have been used for this include Naloxone and Buprenorphine. While this can be a
very useful way to detox from opiates there are many risks associated with the
procedure. This includes vomiting while under anesthesia which is potentially
life threatening. Personally, I feel that rapid detoxification methods should
not be a first line therapy because of the risks involved.
Medications that might help mitigate withdrawal symptoms:
There are several medications that are very helpful to
decrease the symptoms of withdrawal.
Centrally acting alpha
2 adrenergic agonists: Clonidine and Lofexidine have shown to help to
prevent many of the uncomfortable symptoms that occur while withdrawing from
opiates. These medications need to be taken preventatively in order to work
most effectively. Since the worst withdrawal symptoms are often at night, just
when you are trying to sleep, taking clonidine in the evening approximately one
hour before bed might be the most helpful.
Benzodiazepines:
Klonopin and Valium are good options to help with withdrawal symptoms as they help
relax your mind and body. They are GABA agonists, which means that they
increase the neurotransmitter GABA in the brain which leads to sleep,
relaxation and to decrease anxiety. Again, it might be most helpful to take
these medications in the evening to assist with sleep.
Alternative opiates:
Buprenorphine and Methadone are opiates that have interesting characteristics
to help withdrawal. You can ask your doctor if this might be helpful for you.
Naloxone (Naltrexone): Naloxone blocks the opiate receptors in your
body. This has been used for rapid detox and to help addicts from restarting
opiates. Ironically, low dose Naltrexone can also have pain relieving properties.
For example, by taking Naltrexone once a day (let’s say in the evening) your
body thinks that it has too little opiates and so it ramps up production of
your natural endogenous opiates. In the morning, you can have a pain-relieving
boost from the use of Naloxone the night before.
Create your own endogenous opiates:
Exercise, exercise, exercise and sex is good too! We produce our own endogenous opiates (endorphins) when we exercise. It is critical to try to increase your level of exercise while you are withdrawing from opiates. The greater the creation of your own endorphins, the faster you can withdraw with the least discomfort. For patients with chronic pain, who find most exercise painful, water therapy is an excellent way to increase your natural endogenous opiates.
Another way for your body to increase endorphins is to try some Complementary and Holistic treatments like Acupuncture and Osteopathy. These therapies encourage your body to find a natural balance and can offer a significant degree of pain relief.
Having your body touched and rubbed also increases endorphins and so body work with a massage therapist who provides a gentle non irritating massage might be helpful. Of course, having an intimate sexual experience can also increase your bodies natural endorphins. This is especially true with a partner who is gentle and enjoys stroking and massaging you gently as part of the sexual experience.
Create your own endogenous opiates:
Exercise, exercise, exercise and sex is good too! We produce our own endogenous opiates (endorphins) when we exercise. It is critical to try to increase your level of exercise while you are withdrawing from opiates. The greater the creation of your own endorphins, the faster you can withdraw with the least discomfort. For patients with chronic pain, who find most exercise painful, water therapy is an excellent way to increase your natural endogenous opiates.
Another way for your body to increase endorphins is to try some Complementary and Holistic treatments like Acupuncture and Osteopathy. These therapies encourage your body to find a natural balance and can offer a significant degree of pain relief.
Having your body touched and rubbed also increases endorphins and so body work with a massage therapist who provides a gentle non irritating massage might be helpful. Of course, having an intimate sexual experience can also increase your bodies natural endorphins. This is especially true with a partner who is gentle and enjoys stroking and massaging you gently as part of the sexual experience.
Nutrition and Nutraceuticals:
Good nutrition is essential while taking opiates and during
withdrawal. Opiate use can increase the need for certain vitamins (for example
B vitamins). Also, you want to ensure that you are creating enough relaxing neurotransmitters (e.g. GABA). A healthy diet means plenty of good quality protein,
healthy fats along with vegetables and fruits that have plenty of healthy
phytonutrients. I would also recommend supplementing with a multi B complex, a
multi vitamin and mineral complex, as well as extra amino acids (the building
blocks of protein). I recommend that you
seek out the services of a nutritionist and/ or physicians who have experience
with nutrition and who are experienced with issues around withdrawal and Addiction
Medicine.
Withdrawing from the use of opiates can be a
long challenging process. The key is to understand that there may be
significant discomfort as you withdraw but that these symptoms are transient. Withdrawal symptoms can be eased by using formulations of long acting opiates that can be reduced
gradually, the addition of other medications that help ease the symptoms of
withdrawal, increasing your natural endorphins, and by proper nutrition and supplementation.
Notes:
The following manufacturers make Fentanyl Patches that can
be cut in a way that allows the dose to be dropped gradually. Mallinckrodt,
Mylan, Sandoz and Apotex.
REFERENCES:
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