Sunday, July 29, 2018

Withdrawing from Opiates - Part 2 of 2.




(Read Part 1 at this link.)

After 1-2 weeks of taking opiate analgesics our bodies develop tolerance and become dependent on them. This means that it might be very uncomfortable to suddenly discontinue the use of opiates. There are several key concepts to helping withdraw comfortably from opiates.

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 NeuDexta contains Dextramethorphan which is a weak opiate in itself and it can be the last medication that is withdrawn.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. 

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.


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