Why do opioid withdrawal symptoms make opioid detox so difficult?
When a person who is addicted to opioids is told that they must quit taking opiate or opioid drugs, their first thought is often about the physical sickness of opioid withdrawal. In fact, many people continue taking opioids, not to get high, but to feel normal without getting too sick from withdrawal.
In the beginning, opioid use helps to stop the pain of living with past traumas. Opioids are effective at treating physical pain, but users discover that they are also effective at covering up emotional pain as well. Unfortunately, opioids are very addicting for some people, so continued use leads to addiction and physical dependence.
Opioid withdrawal symptoms last for a long time. Even when the symptoms subside after a few days, for the lucky people who do not have prolonged or protracted opioid withdrawal, those few days are very difficult.
A person who is admitted to a residential opioid addiction treatment program will benefit from medical and social support while experiencing opiate withdrawal symptoms. For a person quitting opioids at home, without support or medication assisted treatment, it is often very difficult to get through the opioid withdrawal process.
People who drink coffee regularly are often familiar with physical withdrawal from a drug, even if they have never used legal, illegal or prescription drugs. Caffeine, the drug found in regular coffee, creates a physical dependence. The coffee drinker who stops drinking coffee cold turkey may experience physical caffeine withdrawal syndrome.
Caffeine withdrawal lasts about a day for most people. It is characterized by fatigue and headaches. The headaches are persistent and hard to overcome, until the withdrawal symptoms wear off by the next day, or until the person gives in, and has another cup of coffee.
A coffee drinker finds it challenging to get through even one day without a cup of coffee, for fear of suffering from a caffeine headache. Imagine an intense drug withdrawal, many times more unpleasant than caffeine withdrawal, that does not even peak in intensity until the third day.
Opioid withdrawal typically lasts at least a week, with the worst symptoms, and the greatest intensity of symptoms, appearing around 72 hours. At that time, there are chills, cramps, crawling skin, involuntary limb movements, anxiety, depression, sweating, nausea, vomiting, upset stomach, and much more.
Add to the withdrawal symptoms a powerful craving for opioids, and you can see why many people do not make it through opioid withdrawal without relapsing. The person who makes it to day three, withdrawing from opioids on their own without support, will very likely give in, and take more opioids, just to stop feeling sick.
Unlike alcohol withdrawal, opioid withdrawal is typically not life-threatening. However, going through an opiate detox without medical treatment or support is not easy for anyone.
How long is the opiate withdrawal timeline for most people?
For many people, the opioid withdrawal nightmare will begin to subside after about a week or two. The worst of the symptoms become tolerable, as the ex-opioid user enters a phase where withdrawal symptoms wax and wane.
Unfortunately, if a person detoxes from opioids and gets to the stage where they are past physical opiate withdrawal symptoms, they may still have opioid cravings for months, or even years, to come. Returning to active addiction and drug abuse with opiates is a risk as long as cravings persist.
Cravings for a person with opioid use disorder can be very subtle. Sometimes a craving can be a simple thought, such as what will you do if you have to go to the dentist or get surgery. Won’t it be fine to take a prescription opioid if it is necessary, after a medical procedure?
Unfortunately, relapse is a part of addiction. Relapse, meaning going back to self-harming drug use, occurs for many people who have recovered from opioid addiction.
In order to make relapse less likely, it helps to have a support system of people who understand and are willing to listen when times are tough. opiate addiction is not easy to overcome. There are support systems available, such as Narcotics Anonymous, Alcoholics Anonymous, Smart Recovery, and Celebrate Recovery.
Therapy, counseling, and coaching can be helpful as well. A person in recovery can learn to identify and avoid dangerous triggers that may lead back to active addiction.
In some cases, the physical withdrawal symptoms may last for an extended period, which is known as post acute withdrawal syndrome, or PAWS. Where you might typically expect symptoms to mostly subside after a week or two, with PAWS, the withdrawal symptoms may persist for months, or even beyond a year.
Even with PAWS, there is hope to get beyond the uncomfortable symptoms and get back to feeling normal again. Symptoms do improve over time, becoming less intense, and less frequent.
Focusing on physical activity, creative endeavors, mindfulness, and meditation can make PAWS more tolerable. Of course, returning to opioid use can be a major setback for people who may be predisposed to PAWS.
How long does fentanyl opioid withdrawal last?
Pharmaceutical fentanyl, which is found in the Duragesic Patch, the Actiq lollipop for cancer pain, and IV vials for surgery, is a short-acting opioid. The drug wears off fairly quickly, and the withdrawal from fentanyl will last a similar amount of time to any other opioid withdrawal, depending on the person and the amount and time period of fentanyl use.
Fentanyl bought on the streets, as heroin, or in fake pills, is typically a fentanyl analog, imported from China or Mexico. The properties of this alternate form of fentanyl are different from the FDA approved fentanyl used in surgery and prescription drugs.
Any heroin addiction treatment program must be aware that much of the heroin on the streets contains fentanyl. In fact, much of the street heroin is pure fentanyl, and contains no actual heroin.
Street fentanyl often stays in the user’s system for much longer than would be expected. One theory of this long-lasting activity is that the clandestine fentanyl gets trapped in fat cells, releasing gradually, and continuing to occupy opioid receptors.
Typically, with “real” fentanyl, we expect the drug to wear off and withdrawal to start within less than 24 hours. With street fentanyl analogs, withdrawal may not start for days, and it may last longer than expected.
Because this designer fentanyl has unusual lingering properties, it is more difficult to quit compared to other, more traditional opioids. Users tend to find quitting street opioids to be quite difficult because this exotic fentanyl has infiltrated all forms of street opioids, from heroin to fake pressed oxycodone pills.
Methadone maintenance is a substance abuse treatment program that has recently enjoyed a resurgence because it works better than other available opioid treatment programs in the US for treating street fentanyl addiction. The advantage of methadone is that it can be started immediately, on the same day that the opioid user has taken their final dose of street fentanyl.
For street fentanyl users, starting Suboxone, or other buprenorphine-based drugs, such as Subutex, ZubSolv, and Bunavail, is more problematic, because if these drugs are started while the patient still has significant fentanyl levels in their system, they will experience precipitated withdrawal, which is unpleasant and traumatic. Naltrexone, another medication-assisted treatment drug, has the same problem, in that it can cause precipitated withdrawal if taken too soon.
Because of the prolonged withdrawal syndrome of street fentanyl, and the high potency, there have been more treatment failures, and more overdoses in recent years. Addiction experts are working to find new ways to address this problem, such as microdosing Suboxone, or possibly bridging fentanyl to Suboxone with a short-acting opioid.
The bridging concept is being tested in parts of Canada, and other countries, but it is currently not allowed as a treatment protocol in the US. For this reason, methadone may be the treatment of choice for many opioid users addicted to fentanyl.
Can opioid withdrawal treatment drugs shorten the opioid withdrawal course?
Currently, there is only one drug on the market that is approved to treat opioid withdrawal symptoms. This drug is named Lucemyra, or lofexidine.
Technically, there are two other drugs to treat opiate withdrawal, which are buprenorphine (Suboxone), and methadone. While these drugs will help to get rid of withdrawal symptoms, they are both opioids, so the patient will eventually have withdrawal symptoms when they stop using either of them.
Lucemyra was originally studied as a blood pressure medication. It is chemically related to clonidine, and older blood pressure medication.
Clonidine is known as an alpha agonist, and lowers blood pressure due to its effects in the brain. It is not a very popular blood pressure drug due to side effects.
Yet, it is quite popular, off-label, as a drug used to treat opioid withdrawal symptoms. As an alpha agonist, it reduces excitation of the sympathetic nervous system, which makes it nearly ideal for treating opioid withdrawal.
However, the main problem with clonidine is that it lowers blood pressure, so it is of limited usefulness. Patients can only take it several times daily, and they must be careful of the risk of their blood pressure dropping too much.
While Lucemyra failed as a blood pressure medication, because it did not lower blood pressure much at all, it has turned out to be a very effective drug for treating opioid withdrawal. It works similarly to clonidine, but it can be taken more often, because blood pressure remains more stable in most cases.
Unfortunately, Lucemyra will not relieve all opioid withdrawal symptoms. However, it will make the symptoms more tolerable, reducing their severity, making it a very useful treatment in opioid detox.
While Lucemyra will make opioid detox more tolerable, it will not necessarily shorten the course of withdrawal. The opioid withdrawal timeline remains about the same, whether the patient takes Lucemyra or not.
Does Suboxone withdrawal last longer than other opioid withdrawals?
One major concern about taking Suboxone is that when a person decides to taper off of Suboxone, they will experience opioid withdrawal symptoms. Common symptoms may include anxiety, depression, upset stomach, muscle cramps, chills, and restless leg syndrome or similar movement disorders. Suboxone is, after all, a type of opioid drug, so withdrawal symptoms often occur as the dosage is lowered.
After taking the last dose of Suboxone, which should be as low of a dosage as possible, to minimize withdrawal severity, the withdrawal syndrome may last for quite a while. The experience of Suboxone withdrawal will vary from one person to another.
While some people describe feeling back to normal within a week or two of quitting Suboxone, it is fairly common to hear people complaining of withdrawal symptoms for months after stopping Suboxone, Subutex, or ZubSolv. Sometimes, patients complain during this process that they wish they had never started buprenorphine treatment in the first place.
Of course, hearing a person complaining that they regret starting Suboxone therapy is concerning to both doctors who prescribe Suboxone, and patients who are considering starting Suboxone therapy. Is it worth starting Suboxone, if it will be difficult to quit it in the future?
It is important for doctors to keep this issue in mind when discussing Suboxone therapy with patients. It is important to provide informed consent, explaining to the patient the risks, benefits and alternatives, relating to buprenorphine treatment.
While the risk of protracted withdrawal due to Suboxone therapy is significant, doctors and patients must also consider the life-saving benefits of Suboxone. Medication-assisted treatment with Suboxone saves lives and has a very high success rate.
So, if a patient is currently abusing pain pills or street opioids, putting them at high risk of deadly overdose, and they are at risk of losing their children, marriage, job, money, or their health, Suboxone can reduce risk and allow the person to return to normal functioning.
For a patient who is abusing opioids, but is still working effectively, they may be able to continue work, supporting their lifestyle and their family, with minimal interruption, by starting Suboxone therapy. There are many benefits of buprenorphine treatment, in spite of the risk of prolonged withdrawal while tapering and after quitting.
Additionally, patients who have chronic pain issues may benefit from the pain relieving attribute of Suboxone. As a partial agonist of the opioid receptors, buprenorphine is often an effect analgesic, which can help to reduce the severity of chronic pain.
How can an addiction treatment doctor help with opioid withdrawal?
For a patient quitting opioids, whether it is a patient completing pain management, or a patient quitting street opioids, or prescription opioid misuse with an opioid medication, there are medical detox treatment plans which an experienced doctor can provide. Even for the patient in pain management, who has become physically dependent on opioids, but not necessarily addicted, medical treatment of the physical opioid withdrawal syndrome can help.
While Lucemyra is the only FDA approved medication for treating opioid withdrawal symptoms, there are other medications that doctors may prescribe off-label to improve opioid withdrawal symptoms. Sometimes, a combination of two or more of these “comfort meds” can make a difference in making opioid withdrawal more tolerable.
Patients considering quitting opioids should see a doctor for help in addressing opioid withdrawal symptoms. By getting treatment for opioid withdrawal, they will have a better chance at being successful in quitting opioids and staying opioid-free for the long term.
If a patient chooses to not go forward with methadone maintenance or Suboxone treatment, it is their choice. While their doctor may strongly recommend one of these highly effective therapies, the decision is ultimately in the patient’s hands.
For a person who chooses not to go forward with medication-assisted treatment, and simply quit opioids, cold turkey, they may still ask their doctor for prescription medication to make opioid withdrawal more tolerable. Their doctor may also provide support by talking them through the withdrawal process, giving them hope for the future, knowing that, as uncomfortable as withdrawal can be, it will eventually subside, as the patient’s brain and body goes through a progressive healing process.