What happens to my body when I am going through withdrawal?
Getting through opioid withdrawal without medical treatment is difficult. Many people do not make it through without going back to using opioids again.
Many people who have experienced opioid withdrawal compare it to severe flu. The symptoms usually last for days and are at their worst at about 72 hours.
Even after several days of withdrawal from quitting opioids, the symptoms can persist for weeks, and sometimes months. With the combination of severe discomfort and opioid cravings, no wonder many people relapse.
What does withdrawal do to your body?
Runny nose, yawning, tearing eyes, muscle spasms, muscle aches, sweating, and anxiety are some early opioid withdrawal symptoms. Chills, cold sweats, goosebumps, stomach discomfort, nausea, vomiting, and diarrhea are other common symptoms.
If you quit opioids and experience withdrawal symptoms, you may also experience difficulty concentrating and memory, irritability, anxiety, depression, fatigue, and insomnia.
Overcoming the despair of withdrawal is not easy.
While it is possible to make it through the withdrawal syndrome after quitting opioids cold turkey, it is challenging. I believe that people who have not experienced it should not judge another person’s difficulty in facing the physical effects of quitting opioid drugs.
Unfortunately, many people will tell a victim of opioid dependence that they should “tough it out.” There is even a 2014 movie about prescription opioids and pill addiction: “Suck It Up Buttercup.”
This tough-love advice is unwelcome and cruel. The withdrawal syndrome from quitting opioids is a chemical process that can be treated by a doctor. While often associated with opioid addiction and misuse, the physical withdrawal process is separate from addiction.
While patients who take opioids as prescribed by a doctor can go through the same withdrawal process as a heroin user, we should not make judgments either way. Regardless of the origin of the opioid use that led to withdrawing, that person still deserves medical care and support.
So, giving callous advice, such as, “buck up, buttercup,” to someone suffering from withdrawal sickness is wrong. It is just as bad as providing the same useless orders to someone having chest pain from a heart attack. Even though opioid withdrawal is not life-threatening, it can still be dangerous.
What can we do to make opioid withdrawal more tolerable?
There is no easy solution to the problem of opioid withdrawal. One place we can start is with medications that reduce the severity of symptoms.
The sympathetic nervous system mediates many of the symptoms that patients face. Withdrawing from opioids leads to a sudden increase in sympathetic tone. The “fight or flight” reactions associated with the sympathetic nervous system are similar to opioid withdrawal symptoms.
What medications can help reduce the severity of opioid withdrawal?
Clonidine is a medication that doctors have prescribed for many years to patients suffering from opioid withdrawal. Clonidine, available as a generic and as the brand, Catapres, is an alpha-2 agonist.
Clonidine works on CNS receptors to reduce the heightened tone of the sympathetic nervous system. Interestingly, clonidine is FDA approved as a blood pressure medicine.
Most doctors don’t prescribe clonidine for blood pressure as a first choice. It has too many side effects to be a preferred, long-term blood pressure treatment.
Yet, it is ideally suited for many patients to help make opioid withdrawal more tolerable. Because it does lower blood pressure, doctors must take care in prescribing it for opiate withdrawal.
Lucemyra, or lofexidine, is chemically similar to clonidine, which stimulates the alpha-2 receptors. The benefit of Lucemyra is that it has fewer side effects compared to clonidine. There is a lower risk of low blood pressure.
The biggest downside of Lucemyra is cost. It is a newer medication that has an FDA indication for treating opioid withdrawal. Hence, as a more modern medication covered by a patent, the pharmaceutical company can sell it many times the cost of clonidine.
Are there other comfort medications to help alleviate symptoms?
Another prescription drug that doctors prescribe off-label to treat opioid withdrawal syndrome is gabapentin, sold as the brand-name, Neurontin. Gabapentin is chemically similar to the amino acid, GABA. The FDA indication for gabapentin is for seizure disorders.
Gabapentin works in the central nervous system in ways that are poorly understood. Yet studies show that it reduces the severity of the symptoms from opioid withdrawal.
Is gabapentin a dangerous drug?
In recent years, gabapentin has developed a negative reputation. Previously it was thought to be one of the more safe prescription drugs, with few serious adverse effects. Doctors prescribed it for various uses, including chronic pain.
Now, there has been an outcry of the dangers of long-term gabapentin use. Some states treat it as a controlled drug. Some believe that it potentiates the effects of opioids. It may also increase the risk of overdose when combined with other medications.
Additionally, there are other concerns. One concern is the possibility that long-term use of gabapentin may lead to neurodegeneration.
However, doctors tend to prescribe gabapentin for short periods when it comes to treating opioid withdrawal syndrome. Interestingly, gabapentin shares some similarities with the drug acamprosate. They both are chemically similar to GABA.
Acamprosate is used to reduce the severity of alcohol withdrawal symptoms. While these medications are not interchangeable, the similarities are worth noting.
Can valium help with opioid withdrawal?
Valium is a sedative drug in the benzodiazepine class. Other drugs in this category include Klonopin and Xanax. These drugs work by mediating the effects of GABA at the GABA receptor in the CNS.
The benzodiazepines are known to be habit-forming and are generally not recommended to prescribe to people experiencing addiction. However, in some cases, when withdrawal symptoms are severe, these medications can be useful short term.
It is more likely that a benzodiazepine will be part of the opioid detox process in an inpatient facility. When a patient is under 24-hour observation, it is safer to administer these sedatives.
What is the goal of treating opioid withdrawal?
The purpose of treating withdrawal symptoms is to make the patient more comfortable and reduce the risk of a dangerous relapse. While withdrawal is primarily a physical manifestation of discontinuing opioid use, addiction is a psychological symptom.
Experts consider addiction to be a neurobiological process. Over time, structural changes in the brain occur that are associated with addictive behavior.
While we can help a patient get through opioid withdrawal with medical treatment, the risk of relapse remains for long after the symptoms have subsided. Drug cravings can strike anytime as a response to a variety of environmental triggers.
Rehab programs operate on the premise that if a person can work a 12-step program, they can remain drug-free. If a client fails, the conclusion is that they were not adequately working the program.
When it comes to opioid addiction, science and medical research indicate that medication-assisted treatment has a far higher success rate than the abstinence-based treatment. Abstinence-only is the philosophy of most rehabs and support groups.
How does opioid withdrawal relate to starting medication-assisted treatment (MAT)?
One significant distinction between the three meds of MAT available in the United States is the exposure of the patient to withdrawal symptoms. The longer the patient must experience withdrawal, the higher the risk of relapse.
Methadone requires little if any waiting period from the time of quitting opioids to starting treatment. Hence, the patient does not have to worry about going through prolonged withdrawal. The trade-off is that patients must go to a clinic every day for their daily dose because of methadone’s highly controlled nature.
Buprenorphine treatment, or Suboxone treatment, requires that the patient goes through a brief period of moderate withdrawal after they stop taking opioids and before starting buprenorphine. For some patients, this can be difficult.
Comfort medications, such as clonidine or Lucemyra, and gabapentin, can help make even the mild to moderate withdrawal symptoms during this short period more tolerable. With the current state of street opioids, including opioid analogs, such as the designer drug, U-47700, gray death, and fentanyl, the waiting period for Suboxone can be even longer.
Finally, the third MAT drug is naltrexone. Naltrexone has the appeal of being a non-opioid, non-controlled drug with no abuse potential. The other two, methadone and buprenorphine, are classified as opioids.
Naltrexone is used to treat alcoholism and opioid addiction. In low doses, it is even used to treat pain.
Unfortunately, naltrexone requires the most extended period of going through opioid withdrawal before being able to start treatment safely. The wait can be as long as 1-2 weeks.
For patients getting treatment for opioid addiction in an outpatient health care setting, naltrexone is usually not feasible. However, in rehab, when a patient has been opioid-free for weeks, naltrexone may be ideal.
For patients interested in long-term, monthly treatment, Vivitrol is a monthly injectable form of naltrexone indicated for substance abuse treatment. There has been a significant interest in Vivitrol as a treatment for opioid addiction and alcohol addiction.
What happens when you have a withdrawal syndrome from a non-opioid?
Opioids are not the only drugs associated with physical dependence and withdrawal syndrome. There is alcohol withdrawal, benzodiazepine withdrawal, and also withdrawal due to other medications, such as antidepressants and blood pressure medications.
Some of the other drugs cause withdrawal syndrome that can lead to severe complications and even death. Fortunately, in the case of opioids, the withdrawal syndrome is not typically physically dangerous.
If the opioid withdrawal is not harmful, why is it so dangerous?
While the effects of withdrawal will not hurt you, the risk of relapse makes it dangerous. If you are amid severe withdrawal, several days after quitting opioids, you will find yourself unable to think clearly or rationally.
All you will be able to think about is making the suffering end. Drug cravings manifest as pervasive thoughts of just taking enough opioids to relieve the suffering from withdrawal.
The best hope in such a situation for avoiding relapse is to have no access to opioids. While in rehab or jail, you will not likely have access to drugs.
However, after you get out, the cravings will still be there. Drug cravings often come in waves, and they can be overwhelming.
So, while the physical symptoms of withdrawal are manageable with various treatments, the best long-term treatment for many patients will be medication-assisted treatment.
While there is a place for each of the three MAT drugs, buprenorphine is proving to be the best fit for most patients. Suboxone treatment is safe, effective, and well-tolerated by most patients. It is quickly becoming known as the new gold standard of treatment for opioid use disorder. It works well for heroin addiction and addiction to opioid pain relievers.
When it comes to some of the more difficult street drug use cases, methadone is sometimes the better option. Mainly, when fentanyl and synthetic designer opioids are present in the street heroin, methadone may be the ideal treatment.
Naltrexone, while not the best option in many cases, still has its place. Naltrexone is suitable for patients who have completed MAT with methadone or buprenorphine. After completing treatment, they may still benefit from ongoing medical support.
And, of course, the comfort medications that make withdrawal more tolerable have their place as well. For example, if a patient can hold out to start buprenorphine, it is preferable to going to the methadone clinic. Clonidine or Lucemyra may make all the difference in getting through the 18-24 hours usually needed before starting bupe.
Opioid withdrawal does not have to be dangerous.
As we have discussed, withdrawing from opioids does not have to be a dangerous process. There are excellent medical treatments available. Additionally, there are non-medical treatments that can provide relief from withdrawal.
Hyperbaric oxygen therapy (HBOT) may reduce the severity of opioid withdrawal. Biofeedback therapy and brain wave entrainment therapy, such as binaural beats, can help as well.
We should also consider nutritional support, focusing on amino acids, minerals, and other essential nutrients. Providing the precursors for restoring and balancing brain chemistry can help patients recover from many types of substance use disorders.
Therapy should also be provided to address any mental health issues. Addiction often affects people who have experienced significant trauma.
So, whether the goal is to make the transition to medication-assisted treatment more tolerable or support an abstinence-based program, opioid withdrawal management is an integral part of treating opioid addiction. Fortunately, we have some excellent tools that are effective, and others show promise.