Opiate Withdrawal & Detox
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Opiate drugs are highly addictive and can quickly lead to drug tolerance and dependence with regular use or abuse. The American Society of Addiction Medicine (ASAM) publishes that over 2.5 million people in the United States battled addiction to prescription opioids or the illegal opiate heroin in 2015.
What Are Opiate Addiction and Dependence?
Drug addiction is a disease of the brain that occurs when a person is unable to control how often they take drugs. Drug dependence is usually a component of addiction and occurs when brain chemistry and function are altered due to chronic drug use or abuse. Dependence can occur even when a person takes a prescription opiate, like Codeine, for a legitimate reason, especially if they are taking the potent medication long-term and on a regular basis.
How Do Opiates Affect the Body?
Opiate drugs bind to opioid receptors in the brain, blocking pain signals while slowing central nervous system functions like breathing, body temperature, blood pressure, and heart rate. Some of the brain’s chemical messengers that are involved in pleasure, reward, motivation, memory, learning, movement, stress levels, and sleep functions are impacted. Chronic use of an opiate can cause the natural levels of these chemical messengers, like dopamine, to be altered. Without the opiate drug, the brain may not transmit or even produce these neurotransmitters at normal levels. When the opiate is not present or processes out of the body, withdrawal symptoms can occur.
What Is Opiate Withdrawal?
Opiate withdrawal can be significant and intense; it is therefore optimally managed through a medical detox program.
An opiate drug should never be stopped “cold turkey” as the consequences can be difficult to manage without professional help. Detox is the method of allowing opiates to process out of the body, and a specialized detox program can provide necessary support, medical and mental health interventions, and encouragement during this time. Generally speaking, an opiate detox program lasts 5-7 days on average, and steps are taken during this time to promote abstinence and control cravings and withdrawal symptoms. When maintenance drugs are used, the total detox process can take weeks, months, or even years.
Detox protocols are often dictated by a person’s level of dependence on opiate drugs. An assessment done prior to admission can help trained professionals determine the proper path for the detox and treatment plan.
What Is Opiate Withdrawal Syndrome?
The severity of physical dependence on opiates an individual struggles with will generally determine how significant withdrawal will be. Dependence levels are influenced by how much of a drug a person used, how often they used drugs, how long they have been using them, how they use drugs (e.g., swallowing them, taking them via injection, or smoking or snorting them), what kinds of drugs are being used, if more than one drug is being used at the same time, whether or not the person also suffers from a co-occurring medical or mental health concern, biological and genetic factors, and environmental aspects. A person who has been injecting heroin regularly for a long time will likely be more significantly physically dependent on opiates than someone who pops a pill here and there, for example.
The National Library of Medicine (NLM) warns that opioid withdrawal symptoms may begin within 12 hours after the last dose and can include:
- Runny nose
- Watery eyes
- Fever and sweats
- Chills and goosebumps
- Achy muscles, joints, and bones
- Nausea and vomiting
- Abdominal cramps
- Irregular blood pressure and heart rate
- Dilated pupils
- Difficulties concentrating
- Memory lapses
- Irritability and agitation
Symptoms of acute withdrawal generally peak within the first few days and then start to taper off. The Substance Abuse and Mental Health Services Administration (SAMHSA) warns that in the case of significant dependence, protracted withdrawal symptoms, such as cognitive issues and mood and sleep disturbances, may continue for several weeks or even months.
Withdrawal symptoms from opiate drugs are not generally life-threatening in and of themselves; however, they can be extremely uncomfortable and may lead a person to relapse in order to avoid them. A relapse after stopping taking drugs for any period of time can be especially dangerous, as the risk for fatal overdose increases since the brain may no longer be able to handle dosages of drugs that the person may have previously taken.
The Centers for Disease Control and Prevention (CDC) reports that within the United States 91 people die every day from an opioid overdose. Detox can help to institute initial sobriety, but it will need to be followed with a comprehensive treatment plan to minimize relapse and control potential cravings moving forward.
What Medications Are Used for Opiate Withdrawal?
Typically, in the case of opiate drugs, medical detox is the optimal method of withdrawal. Medical detox is performed in a specialized facility, and the individual remains on site for the duration of the program. In this way, vital signs can be monitored, medical interventions can be administered when necessary, and mental health needs can be attended to around the clock. A secure medical detox facility also provides a stable and calming environment with supportive and encouraging staff present at all times.
Medical detox for opiate drugs often uses medications to minimize cravings and withdrawal symptoms. As published by SAMHSA, the US Food and Drug Administration (FDA) has approved several types of medications for the treatment of opioid dependence and addiction. These include:
- Methadone (Methadose, Dolophine): Dispensed in tablet, liquid, or wafer form usually once a day in federally regulated clinics, methadone is a long-acting opioid drug. In this sense, it can be used to help individuals slowly wean off opiates by replacing shorter-acting drugs (like heroin and oxycodone, for instance). An opiate drug should not be stopped suddenly; instead, it often needs to be tapered off in a slow and controlled manner. Methadone can be taken less frequently than other opiates and still activate the same receptors in the brain to control cravings and hold off withdrawal. Methadone is an opioid agonist drug like all other opiates; it is just longer-acting. During detox, the dosage is typically adjusted slowly until the brain and body are clear of opiates. Methadone can still be abused and taken to produce the opiate high, however, and use should be monitored closely.
- Buprenorphine (Subutex, Buprenex, Butrans): Coming in sublingual filmstrip, tablet, or patch form, buprenorphine is also generally dispensed once daily; however, dosage may vary depending on the specific person. Buprenorphine is a partial opioid agonist that still activates opioid receptors in the brain but does so to a lesser extent. This means that it does not create the same euphoric high that more potent opioids do, and after a certain amount is taken, it stops working altogether. Buprenorphine is commonly used during detox to manage cravings and minimize withdrawal symptoms. Like methadone, it can be slowly tapered off until it is no longer needed.
- Naltrexone (ReVia, Depade): An opioid antagonist drug, naltrexone blocks the effects of opiates in the brain by filling up the receptors and not allowing other drugs to bind to them. For this reason, naltrexone is generally reserved for later in a treatment program after detox. At this point, the brain and body are clear of opiates, so naltrexone will not precipitate withdrawal symptoms. Naltrexone can help with treatment compliance during recovery and to reduce instances of relapse. It is often injected once a month to work in an extended-release fashion.
- Combination buprenorphine/naloxone medications (Zubsolv, Suboxone, Bunavail): These medications contain both an opioid agonist (buprenorphine) and an antagonist (naloxone). The naloxone component remains dormant unless the drug is altered and taken by injection. In this way, it serves as an abuse-deterrent since abuse of these drugs can cause intense withdrawal symptoms to come on. The buprenorphine component helps to minimize cravings and opiate withdrawal. These products are generally reserved for late detox after other opiates are completely clear of the body.
Other medications may also be helpful for specific symptoms of withdrawal, such as:
- Antidepressants for mood stabilization
- Gastrointestinal aids for stomach pain, nausea, vomiting, and diarrhea
- Nonsteroidal and non-narcotic pain medications for bone, joint, muscle, and back pain
- Anticonvulsant medications for tremors and to regulate central nervous system functions
- Sleep aids to regulate sleep patterns
During detox, balanced and nutritious meals and adjunctive therapies can be beneficial. Things like massage therapy, acupuncture, chiropractic care, yoga, mindfulness meditation, and spa treatments may be included in a treatment plan to alleviate stress, tension, physical pain, and other side effects of withdrawal.
Detox can help a person to reach a healthy physical level of stabilization before entering into a complete treatment program. Detox is not designed to be a standalone program. A person will benefit most from entering directly into a comprehensive treatment program after completing detox.
Detox as Part of a Complete Treatment Program
Detox is often an important component in an addiction treatment program and the first step in recovery. The National Institute on Drug Abuse (NIDA) publishes that addiction treatment involves a range of steps not limited to detox; it also includes behavioral therapies, counseling, medications, evaluation and treatment for co-occurring diseases and/or disorders, and long-term follow-up care.
Behavioral therapy and counseling sessions work to develop healthy habits, coping mechanisms, and tools for preventing relapse, recognizing potential triggers, and managing cravings. Life skills training, workshops, educational and relapse prevention programs, and adjunctive therapies like equine or art therapy are often part of a complete treatment plan. Support groups, including 12-Step programs, can provide ongoing peer support and encouragement as well as information and firsthand knowledge on addiction and recovery. Aftercare programs, including alumni activities and groups, can be beneficial in recovery as well.
Detox helps a person to become physically stable; however, physical dependence is only one aspect of addiction. Psychological, emotional, social, and behavioral components will need to be explored and addressed during a thorough treatment plan. Regular assessments can determine what level of care is best, and individuals may move between inpatient, outpatient, and transitional programs as needed.
Opiate addiction is a complex disease that can be managed with a high standard of care that attends to all aspects of the disorder. No two treatment plans will be exactly alike as each person is different. A treatment consultant can help find the right fit.
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