Opiate Addiction Withdrawal
Opiates sometimes interchangeably referred to as opioids and narcotics, are a broad class of drugs. They are widely used legally and abused illicitly and include many substances that are synthesized from a handful of opiate precursors found in the opium poppy, such as 1,2:
- Hydrocodone (Vicodin).
- Oxycodone (OxyContin/Percocet).
In recent years, prescription opioids have been made increasingly available. According to the Centers for Disease Control and Prevention (CDC), in 2013 approximately 250 million opioid prescriptions were written 3.
In medical settings, prescription opiates are used to treat the following 1:
- Treat pain.
- Reduce cough.
- Pre-surgical or procedural sedation.
- Manage diarrhea.
The U.S. National Library of Medicine reports that more than 4 million people abused prescription opioids and more than 400,000 people abused heroin in 2014 alone 2. Opiates are often abused for their ability to elicit several pleasurable or rewarding effects, including 1:
- A feeling of well-being.
- Lowered physical tension.
- Decreased anxiety.
- Decreased aggression.
Opiate use includes risk, though, even when used as prescribed. Unwanted side effects like nausea, vomiting, constipation, and slowed activity levels may lead some people to end their use. Others may wish to end use due to the risk of overdose associated with opiates. According to the CDC, more than 28,000 people died in 2014 as a result of opioid or opiate overdose, which includes heroin and prescription pain medications.
Quitting opiates can be challenging—attempts to slow or abruptly stop use often precipitate the onset of extremely unpleasant withdrawal effects, which often drive the user into immediate relapse.
What Is Opiate Withdrawal?
In people who struggle with opiate addiction or have otherwise developed physiological opioid dependence, a phenomenon known as acute opiate withdrawal frequently arises when the offending drug is sharply reduced in dose or completely eliminated. Opioid withdrawal is a complex topic that involves aspects of tolerance, physical dependence, and addiction. Through a series of complicated physiological processes, the prolonged interaction of the substance with the body primes an individual to experience withdrawal when the drug is no longer used 2,4.
When opiate drugs are used, they are eventually shuttled to the brain via the bloodstream. Once there, the opiate molecules cling to and activate opioid receptors in the brain. This biochemical interaction serves to mediate the analgesic effects of these drugs and is also secondarily associated with a triggering of the release of a neurotransmitter called dopamine. Dopamine offers a rewarding pleasurable sensation that reinforces the drug use behavior that led to the release in the first place, and thereby encourages the person to keep using. Dopamine also suppresses the release of another neurotransmitter called noradrenaline (norepinephrine), which normally increases alertness and energy. So when it is suppressed, the person may feel more calm and sleepy 4.
Over time, the brain begins adapting to increased dopamine availability and the lower noradrenaline levels. With time, the brain transitions to functioning normally when the substance is present and abnormally when the drug is unavailable. This need for the substance is called physical dependence 4.
As part of this adaptation, the brain will begin to register less of a dopamine response when the opiate is used like it did initially. The person will need to consume higher doses of the substance more often to produce the same level of wanted effects. This tendency of the brain to respond less is called tolerance 4.
Even a person using an opiate as prescribed can experience these adaptations. With tolerance driving increasing patterns of use and physical dependence in place, someone who suddenly attempts to end use will experience a combination of very low dopamine levels and very high noradrenaline levels. This out-of-balance neurotransmitter combination helps to explain some of the unpleasant opiate withdrawal symptoms that begin to arise 4.
Since people develop tolerance and dependence at unique rates, it is difficult to know who will experience opioid withdrawal until symptoms present 2.
Is Withdrawal Dangerous?
Opiate withdrawal is not usually medically dangerous or directly life-threatening. It can be extremely uncomfortable, though. The severity of discomfort of the withdrawal is influenced by a number of factors, such as 1:
- The specific drug(s) used.
- The dose.
- The frequency of use.
- The total time using.
- Physical health status.
- Mental health status.
Someone who has used higher doses, more frequently, for longer periods of time will likely have stronger, more uncomfortable withdrawal symptoms 1.
During withdrawal, indirect dangers of opiate withdrawal can emerge, including strong cravings for more drugs and severe depression 1. If someone restarts opioid use due to cravings, they put themselves at greater risk of a fatal overdose—especially if their opioid tolerance has decreased significantly over the abstinent period. Also, the severe depression related to the later stages of withdrawal can place the individual at risk of self-injury or suicide.
Signs and Symptoms
Opiate withdrawal symptoms grow and change over time. Early symptoms may include 1,2,5:
- Watery eyes.
- Runny nose.
- Anxiety or irritability.
- Poor sleep.
- Muscle pain.
These early symptoms give way to later opioid withdrawal symptoms that include 1,2,5:
- Increased heart rate and blood pressure.
- Gooseflesh skin.
- Dilated pupils.
On average, these opioid withdrawal symptoms can begin between 12 and 30 hours after last use and will last between 4 and 10 days in most situations, although someone withdrawing from a longer-acting opioid drug like methadone will require up to 21 days to end this acute withdrawal phase 6.
The withdrawal symptoms do not necessarily end here, though. In some instances, an extended withdrawal period may continue long after the substance has been physically processed by the body, and acute symptoms have all but disappeared. These persisting symptoms are known by many names like post-acute withdrawal syndrome (PAWS), protracted withdrawal, and chronic withdrawal 6.
For some people recovering from opioid dependence, PAWS can last for months with symptoms such as 6:
- Poor sleep.
- Diminished decision-making skills.
Can Medications Help?
Yes. Medications can be used to assist with the treatment of opioid abuse, addiction, and dependence throughout different stages of recovery, as determined by the attending doctor. Several medications have demonstrated effectiveness in their ability to reduce the unwanted effects of opiate withdrawal while increasing comfort 7,8:
- Methadone. A long-acting opioid, methadone is an often-used medication in the treatment of opioid withdrawal. This medication will aid the recovering user by alleviating withdrawal symptoms and reducing cravings without inducing a marked addictive, euphoric high.
- Buprenorphine. Like methadone, buprenorphine is an opioid that can activate the opioid receptors to limit withdrawal syndrome. Since this medication is a partial opioid agonist, it is also less capable of eliciting the euphoria or sedation found with the abused opioids. This medication is usually available as a pill or a sublingual film and may be administered in combination with naloxone, an opioid antagonist, in a branded formulation known as Suboxone.
- Probuphine. A recently approved version of buprenorphine, Probuphine is a unique implant of the medication that steadily releases a low dose of the medication over a 6-month period. This method of use is meant to encourage treatment compliance and to prevent abuse 9.
- Clonidine. Originally used for treatment of high blood pressure, this medication can help reduce certain symptoms of opioid withdrawal. Since this is not an opioid itself, there is little to no potential for abuse.
Methadone, buprenorphine, and another medication called naltrexone, which is a medication that blocks the effects of opioids to discourage abuse, can be used after withdrawal symptoms have subsided to maintain recovery and to minimize cravings 7. Naltrexone is available as a pill or as a monthly injection (Vivitrol).
Detoxification generally refers to the body’s natural ability to break down and remove toxins from the system. In the field of substance abuse treatment, detoxification is the group of strategies used to manage acute intoxication, if necessary, and ease withdrawal symptoms. The medical model of detox employs a treatment team of doctors, nurses, and clinicians to assist in the withdrawal and detox process. Frequently, some combination of the aforementioned medications and other supportive interventions are used to reduce uncomfortable symptoms 8.
Many people detoxing from opiates will benefit from a medically assisted detox period to evaluate their status, stabilize their symptoms, and refer them for additional substance abuse treatment services at the conclusion. Detox can be provided as an inpatient or outpatient service depending on the person’s 8:
- Intensity of withdrawal symptoms.
- Level of supports and stressors.
- Previous detox and treatment attempts.
- Living situation and transportation availability.
A somewhat controversial option for detox from opiates is called rapid or ultrarapid detoxification. The process involves the individual being given a medication like naltrexone to bring about withdrawal symptoms quickly while sedative medications are administered. Here, the goal is to shorten the withdrawal process and to keep the person sedated during the most uncomfortable segments. But studies show that this style of opioid detox does not significantly benefit the individual. In fact, it could trigger other complications like symptoms of delirium 8,10.
Depending on the substance and level of use, detox may focus on slowly weaning the person off of the substance or switching to another opioid like methadone or buprenorphine as a form of medication-assisted treatment.
Behavioral therapy will be an important facet of any ongoing care following withdrawal and detox. Occurring in several levels such as inpatient, residential, and outpatient settings, treatment providers may use 7:
- Cognitive-behavioral therapy (CBT). CBT is a style of therapy based on the idea that thoughts, feelings, behaviors, and beliefs work in conjunction to support substance use, and changing thoughts and beliefs can limit future use.
- Motivational Interviewing (MI). MI is used with the goal of building intrinsic motivation for change for recovery and abstinence in the client.
- Contingency management (CM). Based on behavioral principles, CM works to provide tangible rewards for drug-free, recovery-oriented behaviors to counteract the perceived rewards of continued use.
- Family therapy. Family therapy will work to educate family members regarding substance use issues and to improve relationships to encourage abstinence.
Tips to Handle Cravings
Many treatments focus on responding well to cravings when they emerge. Helpful strategies can be separated into three types, including 11:
- Behavioral. These interventions focus on changing behaviors to limit relapse. Delaying the reaction to the craving, distracting yourself from the urge, and deciding not to use are examples of behavioral strategies.
- Cognitive. These plans are based on acknowledging and changing self-talk before, during, and after cravings. By speaking positively about one’s ability to manage cravings, the risk of relapse shrinks.
- Relaxation. Relaxation skills, such as deep breathing and guided imagery, can reduce cravings by reducing stress.
If you or someone you know is currently struggling with opiate use, abuse, or dependence, taking steps toward treatment can be a great decision. Call 1-888-744-0069Who Answers? today to begin the process.
- Drug Enforcement Administration. (n.d.). Narcotics.
- U.S. National Library of Medicine: MedlinePlus. (2016). Opiate and Opioid Withdrawal.
- Centers for Disease Control and Prevention. (2016). Injury Prevention & Control: Opioid Overdose.
- Kosten, T. & George, T. (2002). The Neurobiology of Opioid Dependence: Implications for Treatment. Science and Practical Perspectives, 13–21.
- National Institute on Drug Abuse. (2015). Clinical Opioid Withdrawal Scale.
- Substance Abuse and Mental Health Services Administration. (2010). Protracted Withdrawal.
- National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide.
- Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.
- U.S. Food and Drug Administration. (2016). FDA Approves First Buprenorphine Implant for Treatment of Opioid Dependence FDA Approves First Buprenorphine Implant for Treatment of Opioid Dependence.
- National Institute on Drug Abuse. (2011). Study Finds Withdrawal No Easier With Ultrarapid Opiate Detox.
- Australian Government: The Department of Health. (2003). Phase 4: Strategies to Cope with Cravings.