Opioids Treatments for symptoms of opioid withdrawal?

[Hatter]

If kratom is legal where you are (no in Thailand, the UK or Aus), that is a good bet. Codeine works quite well for this, but you should only use codeine without APAP, so unless you can get codeine without anything else in it you would have to do a CWE, and that makes it just complicated enough to make kratom a more practical alternative.

I think I can probably still get Kratom. It's probably not legal here. Not much is. But I think it can go through. I have ordered it in the past, and I still have some left. If it can help, that would certainly be wonderful. Is it as effective as codeine or buprenorphine or methadone in dealing with the fentanyl withdrawals?

What Id hope you were doing is working with a doctor on this. Any chance you could find a medical professional to support you? Most don’t know shit about treating opioid withdrawal, so finding a good one might take a couple tries and you’ll probably have to advocate for yourself and educate them unless you’re lucky.

Jeez, I don't know. I have no experience with it. Most of my life, my uncle was our doctor, and everything was easy that way. When he died some years ago, were were assigned a local doctor, and things have been much less simple.

The way I see our doctor, she won't give anything which she doesn't think has a "genuine" medical reason. Like antibiotics for infection, etc. That she will do. And they are good enough to give my mother what she needs, because she has had cancer, amd has diabetes, chronic bronchitis, arrhythmia, arthritis, etc. etc.

But I don't think she would give me anything. Anything where she thinks she could be "responsible" for anything that would happen to me (negatively), I don't think she'd do. If I came and showed her 100 journal articles which showed the validity of something for treating withdrawal, she wouldn't give it to me. She would insist I go the official route and get into a program. Even though it's taken me over a year of battling bureaucrats, a crazy/evil psychiatrist, being referred to doctors who don't know anything about addiction, etc. etc.

She doesn't want any part in what I do.

I don't know how it works in my country. But I am not sure I can just go around shopping for a doctor. I think I have to give notice that I want another doctor, and then one will be appointed to me. Not sure, though.

Anyway, the doctors I have known aren't open to being educated by non-doctors.

Maybe I'm wrong.

There is some cross tolerance between opioids for sure, but it still would take time for you to become dependent on an opioid you aren’t currently using. So another opioid will serve as a stopgap, allowing your body a bit more time to equalize, as you’re only dependent on particular opioids right now, and your body is only used to the particular binding properties of fent. Basically substituting another opioid with different binding properties helps you adjust more slowly to a new baseline. It’s basically that different opioids create differebr dependencies, despite affecting the same primary neurobiology. It’s just like how diazepam is used to detox people from other benzos or alcohol.

Thank you so much for explaining this to me!

This is for me a completely new perspective on the basis of withdrawal symptoms and how opioid drugs work in the mind, and the potential for doing something about it.

I had never considered there could be any difference. I just thought, "they're all called mu-opioid agonists", so they must be interchangeable.

In terms of comfort meds, again I highly recommend working with a doctor. At a very minimum, no doctor in their right mind wouldn’t prescribe gabapentin and clonidine for opioid withdrawal. In its own that won’t solve your problems, but it’s a hell of a lot better than nothing.

Meet my doctor Well, I can try and ask, but like I say, I am sure that if she hears it is to control withdrawals, she will say "they must handle that in the hospital. You mustn't do anything on your own."

It would be worth trying to taper the fent. If you’re able to do that it’s worth doing (reduce dose at no more than 10% each 4-7 days).

How long can I keep going those 10% drops? All the way to 1 mcg? As far as I can see, going from 2 mg to 10 mcg at 10% every 4 days, would take about 200 days. Is that about right?

The catch is that fent being so short acting it’s pretty difficult for most people to do that. I’ve known folks who have tapered off or using the patch, but if you’re using powdered fent or something it will be more difficult.

Can you explain why it is more difficult because it is short acting? Is it because one has to get up in the middle of the night to take some against the withdrawals?

It has been my experience that I can pretty much go up and down between at least 20 mg and above, like 150 mg or more. It doesn't precipitate anything if I take 100 mg one day, and 20 mg the next (although it's been very rare I have been able to only take 20 mg).

So I was hoping to go down to 20 mg, and then to taper down. And I expect I will get down to getting withdrawals within 6 hours of the last dose, when I get down to around 1 mg in dose each time. It's only happened once, but I was once down to a very low intake, and I think I took 0,5 mg, and then about 6 hours later, I felt the withdrawls begin again - that's the last time I tried that, because I then took too much to be certain the withdrawals would stop, and then my mind became so blurry, that I lost the focus and sense of purpose, and I was lost in the fog for the next months, unable to focus on anything.

But if I get down to that point again, and am more careful to take only as little as I need to stop the withdrawals, I am hoping that my system will "acclimatize", and maybe a week later, I will need even less to stop the withdrawals. I don't know, is that likely to happen?

If I ever get to the point where I need fentanyl every few hours, I was thinking of making a slow drop from a flask through a silicone tube into a pacifier I would strap to my mouth, so I would get drops into my mouth throughout the night.

I don't know if it could work or is impractical. I wish I had the patches, but I only have the pure stuff.

There are some OTC meds that can help, depending where you live. If codeine is avaliable that’s a good enough option, but again I’d suggest you find a buprenorphine doctor.

Do you know, can the nasal decongestant oxymetazoline substitute for clonidine? They are apparently both alpha-2 adrenergic agonists, but perhaps they don't work the same in spite of this?

I have been looking at gabapentin. It seems that phenibut, pregabalin and baclofen all look very similar, structurally. All have that same structure as GABA itself, with various things added to it. Do they all substitute for each other, or is gabapentin special somehow?

I don't have any of them, but maybe I could find them on-line. I do have GHB, though. Can that substitute for gabapentin, or do they not have the same effect?

That said it’s anazing the relief that comes from treating withdrawal withcand NMDA antagonist like that.

Why does it work? What is it these substances do which have a beneficial influence on symptoms of opioid withdrawal?

Or even just a month long methadone detox - that would probably be the easiest and more accessible and safe solution for you.

When you say a month long methadone detox, do you then mean that I would take the comfort meds with me to such a place? I don't think they would allow me to take anything they don't have control over, would they?

But, anyway, no one seems to want to take me in this damned country, because A: they don't have any experience with fentanyl, and B: they say I take so much, that they can't take responsibility if something happens during the switch to methadone or buprenorphine.

Do I am being tossed back and forth between institutions. A few are nice people. Most don't really care once they have completed their assigned paper-work.

Now I am being shown back to a psychiatrist to supervise my transfer to methadone, who when I first met him 8 months ago, said he couldn't understand why the authorities had referred me to him, because he knew nothing about addiction.

I have been informed that his preparation has been to call the "poison hotline" who have told him that under no circumstances may he give me more than 100 mg methadone (per day, I guess), and that he cannot guarantee that I won't get withdrawlal symptoms.

Is 100 mg enough? Is it a lot? I don't even know if they have any experience with treating people in withdrawal, or what medicines they would use. Maybe I will be told something more later, I don't know. The doctors I have talked to don't seem to know a lot about this.




All in all, I would probably prefer if it was something I could do on my own. So I could build up my psychological strength - getting myself "together" - less split into all sorts of directions. More focused. And having more access to myself, and better understanding of myself and my position.

As you wrote another place, meditation is great. That's something used to be fairly good at instinctively as an adolescent, but later I kind of drifted away from it. And nowadays, I am really bad at it. But there are certainly times I am more in tune with myself (and my subconscious) and other times I am less so.

I would try to choose a time I am more in tune, to begin the taper.

Whereas when other people are involved, I have to abide by their schedules, and it could be a shitty time for me, but since I agreed to treatment, that's when it's going to be... It doesn't sound ideal, to me. But mostly it's because I don't feel I am getting enough information about what they are planning to do to me, and I want to know what I can expect, how long it will take, etc. I don't know what to do.

If I knew I could do it all on my own, and I would get through the withdrawal symptoms without breaking, then I would do that.

300-600mg DXM/day for four days to treat the fent withdrawal works well if you can tolerate the DXM’s effects/side effects.

When you mention taking it for four days, is that because the fentanyl withdrawals will be over with after those four days?

Back when I tried quitting cold turkey, I think I was into my 6th day, and I felt I was still in withdrawal. But maybe it was because I hadn't slept for all those days, and had taken that overdose of metoclopramide. Maybe I WAS past the acute withdrawals? I don't know. I just knew I couldn't handle it anymore, and the first thing I did when I got hope from the hospital the next day, was take some fentanyl. Did I do it because I had withdrawals? Or was it because I was psychologically drained?

I think I was so exhausted, and I didn't feel good in my skin, and didn't feel like I could stay like that. I think that's why I took it. Maybe I had expected that I would feel fresh and alert after the withdrawals were done, and since I didn't, I felt I was still in withdrawal.

I don't know. I can't remember.

 

[Astrid.]

Is the person toothpaste a doctor? I work in the medical field and it's very wrong for him to tell someone to take medication, one being an antidepressant is very very wrong and not harm reduction at all

 

[Cotcha Yankinov]

What antidepressant are you speaking of? I couldn't find it in the thread. Are you speaking of Tramadol?

With regards to your post in Site Technical Help about mods playing doctor, I personally think advising someone going through opioid withdrawal to seek Clonidine is pretty decent harm reduction advice. Blocking the sympathetic rebound of opioid withdrawal makes it much safer. The concern would be people pursuing Clonidine illicitly and therefore messing up dosages or combining it accidentally with an alpha antagonist et cetera, but risk vs. benefit ratio of the advice to seek Clonidine is probably still good even without TPD's caveats such as:

"What Id hope you were doing is working with a doctor on this. Any chance you could find a medical professional to support you?"

 

[Jabberwocky]

Is the person toothpaste a doctor? I work in the medical field and it's very wrong for him to tell someone to take medication, one being an antidepressant is very very wrong and not harm reduction at all

What is wrong with suggesting someone use WELL KNOWN medications to treat basic things like acute withdrawal?

How is educating someone how to treat something most doctors are unwilling to help with or don’t know how to help with?

I’d hope no one take my SUGGESTIONS as medical advice. No where have I promoted myself as offering medical advice, and frankly the suggestion is absurd considering no where on this site do I pretend to be a doctor. What I am is someone who advocates for drug users, nothing more nothing less.

How would you suggest we support people trying to get off opioids, tell them to get a different doctor? I’m not sure what world you are living in, but most doctors are either unwilling to treat opioid users or don’t have much of a clue. If we just told people to get a different doctor, and if that was the advice I had received when I asked people for help, I’d never have gotten off heroin.

Where is all this coming from?

 

[Jabberwocky]

Apparently from no where...

Sorry for the delay getting back to you OP, having kinda a busy day it turns out. I won’t forget to get back to you about your questions as soon as I get home though.

 

[Hatter]

Thank you. That's okay.

By the way, what does gabapentin do? They say it's an anti-convulsant, but why is that beneficial in withdrawal?`

Also, how much DXM would one have to take to combat the withdrawal symptoms?

Thanks.

 

[Hatter]

I have spoken with my mother, who knows our doctor a lot better than I do, and she says there is no way she would prescribe anything she doesn't know anything about. And that sounds logical to me. I don't think even 1% of doctors would prescribe something, just because a patient says they need it.

Do you guys really have experience with going up to a doctor, and getting medicines to help you with withdrawal, like you are suggesting I do?

 

[Hodor]

Different opioids have different binding affinities to opioid receptors. In other words different opioids bind in slightly (sometimes not so slightly) with opioid receptors in different ways. As the opioids you’re currently dependent leave your system, your body will have to start producing more endogenous endorphins to compensate for the lack of input of exogenous ones (ie opioids). That depletion of exogenous endorphins is what causes withdrawal, your body adjusting to produce more of its own endorphins.

There is some cross tolerance between opioids for sure, but it still would take time for you to become dependent on an opioid you aren’t currently using. So another opioid will serve as a stopgap, allowing your body a bit more time to equalize, as you’re only dependent on particular opioids right now, and your body is only used to the particular binding properties of fent. Basically substituting another opioid with different binding properties helps you adjust more slowly to a new baseline. It’s basically that different opioids create differebr dependencies, despite affecting the same primary neurobiology.

I *strongly* doubt that this is the case. Otherwise you could just avoid dependence in pain management by switching people between different opioids every week. A mu receptor is a mu receptor. If the mu receptor keeps being activated and starts self-destructing by recruiting beta-arrestins, your tolerance goes up. Doesn't matter whether that happens via fentanyl or morphine or oxymorphone.

It’s just like how diazepam is used to detox people from other benzos or alcohol.

Diazepam is used because it has a very long half-life (atleast once enough of it has accumulated in your fatty tissue), it is very well understood, and it is available as a solution that allows for very accurate dosing (making it ideal for doing gradual tapers).
If cross-tolerance between benzos wasn't a major issue, then patients could just avoid benzodiazepine dependence (or atleast delay it greatly) by switching to a different benzo every week.

In terms of comfort meds, again I highly recommend working with a doctor. At a very minimum, no doctor in their right mind wouldn’t prescribe gabapentin and clonidine for opioid withdrawal. In its own that won’t solve your problems, but it’s a hell of a lot better than nothing.

This, however, I very very very much agree with.

 

[Hatter]

This, however, I very very very much agree with.

Well, my doctor won't.

Do you really think many doctors would give a patient a prescription to go ahead and detox on their own? That doesn't sound like the doctors I have come into contact with.

And if it's not supposed to be something patients take on their own, how then? Are they supposed to bring the medicine along to a detox center, and tell them to dose it for them? Sorry, I don't understand.

 

[Jabberwocky]

I *strongly* doubt that this is the case. Otherwise you could just avoid dependence in pain management by switching people between different opioids every week. A mu receptor is a mu receptor. If the mu receptor keeps being activated and starts self-destructing by recruiting beta-arrestins, your tolerance goes up. Doesn't matter whether that happens via fentanyl or morphine or oxymorphone.



Diazepam is used because it has a very long half-life (atleast once enough of it has accumulated in your fatty tissue), it is very well understood, and it is available as a solution that allows for very accurate dosing (making it ideal for doing gradual tapers).
If cross-tolerance between benzos wasn't a major issue, then patients could just avoid benzodiazepine dependence (or atleast delay it greatly) by switching to a different benzo every week.



This, however, I very very very much agree with.

Your point highlights cross tolerance.

Here is a good example of what I’m talking about in terms of binding properties: morphine vs buprenorphine.

Extreme example, as one is a full agonist and another is a partial agonist, but that’s kinda the point. They behavior differently. Part of different neuro-behavior or whatever bs I just coined is also about half-life. Half life is part of that binding property.

Cross tolerance is what prevents what you alluded to about pain management, but cross tolerance is also part of the equation.

As I said, it’s a pretty messy analogy to describe what happens, but different opioids behind differently to opioid receipts. They also bind to different opioid receptors to different degrees. So it’s not a matter of either/or - all opioid are classified as opioids because they share a lot in common, however each performs slightly differently. That difference won’t necessarily overcome cross tolerance, but it does make a difference.

Here is a short list of how opioids behave differently:
Binding affinity (compare codeine to fentanyl)
Half life (compare heroin to methadone)
Site of action (compare tramadol to morphine)
Cross tolerance (applies to all opioids to one degree or another)

I mean, don’t mistake me for a scientific expert on this stuff. At best I’m a lay expert, but I’ll be the first to say I don’t have the final word on this.

What I can say with scientific certainty is... Different opioids have different binding properties, meaning they bind to different opioid receptors in varying degrees of different ways, as well as to the same opioid receptors in different ways. That is to say different opioids have different affinities to specific opioid receptors (as well as other types of receptor systems), AND they bind to the same receptors with different affinities as well. Cross tolerance is a behavioral factor, related to the tolerance developed through taking opioids.

So my underlined statement should have been assigned the caveat - except to the degree cross tolerance comes into play. Otherwise, yea, to degrees varying from little difference to night and day difference, different opioids do bind in different ways.

Does that clear up what you were saying Hodor? I don’t mean to be defensive about it, but this is why I love science. Constructive criticism forces people to make more sense

It was a pretty horrible analogy, as I said before, but it’s the essential knowledge to work with when it comes to practical knowledge oh how something like detoxification meds work (well, using opioids to detox off opioids I mean).

Considered this: using opioids to detox off other opioids is probably the most practical way to detox from an opioid habit. However, it makes a big difference which opioids are used. Using an opioid with a higher binding affinity or a shorter half life is going to be a lot less manageable than using a longer acting opioid with about the same binding affinity.

It’s why fent and heroin are not great detox meds, while methadone and buprenorphine are. Most of that has to do, practically speaking, with half life, but it also related to their other properties.

OP, ugh I feel like a POc about not getting back to you yesterday. It’s been a crazy weekend of dealing with BL drama... drinking my coffee now and after I finish this smoke it’s off to the computer to answer your questions... and probably rewrite this post.

Hodor, you seem like a very intelligent chap. Wanna help me create a blog dedicated to helping people deal with opioid use disorder? I have been thinking it should start with how to treat detox, then move onto other things like ORT and the nuances of how opioids work. Just a thought, I was planning to get to this this summer. I’ll be posting about it in its own thread in OD and a couple other forums sooner or later.

The major challenge with that, at it was with this and my previous post here, is that I am not formally trained in neuroscience, so I imagine I end up using words and terms with horrible imprecision (accurately, but not always precisely). I will be asking especially for help with that, but it would be also s huge help to run my ideas past folks. Maybe I’ll just ask OD as a whole when I plan on making an entry to get it reviewed by the community here.

 

[Hatter]

Here is a good example of what I’m talking about in terms of binding properties: morphine vs buprenorphine.

Extreme example, as one is a full agonist and another is a partial agonist, but that’s kinda the point. They behavior differently. Part of different neuro-behavior or whatever bs I just coined is also about half-life. Half life is part of that binding property.

Personally, my understanding was more in line with what Hodor was saying, about everything acting the same, and potentiating each other. But in the same breath, I know hardly anything about neurology, and I think a lot of stuff is still not understood, even by researchers who deal with this every day.

I am pretty willing to believe that people have discovered things by personal experience, which science won't discover for a long time. So who knows if Toothpastedog has found something which works? Perhaps on the way down through withdrawals from heroin, and maybe fentanyl too, who knows, there is a window where one can use a substance which is also a mu-agonist, but has different binding-affinities (whatever that means), and a different spectrum of activity on other types of receptors, which maybe taken as a whole adds up to give relief from the withdrawal, without extending them?

Just saying that maybe it's possible?

For example, I found a strange quote in an article on buprenorphine. http://www.jneuropsychiatry.org/peer-review/buprenorphine-for-opioid-addiction-neuropsychiatry.pdf

"The high affinity for and limited intrinsic activity at the mu receptor inhibits the reinforcing effects of exogenous opioids."

What does "intrinsic activity" mean? Apparently they are saying that something can bind tightly to a receptor, yet not activate it much? That's something I didn't know.

[...]

"Although buprenorphine is a partial opioid agonist, its tight binding characteristic and slow rate of dissociation result in prolonged clinical effect and limited physical dependence. The ceiling on mu-agonist activity of buprenorphine reduces potential for overdose and confers low toxicity even at high doses."

And this is again something speaking of things I don't understand - that tight binding and slow rate of dissociation (?) means limited physical dependence. Why?

So, at least it seems like it must be at least a little more complicated that just a matter of saying "one mu-agonist is the same as another".

OP, ugh I feel like a POc about not getting back to you yesterday.

Don't. I am just prone to flooding my head with thoughts about everything that will get worse and not better, and then I feel pretty alone with my problems. I don't know how you manage to respond as much as you do. I only have these few, short windows when I manage to write to people, and then I spend months not being able to, and feeling like an asshole for not responding to people's letters.

 

[Jabberwocky]

Naw, science knows how opioids work, this isn't anything new. I mean, we're basically both right:

Opioids as a class of drugs are essentially the same
Different opioids have different effects/properties in the body

It simply is not the case that an opioid is an opioid is an opioid. Again, compare something like heroin to buprenorphine. Totally different kind of action, and not respecting that difference can lead to tremendous pain and suffering (precipitated withdrawal).

I think I can probably still get Kratom. It's probably not legal here. Not much is. But I think it can go through. I have ordered it in the past, and I still have some left. If it can help, that would certainly be wonderful. Is it as effective as codeine or buprenorphine or methadone in dealing with the fentanyl withdrawals?

Kratom will make a big difference, but it won't make as much of a difference as the med you mentioned here.

Jeez, I don't know. I have no experience with it. Most of my life, my uncle was our doctor, and everything was easy that way. When he died some years ago, were were assigned a local doctor, and things have been much less simple.

The way I see our doctor, she won't give anything which she doesn't think has a "genuine" medical reason. Like antibiotics for infection, etc. That she will do. And they are good enough to give my mother what she needs, because she has had cancer, amd has diabetes, chronic bronchitis, arrhythmia, arthritis, etc. etc.

But I don't think she would give me anything. Anything where she thinks she could be "responsible" for anything that would happen to me (negatively), I don't think she'd do. If I came and showed her 100 journal articles which showed the validity of something for treating withdrawal, she wouldn't give it to me. She would insist I go the official route and get into a program. Even though it's taken me over a year of battling bureaucrats, a crazy/evil psychiatrist, being referred to doctors who don't know anything about addiction, etc. etc.

She doesn't want any part in what I do.

I don't know how it works in my country. But I am not sure I can just go around shopping for a doctor. I think I have to give notice that I want another doctor, and then one will be appointed to me. Not sure, though.

Anyway, the doctors I have known aren't open to being educated by non-doctors.

Maybe I'm wrong.

In this case it might be best to find a local clinic that specializes in helping people come off opioids. Methadone clinics are found in most countries, often buprenorphine ones too. If you doctor won't work with you and you can't get another one, the clinic is the next best thing. Methadone clinics, for example, offer 30 day detoxes that would fit your needs to a T.

I'm probably going to have to deal with a bunch of stigma and stereotypes about methadone from other users now, but to preempt that a bit 30 day methadone tapers (sometimes they off three week ones too) will not leave you having to suffer much through acute methadone withdrawal. They taper you down over the period your on it, and coming off is relatively painless. They should also prescribe you stuff like gababentin and clonidine to help you transition off the methadone.

Thank you so much for explaining this to me!

NP. Sorry for the delay. As I said in my PM, let me know what country you're in and hopefully I can forward you info on where to find a clinic or something.

This is for me a completely new perspective on the basis of withdrawal symptoms and how opioid drugs work in the mind, and the potential for doing something about it.

I had never considered there could be any difference. I just thought, "they're all called mu-opioid agonists", so they must be interchangeable.

As I said at the top of this, to a certain degree they are the same. That is to say, opioids are classified as opioids because they share similar properties. However that does not mean all opioids are the same. Some are very similar, such as heroin and morphine, but others couldn't be more different, such as hydrocodone and buprenorphine. So they're all the same, but they're still each different.

Meet my doctor Well, I can try and ask, but like I say, I am sure that if she hears it is to control withdrawals, she will say "they must handle that in the hospital. You mustn't do anything on your own."

I mean, if you wanted to a hospital would be a fairly good place to detox. Personally I find detoxing at home with the right comfort meds to be superior, as it's a lot less stressful than a hospital environment (well, assuming your home is safe etc). But if you can't get the right meds, you would do well to consider inpatient detox. The big caveat is that I absolutely hate inpatient detoxes and have had more success doing it at home with proper meds, so I'm not going to encourage you too much to go inpatient.

How long can I keep going those 10% drops? All the way to 1 mcg? As far as I can see, going from 2 mg to 10 mcg at 10% every 4 days, would take about 200 days. Is that about right?

Theoretically yes, you could do it all the way to 1mcg. However, you shouldn't need to go that low. The more important part of a taper is to slowly reduce you're intake. Getting down to a low dose is important, but the time you spend transitioning to that lower dose is more significant.

It would take a long time, for sure. And you could probably reduce the dose in larger increments between now and then, at least when your dose is super high. What is your dose again?

The 10% reduction thing is more important once you get down to a lower dose of fent. Switching to another opioid will make this a lot easier though, because you won't have to spend as long tapering. In fact, you wouldn't have to spend any time tapering if you were able to treat the withdrawal with methadone or buprenorphine.

Can you explain why it is more difficult because it is short acting? Is it because one has to get up in the middle of the night to take some against the withdrawals?[/quote

Short acting meds are more difficult to taper for practical reasons, such as having to dose more than once or twice a day for the levels of opioids to stay relatively stable in your system. The bigger concern is related to that. When tapering one wants to keep the levels of opioids in their system as stable as possible.

As it has such a short half-life, the levels of fentanyl in your system will be fluctuating more rapidly than a longer acting opioid such as methadone. That fluctuation puts more stress on your body, and keep in mind it will already be a little stressed simply because you're reducing your overall dose.

Essentially, longer acting opioids help keep you more stable, which is very important because you're already going to be experiencing some stressors as you reduce your dose. The goal is to reduce your dose with as little discomfort as possible, so levels remaining as stable as possible even when reducing them (especially once you get down to a certain point where you really begin to feel each dose reduction) is almost a necessity if you want to avoid unnecessary discomfort.

The less discomfort you experience tapering, the more likely you'll be successful with the taper. There are lots of reasons for this. Some people say the discomfort of withdrawal helps keep them from using, but for at least as many people it's the opposite. After being conditioned to deal with discomfort through opioid use, one learns to crave opioid use in the face of discomfort.

The relationship between discomfort and cravings is significant enough to make it a really good idea to do whatever you can to avoid unnecessary pain and suffering. All the more so because a proper taper takes a while (for instance, I spent about 18 months tapering off methadone, but boy am I glad I took my time).

It has been my experience that I can pretty much go up and down between at least 20 mg and above, like 150 mg or more. It doesn't precipitate anything if I take 100 mg one day, and 20 mg the next (although it's been very rare I have been able to only take 20 mg).

So I was hoping to go down to 20 mg, and then to taper down. And I expect I will get down to getting withdrawals within 6 hours of the last dose, when I get down to around 1 mg in dose each time. It's only happened once, but I was once down to a very low intake, and I think I took 0,5 mg, and then about 6 hours later, I felt the withdrawls begin again - that's the last time I tried that, because I then took too much to be certain the withdrawals would stop, and then my mind became so blurry, that I lost the focus and sense of purpose, and I was lost in the fog for the next months, unable to focus on anything.

Assuming you want to try tapering... This is a good idea. Start off the taper by going as low on your dose as you can. Then stabilize on that new lower dose for a week. Then start the further dose reductions. You can play around with dose reductions higher than 10%, but shoot for that eventually.

But if I get down to that point again, and am more careful to take only as little as I need to stop the withdrawals, I am hoping that my system will "acclimatize", and maybe a week later, I will need even less to stop the withdrawals. I don't know, is that likely to happen?

Yes, as long as you give yourself to stabilize on a new dose, your system will acclimatize. The idea is to move in the direction of lower doses as consistently as possible. If you find a dose reduction is too much, there is nothing wrong with going back to the dose you were at just prior to the reduction, and stabilize more there before continue the reduction. In that case you could try to reduce it by the same amount or you could try to reduce is by a small amount. The point is to consistently move in the direction of less opioids.

Again though, unless you're using the patch or some other time release method, tapering straight fent is really difficult. Not impossible, but difficult enough to make me strongly suggest you at least have a backup plan.

If I ever get to the point where I need fentanyl every few hours, I was thinking of making a slow drop from a flask through a silicone tube into a pacifier I would strap to my mouth, so I would get drops into my mouth throughout the night.

I don't know if it could work or is impractical. I wish I had the patches, but I only have the pure stuff.

IMHO that sounds horribly impractical and not very realistic, but hey if you want to try go for it. Who knows. Just give yourself a backup plan no matter what.

Do you know, can the nasal decongestant oxymetazoline substitute for clonidine? They are apparently both alpha-2 adrenergic agonists, but perhaps they don't work the same in spite of this?

I have no idea. Do some research, maybe it will maybe it won't. Part of what clonidine also helps with is high blood pressure during withdrawal, and I have no idea if that med would help in the same way. My gut tells me no, but I have no idea.

I have been looking at gabapentin. It seems that phenibut, pregabalin and baclofen all look very similar, structurally. All have that same structure as GABA itself, with various things added to it. Do they all substitute for each other, or is gabapentin special somehow?

I don't have any of them, but maybe I could find them on-line. I do have GHB, though. Can that substitute for gabapentin, or do they not have the same effect?

Gabapentin, phenibut and GHB/GBL are very different meds. Phenibut and GHB are more similar than gabapentin. The thing about gabapentin is that it is faaaaaar safer and easier to use effectively than the others. Phenibut or GHB would be better than nothing, but just be very careful. DO NOT use GHB long term.

Why does it work? What is it these substances do which have a beneficial influence on symptoms of opioid withdrawal?

Science is still figuring this out: http://www.bluelight.org/vb/threads...lection-of-the-evidence-and-anecdotal-reports

What I can say is that NMDA antagonists can produce mind blowing results when it comes to treating acute withdrawal, but the whys I don't know myself.

When you say a month long methadone detox, do you then mean that I would take the comfort meds with me to such a place? I don't think they would allow me to take anything they don't have control over, would they?

It would likely be outpatient. You'd go in every day and they'd give you your dose of methadone. They probably won't prescribe other comfort meds until you're at the end of the methadone detox.

But, anyway, no one seems to want to take me in this damned country, because A: they don't have any experience with fentanyl, and B: they say I take so much, that they can't take responsibility if something happens during the switch to methadone or buprenorphine.

Do I am being tossed back and forth between institutions. A few are nice people. Most don't really care once they have completed their assigned paper-work.

Now I am being shown back to a psychiatrist to supervise my transfer to methadone, who when I first met him 8 months ago, said he couldn't understand why the authorities had referred me to him, because he knew nothing about addiction.

I have been informed that his preparation has been to call the "poison hotline" who have told him that under no circumstances may he give me more than 100 mg methadone (per day, I guess), and that he cannot guarantee that I won't get withdrawlal symptoms.

Is 100 mg enough? Is it a lot? I don't even know if they have any experience with treating people in withdrawal, or what medicines they would use. Maybe I will be told something more later, I don't know. The doctors I have talked to don't seem to know a lot about this.

I'm sorry to hear this. 100mg methadone should be enough. Generally people do really well around 80mg. Some need more, some need less, but 100mg of methadone should be more than enough to see you through your acute fent withdrawal.

When you mention taking it for four days, is that because the fentanyl withdrawals will be over with after those four days?

Back when I tried quitting cold turkey, I think I was into my 6th day, and I felt I was still in withdrawal. But maybe it was because I hadn't slept for all those days, and had taken that overdose of metoclopramide. Maybe I WAS past the acute withdrawals? I don't know. I just knew I couldn't handle it anymore, and the first thing I did when I got hope from the hospital the next day, was take some fentanyl. Did I do it because I had withdrawals? Or was it because I was psychologically drained?

I think I was so exhausted, and I didn't feel good in my skin, and didn't feel like I could stay like that. I think that's why I took it. Maybe I had expected that I would feel fresh and alert after the withdrawals were done, and since I didn't, I felt I was still in withdrawal.

I don't know. I can't remember.

Acute fent withdrawal often takes just under a week, but everyone is different and each habit is different. It wouldn't surprise me, given your tolerance and how long you've been using, that it would take a week or more to fully get over withdrawal from your habit. I'd imagine it would be about a week, give or take.

I said four days of DXM because that is the minimum it would take to get through acute withdrawal. Although you'd need to be careful with what kind of DXM preparation you take and all that, you could take it for longer. Just a good idea to keep the amount and time on DXM as low as possible do to side effects etc. Ketamine would be a bit safer probably, but it also isn't quite as effective as DXM IMHO (shorter acting, for one thing).

 

[Hodor]

What does "intrinsic activity" mean? Apparently they are saying that something can bind tightly to a receptor, yet not activate it much? That's something I didn't know.

[...]

"Although buprenorphine is a partial opioid agonist, its tight binding characteristic and slow rate of dissociation result in prolonged clinical effect and limited physical dependence. The ceiling on mu-agonist activity of buprenorphine reduces potential for overdose and confers low toxicity even at high doses."

And this is again something speaking of things I don't understand - that tight binding and slow rate of dissociation (?) means limited physical dependence. Why?

So, at least it seems like it must be at least a little more complicated that just a matter of saying "one mu-agonist is the same as another".

"Intrinsic activity" = the degree to which a drug can activate a receptor.
If it can activate it all the way (just like your endogenous neurotransmitters), it is called a full agonist (ex.: morphine, fentanyl).
If there is little to no activation, it is an antagonist (ex.: naltrexone, naloxone).
If it is only activated part-way, it is a partial agonist (ex.: buprenorphine).

If you look at the structure of buprenorphine, it actually resembles naltrexone to some extent, suggesting that it would act as an antagonist. However, in other ways it also resembles etorphine, an ultra-powerful full agonist used as an elephant tranquilizer; the resulting hybrid structure makes it a high-affinity partial agonist.

This means that at lower doses, buprenorphine is still a very potent opioid, because it makes up for its inability to properly activate a single receptor (due to the low intrinsic activity) by attaching to a lot of receptors (due to its high affinity). Compare that to a morphine molecule, which can fully activate a receptor for a short time, but will quickly drift away again.

But at some point, you start to reach a "ceiling" with buprenorphine, where increasing the dose will barely increase the effects. After all, there are only so many receptors you can attach to, meaning that once you've got enough bupe in your system to almost completely saturate your receptors, it can no longer compensate for its lack of intrinsic affinity by attaching to a higher number of receptors.
And once you're at that ceiling, you can't just exceed it by taking a full agonist, either: Because buprenorphine binds to the receptors much more strongly than other opioids, the low-affinity full agonist just won't be able to activate many of your receptors.

This makes buprenorphine an ideal maintenance treatment: It will get people "slightly high" - high enough to stop the cravings - but not high enough to wrap them in a blissfully euphoric slumber or make them stop breathing. And it will prevent other opioids from getting them higher, too.
One downside to this is unfortunately that when you're dependent on a full-agonist opioid and you take buprenorphine, the buprenorphine will displace your previous opioid from the receptors, and rapidly pull your "high" back down to the maximum high that could be achieved with buprenorphine. Which, to someone used to the intense high achieved with fentanyl, is so low that it is basically equivalent to withdrawal (hence the term "precipitated withdrawal"), which is why you normally switch to buprenorphine only when you're already in withdrawal.

Now, a person who's *not* dependent on opioids, or used to a relatively mild/low-dose opioid, would see their opioid tolerance rise if they started taking a standard dose of buprenorphine. However, someone dependent on a much stronger high (like a fentanyl user) would start to see their tolerance go down, as the comparatively mild buprenorphine high is much less intense than what they get from their daily shot of a full agonist. And if they were to succumb to their cravings and shoot heroin again, the buprenorphine would just block its effects, making it much easier to pull off a gradual taper even in people who have a hard time resisting drug cravings.

I think this is what toothpastedog was getting at.

This article explains the pharmacology of buprenorphine quite well:
https://psychopharmacologyinstitute...orphine-opioid-use-disorder-mechanism-action/

 

[lordofthedrugs]

hmm i wonder if tapering would work. i dont know the dosages of fentanyl or the dosages you took but ill use oxycodone for example. its probably hard to judge the dosage for say a 30mg oxy but ill try hehe. lets say you take 30mg of oxy every for a week (yes ik tolerance but lets just say haha) okay now to taper you would take the 30mg for 3 days, then 25mg for 3 days, then 20mg for 3 days, then 15mg, so on and so forth. at least thats how benzos and alcohol are (different dosages obviously) but i wonder if itd work for opiates hmm, but if anything id try quitting the help of the wonderful lady mary jane 3-4 grams of good chronic everyday for your withdrawals i bet would help, sure as fuck helped when i had benzo withdrawals but i would look into detoxing options. but if you wanna do it on youre own, look up tapering and get you some chronic

 

[Hatter]

Naw, science knows how opioids work, this isn't anything new. I mean, we're basically both right:

Oh, alright. I just thought about how complicated stuff like consciousness and the brain is, and how much science still doesn't know how it all works as a whole - "emerging complexity" - and that some of these more complicated interactions may have an influence on what happens to other systems in the brain.

I don't know. I guess I just meant that maybe things can turn out to be more complicated than they seem at first glance.

In this case it might be best to find a local clinic that specializes in helping people come off opioids. Methadone clinics are found in most countries, often buprenorphine ones too. If you doctor won't work with you and you can't get another one, the clinic is the next best thing. Methadone clinics, for example, offer 30 day detoxes that would fit your needs to a T.

I don't know if there are any private clinics here. I think they all operate through the state, and patients have to be referred from a doctor or the municipal authorities.

The only place I have been to, they said they would be willing to treat me, once I was stable on methadone, but they wouldn't be responsible for transferring me from fentanyl to methadone.

First of all because they have no experience with fentanyl, and secondly, because of the amount of fentanyl I use. That's why I was referred to another place, who also can't do it, and told me it could be done in the capital city. Now, some weeks later, they have apparently called the hospital they wanted to do it, but have been told they only specialize in alcohol.

I frankly don't feel I am in very competent hands. At least not in the hands of people who have much experience.

but to preempt that a bit 30 day methadone tapers (sometimes they off three week ones too) will not leave you having to suffer much through acute methadone withdrawal. They taper you down over the period your on it, and coming off is relatively painless.

That seems very quick. When you talk about tapering down over 30 days, do you mean that after those 30 days, I would be free of opioids, or do you mean that after that time, they would put me on buprenorphine?

I mean, if you wanted to a hospital would be a fairly good place to detox.

I don't know how to make them take me! Last time I was admittet, 5-6 years ago, after I tried quitting cold turkey, and I took an overdose of metoclopramide anti-enetics, they wanted to admit me over in the psych ward. But when the doctors called over to that ward, they were told that they didn't want to take me!

When even doctors don't know how to get me admitted, what chance do I have?

Personally I find detoxing at home with the right comfort meds to be superior, as it's a lot less stressful than a hospital environment (well, assuming your home is safe etc).

That was my feeling as well. I don't like to leave my usual surroundings anyway, so that would be another stress factor. Remember, I have Asperger's, which is a form of autism, and I get stressed in new surroundings, among new people, etc. So I, too, thought it was the optimal way for me.

I felt that if I could handle the treatment myself, then I would be in a position to choose the moment when I feel most "together", most at ease with myself, and "strongest", in stead of having to go at a certain date, regardless of how I feel - if I am in the dumps, for instance.

The only thing that would worry me, whether I did it myself, or it was done by others, is how to deal with RLS, if it surfaces. That's the kind only kind of thing I could imagine driving me so crazy, that I would begin using fentanyl again, just to get relief and be able to sleep.

The big caveat is that I absolutely hate inpatient detoxes and have had more success doing it at home with proper meds, so I'm not going to encourage you too much to go inpatient.

That's the only thing they have said so far: "it will be as an inpatient, on a closed ward." Only for the transfer to methadone. After that, I have been told it will be okay if I become an outpatient. But I have yet to be told how long I will have to be on that ward.

Getting down to a low dose is important, but the time you spend transitioning to that lower dose is more significant.

It would take a long time, for sure. And you could probably reduce the dose in larger increments between now and then, at least when your dose is super high. What is your dose again?

It's 100 mg/day.

The 10% reduction thing is more important once you get down to a lower dose of fent.

Okay.

Switching to another opioid will make this a lot easier though, because you won't have to spend as long tapering. In fact, you wouldn't have to spend any time tapering if you were able to treat the withdrawal with methadone or buprenorphine.

You mean, just cold turkey and use the methadone to treat the fentanyl withdrawls for the first 4-7 days, as you have suggested?

That would be my preference as well, but it's not up to me. I can get the medicines I need - clonidine and gabapentin. I might be able to get methadone.

But didn't you just explain to me that it is better to taper it slowly, and take a long time to get out of it, than to do it quickly like that?


"When you say "switching to another opioid will make this a lot easier though, because you won't have to spend as long tapering", why would I not have to spend as long tapering as with fentanyl?

The less discomfort you experience tapering, the more likely you'll be successful with the taper.

The relationship between discomfort and cravings is significant enough to make it a really good idea to do whatever you can to avoid unnecessary pain and suffering. All the more so because a proper taper takes a while (for instance, I spent about 18 months tapering off methadone, but boy am I glad I took my time).

Yeah, that was my instinctive understand as well.

Did you do it only on methadone without buprenorphine?

Can you tell me, is it just as practical to taper down to zero on methadone as it is on buprenorphine, or is it best to switch from methadone to buprenorphine?

Yes, as long as you give yourself to stabilize on a new dose, your system will acclimatize. The idea is to move in the direction of lower doses as consistently as possible. If you find a dose reduction is too much, there is nothing wrong with going back to the dose you were at just prior to the reduction, and stabilize more there before continue the reduction. In that case you could try to reduce it by the same amount or you could try to reduce is by a small amount. The point is to consistently move in the direction of less opioids.

Okay. Thank you. And thanks for all the advice.

But can you tell me what you mean, when you say "If you find a dose reduction is too much"? How will I know if the reduction is too much? How do I tell?

I guess I am asking: during tapering down, am I supposed to feel like normal, or will I constantly be in a sort state of withdrawal, and feeling ill all the time?

IMHO that sounds horribly impractical and not very realistic, but hey if you want to try go for it. Who knows. Just give yourself a backup plan no matter what.

I don't have a backup plan. My ultimate last resort is probably ibogaine. But I still don't think I would dare try it. But that's my only other option, as far as I know about.

The thing about gabapentin is that it is faaaaaar safer and easier to use effectively than the others.

I am glad you told me this. Then I won't try to use phenibut.

I'm sorry to hear this. 100mg methadone should be enough. Generally people do really well around 80mg. Some need more, some need less, but 100mg of methadone should be more than enough to see you through your acute fent withdrawal.

Ah, great! Thank you! That has eased my worries somewhat.

 

[Hatter]

Thanks Hodor!

Thank you very much for explaining it in such detail and depth!

I think I still have a pretty weak grasp of all this. I can't really picture what happens inside the receptor, or what happens when the receptor is activated, and what happens further down the line to combine to make the effects. I think it's just too many things I don't know in detail, for me to be able to picture it. Plus, as I said, my mind doesn't really work very well. My imagination is almost non-existent, and my intelligence must be very low. But I try to learn as much as I can, one step at a time, and keep hoping that eventually I will get an insight into something, and finally feel I have a gained some true understanding.

I really appreciate your effort to help me understand.

 

[Hatter]

hmm i wonder if tapering would work.

That's what I wanted to know as well, originally.

I have an acquaintance who said he was tapered down on buprenorphine over the course of some months. He said he didn't have nausea, but pain in his joints.

I think I could live with that, if that was all. But if I were to get more serious symptoms like Restless Legs Syndrome, I doubt I could go through that for even a week.

But maybe I could at a later point in my life, if I were more focused and had more inner strength. I don't know.

Thanks for trying to help me.

 

[Jabberwocky]

Hopefully others can give you a hand with some of this stuff, because the next two weeks are going to be insane for me IRL. If you still need feedback by the middle of next week and I haven’t responded please remind me.

A quick aside, seems like you feel pursuing buprenorphine might work, and I’d just encourage you to go with you gut. Just do please try to find a doctor or clinic or something to get you set with buprenorphine or methadone or something.

And let us know if you’re able to make any progress with tapering the fent. Nothing wrong with trying that as you get your plans ironed out. Good luck!

 

[cdin]

Really? But, I don't know. I have heard about people going insane on PCP and doing horrible things. I don't know how I'd react. I get very scared about going psychotic when I smoke Cannabis, and if that is anything like it, I probably would be very scared of losing my mind. I used to be so adventurous. I felt the truth would always lead to a good place, and being honest was never the wrong thing. Now I have turned into one of those people I used to think just didn't understand. And maybe I don't. Maybe I am all wrong, and mixing things up, and making all my own problems. I never thought I would become scared of looking into my own mind. But that's what has happened, ever since that stupid bad trip, when I decided I couldn't believe that the fear was an illusion, and I gave into it. I knew it would ruin my life if I did. I had always promised myself I would never believe what happened on a trip. Never give in to the fear. But I couldn't help myself. I was too frightened. After that terrible night, my life gradually disintegrated. I lost the ability to read. Everything I had built up, which required regular tending, all my abilities and insights, decomposed, just like a plant which isn't watered. I instinctively knew it would happen, and so it did. It was like being bord again, but not a good birth this time, but a very awful birth. In many ways, I am still just a child now, whereas I was much more evolved when I was 19. As I gave in, I actually felt myself falling from a great, great height, like I was all the way up in orbit around earth, and I fell all the way to the ground. The I Ching saying, "Not light but darkness. First he climbed up to heaven, then he plunged into the depths of the earth." has always reminded me of what happened back then. I don't know why it happened, or if there is a way back - I don't know how anything, no matter how good or paradisical could ever make up for all that suffering.

It is not at all like PCP. It is comforting and administered in a controlled setting and is the ONLY thing I know that could even approach handling a habit of your size. 100mg of fentanyl DAILY?! that's absolutely over the top. I'm so sorry you have to deal with this but like, at that level I don't think 16mg of suboxone would even cover it. Obviously no matter what you're going to have to taper... maybe eventually switch to morphine or something and continue tapering from there. that's a wicked, wicked habit you have. sorry about that ;( let us know if you get out of this one ok. Seriously think about the ibogaine. It takes the withdrawal away and is not a scary experience, although not necessarily easy either. my .02 ymmv

 

[Jabberwocky]

Yup, that’s why I suggested methadone over buprenorphine. Buprenorphine would be waaay better than nothing, but methadone would probably give significant more relief.

I think the major take away with this is that, given the size of this habit, recovery is going to take a good long while. It’s not a good idea to assume one can just get over the withdrawal, because regardless of how its treated it is going to be a trying experience.

Just trying to say it’s best avoided assuming this is just something one will be able to overcome with a few meds and that’s it. I mean, it’s true to say that, but it will take a lot of preparation, time and effort to bounce back from something like this.

It’s true what they say: all good things come with time. Pls just try not to rush through this OP. Better to take your time and figure it out instead of getting into the position where you end up relapsing because it gets too uncomfortable rushing or something.