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Opiate and opioid withdrawal: Coping strategies and medication

knock

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Dec 30, 2009
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Purpose of this Thread

This thread is a place where we can discuss the withdrawal symptoms of opiates and opioids, coping strategies and medication.

The intention is to have one place where people going through the physical and psychological withdrawal symptoms can find ways of dealing with them. Where there are risks involved in medication, we need to make this clear too.

It should be a self-help guide, although self-help can include going to your doctor and asking for specific treatment. It's not about rehab, overcoming addiction, or staying clean - although it should help people who are trying these. It's not about encouraging abstinence. It's about dealing with the symptoms of abstinence, and the symptoms of the process of becoming abstinent, whether it's temporary or permanent, self-imposed or forced upon us.
 
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The Summary

In this post I will try to summarise what gets discussed in the thread. For instance, if someone mentions that X medicine or coping strategy will help with Y withdrawal symptom, I will note that medicine or coping strategy under the relevant withdrawal symptom heading. I'm not sure at the moment how this will work, exactly, but given some time I hope a handy reference guide will emerge. I'll start off with a couple drawn from my own experience.




General Strategies for Becoming Abstinent
There are two ways to cease your opiate or opioid use: Immediate cessation (cold turkey) and gradual cessation (tapering). In both cases, the body will eventually restore it's normal chemical balance, and you should be able to cease symptomatic treatment. However it's not possible to give a universally applicable figure for how long this will take as it depends on the drug(s) you are taking, the dosage, the frequency of use and your own personal biology.

Cold Turkey
In this strategy, you simply stop taking the drug.

This method will lead to the most severe withdrawal symptoms, possibly so much that you are driven to resume use - however the aim of this thread is to help you manage those symptoms, so this is not necessarily a reason to avoid this method.

You may in fact be less tempted to resume your original dose. You can throw out your stash, cut off your supply to the drug, so you won't have it readily available and it might play less on your mind.

Tapering
In this strategy you continue use of your drug at the current dose and frequency for a period of time. Then you reduce your dose by a certain amount and continue again for a period of time, and so on, until you eventually reduce your dose to zero.

This method should reduce the severity of all withdrawal symptoms. However, for some, it may not be possible. You may no longer have access to your drug of choice. You may have a requirement to immediately cease use of your drug - for example, to pass a drugs test.

You may also be inclined to abandon your abstention. Because you're planning to take the drug, you will certainly have it available, and therefore if the temptation arises to go back to your original dosage, you will be able to do so.

Comparison of Cost

Depending on the cost of your opiate or opiod, and the cost of any medications you might use to treat withdrawal symptoms, one method may be more expensive than the other. If you're tapering, because you're still taking your drug, you're probably still paying for them. However, if you're using medicines to treat withdrawal, they may also be expensive. If the medicines you would take to combat withdrawal using the Cold Turkey method are more expensive than the amount of your opiate or opioid, then tapering might in fact be more affordable.




General Withdrawal Symptoms
  • Switching to a different opioid may be useful. For example, Tramadol may alleviate the withdrawal symptoms in a general way. Kratom may also help general symptoms.
  • Dissociatives can provide temporary relief from withdrawal symptoms. Methoxetamine in particular has been used to good effect.

Specific Withdrawal Symptoms

Sweats
Withdrawal can lead to quite extreme levels of hot flushes and sweating. This may be continual, sporadic or associated with specific times, like during sleep.
If you're sweating a lot, it's important to keep hydrated. Drink plenty of water, or vimto, or ribena or something.

Treatments
  • Clonidine
  • Exercise may help restore the body's temperature regulation



Sniffles
One of the most common withdrawal symptoms is a bit of a runny nose.

Treatments


Nausea and Vomiting
Treatments
  • Cannabis
  • Antihistamines (H1 histamine receptor antagonists)
  • Ginger
  • Peppermint


Diarrhoea
Treatments
Immodium


Depression, Apathy, Lethargy and Anxiety
Treatments


Chills and sensitivity to the cold
Treatments
Baths

Fevers
Treatments
Baths

Aches and Pains
Treatments
Baths

Insomnia and other Sleep Disruption
Treatments
  • Temazepam
  • Melatonin
  • Phenibut
  • Exercise - wear yourself out!
  • Don't watch TV, or use laptops or phones with bright screens, in bed. The light will trick your brain into thinking it's not bedtime. Reading in bed is a much better way of encouraging sleepiness.
  • Sex and sex "alternatives" are usually a good way for men, in particular, to get to sleep ;)
  • Avoid excessive alcohol. Contrary to much popular opinion, alcohol can keep you awake, but for some people a glass of red wine (Merlot in particular as it contains significant levels of melatonin) can help.
  • Milk contains tryptophan which encourages sleep. A mug of warm milk may help you slip off into unconsciousness. Chocolate contains stimulants such as caffeine and theobromine, so hot chocolate may be counter-productive. A banana milkshake might be a suitable alternative if you can't face drinking raw milk, and if you make it with real bananas you get a bit more tryptophan too, and they're full of other useful minerals.



Restlessness, Restless Leg Syndrome
Treatments
Wikipedia's notes on RLS treatment suggests the use of dopamine agonists or gabapentin enacarbil.
  • Cannabis has been reported to help with this.
  • Clonidine is also mentioned as a potential treatment for RLS.
  • Exercise may also help; however it is also possible that it will (temporarily) make your RLS worse! So you should try it and see what works for you.
  • A Chinese burn just above the ankle!
  • Sex and sex "alternatives" release dopamine and should help with RLS, at least for a short time - hopefully enough to get to sleep.
 
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Notes on Medications

Some of the medications which we might use to treat withdrawal symptoms carry their own risks. Some have the potential to cause dependency; some may be dangerous to use in combination with others; and some may be dangerous for those with certain medical conditions. It is advisable, wherever possible, to plan your treatment of withdrawal symptoms in consultation with a knowledgeable doctor. However, doctors sympathetic to opiate users and familiar with the possible treatments for symptomatic relief may be difficult to find. But it's always worth asking.




Clonidine

Clonidine's primary use in opiate withdrawal is to control sweats and hot flushes.

wikipedia said:
Clonidine (trade name Kapvay or Nexiclon) is a sympatholytic medication used to treat medical conditions, such as high blood pressure, ADHD, anxiety/panic disorder, and certain pain conditions. It is classified as a centrally acting α2 adrenergic agonist. An alternative hypothesis that has been proposed is that clonidine acts centrally as an imidazoline receptor agonist.

Clonidine may be used to ease withdrawal symptoms associated with the long-term use of narcotics, alcohol and nicotine (smoking). It can alleviate opioid withdrawal symptoms by reducing the sympathetic nervous system response such as tachycardia and hypertension, as well as reducing sweating, hot and cold flushes, and general restlessness.[5] The sedation effect is also useful although its side effects can include insomnia, thus exacerbating an already common feature of opioid withdrawal.

Clonidine treats high blood pressure by stimulating α2 receptors in the brain, which decreases cardiac output and peripheral vascular resistance, lowering blood pressure.

Total daily dosage for the treatment of opiate withdrawal range between 0.5 and 1.5 mg[citation needed], depending on the stage as well as the severity of withdrawal symptoms. If the clonidine patch is used to treat nicotine withdrawal symptoms, dosages that deliver 0.1–0.2 mg daily are used. For oral therapy (tablets), a total dosage of 0.2–0.4 mg daily is taken in divided doses.

As Clonidine will lower blood pressure, it may be dangerous for those who already suffer from low blood pressure.

wikipedia said:
...sudden discontinuation can cause rebound hypertension due to a rebound in sympathetic outflow. Clonidine therapy should generally be gradually tapered off when discontinuing therapy to avoid rebound effects from occurring. Treatment of clonidine withdrawal hypertension depends on the severity of the condition. Reintroduction of clonidine for mild cases, alpha and beta blockers for more urgent situations. Beta blockers never should be used alone to treat clonidine withdrawal as alpha vasoconstriction would still continue.

So use of clonidine itself should be tapered. Rebound high blood pressure can be very dangerous; I personally know of a man who cut his blood-pressure medication which resulted in a burst blood-vessel in his eye, permanently damaging his already poor eyesight.

Clonidine may also have some promise in controlling restlessness / restless legs:

pubmed.gov said:
A 37-year-old man developed severe symptoms of RLS. Treatment using combinations of levodopa, opioids, benzodiazepines, and baclofen provided only partial benefit or resulted in intolerable adverse effects. Higher dosages of clonidine than previously reported in the literature (0.9 mg/d in divided doses) were needed to completely relieve his RLS symptoms. The only prominent adverse effect was dry mouth. The RLS symptoms returned after subsequent reductions in the dosage. After the dosage of clonidine was again increased, complete relief of the symptoms was achieved again. After several months, clonidine was tapered to zero and the patient entered a period of spontaneous remission. When his symptoms returned four months after clonidine had been discontinued, clonidine therapy was restarted.
DISCUSSION:

Clonidine alleviated RLS symptoms in 30 of 41 patients reported in the literature, indicating that the adrenergic nervous system may play a role in RLS.
CONCLUSIONS:

High-dose clonidine appears to be useful in treating RLS when other therapies fail. However, well-controlled, polysomnographic studies are needed.

One interesting fact about Clonidine is that it's cheap as chips if you can locate the cheap-as-chips source. Like 99p for 10 pills.




Kratom
wikipedia said:
Kratom contains many alkaloids including mitragynine (once thought to be the primary active constituent), mitraphylline, and 7-hydroxymitragynine (which is currently the most likely candidate for the primary active chemical in the plant). Other active chemicals in kratom include raubasine (best known from Rauwolfia serpentina) and some yohimbe alkaloids such as corynantheidine. Kratom also reportedly contains at least one alkaloid (rhynchophylline) that is a calcium channel blocker, and reduces NMDA-induced current. There is considerable research as to the role of NMDA receptor activity in the formation of dependence, and the symptoms of withdrawal. In 2005, Inturrisi demonstrated that co-administration of d-methadone (the isomer that lacks opioid activity, but is an NMDA antagonist) in small doses with morphine prevented the development of morphine tolerance in rats.

Kratom is a µ-opioid agonist so can itself lead to dependency, and it's been reported that the withdrawal symptoms can be unpleasant. However, at low doses, say 5-10g a day, and if used for a short period of time, it's likely that you will not develop a tolerance, and that any withdrawal symptoms would be mild.




Stimulants
Stimulants may help with lethargy, apathy and general low-mood. Choice of stimulant will depend on various factors:
- severity of the symptoms
- any other medication you're taking
- availbility
- preference.

Typically, when trying to achieve "normality", what you'd look for is a mild stimulant which provides focus, motivation and clear thinking, and with minimal "crash". A longer-lasting stimulant is probably more desirable, so you don't need to redose frequently. It should be something that you can use regularly without building a serious tolerance, or indeed a dependency. Things like Cocaine, MDMA, Mephedrone etc. are probably unsuitable ;)

Different people have differing results with the same stimulant. I find ethylphenidate works very well for me. I don't get any crash, I can think clearly and with focus, I don't feel a compulsion to redose, and it gives me a lot of motivation. It's also, currently, legally available (in the UK anyway) as a research chemical. However there are many other alternatives which might suit others better.
 
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So, here's my initial stab, it's very much a draft and full of holes. Please give me your feedback and ideas! I've got three empty posts you can't see which are ready for use if we need to split out the information into more sections or add new sections.

I've been told Tramadol will help. Do many people use tramadol for the WDs?

How long are tapers, typically? What sort of dose reduction schedule do people use?
 
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Thanks for doing this knock, I'm sure this'll be a very helpful thread :)
Just a few quick thoughts - you may wanna add nausea/vomiting to the specific symptoms thing; and in treatment options for insomnia/sleep disturbances, I find temazepam in particular to be great. Also, this is going to sound dumb but baths actually go a ridiculously long way in helping with the chills/fever/general aching.
 
Another tempory treatment for restless leg, or when it feels like there is snakes in your legs is get get someone to give a Chinese burn just above the ankle. I didn't believe it when I heard it in a detox centre from some ti-chi guru, but believe me it's the best, most instant relief from it I have felt.
 
Interesting. I will add Chinese Burns to the list! :)


So, what do people suggest for:

Nausea and vomiting - I'm guessing cannabis would help here?

Chills and sensitivity to the cold (other than baths) - is there a drug to help with this? The only fix I found was more opioids.

Fevers - again, other than baths, more opioids worked for me, or taking my jumper off and fanning myself.

Aches and Pains (we've covered baths) - Just the usual low-grade painkillers like ibuprofen and paracetemol? Or something better?

Also, any WD symptoms that I've missed?

I suppose diet plays an important role too, maybe supplements? And keeping hydrated?
 
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Mmh I guess we could add anxiety/general restlesness? Which I personally treat with alprazolam :)
Nausea and vomiting - cannabis does help, as well as your basic OTC medicine really.

As for diet, since eating is usually the last thing on my mind during WDs I try to force myself to eat bread mostly and anything easy to digest that I also eat if I have the stomach flu for instance. Carbonated sodas are also supposed to be very helpful. Eating/drinking does help with the nausea eventually and I'm sure it contributes to healing faster overall.

Also maybe we could add that for people who live in countries where you can get OTC codeine, it really is a miracle...obviously it's an opiate so I guess that doesn't work if you wanna be 100% clean, but it helps calm down pretty much all of the symptoms.
 
Thanks Pagey, you're our top contributor! <3

I'm taking a break for dinner and then some personal business but keep the ideas coming and I'll take care of updates later on.
 
I have a habit of 13 years. (Unlucky for some ;) )
It isn't a big habit, about 0.2 a day smoked if I am lucky.
I am finding that when I want to do h free days i have to drink about 30 ml of green in the morning. I may have to drink another 15-25 later on in the day. i will do this for the 1st 2 days without heroin. Then I will drink a little bit less on the 3rd and 4th day in 2 doses rather than 3 doses.
I may smoke heroin on the 4th day, i call it a methadone break.

grrrrrr. I will be back. i do hit that 4 day "need to smoke something" barrier.

Am thinking of using poppy tea to help out with this. Any worries anout that being mixed with methadone and in what quantities?
 
I could go on but I have other stuff to do. i will be back.

it is good to be very busy and do some exercise .

I wear lots of layers to keep warm. People who don't know laugh when they see me stripping off. The clothes just keep on coming. I sweat terribly though. layers are the best because you can take them off and put them back on.

I must say as well that it is quite nice to go to sleep and wake up straight headed, but as I noticed last week it's a bit scary when everything comes back in 3 dimensions as well as in high definition.
 
Backroll's 10 Point Plan

1. Taper down whatever you are on to the lowest you can go
2. This is the time to then jump off...I don't personally advocate the use of further opiates here (such as subs or less strong things like codeine). My theory is that you are going to be dragging out the pain if doing this. You are going to fucking suffer as it is, but if you tapered (over 2 weeks minimum) then this won't be anywhere near as bad as cold turkey
3. 2 types of BZP...something for the daytime (diazepam or clonazepam) and something to sleep (moggies or xanax)
4. Multivitamins & Loperamide Hydrochloride both in massive doses
5. 5-Htp, L-theanine etc etc. Whether you think these are mumbo jumbo hippy shit or not they do work
6. Try and eat and live well (your instincts will be to eat junk, which is fine, you are probably just happy to be eating again, but not best long-term) A bit of exercise similarly will seem like the last thing you want to do. But where else you gonna get your dopamine from? Apart from shagging! Which after 2 weeks is all you will be thinking of! Warm up with some good wanking sessions
7. Long-term thinking...tomorrow won't be as bad, take everyday day as it comes, get through hours and minutes if days are too long
8. Hot baths / cold showers. Really helps with the RLS
9. Delete those fucking numbers like my man says! And change your number! You are kidding yourself if you don't
10. WEED. Now this doesn't work for everyone but I personally find it to be almost as helpful as BZPs. It is like having company and strong enough to be both physically and mentally soothing.

Good Luck:D
 
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People have mentioned other drugs here...MXE is helpful for sure, as is DXM, I personally like smoking loads of crack=D

Just make sure you know how to come down off whatever it is, and aren't going to get addicted to it.
 
Gabapentin is helpful for RLS as well as low mood and physical discomfort, but not as much as carisoprodol, from what I've read and been told. Tolerance to gabapentin's therapeutic effects however develops very fast so it's only helpful for those first three/four days of acute discomfort, after which its validity as a palliative for opiate withdrawals is negligible.

Tolerance to gabapentin (or to the mostly superior pregabalin) does build rapidly, but usually not so rapidly that the effects are only useful for three/four days.

Being high 24/7 on pregabalin would be possible for at least two weeks without ever going over 600mg per day, I'd say. Especially when potentiated by benzo's, which allow you to keep the dose of both as low as possible.

Pregabalin absolutely slays the depression/lethargy/gloom of (light or moderate) opioid WD for me. It feels like a tamed long-lasting GHB to me without the jitters/rebound stimulation.
 
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I reckon in the name of Harm Reduction and Addiction Swap/Substitution I have to put forward a couple of comments regarding Kratom, as I have pretty much been taking it daily since 2007, with two six month long interruptions due to working abroad/travelling, so I have experienced the good, helpfulness but also the bad.

1: Quote "It is reported that Kratom WDs can be unpleasant". I'd say that is a massive understatement, I know that myself included and a couple of other people were actually taken by surprise by both the severity and sheer lenght of long-term, high dose kratom WDs.

True for the short term, at the doses you mention it is unlikely you will have bad WDs, however the doses mentioned, which I feel are quite low, especially if somebody is using kratom as an opiod substitution substance.

I know that even if it's after a couple of weeks of daily oxy, I would need at least 25 grams of kratom leaf before all the WDs symptoms are taken care of. I have a friend who I lived with who used kratom to come off heroin and he used to dig into my at the time multiple-kilo stash of bali leaf several times per day, I think he was probably eating up to 50 grams a day to effectively negate WD symptoms from daily brown.

If somebody is coming off any opiate stronger than codeine and needing kratom to come off, it is very likely a dose under 10/15 grams would not even be felt in the slightest and would not provide any comfort.

2: WDs from kratom itself: I have to say that I don't have that much experience with proper opiates, apart from a few month stint with oxy in the US and other weeks of occasional binging also with oxy, I have never really consumed any heavy duty opiate on a daily basis for a period longer than six months so I can't comment too much. But for me even a three month oxy habit (daily dose anywhere between 40/80 mgs) is much much easier to come off than kratom. While with oxy most of the bad physical symptoms would be pretty much gone by the third day of abstinence, with kratom WDs haven't even peaked by then. It usually takes me at least 48 hours to develop full blown WDs, sweating, diarreah, vomiting, gagging reflex, yawning, runny nose, red devil eyes that itch and lacrimate, no energy, shakes, uncrontrollable ejaculation(fucking awful that one), severe anxiety, inability to sleep or eat. For me if quitting after three or four months of daily oxy would be sorted within less than a week(3/4 days), with kratom symptoms last for at least twice the amount of time and are more severe in intensity, I have managed to attend conferences and work after quitting oxy, but could never do that with kratom.

Also the worst thing is the depression and lack of motivation, will to live, severe dysphoria that sets in after a week and lasts for as long as it took me to pick up another habit, methoxetamine in my case, the last time I quit long term daily kratom.


Also another thing, high dose LOPERAMIDE. I feel this hasn't been stressed enough in the OP, but taking high doses of immodium, actually negates a lot of the symptoms, not only diarreah, but in my experience it helps with restless legs, yawning, runny nose, itchy eyes, anxiety, depression and sleep. It actually enables one to attend work and not be confined home for days on end. A taper plan starting with 80/100 mgs of loperamide the first day, that's 40/50 pills, with a daily reduction over the course of the week, helps tremendously with opiate WDs. I buy bottles of American loperamide online as here in Europe in pharmacies they only have small boxes with like 16 pills, online you can source bottles with up to 200 pills. I have one bottle in my backpack, which is always with me whenever I leave the house, and other stashed at home just in case.
 
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Also another thing, high dose LOPERAMIDE. I feel this hasn't been stressed enough in the OP, but taking high doses of immodium, actually negates a lot of the symptoms, not only diarreah, but in my experience it helps with restless legs, yawning, runny nose, itchy eyes, anxiety, depression and sleep. It actually enables one to attend work and not be confined home for days on end. A taper plan starting with 80/100 mgs of loperamide the first day, that's 40/50 pills, with a daily reduction over the course of the week, helps tremendously with opiate WDs. I buy bottles of American loperamide online as here in Europe in pharmacies they only have small boxes with like 16 pills, online you can source bottles with up to 200 pills. I have one bottle in my backpack, which is always with me whenever I leave the house, and other stashed at home just in case.

I completely forgot...this is crucial. It will not only help your bottom, and tummy but will actually alleviate other symptons at high doses.

CRUCIAL
 
any one got any rough equivalents of poppy tea? pods = 1 bag or pods = 10 ml green
 
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