Pharmaceutical Tools for Opiate Detoxification
This originally started as a short, unofficial guide for my doctor friends to use in helping patients come off opiates. I put this together myself and it should be noted that the medications outlined below require a prescription and monitoring in some cases, therefore please seek a doctors advice as I am no doctor. I was a compounding pharmaceutical rep who supported doctors, and this was during the time of the Florida opiate purge where the law enforcement started shutting down the horrible pill mills dealing prescription narcotics in volumes that would startle you. When the hammer came down there were (and are) so many patients cut off from opiates and seeking help for the agony of WD they were not prepared for. There is so much more behind this and one day I will put it all together and get the info out there. I am sharing this excerpted protocol because it will hopefully serve a better purpose for someone than being stuck on my desktop.
Here is a list of comfort medications that can assist a patient experiencing Acute Opiate Withdrawals Symptoms (initial 1-2 weeks) after discontinuing their last dose.
1.
Suboxone or Subutex: Prelude: Suboxone (Buprenorphine) only provides any benefit when administered within the initial 24-48 hours of acute withdrawal symptoms (AWS) and used short-term. Suboxone or Buprenorphine should be administered only after the patient has started experiencing withdrawal symptoms, therefore it is recommended that the patient has completely abstained from opioid drugs for a minimum of 12 hours prior to starting buprenorphine.
Do not provide buprenorphine to a patient who is already beyond 48 hours of acute WD as this will only lengthen WD. Acute WD last average 3-10 days, if the patient has been in acute WD for 48+ hours do not admin buprenorphine and skip to #2 below. Patients are recommended to receive 2mg-16mg per day, depending on degree of withdrawal symptoms. Relief of AWS will occur within 15min of initial dose. Suboxone can be a great tool when utilized correctly, but unfortunately many opiate “detox” doctors fail to recognize the danger related to improper and long-term prescribing which is only replacing one opiate dependency with another. Suboxone (Buprenorphine) should only be used for the short-term relief of acute-withdrawal-syndrome (AWS), which occurs within hours of the patient's last dose of abused/prescribed opiate (oxycodone, hydrocodone, morphine, etc). Remember, buprenorphine is also an opiate and can increase withdrawal symptoms if taken too long. The difference between buprenorphine and commonly abused opioid medications is that bupe interacts differently with opioid receptors in the brain. In simplified terms, buprenorphine can essentially be thought of as a non-selective, mixed agonist–antagonist opioid receptor modulator, acting as a partial agonist of the MOR, an antagonist of the KOR, an antagonist of the DOR, and a relatively low-affinity, weak partial agonist of the ORL-1. Many experienced opiate dependent patients report that withdrawal symptoms are more severe and last longer in duration after long term suboxone use than with commonly abused short-acting opioids like oxycodone. This may be due to the strong affinity buprenorphine has on opioid brain receptors along with its lengthy half-life. On the contrary, experienced opiate dependent patients who have experienced WD report that the severity of WD symptoms can be significantly reduced when buprenorphine is administered within 24 hrs of WD onset and titrated down over 3-10 days where it is then discontinued. The Acute Withdrawal Symptoms (AWS) are the severe physical withdrawal symptoms that occur from physical/psychological dependency and they can last from 3 days-10 days. Withdrawal from long term use of longer-acting opiates like Methadone and Buprenorphine can last 24+ days. Acute Withdrawal symptoms are described as physically and emotionally torturous- sometimes unbearable for the patient to experience without medical assistance. Here are some of the symptoms of AWD; “Diaphoresis, nausea, constant yawning, lacrimation,tremor, rhinorrhea, extreme irritability, dilated pupils, resp. rate, pulse>90 Severe Signs (begins 12-48 hrs after last dose): Insomnia, elevated T,P,R,& BP, nausea,vomiting, abdominal cramps, chills, diarrhea, muscle twitching,dilated pupilsCourse: (1) Heroin: onset in 8-12 hrs, lasting 5-10 d, untreated.(2) Methadone: onset in 24-48 hrs., lasting 2-4 wks.” Note, the AWS symptoms mentioned above were an excerpt from a medical website. In reality, many of the most uncomfortable symptoms can last for a few months to one year depending on the patients drug use, lifestyle, and underlying illnesses.
**Suboxone should ONLY be used to manage AWS for 3 days- 10 days maximum. (10 days being reserved for high tolerance patients- inpatient advised). Due to its long acting nature and ability to attach only to specific, less rewarding, opioid receptors using Suboxone can help alleviate AWS significantly, making the patient more comfortable during the AWS phase. Using Suboxine any longer than 10 days will cause a tolerance and therefore further WD syndrome caused by the long acting Buprinorphine found in Suboxone.
Suboxone dosing:
Many physicians mistaketly start with a dosage that is too high and not necessary for the goals at hand. This improper dosing is probably due to the recommendations provided by the pharmaceutical companies coupled with the doctors not understanding addiction and subsequent withdrawal. The drug manufactuerer recommends 8mg-16mg daily, however this is a quick way to increase the patients tolerance very quickly and enable a dependency for the Suboxone. Rather, a lower dosage should be used for a short period of time. 2mg-4mg appears to work well for moderate cases of AWS while 6mg appears to work for more severe cases.
Suboxone should be quickly titrated starting after the initial dosage.
What can patients expect after Suboxone: There is no miracle drug that will eliminate with discomfort and agony of opiate WD, Suboxone included. When used correctly Suboxone will significantly reduce the severity of AWS allowing for a more comfortable detox as your receptors self titrate down as the opiates leave the body. Nevertheless, when Suboxone is discontinued the patient will still experience withdrawal symptoms at varying degrees depending on the person. The AWS symptoms will start to resolve progressively over 2 weeks after the last dose.
Additional compounds that can safely be used during and after Acute Opiate WD
2. Clonadine: Upon interviewing numerous opiate dependent patients (and addicts) all commonly mentioned this important tool for helping reduce the severe discomfort that occurs with AWS. Here is an excerpt from an opiate detox forum, someone's explanation of what the medication called clonadine helps with physically:
Clonadine also reduces the usually very high BP in patients experiencing withdrawals. Detoxing patients have reported that clonidine saved them from much of the physical suffering associated with acute withdrawal. Patients blood pressure must be taken prior to taking clonadine, and a BP cuff should be provided to them to take home, so they may record their BP prior to taking clonidine. This is just a safety precaution as many detoxing patients use clonidine safely without monitoring, although this is not recommended. In addition one of the typical symptoms of WD includes elevated BP in which low dose clonidine can be low risk due to reduced possibility of lowering BP too low.
Excerpt from online detox forum of person describing clonidine use during acute WD from opiates:
**“Clonidine can help minimize the following WD side-effects; panic/anxiety; hole in gut; heebie-jeeebies, kicking leg sensation, sleep issues. Some have reported that it also helps with associated sweats.When taking Clonidine you may experience a dry mouth and sense of lethargy....feeling like you're walking through mud. Guard against any quick, sudden movements like picking up your head too quickly”.
1.Vistiril: An anti-histamine which helps with two things; opiate withdrawal produces a histamine response which makes the patient have runny eyes, nose, and itching. Vistiril will help treat this symptom along with reducing anxiety and assisting in sleep. It is a very potent anti-histamine similar to Benadryl but much stronger and more effective at reducing some anxiety while providing some sedation. This medication may be used a few weeks beyond the suboxone to help manage the mild withdrawals that occur after suboxone therapy. Patients cannot expect any of these medications to completely eliminate WD symptoms. This includes Vistiril. In the minimum these medications will provide comfort and reduce the severity of WD symptoms.
Other comfort Medications used during WD;
Milk of Magnesia
Imodium AD (higher dosages can relieve the stomach WD symptoms)
RX strength Motrin (for re-bound pain which will occur)
Supplements Needed: Use for 6-12 months post-acute WD-
1.Multi-Vitamin/Mineral High potency/quality- take daily
2.DL-Phenylalanine (1g-2g daily): Restores natural endorphins
3.5-HTP (100mg TID): Restores serotonin and provides calming effect (don't use with SSRIs)
4.Magnesium: Helps with muscle pain, tension, spasms, and promotes relaxation
5.Methylcobalamin injection once per week: Restores appetite, reduces nerve pain, improves energy
6.B-Complex 100mg daily: Helps with mood, energy, and CNS repair
7.Glutathione (IV would be beneficial since most pain meds have acetometaphin which causes high liver enzymes): Expedites detoxification process and restores liver health
8.Glycine (Administer 10ml IV)- Helps restore neurotransmitters in the brain. Improves mood.
A compounding pharmacy can compound 2-3 formulations combining the above nutracueticals and provide them as part of the detox program. Here is an example: •1 capsule contains:
•500mg DL-Phenylalanine
•100mg 5-HTP
•100mg magnesium
DLPA-This particular supplement would help increase levels of serotonin, dopamine, and endorphins, which are deficient in the brain after opiate use. DL-P is clinically proven to help manage pain and also reduce opiate tolerance. Patient would take 1-2 capsules 3 times per day.
The program should be divided into two phases:
Phase 1 would deal with the initial acute withdrawals which occur after stopping the opiates. This phase would last from 1-2 weeks, and up to 30 days for those discontinuing methadone. The majority of the pharmaceuticals, such as Suboxone, will be used just for this phase.
Phase 2 will deal with the recently identified Post Acute Withdrawal syndrome, which can last from 30 days to 1 year after discontinuing opiates. PAWS (see below). This phase will utilize nutrition, nutraceuticals, and alternative therapies to assist the brain as it heals from long term opiate use. Some of these supplements, such as DL Phenylalanine, will help the patient manage some physical symptoms along with helping the central-nervous-system increase its production of neuro-hormones. Many symptoms of withdrawal are caused by a deficiency of a nuero hormone caused by opiate use.
**Don't forget to check hormone levels and treat deficiencies. Especially Testosterone.
**Long term. Opiate use causes hypogonadism.
http://defymedical.com/resources/he...suppression-in-patients-with-opioid-addiction
**ED/Low T and opioid use: http://defymedical.com/resources/he...sfunction-may-be-tied-to-prolonged-opioid-use
Testosterone helps with pain perception:
http://defymedical.com/resources/health-articles/149-testosterone-tx-may-ease-pain-perception
by Jasen Bruce