Managing Opioid Withdrawal

The first step in discontinuing opioid use (OUD) is the withdrawal period. Opioid withdrawal can be extremely difficult to tolerate. Effective treatment of withdrawal is crucial to the success of staying abstinent long term. An array of treatment options are available: opioid medications, non-opioid adjunctive medications, and a host of non-pharmacologic therapies including nutrition, exercise, and alternative modalities. 

Understanding Opioid Withdrawal 

If you're a longtime user of any kind of opioid, including illicit drugs like heroin and prescription painkillers like Vicodin, you'll likely experience withdrawal symptoms on discontinuation. 

Everyone is different, and your symptoms and timeframes are as unique as you are. But most people follow a predictable pattern after their last dose:

• 8–24 hours after the last dose: Symptoms include nausea and vomiting, anxiety, insomnia, hot and cold flashes, perspiration, muscle cramps, watery discharge from the eyes and nose, and diarrhea.
• 48–72 hours after the last dose: Symptoms intensify, and you may experience diarrhea, abdominal cramping, and chills. Drug cravings intensify.
• 72 hours after the last dose: Symptoms begin to fade, but your drug cravings may increase. 
• Days 10–20: Your symptoms improve and eventually fade, however cravings may persist

The intensity of withdrawal depends on factors like the specific opioids you took, how long you've been misusing opioids, your overall health, and your family history.[1]

Medications like Suboxone reduce withdrawal symptoms and lower your relapse risk. They can be incredibly important in helping you to withdraw comfortably and maintain abstinence. 

Treating withdrawal

Opioid based medications

Management of acute opioid withdrawal symptoms is the first step during opioid discontinuation or dose reduction.

Of the three principal types of opioid-based medication assisted treatment (MAT) for opioid use disorder — methadone, buprenorphine/naloxone (Suboxone) and naltrexone — Suboxone is often preferred because it can be prescribed by licensed medical provider in any treatment setting, whereas methadone can only be provided through federally licensed treatment centers.

Prior to starting Suboxone, the individual should be experiencing mild-to-moderate withdrawal symptoms from the opioid that they were taking previously—in order to prevent precipitated withdrawal.

This first phase of Suboxone treatment is sometimes called the initiation phase. During this period, effective treatment of withdrawal symptoms is a crucial first step on the pathway to successful OUD treatment because the distress in the first few days after discontinuation can be severe. Without adequate treatment, many patients are unable to sustain abstinence from opioids (2019 clinical review).

Non-opioid/adjunct medications

Evidence for the effectiveness of treatment of withdrawal symptoms with opioid medications (MAT) is by far the best. The evidence for non-opioid medications in treating withdrawal is not as strong. However, these medications can be good adjunctive, or additional, medications to use, or good substitutions if MAT is not available or tolerable. Some adjunctive, non-opioid medications include:

• a-2 adrenergic agonists can be useful in treating the symptoms of anxiety, tremors, and restlessness. Clonidine is the medication most commonly prescribed for this purpose. However, there are a few others: The FDA approved lofexidine in May 2018 and it is the first non-opioid medication indicated for treatment of opioid withdrawal symptoms. One clinical review paper concludes that “Clonidine and lofexidine are more effective than placebo for the management of withdrawal from heroin or methadone”

• Loperamide, an anti-diarrheal, can be used to treat GI upset and diarrhea symptoms. 
• Bentyl, an antispasmodic, can be used to assist with stomach cramping. 

Talk to your doctor if you have questions about whether any of these medications are right for you. You can learn more about managing withdrawal symptoms here.

Nutrition, hydration and exercise

Depending on the severity of the addiction, patients with OUD often go long periods of time without adequate nutrition and can be malnourished. Opioids also affect the gastrointestinal system in numerous ways. Constipation is a common symptom of opioid use, and conversely, withdrawal often causes the opposite symptom of diarrhea, nausea and vomiting. This can all lead to nutrient losses, imbalance of electrolytes, and dehydration, that can further exhaust a person as their body goes through withdrawal.

Thus, adequate hydration and nutrition are essential as the body undergoes withdrawal. Eating balanced meals, maintaining a high-fiber diet with plenty of complex carbohydrates (such as whole grains, vegetables, peas, and beans), maintaining adequate hydration and increasing dietary intake of protein can all help to strengthen the body as it goes through withdrawal. 

Light exercise is encouraged as endorphins released by physical movement can improve mood and pain tolerance. Endorphins themselves are natural opioids. 

Psycho-social support

Psycho-social support from both professionals and loved ones is essential during withdrawal. Families are encouraged to create a judgment-free, loving environment. If you are concerned about a loved one’s recovery process, speak up! For more information on how to have this conversation, here are several helpful websites/resources:

• https://www.samhsa.gov/sites/default/files/samhsa_families_conversation_guide_final508.pdf
• https://www.samhsa.gov/families/resources
• additional guidelines regarding family support and guidance.

Do You Need Medical Help?

Opioid withdrawal is never a life threatening condition, but can be extremely uncomfortable and can lead people to relapse, which can be life threatening: [2] 

If you are planning to discontinue opioid use and are hoping to prevent withdrawal, talk to your doctor about how best to proceed, and whether Suboxone might be right for you in easing withdrawal and preventing a relapse more long term. 

To learn more about the success rates and safety of Bicycle Health’s telemedicine addiction treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment here.