Opioid Withdrawal Treatments

A post on the Forum asked about the best remedies for opioid withdrawal.   I will review the medications and other treatments for opioid withdrawal that I have heard discussed by physicians or by people on the internet.  Hopefully readers will leave comments about medications or approaches that they have found useful.  Likewise, if you are a physician, please weigh in with the approaches that you have found to be useful.
For readers, it is very important to understand a couple things about this post.  First, the medications listed here are not FDA approved for treating opioid withdrawal.  They have not been systematically tested for that purpose. Most of the medications that I will list are available only by prescription— and must be taken ONLY by prescription.  They all have interactions with other medications, and they all have toxicity in certain doses, and in people with certain conditions.  Do NOT take them other than through guidance by your doctor.  This post is intended to spark discussion with your doctor— and to help doctors learn about approaches that they have not heard about elsewhere.
I will encourage doctors or other contributors to this post to avoid discussion specific dosages.  These medications must be prescribed by physicians who understand them, or who know how to become knowledgeable about them.
One problem for doctors is that CME meetings generally discuss treatments that are FDA indicated.  I do not know of any medications that have been approved or marketed specifically for opioid withdrawal, and I do not have the sense that the field of medicine views opioid withdrawal as a pressing issue.  But I am aware that for buprenorphine patients, the treatment of withdrawal symptoms has the highest priority of any medical concern.
With those caveats, here are the medications that I have heard the most about, roughly in the order of what consider their usefulness:
– Clonidine:  Available by tablet or by patch.  The medication reduces CNS excitability, and relieves all opioid WD symptoms to some extent.  Side effects include sedation (which may be useful), dry mouth, and hypotension.
– Gabapentin:  An anticonvulsant that some people find relieves anxiety and perhaps the sweating during withdrawal.
– Benzodiazepines: A controversial topic.  They are potent sedatives, but they are also potent respiratory depressants when combined with opioids.  Most overdose victims have these drugs on board.  They relieve anxiety, insomnia, and muscle tension, and cause fatigue.  Should NEVER be combined with opioids unless under very careful supervision (i.e. ‘self treatment’ = NO treatment).
– Phenobarbital: A Forum participant wrote that his/her doc prescribed phenobarbital for opioid withdrawal with great success.  All barbiturates act similarly to benzodiazepines, and have potent respiratory depression, especially with opioids.  Again, must NOT be used except under close supervision.  Have effects similar to benzodiazepines.  Dangerous if combined with alcohol.
– Quetiapine: AKA Seroquel.  A potent sedative, used to treat psychosis, bipolar mania, depression… and off label, insomnia.  Side effects include dry mouth and sleepiness.
– Natural ‘remedies’: A variety of withdrawal remedies are advertised on opioid-related web sites.  I’ve had patients who tried most of them, and I’ve never heard anyone say they were useful. Some come in ‘daytime formula’ and ‘nighttime formula’.  Always read the ingredients– and if you see a long list of herbs and roots, realize that there is NO oversight of the claims that are made.  You could put bundles of dandelions into empty capsules and sell them over the internet, making the same claims.  How hard do you think it would be to find a people to write ‘testimonials’ for twenty bucks? Or you could just write them yourself! Buyer beware.
– Amino acids:  Again, advertised on the internet, and offered at steep cost by ‘select’ doctors.  One of the ‘pioneers’ of amino acid treatments for withdrawal was convicted of fraudulent practice in Texas, and now offers the same as he did in Texas, but safely across the border, in Mexico.  He has clinics in the US, run by other doctors, who boast of using his methods.  The appeal of buying into a treatment that was proven fraudulent in court escapes me.  But the treatment of opioid dependence is strongly influenced by perception, and so is strongly subject to placebo effects.  The appeal of snake-oil remedies has created a living for many, many charlatans over the years, and a sucker is born (at least) every minute.
– General sedatives:  Insomnia is such a big problem that anything that helps with sleep will help during opioid withdrawal.  Meds include diphenhydramine and hydroxyzine (antihistamines), zolpidem and zopiclone (short-term sleep meds), and trazodone and mirtazapine (sedating antidepressants).   Cyproheptadine is a sedating antihistamine that reduces nightmares, and stimulates the appetite.
– Stimulants:  I’ve read of people using them to fight the depression and fatigue during withdrawal.  That use of a schedule II medication may be illegal in some states, and is probably frowned-upon by agencies that regulate medical practice.  The energy and mood effects from stimulants are temporary, and must be ‘paid back’ with fatigue and depression when the stimulants are discontinued.
– Naltrexone: An opioid antagonist that has been used to speed the reduction of opioid tolerance.  Naloxone and naltrexone are used during rapid detox, under strong sedation or anesthesia, but I believe that some have used naltrexone in very low doses in awake patients.  If you are a doc who knows about this approach, I’m all ears…
– Antidepressants:  Depression is one of the worst aspects of opioid withdrawal.  Antidepressants would seem appropriate… but I know of no antidepressant medications that have a chance against the severe depression caused by opioid withdrawal.  I’ve used them for patients after the withdrawal ends, when depression lingers… but I see little use for them during acute withdrawal.
Gosh, I thought my list would be longer.  Given how many people suffer through discontinuation of opioids, our approach to easing misery is pretty limited.   I will remind readers–  most of the medications listed above will cause serious harm, if taken without doctor supervision.
If you are a doctor who has found success with other medications, or if you are a patient of such a doctor, leave a comment to help spread the knowledge.  If you are not comfortable with leaving a post, send me an email, or a message through LinkedIN.
 

Suboxone Detox is a Sucker’s Bet

First Posted 10/6/2013
I attended the US Psychiatric and Mental Health Congress meeting last week and actually attended the meetings (the event was held in Las Vegas), but I was disappointed by the absence of lectures about addiction.  There are other mental health groups geared more toward addiction, but one would think that psychiatry would maintain a strong presence in the field.  This was my first time at the annual meeting for this group, and so I can’t say that I’m witnessing a trend away from addiction by psychiatry—which would be a real shame.
At any rate, I had a very busy Friday and Saturday catching up with the office work I put off for a few days. So today I had to cram in a lot of non-work activities, to make sure that my life remains well-balanced.  That meant watching the entire Packer game, going to the movie ‘Gravity’ complete with 3-D glasses, and then catching the latest episode of Homeland, where psychiatrists continue to gain a bad name.  Thorazine injection, anyone?
So I’m beat…  but I’ve been intending to write something for the past couple weeks, and I think I can knock it off fairly quickly.  Readers know that I get many emails from across the country describing atrocious behavior by physicians.  The latest scam?  It appears that everyone with a medical clinic has a secret recipe for tapering off Suboxone.
I received an email from a person who wanted to stop Suboxone/buprenorphine for months, if not years.  For people who don’t know my attitude, I tend to believe my own eyes, and also what the research shows—that over 9 out of 10 of the people who stop buprenorphine are using opioids again within one year.  When people moan that ‘it is hard to stop buprenorphine’, I remind them that the reason they are TAKING buprenorphine is because they were unable to stop opioids.  Why would they expect that to change?  Oh- I know— counseling!  That’s the line from all of the addiction insiders—that patients take buprenorphine and do ‘counseling’, and the addiction goes away.
There are two scientific findings that keep trickling out these days that are driving some people crazy— and I admit to a bit of amusement with each headline.  The first set of findings concern the troubling lack of global warming over the past 8 years—including the recent headlines that polar icecaps, predicted by Gore et al. to be completely gone by now, have grown by almost a third in the past year.  The other interesting findings are the several studies that failed to demonstrate an increase in sobriety in buprenorphine patients engaged in ‘counseling.’    There is real danger for people who borrow science just in order to hide behind It for an argument or two; they risk getting caught naked when the science moves in an unexpected direction!
Anyway, the person wrote to tell me that after multiple failed efforts to taper off buprenorphine on her own, she had gone to a rapid-detox clinic that promised to ‘heal’ her receptors over a few days. The $7 grand was spent, and I had no desire to ruin whatever placebo effect she would gain from the silly cocktail of nutritional supplements she purchased.  So I told her that I hoped she felt better soon, not adding that she will feel better at about the same time she would have felt better without the rapid detox and nutritional supplements.
She wrote again a week later, struggling from withdrawal, and then again a few days after that to say that she went back on buprenorphine.  But the good news was that she found a different doctor who SPECIALIZES in getting people off buprenorphine.
A few days later she wrote to tell me about the hundreds of dollars the visit cost— and asked if his taper schedule appeared reasonable.  ‘He’s your doctor’, I explained, trying to sound neutral.  I shared my belief, though, that it was a conflict of interest for doctors to sell nutrient products that they themselves prescribed, and that opioid receptors are able to return to health without the addition of trace nutrients.
A week later she wrote about yet another specialist, who this time took $800 to tell her to take 3 mg for a few days, then 2 mg for a few days, then 1 mg for a few days.  She said she had to go back for another appointment for him to tell her what to do after that.
I know it sounds like I’m joking, but sadly, I’m not.  More sadly, I’ve read similar messages a number of times over the past few years.  I’ve stated that I would try to point out things I write that are based on science, vs. things based on personal experience, vs. what I’ve witnessed as a clinician.  What I’m about to say is based on all three.
I had my own nightmare withdrawal from potent opioids when I was in treatment 13 years ago.  I lost 30 pounds from my already-skinny frame at that time, having no appetite and without taking nutrient supplements.   But my withdrawal ended and my receptors healed in about 6-8 week, just as in every opioid addict who I’ve assisted through detoxification.  And when I’ve seen people go away for rapid detox, they complain about feeling lousy— the same amount of complaining over the same lousiness—for the same 6-8 weeks.  One would think that all of this would be enough to outrage the FDA, who usually get irritated at stories about high-cost, low-yield medical procedures.  But once again, the truth is even worse.  For those who do manage to white-knuckle through 6-8 weeks of withdrawal, guess how many are still clean a year later?  Wanna bet?
As for the warming of the planet, I’ll continue to read the science with an open mind.  Maybe Gore will be right in the long run, which would be bad for the planet but good for those who give out Nobel Prizes.  But we know one thing for certain now; that asserting the ice caps would be gone by 2014 was a sucker’s bet.  And the same is true about promises for a rapid or gentle path through opioid withdrawal.