The first step in discontinuing an opioid use disorder (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.
When an individual stops taking opioids (e.g., heroin), withdrawal symptoms typically begin 8-24 hours after the last use, and can persist for 4-10 days. After curtailing use of a long-acting opioid (e.g., methadone), withdrawal symptoms begin 12-48 hours after last use and can persist for 10-20 days. Symptoms include nausea and vomiting, anxiety, insomnia, hot and cold flashes, perspiration, muscle cramps, watery discharge from eyes and nose, and diarrhea.
The severity and duration of opioid withdrawal symptoms vary greatly from person to person, and are affected by multiple factors that are hard to predict.
Regardless of the ultimate treatment goal, 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 in the U.S., methadone is strictly regulated and 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 (e.g., heroin) that they were taking previously—in order to prevent precipitated withdrawal.
This first phase of Suboxone treatment is 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).
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:
The following chart lists many of the most commonly experienced opioid withdrawal symptoms, and the corresponding non-opioid medications that can provide relief adjunctive to MAT. 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.
Depending on the severity of the addiction, patients with OUD are often going long periods of time without adequate nutrition and are often 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 really 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 the withdrawal process. Zinc can help to improve immune system and proper brain function, and calcium and magnesium deficiencies are the major factors of pain and nervous/muscular disorders among addicts. Vitamin B and vitamin C supplements are often recommended as well.
Light exercise is encouraged as endorphins released by physical movement can improve mood and pain tolerance. Endorphins themselves are natural opioids.
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:
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.