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Medications for Opioid Withdrawal and Dependence

People who are thinking of quitting opioids, such as heroin or prescription painkillers, might wonder about the use of medication during detox to help with their withdrawal symptoms and cravings. Generally, when withdrawal is not complicated by medical events like severe dehydration or cardiovascular issues, medications for opioid withdrawal aren't essential to ensure patient safety; however, they can be extremely useful in improving a person's experience.1

In attempting to quit on their own, many people have faced opioid withdrawal alone, without a significant risk of life-threatening symptoms.1,2 However, the intensity of a detox where no medications are employed—whether at home or in a professional setting—may be such that it causes needless suffering and may lead people to question whether they can make it through withdrawal and continue on with their recovery efforts. In fact, the Substance Abuse and Mental Health Services Administration (SAMHSA) has noted that even people with mild opioid dependence can experience severely uncomfortable symptoms and advises clinicians to manage those symptoms with medications.1

Why Use Medications?

Medication assisted drug treatment with pillsWhen you receive medication under the care and monitoring of a qualified physician, you benefit from a safe, regulated, and supervised method for curbing opioid abuse and managing withdrawal.3 Medications are not only helpful for withdrawal but can aid recovery after detox and prevent relapse. They work to relieve “the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body.”3  The use of medications in combination with behavioral therapeutic approaches to addiction recovery is referred to as medication-assisted treatment, or MAT.

Here, you can learn how medications help in the management of acute withdrawal as well as how they serve as a valuable treatment tool beyond the detox phase.

How Are They Used in Detox?

Opioid withdrawal can be significantly uncomfortable, even painful, especially considering that people who use opioids often already have a reduced tolerance for pain.1,2

Opioid withdrawal symptoms include:2

  • Yawning.
  • Insomnia.
  • Fever.
  • Goosebumps.
  • Sweating.
  • Muscle aches.
  • Excessively watery eyes.
  • Runny nose.
  • Dilated pupils.
  • Nausea and vomiting.
  • Diarrhea.
  • Dysphoric mood (general feeling of dissatisfaction or unhappiness).

The onset and duration of these symptoms can be predicted by whether the opioid is short- or long-acting:2,7

  • People who use short-acting opioids like heroin can expect to develop symptoms within 6-12 hours after the last use. Acute symptoms often peak after 1-3 days and then gradually dissipate over a period of 5-7 days.
  • People who use longer-acting opioids like methadone can develop symptoms within 12-48 days after last use. Symptoms may last up to 20 days.

Protracted, or post-acute, symptoms, such as insomnia and low mood, can persist for weeks or even months.2

In addition, opioid-dependent individuals may suffer from other psychological and physical issues existing before or brought on by withdrawal that need treatment. If you enter a medical detox program, you may receive adjunctive medications that can help address these other issues.1

Methadone

Methadone is “the most frequently used agent approved for detoxification by the FDA.”1 A full opioid agonist, methadone attaches to and activates the opioid receptors in your brain. When methadone activates these receptors, it produces opioid effects and lessens the symptoms of withdrawal. Unlike drugs like heroin, when administered at therapeutic doses, it produces its opioid effects at a more manageable level that does not promote abuse in the same way. Methadone can be misused/abused, however, and thus is only dispensed (with a few exceptions) as a treatment for opioid dependence in methadone clinics, where administration of the medication may be controlled.4

According to SAMHSA, methadone is “the treatment of choice” over other medications for pregnant or breastfeeding women withdrawing from opioids because it can prevent dangerous withdrawal symptoms that may bring on uterine contractions and, consequently, miscarriage or premature birth.6

However, methadone is not suitable for everyone, including those with cardiac issues, including the rare condition known as long QT syndrome (LQTS).5 Methadone should be used with caution by people with respiratory deficiency, acute alcohol dependence, head injury, Crohn’s disease, severe liver problems, or those who are being treated with monoamine oxidase inhibitors (MAOIs).7

Methadone is approved for use as a short-term treatment for withdrawal and may be continued as a part of maintenance treatment in an MAT program.6

Buprenorphine

Buprenorphine is another medication that is commonly used in the management of opioid withdrawal to limit the severity of symptoms.

Unlike methadone (a full opioid agonist), it is a partial opioid agonist, and there is a limit, or ceiling, to the euphoria and other opioid effects (like respiratory depression) that it will bring about.8 This means that it may have a lower potential for misuse and dependence than methadone but will still provide the same types of benefits, such as alleviating symptoms of withdrawal and decreasing cravings.

Suboxone is a medication that contains a combination of buprenorphine and naloxone, an opioid antagonist that prevents intravenous abuse of buprenorphine by people seeking a high from the drug. If you try injecting Suboxone, you will experience immediate withdrawal.8

Buprenorphine is used with caution in people who have respiratory deficiency, urethral obstruction, liver problems, or diabetes.7,9 Like methadone, buprenorphine can be used both to address the symptoms of acute withdrawal and serve as an integral part of MAT.9

Other Medications Prescribed for Withdrawal

Other medications may also be prescribed for the treatment of opioid withdrawal, including:

  • Clonidine. Generally, this medication is used to manage high blood pressure but may also be used off-label to alleviate some symptoms of withdrawal.1
  • Lucemyra (lofexidine). Like clonidine, lofexidine is an alpha-2-receptor agonist drug. It is the first non-opioid drug approved by the FDA for the treatment of opioid withdrawal. It can reduce the severity of opioid withdrawal symptoms but is only approved for treatment for a period of up to 14 days.10
  • Anti-nausea medications. This includes medications like ondansetron (Zofran).11
  • Anti-diarrhea medications. This can include prescription medications and/or over-the-counter medication.11
  • Nonsteroidal anti-inflammatory medications (NSAIDs). These medications, which include ibuprofen and aspirin, can be used to relieve pain and muscle aches.12
  • Topical analgesics. Certain creams or lotions may be applied to the skin to alleviate muscle pain.12

Can They Be Used in Recovery?

Once you complete withdrawal, you may still use certain medications over a longer period of time to help maintain sobriety, prevent cravings, and assist in your overall recovery.

Doctor with patientMany people use methadone for a period of at least 12 months; some people use this drug for years.6 Methadone is prescribed and dispensed under the supervision of a physician in an approved opioid treatment program (OTP), commonly called a methadone clinic, that is certified by SAMHSA.5 As methadone must be taken daily, it requires a commitment and adherence to the treatment regimen. It is crucial that you take this drug as prescribed because it can produce a high when abused and does have a potential for addiction; this is especially important if you are permitted eventually to take it at home and visit the OTP intermittently instead of every day.6 Buprenorphine is another option for the primary medication used as part of an MAT.

It may be more convenient for someone taking it long-term, as it can be prescribed by any physician qualified to dispense it and does not require daily visits to an OTP.9 Buprenorphine's ceiling on opioid effects also helps to prevent abuse. It only produces opioid effects to a certain degree and then stops. Also, if buprenorphine is taken when there is already a full agonist such as heroin in the body, it can actually block some of its effects. This is due to the fact the buprenorphine has a higher affinity for the brain's opioid receptors and can actually "knock off" other opioids from those receptors and occupy the receptor itself.8 In some cases, this can lead the person to go into opioid withdrawal, another motivating factor for a person using buprenorphine not to return to their opioid of abuse.8

Finally, the drug may be safer than methadone in the event of an overdose because unlike methadone, which produces increasing respiratory suppression with increasing dose, respiratory effects of buprenorphine tend to level off at a certain point.” 1 This essentially means that the potential for life-threatening breathing difficulties if you overdose is less likely than with methadone.

Buprenorphine Implant

Probuphine, an arm implant that delivers a steady stream of the buprenorphine over 6 months, enables people in recovery to get needed treatment without the daily medication compliance required by methadone or other forms of buprenorphine.13

The following criteria make someone a good candidate for such treatment:9

  • Formal diagnosis of an opioid dependency
  • Willingness to follow safety precautions
  • Free of potential health problems that might interfere with treatment
  • Exhausted all other treatment alternatives

Another drug, naltrexone, is only used in MAT and not in detox. Naltrexone differs from methadone and buprenorphine in that it is not a full or partial opioid agonist—rather, it is an opioid antagonist that blocks the effects of opioids. When you consume a drug like heroin or oxycodone while on naltrexone, you won't feel the normal euphoria because the medication is blocking those effects. Without the high, the motivation to abuse opioids may be drastically reduced. The pill form is taken once daily, but naltrexone is also available as a once-monthly injection, known as Vivitrol. Any healthcare provider who is licensed to prescribe medication can prescribe naltrexone.14

Medications alone are usually not enough to combat opioid addiction—they are most effective when combined with counseling and other behavioral therapies. Medication-assisted treatment is a specific type of treatment that was designed with this purpose in mind. If you are part of an MAT program, you will be given medication, but you are also required under federal law to participate in counseling.3 Counseling and behavioral therapies can help address traumas and other issues that led to your substance abuse and addiction and teach you better coping skills, stress management, and tools to prevent relapse so that you can maintain your sobriety and stay on the path to recovery.

References

  1. Center for Substance Abuse Treatment. (2015). Detoxification and Substance Abuse Treatment: A Treatment Improvement Protocol (TIP 45). Rockville, MD: Substance Abuse and Mental Health Services Administration.
  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  3. Substance Abuse and Mental Health Services Administration. (2015). Medication and Counseling Treatment.
  4. Kleber, H. D. (2007). Pharmacologic treatments for opioid dependence: detoxification and maintenance optionsDialogues in Clinical Neuroscience9(4), 455–470.
  5. U.S. National Library of Medicine. (2018). MedlinePlus, Methadone.
  6. Substance Abuse and Mental Health Services Administration. (2015). Methadone.
  7. World Health Organization. (2009). Clinical Guidelines for Withdrawal Management and Treatment of Drug Dependence in Closed Settings. 4. Withdrawal Management. Geneva: World Health Organization.
  8. National Alliance of Advocates for Buprenorphine Treatment. What exactly is Buprenorphine?
  9. Substance Abuse and Mental Health Services Administration. (2016). Buprenorphine.
  10. U.S. Food & Drug Administration. (2018). FDA approves the first non-opioid treatment for management of opioid withdrawal symptoms in adults.
  11. Kleber, H. D. (2007). Pharmacologic treatments for opioid dependence: detoxification and maintenance optionsDialogues in Clinical Neuroscience9(4), 455–470.
  12. Government of South Australia SA Health. Opioid withdrawal management.
  13. Itzoe, M., & Guarnieri, M. (2017). New developments in managing opioid addiction: impact of a subdermal buprenorphine implantDrug Design, Development and Therapy11, 1429–1437.
  14. Substance Abuse and Mental Health Services Administration. (2016). Naltrexone.
  15. U.S. National Library of Medicine. (2017). Naltrexone.
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