Withdrawal IV: Opioids

17 June 2023

Here we go with the final withdrawal blog.  Last week we looked at stimulants (here), the week prior at hallucinogens (here) and a while ago, depressants, mostly alcohol,(here).  Today, in the midst of an opioid crisis, that never seems to end, we’ll gain an overview of withdrawal procedures from this fourth category of psychoactive drugs.  As the image that accompanies this blog attests, in 2020, 187 deaths occurred per day in the United States from legal and illegal opioid use.  When I Googled the parallel Canadian statistic, in September 2022, the reported number was 20 deaths per day.  Population wise, Canada’s stats are about 7% lower than the States i.e., more or less the same.

Typical drugs falling within the opioid category are codeine, fentanyl, heroin, methadone, morphine, and opium.  Opioids are actually a division of depressants but act on different neuroreceptors than the best-known depressant, alcohol.  Opioids act on the mu receptor transmitting more endorphins while, through a complex interaction, providing more dopamine in a user’s system, as well. 

So here’s what withdrawal from opioids looks like:

• Nausea and vomiting
• Anxiety
• Insomnia
• Hot & cold flashes
• Perspiration
• Muscle cramps
• Watery discharge from eyes and nose
• Diarrhoea (National Library of Medicine, 2023, Section 4.3). 

The (U.S.) National Library of Medicine also helpfully provides a symptom scale with scores:

Symptom	Not present	Mild	Moderate	Severe
Feeling sick	0	1	2	3
Stomach cramps	0	1	2	3
Muscle spasms or twitching	0	1	2	3
Feeling cold	0	1	2	3
Heart pounding	0	1	2	3
Muscular tension	0	1	2	3
Aches and pains	0	1	2	3
Yawning	0	1	2	3
Runny/watery eyes	0	1	2	3
Difficulty sleeping	0	1	2	3

Score  Suggested withdrawal management

0-10     Mild withdrawal; symptomatic medication only

10-20   Moderate withdrawal; symptomatic or opioid medication

20-30   Severe withdrawal; opioid medication

That site also suggests patients be monitored 3-4 times per day for symptoms and complications using the scale and scores, above, 1-2 times per day.  There are treatments for all levels of withdrawal i.e., mild, moderate, or severe meaning—to me—this withdrawal process is best managed by experienced medical personnel, especially if symptom scores reach moderate, severe, or if the patient is pregnant.

In the case of pregnancy, withdrawal can result in miscarriage or premature delivery so stepping down through methadone use is the recommended way to go.

Returning to a Canadian source, Csiernik (2019), we learn that opioid use is hard to defeat resulting in high lapse and relapse rates.  Probably part of that challenge is the physical pain associated with withdrawal, especially in long-term users, which has been compared to the pain that comes with bone cancer.  Withdrawal symptoms are expected to be at their most severe 48-72 hours after the last use, with those symptoms subsiding in 7-10 days, though some bodily functions may not return to full normality for 6 months.  Csiernik says to expect symptoms akin to an extremely severe and painful case of the flu together with cravings, with the greatest concern being relapse.  It’s a tough go, but it’s also a new lease on life.  From those I’ve spoken with, who’ve left opioids behind, it’s completely worth the fight.

If anyone doubts the prevalence of opioid use, I have a from-the-streets anecdote that provides confirmation.  A twenty-year-old person told me she has taken the Canadian Lifesaving certification three times for various work & volunteer roles she has held.  The most recent certification included Naloxone administration for the first time i.e., there are so many people in danger of dying from opioid use—on Canadian streets—that the use of Naloxone is now considered a component of basic first aid.  While I was impressed by this advance, I was saddened by the prevalence that makes this necessary.

To end, two clarifying definitions and some Canadian stats. 

Physical dependency is a biological change that occurs in the body at the cellular level.  It happens when a drug has been administered for an extended time period, and the body’s homeostatic level, its balance point, is altered such that the body functions best when the drug is present.  When the psychoactive drug is not present in the body at a sufficient level, the individual will become physically ill.  This physical state is termed being in withdrawal.  Withdrawal symptoms are typically the opposite reactions of those that the use of the drug initially produces upon administration (Csiernik, 2019, p. 3, bolding added). 

Psychological dependency typically develops alongside physical dependency but can also occur independently.  In contrast, physical dependency rarely occurs without psychological dependency ensuing.  Psychological dependency is the belief that a drug must be taken for the individual to be able to function.  It is evident that the psychoactive agent becomes the central organizing principle of a user’s life...Unlike physical dependency, psychological dependency can also occur with behaviours such as gambling, internet use, and even sex, though there is a significant biological distinction between compulsive behaviours and addiction (Csiernik, 2016 cited in Csiernik, 2019, pp. 3-4, bolding added).

Health Canada (2017/2023) published the following stats:

• 9,414 people died due to substance-related acute toxicity, including 4,164 people who died in 2016 and 5,247 people who died in 2017.
• 70% of people who died were male and the remaining 30% were female.
• 84% of people died accidentally, 13% of people died by suicide, and the manner of death was undetermined for 4% of people.
• The average age of people who died was 43.0 years. For females who died, the average age was 45.3 years, while the average age of males who died was 42.1 years (Gov’t of Canada, Key findings, Overview).

Substances involved

• Stimulants (44%), fentanyl opioids (44%), and non-fentanyl opioids (37%) were the most common substance types identified as causing death. Alcohol was detected in 34% of people who died and benzodiazepines in 28%.
• While the majority of coroner and medical examiner files identified 1 (30%) or 2(24%) substances as causing death, 3 (18%) and 4 (17%) substances were most often detected. Only 8% of people who died had only 1 substance detected.
• While the substances identified as causing death varied by province and territory, ethanol (alcohol) and cocaine were usually among the top 3 substances, and fentanyl among the top 10.

A lot of what I do, professionally, and as a volunteer, is aimed at reducing those stats.  If you’re an opiate user, there are legions of recovered users you can talk to, recovery meetings you can attend to quit or reduce harms...We want you here as part of the game, not adding to the body count.  Please reach out.

Dan Chalykoff is (finally!) a Registered Psychotherapist (Qualifying).  He works at CMHA-Hamilton and Healing Pathways Counselling, Oakville, where his focus is clients with addiction, trauma, burnout, and major life changes.  He writes these blogs to increase (and share) his own evolving understanding of ideas.  Since 2017, he has facilitated two voluntary weekly group meetings of SMART Recovery.  Please email him (danchalykoff@hotmail.com) to be added to or removed from the Bcc’d emailing list.

References

Csiernik, R. (2019). The Essential Guide to Psychoactive Drugs in Canada: A Resource for Counselling Professionals, Second Edition.  Canadian Scholars.

Government of Canada, Substance-related acute toxicity deaths in Canada from 2016 to 2017: A review of coroner and medical examiner files.  https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research/substance-related-acute-toxicity-deaths-canada-2016-2017-review-coroner-medical-examiner-files.html

National Library of Medicine, (2023, May 29).  Clinical Guidelines of Withdrawal Management and Treatment of Drug Dependence in Closed Settings.  https://www.ncbi.nlm.nih.gov/books/NBK310652/