Introduction

Opioids (for example: pain medication such as morphine, codeine, oxycodone) are used recreationally for their euphoric effects. This use induces tolerance to the drugs effects in the individual. As a result, higher doses are required to achieve the euphoric drug effects the user seeks.

When the user stops ingesting opioids withdrawal will often occur if they have been consumed for a lengthy period of time. It can set in within hours or days depending on the drug used and the route of administration (orally, intravenously). Depending on the individual and the drug of choice different physical (hot/cold flashes, excessive sweating, cramps/pains, yawning and watery eyes) and psychological (depression, anxiety, amotivational syndrome) symptoms will become evident.

Symptoms

Physical

• Tremors
• Cramps
• Muscle and bone pain
• Chills
• Perspiration (sweating)
• Priapism (persistent erection)
• Tachycardia (rapid heart beat)
• Itch
• Restless legs syndrome
• Flu-like symptoms
• Rhinitis (runny, inflamed nose)
• Yawning
• Sneezing
• Vomiting
• Diarrhea
• Weakness
• Akathisia (a profoundly uncomfortable feeling of inner restlessness)

Psychological

• Dysphoria (a state of unease or general dissatisfaction with life)
• Malaise (overall sense of discomfort and illness)
• Cravings
• Anxiety/Panic Attacks
• Paranoia
• Insomnia
• Dizziness
• Nausea
• Depression

Acute Opioid Withdrawal

Acute opioid withdrawal starts within hours-days of cessation of opioid use, and can last 2-3 weeks. This phase encompasses the onset of physical and psychological withdrawal signs, which can both come and go during this time.
Generally, the first 72 hours is the most difficult time during opioid withdrawal. It is said that 'day 3' is the worst, because at this point in time drug levels are lowest while withdrawal symptoms are still increasing. During the first few days, the user will feel physically ill, often very weak in part due to a lack of appetite and at times a physical inability to eat or drink. Nausea, chills, stiff joints, excessive sweating, chills are a few of the many physical symptoms that may be present. Mood swings are common, the user may feel depressed one afternoon and then anxious the next.
During the first two-three weeks of opioid withdrawal the physical symptoms will begin to subside, or one might take the place of another. If the user was sleeping a lot during the first few days, they may develop insomnia thereafter. They may have vivid dreams around acquiring and taking their drug of choice. Suicidal thoughts may occur. Most of the physical withdrawal symptoms will become less frequent, however, for several months, the user may experience "flashes" of withdrawal symptoms, where they feel sick for an hour or more, and thereafter the symptoms subside. These flashes can be triggered by an experience or a location that reminds them of opioid use or opioid effects.

Post-acute Opioid Withdrawal

Post-acute opioid withdrawal (PAWS) begins several weeks after cessation of opioid use, and can last a year or more. In this phase many if not all of the physical withdrawal symptoms have subsided, however, psychological symptoms may still be present. The user may feel depressed, unmotivated, or anxious at times. These psychological conditions are worsened by prolonged opioid use, which can temporarily alleviate depression or anxiety.

Alleviating Opioid Withdrawal Symptoms

Although many people faced with opioid withdrawal will find the medications listed below key to ensuring a successful detox, the general care of your body is essential at this time and there are some key factors to be considered when facing an opioid withdrawal.
Hydration
While detoxing from opiates diarrhoea, nausea, and profuse sweating are all highly likely and all of which contribute to dehydration. Maintaining good fluid levels is integral to getting and feeling better and should be a priority during withdrawal. Water, juice and soup are all good sources of hydration.
Electrolytes
Along with needing fluids in your body, you need ions in those fluids which are known as electrolytes. They are integral to proper muscle and nerve function (including your heart) and a lack of them will result in cramps, and eventually seizures. Just as diarrhea, vomiting, and sweating decrease fluid content, they also decrease electrolytes (especially sodium and potassium) and need to be replaced. Sports drinks are an excellent source, but juice and soup will do as well.
Vitamins/minerals
Although some of these fall under the category of electrolytes, vitamins and minerals are important for proper bodily functions. Although they can be obtained naturally from dietary sources, the lack of appetite and possible vomiting associated with opioid withdrawal means vitamins can be instrumental with supplying your body with everything it needs to get back on track.
Food
During opioid withdrawal, appetite can be reduced to a bare minimum or become non existent. However, a healthy diet will provide calories and in turn, energy. Soups and fruits should be sufficient if sickness if an issue.
Sleep
It may be hard, but your body and brain needs sleep to heal and repair. There are drugs which can help but resting and at least trying to sleep is just as important as keeping active and trying to keep your mind off of withdrawal.
Many people experiencing opioid withdrawal may find the use of both over the counter and prescription medications especially helpful.
Over the counter medications include:
Non steroidal anti-inflammatory drugs

• Ibuprofen
• acetaminophen (paracetamol)
• Naproxen (Alleve)
• Aspirin

These pain relievers will help mostly with the aching muscles associated with opioid/opiate withdrawal. Naproxen is often preferred for withdrawal. These drugs should not be used beyond the recommend dosage as they can cause intestinal issues and should not be mixed.

Antihistamines

• Diphenhydramine (Benadryl)
• Dimenhydrinate (Dramamine)
• Meclizine (Dramamine II)

Antihistamines are used to help with nausea and insomnia, although it has been noted that antihistamines may induce repeated waking during period of sleep. Diphenhydramine (Benedryl) is usually used to treat allergies and is the most commonly used antihistamine for opioid withdrawals. It is also used off label as a sleeping aid and just a few pills will help you get to sleep. Taking too much it acts as a psychedelic deliriant and there is no need to go much beyond the recommended dosage.
Diarrhoea and antispasmodics

• Loperamide hydrochloride (Immodium AD)
• Hyoscine (Buscopan)

Loperamide (Immodium) is a very strong opioid. However in low doses it does not cross the blood-brain barrier (BBB) and therefore only acts on your peripheral nervous system and not your central nervous system (CNS). In lower doses it is extremely useful for limiting diarrhea and related symptoms, and in high doses it actually does somewhat cross the BBB and can almost completely eliminate withdrawal and can actually be used to perform a taper of its own. Other anti diarrhoea medications e.g dioralyte may also be useful.
Prescription medications include:

• Clonidine
• Diazepam (Valium)
• Clonazepam (Klonopin)

Clonidine a non-opiate, non-addictive blood pressure medication. Clonidine inhibits the body's sympathetic response and helps decrease the sweating, chills, anxiety and restlessness that you may feel during withdrawal.
Side effects include dry mouth, sleepiness, and, for some, insomnia.
Clonidine does have the potential for physical addiction even though it doesn't remotely provide the euphoria experienced from narcotics. Try to maintain a low dosage: Take between 0.1 to 0.3 mg of Clonidine, 2 to 3 times daily.
Diazepam and clonazepam are examples of benzodiazepines which, depending on the specific one, can be a combination of a sedative, hypnotic (sleep-inducing), anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant. Benzos are often prescribed by detox clinics and are definitely a good thing to have.
Recreational Drugs include:

• Cannabis
• Krantom

The effects of cannabinoids can reduce or eliminate the majority of symptoms of opiate withdrawal. Cannabis can reduce anxiety and agitation, improve sleep and helps normalize the digestive tract. However, in some cases it can be detrimental; inducing an elevated heart rate, paranoia and anxiety.
Krantom leaves are often used to make tea, but you can also crush them into a powder which is then swallowed. There are several different types but the most effective for opioid withdrawal is the Red Veined Borneo variety. Different doses will produce different effects, but overall Krantom can help with, pain, stress, anxiety, motivation, relaxation, energy and provide a general feeling of happiness and well being. It can reduce up to 70% of opioid withdrawal symptoms but this varies from person to person.
Endogenous opioids, aka endorphins
Endorphins are a natural opioid (hormone) produced by the central nervous system and the pituitary gland and are released by the body in response to certain situations to reduce the perception of pain. There are several ways of inducing the release of endorphins into the brain, this can provide a short term release from opioid withdrawal.
Exercise
Exercise can really help alleviate withdrawal symptoms. The lack of energy experienced at this can make this seem a daunting task but, exercise (the more vigorous the better) is a sure fire way to actually feel better. An exercise regime is also very important to getting over PAWS and maintaining your sobriety.
Sexual release
This can give you a much needed break from the pain. Although reaching orgasm will flood the body system with endorphins, (giving an instantly noticeable relief) even just being sexually stimulated (mentally and/or physically) will help somewhat.
High sugar products e.g candy, chocolate, fruit
Some people may notice sugar cravings, the taste can provide a welcome distraction, endorphins are released which then increase the pleasure even more.
spicy foods
The pain inflicted from spicy foods is another way of getting some endorphins released into the body in the later stages of withdrawal as appetite returns and diarrhoea ceases.

References