Q&A: "How Intense Is Opioid Withdrawal?"

Q&A: "How Intense Is Opioid Withdrawal?"
Includes Subjective Opinions

Originally composed January 14, 2019

From time to time, I will take and answer questions. Additionally, on occasion, I will also answer questions or write articles by throwing my personal experience into the mix (always labelled as editorials).

Question: "How Intense Is Opioid Withdrawal?"

Well, it depends. That’s like asking “how much does getting a body part chopped off hurt?” One could lose a finger or a whole limb, and both will really hurt, though one will bring more severe pain than the other.

Likewise, with opioid withdrawal, consider it on a spectrum. Somebody who has taken 5 mg of Vicodin (hydrocodone) twice a day for two months will likely experience some symptoms when ceasing to take the drug, though not nearly as many symptoms or to the degree that will be experienced by an I.V. heroin user who has injected $100 of the stuff each day for two years.

Regardless of the degree to which somebody feels withdrawal, nobody considers it pleasant. Best case scenario a person will feel like they have a very mild case of the flu, coupled with an inability to feel rested or fall asleep for long, and probably some anxiety and sadness.

Now, for the typical person who goes through it—and by typical, I mean in the stories you hear of people using moderate to large amounts of painkillers or heroin. In these cases, withdrawal is nothing short of unbearable. Women who have gone through childbirth without an epidural or men who have had kidney stones and other medical problems almost universally consider opioid withdrawal more difficult to go through. 

Perhaps on a minute-by-minute basis, withdrawal does not feel quite as painful as some of these other afflictions, at least in a classical sense. But the experience goes far beyond simply pain; first though, it is crucial to understand the purely physical symptoms of opioid withdrawal. It begins with things like a runny nose, yawning, goosebumps (their skin looks like an uncooked-or cold-turkey, hence the phrase's origin), and teary eyes (aka "lacrimation"). When it peaks, a user will feel nauseous and may vomit repeatedly, have some to extreme diarrhea, sweating (from sweats to vomit to diarrhea, teary eyes, runny nose, and ejaculating for no reason, something will be coming out of every orifice), feel chills, difficulty regulating temperature (too hot, too cold, too hot and cold), random erections and spontaneous ejaculation in men, muscle aches, restless leg syndrome (or restless arms or anywhere), joint pain, tremors, increased heart rate and blood pressure, a perceived inability to eat or even drink water…imagine the worst case of the flu you’ve ever seen times 15.

Now you may think: 'oh, I can power through the flu, why don't these addicts just tough it out and be done with it?' 'That doesn't sound pleasant but all in all it doesn’t sound that bad, right?'

Wrong.
Because opioid withdrawal has a strong psychological component as well. First of all, good luck sleeping for a few days. Perhaps for the first four or five days of a cold turkey withdrawal, the addict will manage to amass a couple of cat naps adding up to a few hours of light sleep. Not only that, but despite feeling exhausted and weak, you can’t seem to get comfortable for more than a few seconds at a time. Your legs probably won’t stop jerking (the term “kicking the habit” derives from the restless legs of opioid withdrawal). Anxiety will plague the person, with rolling panic attacks and a constant feeling of worry. All the emotions suppressed by the opioids come roaring back. Depressive feelings proliferate, as the brain has been robbed of the blunted euphoria it has grown accustomed to. Neutral things like car commercials might make even the manliest man cry for some reason, hopelessness dominates the mind as the individual comes to realize that they can’t live with their drug and can’t live without it, either; suicidal ideation is not uncommon. What other way can this desperate person escape this horrible disease?

Also, consider the fact that the person knows how to make this all go away: if they can just get up $30,20,10, maybe even $5 (depending on location, connections, drug of choice and size of habit), then all of this will go away (for a few hours, anyway).

The East Coast boasts the strongest dope, especially from Baltimore up to New York City and some of New England. States bordering Mexico and the area around Chicago also have above average strength heroin. But dealers in the city of Philadelphia sell some of the country's purest heroin: samples seized by police exceeding 80 or even 90% purity does not surprise lab workers any more. Additionally, a bag often also has fentanyl or 'fentalogues' (fentanyl's sister drugs, sold by Chinese labs to American buyers in bulk for super cheap) laced into the mix. The Kensington area of the city operates like nowhere else in the country; on every corner, somebody has heroin and other drugs for sale. As people walk by, they shout out the name of their batch: "Flatline!" "Rotten Apple and hard [crack]!" "Monkey Shine!" "I got Ghost Rider, Ghost Rider is back everybody!" Police here of course make arrests--and yet this whole section of the city acts casually as if hard drugs are as legal as hot dogs or hamburgers. Anyway, because every corner in this area constantly competes with one another, the price has stayed low and even dropped from $10 a bag a few years ago to $5 everywhere now. Meanwhile, the purity of heroin got higher and it produces an even stronger high with the addition of fentanyl et al. Basically, a dope sick addict need only to get up $5 to buy one bag and feel better. Pill addicts elsewhere might need to hustle up $30 just to buy a single oxycodone to "get well."

Most addicts enter in withdrawal due to issues with access to their drug of choice: either they don't have any cash or they can't get ahold of a dealer, or possibly their schedule won't allow time to go meet up and buy drugs until later and so they must suffer for a few hours. Other times, addicts go into withdrawal with the intention of never using again; most heroin addicts will attempt to quit by detoxing cold turkey at least once. Even for this population, not only does the person consider getting more of the drug just to not feel sick, but they likely also still crave the high. This is especially true of I.V. heroin addicts: it really messes with your brain going from sick and depressed like this, then shooting up, and within 15 seconds feeling first better physically and then HIGH with the drug's trademark rush with all its inherent orgasmic euphoria and warm blanket-like comfort.

Because withdrawal sucks so much, quitting an opioid proves one of the most challenging tasks a human being can face. Stopping any addictive drug once somebody has caught a habit is hard because nobody ever just forgets how good that substance can make them feel. But the physical as well as specific psychological symptoms that come with opioid withdrawal make drugs like heroin, fentanyl, and oxycodone uniquely difficult to get away from. All opioids tickle the brain's Mu opiate receptors and similar ones, which release endorphins (named as a condensed version of the term "endogenous morphine"). All humans have these opioid-like chemicals built into our brains, though never will it naturally release the amount of endorphins that a shot of heroin or a bunch of oxycodone pills will. Nonetheless, activities like laughing, sex, and exercise (e.g. "runner's high") stimulate the release of endorphins without drugs. Scientists still don't completely understand all the activity of this neurochemical. But since endorphins definitely do things like fight pain, reduce stress, and make a person experience euphoria, maybe that illustrates the difficulty with quitting opioids. Not to mention they also effect dopamine, the brain's reward system.

In order to increase the chances of success when stopping an opioid, some form of detoxification is probably required. Inpatient rehabs will usually take about 7 days (give or take) to quickly ween the addict off of their drug of choice using a more mild opioid, followed by a few weeks at the rehab in lectures, group therapy, and counseling, away from the world where they can easily access drugs in order to recover. This works for a handful of people. Even more successful are opioid maintenance programs which utilize drugs like Suboxone (buprenorphine) and methadone. In essence, the patient is transitioned to one of the aforementioned medications, both being long-acting opioids themselves albeit less abusable ones than, say, oxycodone. Taking that prevents them from feeling withdrawal and mitigates cravings so that they can begin to rebuild their lives; usually therapy coincides with maintenance medications, especially at first. Over an extended period of time (years, even), doctors will slowly lower the dose until eventually they’ve been weened off it entirely. 

Why does giving opioid addicts a different opioid drug work best to get someone away from their drug of choice? That’s a complicated question but it just does. Realistically, opioids have a benign effect on the body: they don't do any major damage to organs, hence why terminally ill patients take painkillers from this class. Also, unlike alcohol, sedatives, or stimulants, the high itself does not usually lead to erratic or uncontrollable behavior. Rather, the user maintains a fairly clear head and can function normally. If an opiate naive individual takes the drug or somebody accustomed to opioids ingests a larger amount, they may nod in an out of consciousness. However, once an addict has taken a particular dose for a period of time, they grow used to it. Some studies show that drivers on methadone or high-dose morphine regiments for pain drive just as well as the control group. Opioids carry the risk of overdose, which frequently occurs with street opioids, a byproduct of prohibition: an unregulated product containing an unknown amount of an alleged substance; not knowing how much a person puts into their body leads to so many ODs. Still, aside from consequences that come from the legal status of these drugs, the main negative of opioids impact derive from the inevitable withdrawal that happens when the addict runs through their stash. With maintenance, the addict continuously receives a dose of a drug which prevents them from withdrawing each day, which allows them to then lead a normal life. And odd as it may seem, it works for tens of thousands of former addicts.

Only opioids currently have drugs approved for long-term use to help addicts get better in this manner. Doctors don’t have any equivalent to prescribe for cocaine or meth addicts and while alcohol and benzodiazepine (i.e. Xanax, Valium) addicts will receive something like phenobarbitol or oxazepam to detox; these are only used short-term to minimize the withdrawal syndrome of those substances and stop deadly seizures from happening. Perhaps only opioids have maintenance drugs available because of how uniquely horrible opioid withdrawal and addiction is to a person.

So if you know somebody addicted to opioids who complains about how horrible the withdrawal is, don’t just think they’re exaggerating or being dramatic or just trying to get some money out of you Well, they probably do want some money out of you somehow, seeing as it will remedy them. Don't take it personally if they borrow or steal from you, as chemical forces compel them to do so--they do not 'want to' do things like steal from loved ones. When considering why heroin addicts steal from their mothers and the like, remember the type of hell that threatens them every couple of hours if they don’t get their drug (not to justify it, though). An addict of heroin might start to feel antsy with yawning and tearing as early as 8 hours after their last dose, with withdrawal becoming full blown almost invariably by hour 24. The good news is that untreated, "cold turkey" withdrawal from heroin or other short-acting opioids (e.g. oxycodone) will peak around day 3 and should start to get noticeably more manageable after 5-7 days, though expect a lengthy road to recovery ahead. Most people lack the ability to simply go cold turkey and stop for good, requiring some form of medically assisted detox or even maintenance.

With the way it feels and how it can prompt people to act, ‘standard’ opioid withdrawal will rank amongst the most intense and intensely negative experiences endured by the people who’ve undergone it. For readers facing opioid withdrawal right now, get help! Even most state insurances will cover a generic version of Suboxone, and methadone clinics frequently accept payments on a sliding scale according to your needs. Maybe checking into an inpatient facility will work best for you: call a rehab center now because sometimes they'll have a wait list, particularly if you have state-funded insurance. At any rate, you can alleviate the withdrawal symptoms through legal channels which will also help to improve the quality of your life in some way(s), most likely. Don't do drugs, people!