Methadone/Opiate withdrawal Dr. David Arneson, NMD firstname.lastname@example.org ‘There is no free lunch.’ Last updated 10/01/08
Some 6 years ago I wrote this original document in response to an endless stream of questions involving methadone detox. How it got embedded on the net I don’t know. I did not write this article to talk you out of doing methadone—especially if methadone gives you some sense of normalcy in your life. Yet is rare over the long term for individuals to want to stay on any mind-altering drug—and methadone is certainly mind altering. If you are on any opiate therapy your biochemistry/neurochemistry is impaired. This impairment can last an extended period of time even when one chooses to end their relationship with the opiate treatment. I have spent the last 8 years of my life assisting patients in detoxing from methadone and opiates as well as other drugs and alcohol. I have never seen anything close to death in doing so. This is a testament to utilizing nutritional treatment as the mainstay of treatment. One must look at this as repairing the house that has been damaged in the storm—and the only repair materials that the body/mind knows comes from nutritional biochemistry.
I believe in the search for truth…the following monograph is what I know to be true about the use and withdrawal from methadone. I also understand that in life, the truth is constantly evolving. My 22 years on the road to recovery probably taints my judgment somewhat…but friends—I know recovery from the bottom rung. I’ve written countless e-mail replies to those of you who wish to discontinue methadone. In order to save myself time, I’ve decided to write as much as I can on one, or two, pages…the truth as I see it…to assist you in your endeavor. I will be adding and subtracting as more information is made available. Certainly, you may perceive your truth to be different. If you think that going to the methadone clinic every morning to get your dose for the rest of your life…gives your quality of life…then read no further and God bless you. I assure you, the standard medical establishment does not have an answer for withdrawal. In fact, the new way of thinking is that many of you will have to be on methadone for the rest of your lives. Nothing could be farther from the truth. They will try and convince you that sudden withdrawal will cause your untimely demise. Another falsehood, although the truth is you may feel like you’re dying. I consistently work with people stopping cold turkey and have better luck than lowering the dose over time. I’ve had a fewer than 2% of our in-house methadone withdrawal cases leave the program early…all have gone cold turkey from 60-300 mg per day…Many do this without the aid of other mind-altering prescriptive drugs…even though I’m licensed to prescribe these drugs. There are exceptions, for those that I detox out-patient, and for those that are on other medications when they come in for treatment…I’ll cover those medications in the following paragraphs. Personally, I urge all to consider in-house detox for methadone…especially if going cold turkey. Although in my personal experience I’ve never seen any advantage in lowering the dose over time. Especially, if one is at 45 mg or less per day. Methadone Detox can normally be accomplished in 3-4 weeks. For information on natural methadone detox, in-patient, Please call 602-276-3999 and talk to the staff at World Addiction and Health Institute…the web site is being generated as I write this…The most important issue in treatment for withdrawal is not so much treating the disease state but treating the individual. One specific protocol designed to treat a disease is standard medicine’s answer to all disease states. This is mechanistic medicine. It does not take into account our genetic variability…we respond to treatment in different ways…not just through biochemistry, but also on the emotional and spiritual levels. For the last 4 years, I’ve been using nutrition—Intravenous and oral—to rebuild and repair the biochemistry pathways in the body and mind. Over four years experience —this includes heroin, and all other street drugs, alcohol, and prescription medications–has taught me that natural detox works 100 times better than detox formulated and predicated by the use of other mind-altering chemicals. It is also important to recognize that there are many of you that were prescribed methadone for chronic pain. Yet one must recognize that the end result is the same—and therefore the remedies for withdrawal are the same.
One more important point is that emotional and spiritual supports are necessary for this journey back to health. It would be rare that a person is not stretched to the absolute limit—body, mind, and spirit–in the process of withdrawing from methadone. Those who chose to do this alone, rarely succeed. The support of family, friends, or even the 12-step programs are important adjuncts to this journey.
One final point needs to made about the use of methadone. There are those that were put on methadone for pain management. This occurs because opiates in general—while good acute therapy—are not good choices for chronic long-term pain. The body adjusts to opiate therapy by downregulating opiate receptors and the patient will eventually build a tolerance to the standard opiates like Vicodin, Percocet, or oxycontin just to name a few. Methadone is the last ditch effort to control pain…unfortunately, the use of methadone usually creates more long-term health problems. The other unfortunate aspect of taking someone off methadone—those that have been using it to treat chronic pain—is what will be used to control pain in the future. There has been some movement in treating pain with anti-depressants with poor results. Furthermore, long term opiate use eventually create what is termed the opiate pain syndrome…which simply is the fact that the receptors are so down regulated that the opiate has nothing to act on…and that’s why opiate therapy doesn’t work over the long term…For many of those with chronic pain, choices have to be made…and the withdrawal from methadone will be especially trying…but it can be done following the protocols listed below…as your body heals and the receptors are synthesized in the body your own enkephalins and endorphins (natural body opiates) will start to be interactive in pain management…this may not be enough…yet many cases of chronic pain will subside if serotonin levels in the brain can be increased—the reason for doing amino acid therapy is to increase these levels. Anti-depressants don’t increase the production of anything over the long term…in fact it is well known that in the long term they decrease levels of neurotransmitters such as serotonin. Amino acids therapies work well in most cases of fibromyalgia even though many of these patients will fall victim to the use of methadone which just creates more problems. The good news is that if a fibromyalgia patient will start the following protocols to get off methadone…these are the same basic protocols for treating Fibromyalgia…
Those who choose to eliminate methadone from their lives must be made aware of the post acute withdrawal syndrome…in the literature, this is called PAWS…if one just quits methadone, or any other drug or alcohol, it takes the average person 6 months to two years to reach some sense of bio/neurochemical normalcy…that’s if one does nothing…one must look at this as remodeling or repairing the house that has been damaged in the storm…the body/mind house only knows nutrition…for sure one must focus this nutrition to repair and rebalance these bio/neurochemical pathways as quickly as possible…step downs will benefit from some level of nutritional input…the next few paragraphs will line that out for you… Many have contacted me via the internet and I have responded to each and every e-mail that I have received. I will continue to do so but have written this addendum to address the issue of proper supplementation to reduce the severity and time associated with methadone withdrawal. As I stated in my original article-there is no free lunch—but there are ways of minimizing the time and discomfort.
For those who are stretched to their financial limits the following is the basic minimum requirements and many over the internet succeed with this simple list of supplements
1) Go to the health food store and get a product called Emergen-C…this is a powdered electrolyte drink, which also contains vitamins and minerals, do three of these drinks per day…THIS IS ONE OF THE MOST IMPORTANT ITEMS IN EARLY DETOX…this will treat dehydration and the loss of critical electrolytes during the early phases of detox
2) Get the best quality protein powder you can and do 3 doses per day mixed with fresh fruit or veggie juices
3) Get flax seed oil in capsules, or fish oil, these are the omega essential fatty acids you will need to re-stabilize membrane function of all cells…they also are essential in chronic pain patients to reduce inflammation…do 3000 mg twice per day
4) Get a good quality multivitamin in capsular form…do the recommended daily dosing The above will save me a lot of future pounding on the keyboard—yet I assure you I will continue to respond to each mail…with respect—dr dave
1) Most Methadone clinics are for-profit, private enterprises, do you really think they want you off the methadone. The cost of a dose of methadone is about $1.00…what are they charging you?
2) Since all associated therapists and counselors that work the methadone clinics are trained and get their information from the standard medical establishment…do you really think they know the truth…no one is saying that they are not caring individuals–but they don’t know the truth any more than the people who prescribe the medication to you. In fact, most of them think we’re idiots because we doubt and ask questions. The fact is that we do not know the long-range effects of methadone on the human body and mind…many are now thinking that the longer you are on the methadone the more profound, and possibly irreversible these changes may be…In fact, we don’t know the exact mechanism of action of many psychotropic drugs—just review the Physicians Desk Reference on Prozac…along with the countless other caustic chemicals we insist on putting in the human body.
3) Methadone is one of the most physically dependent medications invented in the 20th century. The reason for this is a) its long half-life (24-36 hours)…b) it is a synthetic morphine, c) the diabolic symptomology associated with withdrawal and the length of the withdrawal symptoms. Methadone, like all opioids, creates profound changes to gastrointestinal function… In layman’s terms, this means that regardless of the food you eat– the absorption of the vital nutrients is impaired. If nutrients cannot be absorbed in sufficient quantities and associated quality…all biochemical pathways in the body are affected negatively. Chronic fatigue, sleeplessness, aches and pains, depression, anxiety, are all signs and symptoms of these deficiencies. Methadone also has profound effects on brain neurotransmitter production and function. It is also known that it creates havoc in what is called the hypothalamic-pituitary-adrenal axis…which accounts for chronic fatigue. And like all opiates, methadone down-regulates opiate receptors in the human body thus the long-lasting aches and pains associated with withdrawal. Methadone withdrawal is particularly insidious because left untreated; these symptoms can last literally for months. Also the longer you are on methadone the more profound these changes in body and mind function.
4) Regardless of the level, you decrease the dose before quitting…you will suffer some level of withdrawal…Frankly, I’ve never been able to discern much difference in the withdrawal intensity between 1 mg or 80 mg…it’s always difficult. The withdrawal is unique to each individual…I’ve had some come off 65 mg or more, and while uncomfortable, hardly seem to break a sweat. Others coming off low doses and be in pure agony. One must treat the individual, not the disease.
Nutritional treatment is essential in the recovery and withdrawal phase of any type of drug or alcohol dependency. To clarify nutritional treatment, consider the following statement:
The body on methadone, or any other mind altering drug or alcohol, is like the house that has been damaged in a storm. If you were repairing the house what building materials would you need? You would need lumber, sheetrock, shingles, and etc for the major supplies…these are the equivalent of the bodies need for protein, carbohydrates, and fats. How would you hold everything together?…nuts and bolts, nails, and screws—these are the equivalent of the bodies need for vitamins and minerals. To make the repairs we need the proper tools to cut the lumber and fit it into place…one would need the saws, the equivalent of the bodies production of enzymes…these are made from the proteins we eat…one can draw analogy after analogy to explain the necessity for nutritional treatment to facilitate one back to health…only one thing needs to be clearly understood…you put back into the body the things it needs to come back to health.
Any nutritional therapy should be adhered to for at least 90 to 180 days regardless of how you feel. Just like it takes time to alter profoundly the body’s biochemistry with drugs…it takes time to repair with proper nutrition. Oral nutrition is best but often is difficult for those in their first week of detox and recovery. Proteins, complex carbs, and essential fatty acids are necessary building blocks for repair and return of proper function of organ systems and brain neurochemistry. Vitamins and minerals are “co-factors and co-enzymes” which work on the building blocks to do repair and rebuilding. Additionally, it is always counter-productive to move from the complex to the simple…my philosophy is to start simple and move to the level of complexity that works for you…remember all patients are unique in the way they process nutrients and in their ability to maximize therapy. The following I suggest for those who wish to detox out-patient:
1) Pharmaceuticals: Vistaril 50-100mg…three times daily…this is a sedating antihistamine which helps with anxiety and sleep…downside is that after 10 days or so it loses its therapeutic efficacy; Phenergan 25 mg tab…one every 6 hours for nausea and cramps. I may use these medications on my out/in-patient clients depending on the severity of symptoms. Imodium A/D works well for diarrhea. In some cases, especially in-house, we do utilize low dose benzodiazepine therapy—not without some reticent—these are drugs that have a high degree of potential for addiction…one must go here with caution
2) Intra-Venous Nutritional therapy: Inpatient or out-patient…typically every day for the first 5-6 days, then every other day until the symptomology has subsided. These nutrient bags can contain proteins, vitamins, electrolytes, and other elements necessary for the body-mind to heal. The advantage of IV therapy is that all essential cofactors bypass compromised gut function. Only when the healing occurs will the symptoms of withdrawal disappear totally. Diarrhea is uncommon in those that receive IV nutrient therapy…but for those not so fortunate, Imodium A-D seems to work well in most. If you are a medical professional and wish I.V. treatment protocols contact me at email@example.com
3) Oral nutrition: Increase the right proteins!!!!Proteins are the building blocks for neurotransmitters and neurotransmitter receptors…as well as the building blocks for your natural opiate receptors · For 3 weeks you must remove all red meats from your diet. Red meat has chemical components that increase inflammation and pain. Fish, chicken, eggs are good sources of protein. If you are having a hard time taking in solid foods go to a health food store and buy protein powders that can be made into smoothies or drinks. You absolutely must have increased protein intake…proteins are the building blocks for all enzymes, neurotransmitters, and enzyme receptors in the body. No chemical works in the body without receptors. Just like opioids have to have opioid receptors—which are down-regulated during methadone use—this is the reason people have long-lasting pain and aggravation coming off methadone…this isn’t much of a problem with heroin use because of it’s short half-life…proteins are essential for the repair work in recovery…I now use a formulation that I specifically formulated myself. These formulas are called Tyrosine Plus and Tyrosine/Mucuna…generally the formula Tyrosine with Mucuna works well for those coming off of methadone, methamphetamines, and benzodiazepines or any drug for that matter… I treat all my methadone withdrawal patients with this formula…the Tyrosine Plus and the Tyrosine with Mucuna formulas have all the amino acids listed below…the advantage is that you get the same dosing with fewer capsules to take and generally the formula will be cheaper overall than the singular amino acids. For those that choose to find their own supplements that following are suggested
- L-Methionine—a sulfur-bearing amino acid…necessary for the production of S-Adenosyl-methionine (SAM-e)…SAM-e is a necessary cofactor in the production of the master neurotransmitters—serotonin, dopamine, adrenalin, and nor-adrenalin…this must be added to any amino acid therapy directed at rebuilding neurotransmitter production and function…500 mg—two twice per day
- 5-HTP the basic building block to produce serotonin…100-150 mg twice per day
- L-tyrosine the basic building block for dopamine, norepinephrine, and epinephrine—1000-1500 mg twice per day
- Increase your intake of raw fruits and vegetables…you get little or nothing from canned foods…fresh fruits and veggies are loaded with fiber which helps bind and removes toxins from your body…they also normalize gut function
- Stay off candy, and other sugar-heavy foods
- Drink lots of good water, green teas are good for the antioxidants and anti-inflammatory properties…no cokes or soda waters for three weeks
- When capable you must start exercising…swimming is best because it is low impact exercise…yoga…tai chi…walking daily…detoxing or otherwise…exercise is a normal component of good health
Supplements: Some need less and some more…remember the efficacy of all nutrition and supplement use is ultimately guided by your genetics…and we are all different to some degree…This is the value of seeing a good Naturopathic physician in the state you are in…The fact is that very few Medical Doctors know anything about nutrition…70%-75% of the standard medical schools in this country have absolutely no nutritional classes what-so-ever…in the other 25 %–nutrition is often a 14-20 hour block of education and this is commonly an elective…Naturopathic physicians that are educated in a medical school environment are taught nutrition extensively with the associated biochemistry.
I use the following with all types of drug and alcohol recovery…
- Multivitamin with a strong mineral component: in gel caps only…an excellent quality multivitamin is absolutely necessary…remember that vitamins and minerals are cofactors, coenzymes for repair, healing, and normal function of the body…most times I have patients double up on multivitamins for the first 3-4 weeks
- Mineral complex: see above
- Fish oils, or flaxseed oil: necessary for repair and proper function of cellular membranes…anti-inflammatory…these need to be mixed omega 3, omega 6, omega 9 oils—4000 to 6000 mg per day in split doses…although some can be purchased as liquids and mixed with your smoothies.
- If you don’t do the drinks…get proteins as free amino acids…double up
- L-Glutamine 500mg caps…at least 2000-3000 mg per day…split the dose so that your doing it at least twice per day…helps heal the gut and the building block for GABA…the primary inhibitory neurotransmitter…helps slow things down…Do not take GABA as a supplement…GABA is made in the brain…when outside the brain the molecule is too large to cross the blood-brain barrier…the building block for GABA is L-Glutamine or Glutamic acid…these building blocks readily cross the blood-brain barrier.
- Valerian Root 450 mg: Botanical that reduces anxiety and helps one to sleep…Kava, Jamaican Dog Wood, Lemon Balm, Avena are all nervine botanicals which can be used together or by self…I find the doses for each individual varies but typically 1000 to 1500 mg every 4 hours.
- Melatonin…dosages vary…this is a hormone released from the pineal gland in the human body at night time for sleep…this is essential for those coming off opioids…in my experience as little as 1 mg to 30 mg has been effective…do what you have to do…I’ve had addicts coming off $100.00 a day habits sleep 4 hours the first night…start low and add 3-5 mg every half-hour till sleep…research on healthy volunteers using up to 100 mg of melatonin in a single dose shows little side effects… Melatonin is also known as a very strong antioxidant with 1000 times the potency as Vit E…Take only at night when you would be going to bed at the regular time…the room must be dark…that’s the way this hormone is released in the natural state…
- Full Spectrum antioxidants: relieves inflammation and helps normalize inflammatory pathways and reduces damaging molecules (free radicals) present in the system while detoxing
- Vitamin C: 2000-3000 mg per day divided doses…
- Reduced L-Glutathione 300mg per day: Helps liver detox metabolites of methadone…Detoxing agents can be found in many products…most in combinations…
- Adrenal Support: Research has shown that methadone, and drug use in general, has profound effects on the adrenal glands. In fact, research shows that there is a profound negative effect by methadone on the hypothalamic-pituitary-adrenal axis. This is why those that withdraw from methadone have protracted fatigue and problems with anxiety and insomnia. I often use freeze-dried adrenal extracts in treatment with fairly good results. You’ll find these products listed under names such as Adrenal Plus, or Adrenplus…the starting dose is around 1000 mg per day in split doses.
- Milk Thistle with alpha-Lipoic Acid is one combination that I use extensively for liver repair and detoxification…1200 to 1500 mg of milk thistle and 400 mg of lipoic acid per day in split doses
This is the basics. There is absolutely no way to eliminate all the problems associated with withdrawal from methadone…one must have a supportive environment and often with daily visits from a compassionate health care provider…This will not kill you…it will be a miserable event…what kills most is the movement back to street drugs to ward off the side effects of withdrawal. In fact, cold turkey deaths coming off opioids and methadone are rare and usually associated with other health problems, or overdosing on prescription medications…withdrawal from methadone is much less of a risk than total withdrawal from alcohol. I wish you all luck on this endeavor…My compassion and empathy go out to you…Ultimately, I know that you can do this…after all…it has to be done.