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Dealing with Secondary Withdrawal

There are really two phases of heroin withdrawal: acute and secondary. Acute withdrawal takes place during the time the body is "cleansed" of heroin and its metabolites. During this period, the body is greatly stressed and experiences the withdrawal syndrome. Following acute withdrawal, the body experiences secondary withdrawal. During this phase, the body slowly fine-tunes its metabolism and achieves a new chemical equilibrium.

How Long, Oh Lord?

Acute withdrawal can last anywhere from a few hours, as when a antagonist procedure is used, to many years, as when a methadone maintenance program is followed by a slow weaning. The intensity and length of secondary withdrawal is highly variable. For a straight antagonist detox, secondary withdrawal can be long and intense--so intense, that some have likened it to a straight cold turkey detox as in Derek Thiel's Rapid Nightmare. A very gentle methadone detox, on the other hand, can effectively have no secondary withdrawal.

The table below provides rough estimates of the number of days the acute and secondary withdrawal syndromes last. Note that there are far too many variables for this table to provide numbers that are anything more than rules of thumb. Some of the issues that can greatly change these numbers are: patient idiosyncrasies in genetics and behavior during both phases, length of addiction, level of addiction, and specifics of the detox process.

 
Detox MethodLength (in days)
 AcuteSecondary
 
Antagonist130
Medicated + Antagonist515
Medicated730
21-day Methadone3060
Cold Turkey730
 


Secondary Withdrawal

Secondary withdrawal has a number of potential symptoms. The most common are: depression, insomnia, muscle aches (especially back pain), and nausea. In addition to this, boredom can modulate the pain of all these. The secondary withdrawal syndrome is probably the cause of more re-addictions than is acute withdrawal. The reason is that the ex-addict still feels bad when he is supposedly done with withdrawal. "I went through all that for this?" he says. "I'd rather not live than live with this; where's that pager number?"

Detox Well

It helps enormously if the acute-withdrawal was managed properly. People who do a cold turkey withdrawal are perhaps at the greatest advantage here. Having been through a week of living hell, the relatively minor symptoms of secondary withdrawal may not even register. This is not a recommendation for a cold turkey withdrawal, however. It is harder to get through and I believe in quantifiable terms, it slows the process of complete physical recuperation.

Medicated Detox

The traditional clonidine detox can be helped greatly with the use of naltrexone. In this procedure, the patient is given higher clonidine and Librium® doses as increasing doses of naltrexone are given during the five-day process. Addicts find that after a five day detox, the body feels as well as it normally would after three weeks with a straight clonidine detox.. The down side is that many people find this detox very painful. The drug dosing must be exacting by the medical staff. Generall he benefits out-weight the extra care needed, however.

Methadone Detox

Methadone replacement with slowly reducing doses is probably the best heroin detox method available. The biggest problem with it is that the methadone doses are lowered too quickly. I think that the maximum rate of decrease should be 1 mg every 3 days (one week is better). This means someone maintained at 60 mg of methadone would require 6 months (180 days) to detox. Any rate faster, leaves the patient somewhat uncomfortable for the month or two after the completion of the methadone doses.

Back Pain and Muscle Aches

There are many over the counter (OTC) drugs for relieving back and muscle pain. The standard is aspirin. There are several others however, as shown in the following table.

 
Generic Brand Dose Onset Length Strength
Name Name (mg) (minutes) (hours)  
 
Aspirin Bayer 325-1000 60 4 Fair
Acetaminophen Tylenol® 325-1000 60 2 Poor
Ibuprofen Advil® 200-400 15 4-8 Excellent
Ketoprofen Orudis 12-25 30 4-8 Good
Naproxen Aleve® 220-440 30 10-12 Good
 


Ibuprofen

Ibuprofen is the best medication for this kind of pain. It is nothing short of a miracle drug. For most pain, it is more effective than Tylenol 3 (300 mg acetaminophen with 30 mg of codeine) and Vicodin (500 mg of acetaminophen with 5 mg of hydrocodone bitartrate). I have repeatedly seen people who need root canals go from experiencing almost intolerable pain to feeling fairly good within 30 minutes after taking 800 mg of ibuprofen. And every one of those patients fought taking the ibuprofen. They always felt they needed strong narcotics, "How can an over the counter (OTC) pain killer do anything for this kind of pain?" Later, they were complete converts.

It is possible to overdose on ibuprofen; but this is with very high doses (like 1000s of mg). In addition, some people experience allergic reactions to ibuprofen--things like hives. Finally, ibuprofen interacts with many different drugs.

Doses of 600 mg of ibuprofen every 8 hours for this kind of pain works well. Definitely don't go over 1800 mg of ibuprofen in a 24 hour period.

These issues of dose and safety should be discussed with your doctor unless you already have experience with continued use of ibuprofen at these levels. Remember, a drugs legal status says nothing about its safety or efficacy. What's more, ibuprofen was by prescription not that long ago.

Can't Take Ibuprofen?

If you cannot take ibuprofen, there are other OTC pain killers. Aspirin--invented by the same people who brought you heroin--is a very good pain killer. Aspirin can cause various problems; it is particularly hard on the stomach (the same is true of ibuprofen, affecting about half as many people). There are many other possible problems, but they are rare.

Aleve and Orudis are quite effective--comparable, if less effective, to Ibuprofen. Naproxen is of special interest because it is very long acting. Unfortunately, if ibuprofen is a problem, these two drugs most likely will be too. In fact, ketoprofen is the most likely of all these drugs to cause intestinal problems.

The Worthless Pain Reliever

If all else fails, there is always the acetaminophen, the worthless pain reliever™. It takes about an hour to take effect. Its pain relieving ability is poor. And it only lasts about an hour. The reason it is given out by doctors so much is that almost no one has any adverse reactions to it. None the less, one can overdose and die from it. People do every year. Use it if you have absolutely no other options. But remember, it is not completely safe and should not be taken by anyone with hepatitis. Read the FDA Report before using it.

Take a Soak

If you know someone with one, or there are public ones near you (look in the yellow pages), hot tubs are really helpful to relieve pain. In addition it can improve mood and help sleep. Even without a hot tub, just a hot bath can do wonders.

Nausea

Unfortunately, there are no OTC medications that work well to relieve nausea. There is an effective anti-nausea drug, however. It is also commonly available. Unfortunately, it is illegal. Of all the people in federal prisons, 60% are there for non-violent drug offenses. Of these people, roughly 30% are there for possessing this anti-nausea drug. The drug is cannabis. It is an excellent medication with many uses. Despite what the federal government will tell you, it was found in over 30 prescribed drugs when the U.S. outlawed it. And despite what the state government might tell you, you can still go to jail for a very long time for possessing it.

Acupuncture and "Alternative" Medicine

There are some remedies that "alternative" medicine has to offer for nausea. Goldenseal, for example. It can be found at health-food and vitamin stores.

In addition, a couple of acupuncture points are effective: P.6 and St-36. You would have to see a license acupuncturist regarding this however. The acupuncturist could apply "beads" or "seeds" on these points. These are basically tiny steel balls that are taped on the skin. Once they are placed, the patient can perform his own acu-pressure simple by pressing on them. Thus, when the nausea comes on, you can treat yourself.

Insomnia

Other than things like Valium®, everything available for insomnia is either ineffective or has so many nasty side-effects that it isn't worth using. In addition, a lot of things that are supposed to produce sleep are idiosyncratic. For example, antihistamines produce sleep in some and hyperactivity in others.

Acupuncture and "Alternative" Medicine

Acupuncture can be helpful for insomnia. So can some herbal formulae. Two that are pretty easy to find are "An Shen" and "An Mien Pian". If you go to a Chinese pharmacy, they may have other remedies for sleep. If you live near a "Chinatown", it is worth looking around.

Jin Bu Huan

There are also herbal pills called "Jin Bu Huan". These little pills are amazing. Unfortunately, they are no longer sold in the United States because they are made by one family in China that will not list the contents. The Pure Food and Drug Act requires the listing of contents, so people in the United States are not allowed access to these pills.

From the packaging, "Jin Bu Huan is a kind of Herb Medicine which is, in history, used by the people as an important medicine good for the relief of pain with conspicuous result. [sic.]"

They don't make the patient "high". He simply takes it and in a half hour he is quite suddenly asleep. The chemistry of the pills have been analyzed, of course; they do not contain any opioids; but we don't know exact what the stuff in it is.

Although these pills are illegal in the United States,they are still around and you might find them. I warn you, however: don't go around asking for them because you will scare people. They'll think you are a government agent.

Relax

The main thing to remember about the insomnia is that it will gradually go away. The way to deal with it is to simply accept it. Insomnia is at its worst when the sufferer fights it, thinking that he must sleep. While you are suffering from it, you will find that your body really doesn't need that much sleep. It's hard to deal with, of course--your body wants to sleep--but just stay calm. It is a real pleasure when you start sleeping normally--and eventually, you will.

Depression

Without a doubt, the best thing that can be done about depression is exercise. It helps the whole body to get working normally. This is very important. Daily exercise will help in endless ways.

It is also a very good idea to start taking vitamins. In short, the path to physical health is the path from addiction. The new ex-addict needs to take care of his body. It is surprising how dramatic and quick it is paid back.

A Life Worth Living

Once a person detoxes, he needs something to live for. Work, school, hobbies, it doesn't matter. Commonly, ex-addicts fill up their new free time with 12-step meetings. This is okay, but the time could be better spent. When 12-step meetings become the focus of an ex-addict's life, he has simply changed his focus from doing heroin to not doing heroin. A life that is preoccupied with not doing drugs is a minor improvement over a life preoccupied with doing drugs.

Gathering Information

Going to meetings of model-makers or Java-programmers is more healthy than going to 12-step meetings. For one thing, the ex-addict won't be spending all his time with drug addicts. He'll see regular people getting pleasure from regular, legal activities. It is part of gathering information for building the new life he wants to lead.

Detoxing is extremely difficult. What follows is at least as difficult. The first month is particularly hard. It's not that there is great pain--there just won't be anything that is all that pleasant. The whole world seems like a black and white movie. The life worth living--the one the addict detoxed to get to--only exists in the future. But there is a wonderful life waiting just up ahead. It isn't an illusion. Once a person has been a junkie, it is easy to appreciate the any joy in life.

Finding a Purpose

What is the pay-off for kicking dope? A great life. A life worth waking up to each day. How does one get one of those? The ex-addict can start by supporting himself: encouraging his dreams, abilities, pleasures, loves. A junkie's life has a clear purpose: junk. Without junk, he must find a new purpose. An ex-addict is lucky in this regard. He really can follow his dreams, because compared to being a heroin addict, almost everything is easy. He can re-invent himself. He can become one of the most exotic people on the earth. Or he can just enjoy living a quiet, simple life. All he has to do is choose because he no longer has his heroin addiction defining how to live.

Deciding what kind of life you want to lead can be difficult. Fortunately, there is a lot of help out there in the world. Instead of going to a 12-step meeting, an ex-addict might go to see a career counselor. He could talk to people he admires about what their goals our, what their ideal life is, what give their lives purpose. There is an excellent book that helps determine one's life goals: High Performance Goal Setting - Using Intuition to Conceive & Achieve Your Goals by Beverly "Doc" Potter.

Remember: You're Lucky

After you kick dope, you're like Dorothy opening that door from Kansas into Oz. But it takes a long time to get that door open. Be patient. You have time--all the time in the world. And things will be better, regardless. You're lucky. Remember that.

by Dr. H © 2003
Last Modified: 11 January 2004


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