There are many different types of opiates used today and while they are used for the same purpose, all of them have unique characteristics. There are 3 major classes of opiates which encompasses every opiate drug:
Also referred to these days as opioids, all of these drugs produce very similar effects through very similar mechanisms of action. They all work on the opioid system of the brain through opioid receptors. Some opiate drugs have a greater affinity for certain types of receptors, and this, along with the specifics of their metabolism in the body produces the difference in the effects of these drugs.
Some of the most commonly used and abused opiates drugs include:
Heroin is one of the oldest and most widely abused semi-synthetic opiates. Due to its chemical structure, it can be thought of as a supercharged version of morphine. It is often injected, as this produces extreme euphoria which is almost instant. Because of the intensity of high that heroin produces, addiction can happen very quickly. Heroin withdrawal, while not fatal, is a truly agonizing experience, and it is highly recommended for someone to enter an opiate detox center if they are attempting to quit. Because of the intensity of heroin withdrawal, the chances of successful recovery are very low unless someone gets help.Heroin Withdrawal & Detox Guide
Morphine is the original opiate drug as it was first extracted from opium poppies in 1805 and saw widespread use for over a century before people realized its addictive dangers. It is a broad spectrum opiate, interacting with every known opiate receptor in the brain. While it is still used for pain relief today, it is only used short term as it rapidly produces tolerance, dependence, and subsequently withdrawal. It is the gold standard by which the potency of other opiates is gauged by a “potency-to-morphine” measuring metric. Since it is so widely potent in the brain, morphine withdrawal symptoms are extremely uncomfortable. Even though morphine withdrawal is almost never fatal, it is highly recommended for someone experiencing withdrawal to attend an opiate detox center, as medications and medical supervision can make the experience more bearable.Morphine Withdrawal & Detox Guide
Suboxone is a fully synthetic opiate that has risen to great popularity recently as an opiate withdrawal treatment medication, even though it is itself an opiate. The specifics of the way buprenorphine (the active ingredient in Suboxone) works produces a phenomenon known as the ceiling effect. This means that while the euphoria is dose-dependent, it will only increase to a certain point and then cease. This is specifically in the case of opiate addicts, and those who are naive to opiates may feel a mild euphoria when taking Suboxone. The withdrawal symptoms of Suboxone are unpleasant, although not as intense but longer-lived than other opiates like morphine.Suboxone Withdrawal & Detox Guide
Oxycodone is an extremely powerful semi-synthetic opiate that is used pharmaceutically in the treatment of severe pain. Very similar in heroin to its effects, this drug may also be injected depending on the formulation and manufacturer. There are extended-release (Oxycontin) and instant release (Roxicet) formulations although both of these see widespread abuse. Oxycodone withdrawal symptoms are very similar in intensity and duration to heroin, depending on the doses used of course, and entering a detox center is highly recommended when someone is trying to quit.Oxycodone Withdrawal & Detox Guide
Fentanyl is an extremely powerful fully synthetic opiate that is commonly used to treat severe pain, such as that experienced by cancer patients. Recently, it has been used to cut opiates and other drugs to increase their potency and this has resulted in thousands of overdoses and deaths. Fentanyl can be between 50 to 100 times more potent than morphine per unit weight depending on the route of intake someone chooses, and it is between 30 to 50 times more potent than heroin. There are also fentanyl analogs that can be 1,000 to 10,000 times more potent than morphine, such as sufentanil and carfentanil, respectively. Withdrawal symptoms from fentanyl can be horrible and can be very similar to heroin withdrawal.Fentanyl Withdrawal & Detox Guide
Hydrocodone is a fairly common and relatively weak opiate when compared with the others on this list. Although it produces similar analgesic effects as oxycodone, the euphoria experienced can be much less intense. That being said, hydrocodone addiction and withdrawal is a very real, and often painful experience. Hydrocodone has a fairly long half-life, so the symptoms of hydrocodone withdrawal may be less intense than oxycodone withdrawal but will last longer. Someone is highly recommended to enter an opiate detox center when undergoing hydrocodone withdrawal, as these centers can reduce the discomfort as well as increase someone’s chances through support and continuing care.Hydrocodone Withdrawal & Detox Guide
Codeine is a natural opiate which is used to treat mild to moderate pain and as a cough suppressant. It is similar to morphine and hydrocodone, but is roughly 8 times weaker than morphine. Codeine has a similar half life to morphine, but due to its weaker affinity for opioid receptors, the codeine withdrawal symptoms will be much less intense than with other opioids. That being said, withdrawal from codeine is still a very unpleasant experience and someone is highly encouraged to seek help if they expect to undergo withdrawal.Codeine Withdrawal & Detox Guide
Vicodin and Lortab are prescription painkillers which both contain a combination of hydrocodone and acetaminophen. They produce effective pain relief but lack the euphoria associated with many other opiates unless taken in large doses. Due to the inclusion of acetaminophen, these large, euphoria producing doses are extremely toxic to the liver since a common ratio of hydrocodone-to-acetaminophen is 5:500mg. These levels of acetaminophen toxicity common in Vicodin or Lortab abuse result in extreme liver damage and reduced function. The sooner someone quits abusing these prescription drugs, the better off they will be as liver damage can be fatal.Vicodin Withdrawal & Detox Guide
Dilaudid is a very powerful semi-synthetic opiate painkiller that is used to treat both acute and chronic pain. It can be either short or long-acting depending on the formulation. Hydromorphone (the active opiate in dilaudid) is around 4 to 7 times as potent as morphine per unit weight and it has a similar half-life. Due to this, dilaudid withdrawal symptoms will be quite severe and may resemble heroin withdrawal in both intensity and duration.Dilaudid Withdrawal & Detox Guide
Opana is a semi-synthetic opiate which is about three times as potent as morphine and roughly twice as potent as oxycodone with regard to analgesia. Oxymorphone (the active ingredient in opana) is an outlier as it does not have any cough suppressant effects, as almost every other opiate does. Commonly used for pain relief, including obstetric pain, in 2006 there was an extended-release formulation released which quickly proved to be liable for abuse. Due to the very short half-life of opana, the withdrawal symptoms of oxymorphone can be quite severe; both duration and intensity are comparable to heroin.Opana Withdrawal & Detox Guide
One of the first fully synthetic opiates which saw widespread use, methadone originally entered the pharmacopeia as a heroin withdrawal medication. It is unique among opiates as it exhibits both opiate and non-opiate characteristics as its mechanism(s) of action. As far as potency goes, methadone exhibits what is known as “therapeutic inequivalence” as there is no direct equivalence in potency between methadone and other opiates. While the potency may vary, methadone has an extremely long half-life, which means that methadone withdrawal symptoms will persist for much longer than during withdrawal from other opiates. While the symptoms may not be quite as severe, the prolonged withdrawal period may be overwhelming for many people. This can be likened to an opioid taper, where someone will experience somewhat milder withdrawal symptoms for a longer duration.Methadone Withdrawal & Detox Guide
Tramadol is a unique opiate in the sense that it works on both the opioid system and serotonin and norepinephrine systems in the brain. The fact that it affects these other, nonopioid systems increases its effectiveness at pain management through avenues different from other opiates. It has fairly weak opiate interactions, with potencies ranging from 1/5th to 1/10th the potency of morphine depending on the route of intake. That being said, the symptoms of tramadol withdrawal are very unpleasant and include more intense psychological symptoms than other opiates due to its other interactions.Tramadol Withdrawal & Detox Guide
Withdrawal from opiates is one of the most physically and mentally uncomfortable drug withdrawal syndromes. Chronic opiate use can produce severe disruptions in neurotransmitter balance which takes the brain and body time to repair. This time is characterized by intense physical discomfort, mental distress, and a sense of hopelessness and depression.
To get a better idea of the experience of opiate withdrawal, it will be helpful to know a little more about how opiates work. The main mechanism of opiate action is through the endogenous opioid system of the brain and body. “Endogenous” simply refers to the fact that these opioids are produced by the body and are in contrast to “exogenous” opioids which are introduced from outside the body. This is a network of opioid receptors which are present in large numbers in the brain and gastrointestinal tract, and imbalances in these systems produced through opiate addiction is directly responsible for the symptoms of opiate withdrawal. While the body produces its own opioid peptides that interact and regulate this system, opiate drugs will stimulate this system to a much higher degree than our natural opioid peptides are capable of doing.
The main way that opiates interact with this system is through the μ (Mu), κ (Kappa), and δ (Delta) opioid receptors. The main euphoric and painkilling effects of opiates are mainly produced through interactions with the μ opioid receptors. These are present in the brain where they help to regulate the perception of pain (analgesia), heart function, and mood. These receptors are also present in the gut in large numbers where they help to slow and synchronize intestinal muscle contractions. The κ and δ also contribute to opiate drug effects, with the κ receptors affecting analgesia and mood while the δ influence analgesia and intestinal function.
Through chronic opiate use, this natural opioid system undergoes changes which reduce the sensitivity of these receptors through a process known as downregulation. This is the brain and body’s attempt to maintain balance and efficient function while also protecting against neurotoxic overstimulation. This process is initially responsible for tolerance, as the reduction in receptor sensitivity means that more opiate drugs are needed to produce the same effects. If opiate use continues, physical dependence will be the result, with the body’s own opioid peptides being unable to stimulate this system to the degree necessary for healthy function. Opiate withdrawal is the result, and the longer someone uses opiates, the more uncomfortable this experience will be.
Opiate withdrawal can be separated into two distinct phases, the acute and post-acute phases. The acute phase is characterized by physical symptoms, while the post-acute is more of a mental struggle. While the symptoms differ between these two phases, the discomfort in acute withdrawal is a product of opioid receptor downregulation which results from chronic opiate use, and the subsequent cessation of opiates. The symptoms of post-acute withdrawal arise from structural changes the brain makes in response to prolonged downregulation, and these changes can take time to reverse.
The acute phase is the first phase of withdrawal, and while not very long-lasting, it may be extremely uncomfortable or even painful. The sharp drop in opiate use results in a severe shortcoming in the normal regulatory and maintenance functions of the opioid system. This may result in withdrawal symptoms appearing within 4 to 8 hours of the last opiate use and persisting for around a week. This depends on the specific opiates used of course.
Some of the most frequently reported symptoms of acute withdrawal from opiates include:
These symptoms may reach their maximum within three or four days of their appearance, and acute withdrawal is commonly described as “agonizing” by opiate addicts. This is frequently one of the main reasons for users to continue opiate use; withdrawal avoidance. This phase may last around a week, give or take depending on the person, and is an extremely unpleasant experience. Medications may help reduce the symptoms and give someone a better chance of making it through acute withdrawal. It is very highly recommended for someone to seek medical help if they are experiencing acute withdrawal.
The post-acute phase of withdrawal, while much less intense than acute withdrawal, can be extremely long-lasting. This phase differs greatly in duration between individuals but is commonly several months long. The symptoms are strictly psychological in nature, but that does not mean it is an easy phase to endure. The hopelessness, depression, and anxiety can severely impact someone’s daily life and cause them to withdraw into isolation.
Some of the most commonly reported symptoms of post-acute withdrawal include:
These symptoms will be most intense early on and will gradually subside over weeks or months. This phase is associated with a high risk of relapse, as depression and anxiety may seem unending and permanent. The memory of the “good times” provided by opiates may seem more attractive as the pain and misery of acute withdrawal become more distant over time. Medications and therapies have been very successful in treating symptoms of post-acute withdrawal and it is highly recommended for someone to seek help during this time.
There is some variability between people as to how long opiate withdrawal will last, but the early stages are identical for the most part. Within hours of the last opiate use, symptoms will appear and begin to escalate. Physical symptoms will appear first and then psychological symptoms will join them, resulting in a truly miserable experience. For an illustration of a common timeline of opiate withdrawal, let’s look at the first few weeks:
Within 8 to 24 hours of the last time someone used opiates, physical symptoms will begin to appear. Sweating and chills are commonly the first to emerge, joined shortly after by anxiety and a growing sense of dread. Shaking may begin shortly afterward, and then an increasing uncomfortability in the muscles or joints. This should be joined by hot and cold flashes, increased heart rate and blood pressure, and a drastic reduction in appetite. One the second day of withdrawal, diarrhea and muscle cramps should begin and insomnia will be increasingly prominent as yawning, tossing, and turning becomes frequent. Anxiety and depression will have been escalating all the while and will continue to do so over the first week.
The physical symptoms will usually peak around the 3rd or 4th day after withdrawal symptoms begin, and begin a gradual reduction from that point forward. Sweating, chills, diarrhea, and joint pain are commonly the last to resolve, typically persisting until 5 to 7 days after withdrawal initially began.
The psychological symptoms of depression, anxiety, and insomnia will still be very much present and will be joined by profound fatigue and lethargy, with someone feeling totally drained of energy and motivation. Appetite may begin to return to normal during the second week, and sleep may become a little easier, although it will still be a challenge. The yawning, while still present may begin to subside somewhat during this time as well.
While insomnia and yawning may be much improved by this time, depression, anxiety, and extremely low energy levels will be the main features of the third week after withdrawal began. These may improve somewhat throughout the course of the third week, but should still be expected to be very fairly intense. Energy levels may improve more than the other symptoms, but someone will still be quite lethargic and fatigued.
The fourth week into withdrawal will be much better than the first. The physical symptoms will be an increasingly distant memory, energy levels and sleep habits will be much closer to normal, however the psychological symptoms of depression and anxiety will still be present. These mood issues can be expected for some time, but they will gradually resolve over the course of the next few weeks or months. Medications and therapy have proven very effective at treating symptoms in the weeks after opiate use ceases, and these may greatly improve someone’s state of mind during this time.
The physical symptoms are certainly the most severe and prominent feature of opiate detox. The opioid system imbalances produced through chronic opiate use will result in profound disruptions in a variety of physical processes and systems. This is caused, indirectly, by downregulation of opioid receptors in the brain and body.
The opioid system is known to slow and reduce nerve signals in other systems, and downregulation results in the opioid system having a greatly reduced effect on these other systems. During opiate withdrawal, since the body is less sensitive to endogenous opioids the opioid system is unable to exert its calming effects on dependent systems. Subsequently, many systems that are neurologically “downstream” of the opioid system will enter a hyper-excited state during opiate detox.
Some of the systems which are heavily affected in this way include:
The gastrointestinal tract is home to a very large number of opioid receptors, including μ-opioid receptors which are a common target of opiate drugs. In the digestive tract, these receptors act to slow and moderate the stomach emptying into the intestines, intestinal muscle contractions, and control of the sphincter muscles. Due to the hyper-excited state of these systems during opiate detox, this entire system enters a hyperexcited state.
The most noticeable effect of opiate withdrawal on digestion is the prevalence of diarrhea. This is intense and frequent in the first week or so of detox and is very unpleasant. Additionally, appetite is greatly reduced or absent entirely, stomach cramps are frequent, and nausea is a constant companion. These symptoms will resolve with time, but the body must first restore balance to the opioid receptors in the enteric nervous system and this is a slow process.
The cardiovascular system is impacted by the detox process. There are direct effects that are produced through opiate detox, while the psychological effects of detox may contribute as well. There is still some mystery as to the exact nature and mechanisms for the influence that opioids have over the cardiovascular system. While their exact cardiovascular functions are currently unclear, it is known for sure that the μ and κ opioid receptors play some role in heart function and regulation, and detox can subsequently affect the function of these receptors.
Due to the downregulation of opioid receptors, and the subsequent lack of stimulation resulting from detox, these receptors are unable to slow and moderate cardiac nerve impulses. Additionally, extreme anxiety and other neurological hyperactive states will result in an increase in adrenaline which will absolutely increase heart rate and blood pressure. This is not dangerous to an otherwise healthy person, but if someone were to have a pre-existing heart condition, this could potentially lead to very dangerous complications, although this is rare.
There are a number of disparate systems that do not fit neatly into a single physical system which are affected by detox. These include systems involving voluntary muscles, skin and mucous membranes, and sensory systems. While the sensory effects may technically be psychological or neurological in nature, we will include them here since they alter the perception of the physical aspects of the body.
Some of the peripheral effects of opiate detox which result from an increase in adrenaline or glutamate levels include:
Some sensory effects of opiate detox include:
These effects are very unpleasant and will take time to subside naturally. As the body readjusts to the absence of opiates and subsequently undergoes upregulation (the opposite of downregulation), these symptoms will begin to resolve. This is a slow process and can take time, but the physical effects of opiate detox are always the first to resolve.
There is some variability in the psychological effects between individuals during opiate detox, but for the most part, everyone will experience certain symptoms to a greater or lesser degree. These effects are likewise caused by the disruption of the endogenous opioid system, and the cascade effect this produces in “downstream” neurological processes.
The most common symptom of opiate detox by far is the presence of very powerful and persistent cravings. These cravings are produced through very complex mechanisms that aren’t fully understood but certainly involve dopamine and parts of the limbic system, also referred to as the “reward center” of the brain. The chronic use of opiates and the way this affects opioid receptors, particularly at the κ opioid receptors, can produce long term disruptions to key areas of the limbic system such as the ventral tegmental area and the nucleus accumbens. These areas are known to be heavily involved in learned behavior, memory formation linked to behavior, and feelings of reward and euphoria.
Through chronic opiate use, someone may temporarily eliminate their ability to feel good unless they use opiates. This is due to the prolonged overstimulation of the opioid system and the very high levels of dopamine this produces. After chronic opiate use, the normal sensations of pleasure can barely be perceived, as they have been outshone for so long by the opiate-induced dopamine surges. The result of this is very strong and very long-lived cravings for opiates. The inability to feel good will combine with the strong sense memory of pleasure and opiates, which will make someone want to do opiates. This can be so severe in some cases as to manifest as a preoccupation or an outright obsession with thinking about opiates and opiate use. This will reduce with time, but has been known to persist for years in some cases.
Depression is an extremely common effect of opiate detox and can often last for many months. While the causes are not clearly understood, there are some factors which certainly contribute to the severity of depression during detox. This may be due to both neurotransmitter disruptions as well as the loss of such a powerful, although unhealthy, coping mechanism as provided by opiates. Similar to cravings, the severe downregulation and subsequent structural changes which occur to the limbic system during opiate addiction can take time to reverse and repair. Disruptions to the limbic system can have downstream effects on the neurotransmitter dopamine, serotonin, and GABA and all of these neurotransmitters contribute to someone’s mood and state of mind. Serotonin is probably the greatest contributor, being heavily responsible for mood elevation and regulation.
This results in a state of mind and outlook on the world which may best be characterized by the words hopeless, pointless, unmotivated, and unrewarded. People who are early in the detox process often feel hollow and cold with a sense that they will always feel this way, and nothing is going to change that. This is not the case, and only extended periods of abstinence will give their brain time to heal these changes. Once the brain can regain some sort of neurotransmitter balance, someone’s outlook will begin to lighten, becoming less bleak, hopeless, and depressed.
Anxiety is another very common symptom of opiate detox, usually beginning as generalized anxiety and tending more towards social anxiety as the weeks pass. This can be a minor or major symptom depending on the person with some people experiencing a great deal of anxiety, while others experience very little. While this is always most intense in the week or two immediately after opiate use has ceased, anxious symptoms may persist for several weeks. This is due to imbalances in dopamine, serotonin, and norepinephrine along with structural changes the brain has undergone in response to neurotransmitter imbalances and downregulation.
Norepinephrine is both a neurotransmitter in the brain and a hormone when it is present in the blood. It is responsible for stimulating the release of adrenaline, so increased levels of norepinephrine will lead to a heightened state of awareness, often to an uncomfortable degree. Adrenaline is a major component of the fight-or-flight response, so the anxiety experienced during detox is akin to a panicked state of fear. This symptom will resolve with time, but continued abstinence is the only permanent solution.
Opiate detox is an extremely uncomfortable and sometimes painful process, and medical help is always recommended. In an average healthy person, there are minimal risks to their life, although if someone had underlying or preexisting medical conditions, they may be at great risk of serious complications or even death. Likewise, if someone has had a drug or opiate problem and tried to quit on their own but failed, then an opiate detox center is highly recommended.
Due to the relatively minor cardiovascular disruptions which occur during detox, if someone has a heart condition then they should absolutely seek medical help during detox. The increases in heart rate can put a great strain on their heart, and also increase the risk of hemorrhagic stroke due to sharp spikes in blood pressure. In most cases, this does not pose a serious threat, but if someone already had poor cardiovascular health, they may be at increased risk for these issues. With the medical expertise of doctors and medications, these risks can be minimized and managed.
Another effect of detox is wild fluctuations in blood sugar. This results from the increase in norepinephrine and adrenaline, which can greatly increase blood sugar levels and cause stored glucose to be released in very large amounts. This is extremely dangerous to a diabetic and can lead to hyper- or hypoglycemia which may result in seizures, coma, or death if it is left unmonitored and untreated. Medical monitoring and supplemental therapies may be able to reduce these risks and help someone make it through opiate detox in one piece.
People who are experiencing severe symptoms from opiate detox are highly encouraged to seek a medical detox center. These symptoms, while not only being extremely uncomfortable, can reduce the chances someone has of completing detox. The worse the detox symptoms are, the more likely someone is to get relief the fastest way they know how; do more opiates.
If someone was an IV opiate user this is especially the case, as IV opiate use produces much more severe detox symptoms much sooner. Because the drug enters the brain and body so fast when someone injects opiates, the symptoms of detox will appear much more quickly and also escalate more quickly. Additionally, there is a wide range of health and recovery risks that come along with intravenous drug use, and an IV opiate user will stand a better chance at a safe, healthy, and successful recovery if they enter an opiate detox center.
The first step towards finding an opiate detox center will be to search for one which is closeby. Once a few candidate centers have been chosen, someone can move on to the details of insurance coverage or out-of-pocket cost to refine their options. A good place to start would be right here and right now…
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