THE PATHOLOGY OF WITHDRAWAL
Habitual methadone use inevitably leads to the development of tolerance for the drug and, ultimately, addiction. Like other opiates, methadone works through a chemical binding process in the central nervous system (CNS) and brain. This binding process—combined with an artificial increase in neurotransmitters such as dopamine and serotonin—helps immediately reduce the sensation of pain and creates what many users describe as a euphoric, dreamlike state.
Over time, a user’s body and mind become desensitized to methadone’s potent effects and they require more frequent use of the drug in higher doses in order to sustain the same benefits. This vicious cycle sets the stage for a backlash effect which occurs in the form of various withdrawal symptoms that appear whenever there is a decrease or abrupt cessation in use. Methadone’s potency is such that even in cases of casual recreational use or occasional experimentation, a user can quickly progress to full-blown addiction—in which case more severe withdrawal symptoms are virtually guaranteed.
WITHDRAWAL SYMPTOMS AND TIMELINE
Although not typically life-threatening—methadone withdrawal is considered extremely serious. In most cases, methadone withdrawal requires professional medical management and ongoing psychiatric evaluation. In the early detox and withdrawal stages of methadone addiction, trained doctors and licensed clinicians work together to help determine a client’s individual treatment requirements using a variety of tools such as the Clinical Opiate Withdrawal Scale (COWS). These tools help quantify and evaluate the severity of symptoms and provide the basis for implementing safe and effective pharmacological and therapeutic interventions. Initial methadone withdrawal symptoms may include, but are not limited to the following:
- Lightheadedness
- Intense cravings
- Disorientation
- Insomnia
- Chills
- Mood swings
- Fatigue
- Diarrhea
- Vomiting
- Psychosis
- Dilated pupils
- Muscle and joint pain
Exact timelines for methadone withdrawal are difficult to establish due to the drug’s unpredictable reaction with individual biochemistry. Methadone features a long half-life of approximately 8-60 hours, which is the primary reason why it is so beneficial to those detoxing from heroin and other opiate addictions. However, this extended effect creates an element of unpredictability and danger when it comes to the withdrawal process.
During withdrawal, symptoms generally appear within 30 hours following dosage. In many users, initial symptoms are mild to moderate, but the intensity can quickly escalate depending upon aggravating factors such as the presence of other potent substances in the system or co-occurring mental health disorders. Methadone withdrawal is typically broken down into two distinct stages:
- The first stage is known as the peak, or acute phase. This stage is characterized by an intense onset of symptoms that climaxes within two to three days, but may last for two to three weeks. In most cases, symptoms gradually begin improving around the 10th day of the withdrawal process.
- The second and final stage of methadone withdrawal is known as post-acute withdrawal syndrome (PAWS). This stage is characterized by diminishing effects and a gradual return to equilibrium that may last for months and, in some cases, years.
POST ACUTE WITHDRAWAL SYMPTOM
Methadone, like other illicit or legitimately prescribed opiates, can have a dramatic effect on brain health and cognitive function. Chronic use almost always results in long-term damage and may create permanent structural changes—all of which are negative. Many of these changes are reversible with early intervention and proper treatment. The protracted symptoms of methadone withdrawal may mimic early-onset symptoms, but occur with less frequency and intensity. These long-term withdrawal symptoms frequently include:
- Anxiety
- Depression
- Irritability
- Difficulty concentrating
- Fatigue
- Residual cravings
TREATMENT OPTIONS
- Inpatient treatment (and detox)—this popular methadone treatment option occurs in a medically managed, residential setting. In inpatient facilities, highly trained staff are available to provide 24/7 client care and monitoring. Inpatient programs are extremely structured and typically last for a period of one month, although some cases require a stay of up to 90 days. Inpatient treatment involves group therapy and one-on-one sessions, as well as medication-assisted treatment (MAT) geared toward physical and psychological stabilization. Although inpatient detox is a critical step to successful methadone treatment and safely navigating the withdrawal process—it is not a replacement for long-term treatment.
- Partial hospitalization (PH)—this treatment protocol is generally considered more intense than outpatient treatment but less intense than inpatient treatment. Partial hospitalization programs are based on a highly structured regimen of group therapy and individual therapy sessions in addition to ongoing medication management. Unlike inpatient treatment, the sessions are usually scheduled five times per week, at shorter intervals, and without clients living on site.
- Outpatient—this treatment method is an excellent option for clients transitioning from more intensive levels of care, as well as those with highly demanding personal or professional schedules. As with inpatient treatment and partial hospitalization, group therapy, as well as individual sessions, are considered the primary interventions used to treat clients. In some cases, psychiatric evaluation and medication management are part of the protocol depending upon individual client need.
MEDICATION-ASSISTED TREATMENT
Modern pharmaceutical advancements have created a variety of highly effective methadone treatment options. In addition to whatever medications may be used to treat co-occurring mental disorders or physical health issues, the following Food and Drug Administration (FDA) approved medications are considered the nucleus of safe, effective treatment in many methadone treatment facilities:
- Suboxone: Used early in symptom onset, this combination of buprenorphine (a partial opiate agonist) and naloxone (an opiate antagonist), is frequently used to help prevent intravenous buprenorphine abuse. Suboxone is a highly regarded medication for opiate dependence that significantly lowers the risk of precipitated withdrawal and results in optimal stabilization. Suboxone triggers the same neurological receptors as methadone and is generally well-tolerated in the majority of clients.
- Subutex: This pure buprenorphine medication was developed around the same time as Suboxone. Subutex is considered a partial opiate agonist and is available sublingually, intravenously, and as an under-the-skin implant. It is administered early in symptom onset to reduce severity and diminish cravings and—like Suboxone—always under the close supervision of a licensed health care provider.
QUITTING “COLD TURKEY”
Although sometimes done despite prevailing medical wisdom, quitting methadone abruptly (cold turkey) is extremely dangerous and increases the likelihood of precipitated withdrawal—the rapid acceleration and intensification of withdrawal symptoms. Quitting cold turkey does not give the methadone-dependent body sufficient time to readjust and may result in a number of harsh, debilitating symptoms. Generally speaking, quitting “cold turkey” and self-administered treatment are not recommended and should never be performed under any circumstances.
TAKING THE FIRST STEP
Methadone withdrawal is often a long and arduous journey that entails many challenges and includes many set-backs. Those in long-term methadone recovery can attest to the fact that withdrawal is a marathon, not a sprint, and is best approached methodically under ongoing professional guidance. If you or someone you love is suffering from methadone addiction, call a substance abuse professional today. A wide range of treatment options are available to help and, as evidence clearly indicates, early intervention is critical to achieving optimal outcomes.
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