Opioid Dependence, Withdrawal, Medically Assisted Detox and More!

Dwight Hurst: Hey, everybody, welcome back to Waismann Method® podcast. I am a co-host to Dwight Hurst. I’m going to be joined today by Clare Waismann. As always, we’re always here to talk to you about questions about opioid dependence and treatment. We are super excited to have Dr. Michael Lowenstein, who is the Waismann Method’s medical director, is going to come on today as well.

Dwight Hurst: And we’re going to talk about some of the physiological effects of acute withdrawal and detox and some of the things that you really want to know about your health and your health management when it comes to starting sobriety.

Dwight Hurst: One of the big takeaways that you’re going to get out of today’s discussion is the complexity of beginning sobriety and how important it is to do that correctly. Want to make a quick statement, too, that the Coronavirus outbreak we know is gripping the world right now. And I just want to take a minute to say hope that everybody out there that’s listening is safe. This can have a tremendous effect on everyone. It is a health crisis. But, you know, we in this field, more than anybody know the difficulties that can be gripping those who they or their family members are in the grips of dependence or in addictive patterns or different things that can be harmful and difficult in the best of times. It’s all amplified by this kind of a thing. In fact, in the next recording, we’re going to get together and talk about some of the things that can impact families and individuals struggling with opioid dependence during it, during a crisis like this where they may not have access to treatment and things and things like that. So we’re going to be coming back to that topic a little bit more in the future. So please be safe out there and please take care of each other. For right now, please, lay on back and unless you’re driving than sit on up straight and drive ahead.

Dwight Hurst: But listen to this cool conversation that we’re going to have, a really informative conversation about the physiological effects of dependence and withdrawal. And yes, we’ll go from there.

Dwight Hurst: Now, it’s exciting to be here with you, Dr. Lowenstein. It’s also great to have you here today. It’s a pleasure to be here.

Dwight Hurst: Well, we’re going to be talking about some of the medical and physical things that we observe about opioid dependence, as well as about treatment right now and the things that people go through. Why don’t we just kind of start out with that? Well, let’s talk about some of the physical effects that we do see with people who’ve been using for a long time.

Michael Lowenstein, M.D.: Opiates affect multiple body systems and it becomes very evident when someone stops taking their opiates and begins to withdraw. You can see how many different body systems opiates actually have an impact on. Opiates can affect the brain and its function. They can affect neurotransmitter production. They affect hormone production in men. Or even in women, you see reduced testosterone production. They affect sleep-wake cycles. Opiates affect gut function – constipation is frequently a common side effect of opiate use. Opiates affect people’s appetite, you can see weight gain or weight loss, dips in energy levels. It affects people’s cognitive functions, ability to think. With overdosing, you see respiratory depression. So there’s probably not a single body system that opiate use doesn’t affect.

Dwight Hurst: I know that one of the things that opioid use is famous for is that once people have started to abuse the rush of pleasure or the high that people talk about diminishes greatly. I mean, it seems like that happens pretty quickly, right, to where all of a sudden I’m not taking it for any kind of pleasure as much anymore as I am, just to avoid the nasty things that happen to me when I’m when I stop.

Michael Lowenstein, M.D.: Yeah. So people who would take opiates for chronic pain can usually maintain a certain dosage for long periods of time. People that are using it for other reasons, it treats underlying issues, get very tolerant to the euphoric effect from it. And for that reason, it takes increasing larger and larger doses to maintain that effect. And at some point that patients really almost don’t even get the euphoria anymore and they get to the point where they’re just taking it to avoid being sick. Those in search of the ongoing euphoria of those effects from the opiates are the ones that are the patients that will continually use more and more and more and attempt to maintain that.

Dwight Hurst: And gosh, that gets dangerous pretty quickly.

Michael Lowenstein, M.D.: Yes, you can’t because, you know, the risk of opiates is overdosing, respiratory depression, death. So the more opiate you use, the greater those risks become. Also, with the current drug supply that’s out there with changes every day, we think they’re taking OxyContin pills or heroin, but they could be laced with fentanyl and other substances. Most people don’t even know what they’re taking.

Dwight Hurst: Is it just the street drugs you’re seeing where the fentanyl is laced in?

Michael Lowenstein, M.D.: Yes.

Michael Lowenstein, M.D.: Increasing amounts of fentanyl in products, whether it be heroin that people are shooting or smoking or even the oxycodone tablets that are probably coming into this country, all the people that are using or abusing are aware that this is a fact. But their dependence has become so great, addiction to these meds, that they’re willing to take the risk, the increased risk of overdose associated with fentanyl just to maintain the effect they’re getting from the opiates and to avoid withdrawing. So even with the known additional risks, they continue to use substances laced with all kinds of things. And some of the drug tests I’ve even seen anti tricyclic anti-depressants showing up positive. So they…

Dwight Hurst: Really?

Michael Lowenstein, M.D.: Yes, it’s. There so we don’t even know what’s in the supply. And depending on which part of the country they come from, there tend to be different amounts of fentanyl, but they’re used to people using it are usually very aware of the fact that there is stronger, but they continue to use it again to avoid being sick.

Dwight Hurst: A while back, I’ve worked with many people with addictions, but I just remember one story someone told in a group once where they went and tried to purchase heroin. And what they ended up getting was a long story short. They didn’t get any. It was fake or whatever. When they realize that what they’ve been given was not actually going to work. They just give this picture of just sitting in their car and weeping because they knew what was going to happen to them. And they were right at the point where if I don’t use today, I’m starting to go into withdrawals and just sitting there just crying, knowing that it was coming.

Michael Lowenstein, M.D.: Yeah. They become desperate and are willing to use almost anything they can get their hands on.

Michael Lowenstein, M.D.: So when people are opiate dependent, I think that’s a really important point for us to touch on as do you know how many people stay on their active use to avoid withdrawal or to because they are scared of not making it through withdrawal of, you know, how hopeless they become after they tried, you know, 2, 3, 4, five times and they fail. Also, there is this myth that opioid withdrawal is not dangerous. We do see patients with tremendous high blood pressure. Now we keep patients that go through withdrawal and dehydrate. Having a medically assisted detox where we give patients the ability to come off opioids with medical supervision should be part of the standard treatment. As Dr. Lowenstein explained, long-term opioids, regardless of what they are, cause a number of different issues, the ability, the choice to come off opioids should be on the table.

Dwight Hurst: Yes, that’s I know, you know, we’ve touched on before the whole like sitting in my friend’s basement with a blanket wrapped around me and my knees wrapped around a bucket is obviously not pleasant and obviously not good, but it’s also highly, highly dangerous. As I was just talking about, it might help to walk us through that a little bit. Like if I’m opioid-dependent and I stop using what starts happening inside my body.

Michael Lowenstein, M.D.: So when people are opiate dependent and discontinue the use of opiate medications, they will go into withdrawal. And the reason that happens is because when you use opiates over time, your nervous system will compensate for the dating effects by increasing certain neurotransmitter productions like noradrenaline. So when the opiates are stopped, you still have neurotransmitters being produced at increased levels. You can see the elevation in blood pressure increase, heart rate increase, respiratory rate. Nausea and vomiting and diarrhea that you see can cause dehydration can lose important minerals such as magnesium and potassium, which can then potentially affect your heart function inability to eat. All of these things can have a huge physiologic effect. The detox that I performed, the initial 2 to 3 days are in the hospital and the first thing I do for patients is starting an I.V. and hydrating them while doing bloodwork to look at the liver, their kidneys, their pancreas, their thyroid, their electrolyte levels, treat the nervous system with medications that prevent that huge surge of noradrenaline and keeps blood pressure and heart rate stable. I can decrease the chances of nausea and vomiting. And if any of these things do occur, I can treat them with medications by mouth or by I.V. to minimize the symptoms to as low as possible and to control the physiology, the blood pressure, the heart rate, the respiratory rate, all those physiologic changes that you see tensely as a result of withdrawal to a non-doctor here I’m hearing isn’t saying there’s a lot of that that I wouldn’t be aware of if I’m just like sitting going through withdrawal, my own thinking, well, I’ll be sick for a minute that it will be OK.

Dwight Hurst: Serves me right for using drugs. You know, if I’m going through that, I’m nobody’s monitoring all those. I think hundreds of things you just said. I mean, there’s a lot there to be conscious of. It sounds it could be very, very risky without that close monitoring.

Michael Lowenstein, M.D.: They can, and as patients are older or as they have underlying medical problems, they are at more risk with those dramatic physiologic changes that you see in cold turkey, unaided withdrawal. So in a hospital setting, we’re able to monitor diabetes and monitor blood pressure and monitor any of the underlying medical issues that patients have. In addition to their opiate dependence is very rarely is it? Are they just opiate-dependent with no other medical issues? So you’re not only managing the physiologic effects of opiate withdrawal, but you’re also having to manage all of their other underlying medical issues. And as patients get older and older, the number of underlying medical conditions usually increases. Also, patients who are using opiates tend to be sedentary. So they really don’t, we don’t really know what kind of physical condition they’re in. As far as heart and lung. So it’s really important to just be able to assess all of those things upfront so you can be proactive rather than reactive. You know, when somebody comes to an emergency room, dehydrated with low electrolytes and hyper elevated blood pressure and heart rate, it’s much harder to get control of them than if you’re proactive…

Clare Waismann, CATC: Patients they are 50, 60, 65 years old. And we have the proper medical assistance to go through a withdrawal, you know, once we have seen a lot of patients coming in. It’s a blessing that they walk into a hospital withdrawal at all because they wouldn’t have lasted a day or two trying to do it at home.

Michael Lowenstein, M.D.: Yes. So we’ve managed to identify in the last few years patients with metastatic lung cancer that didn’t know they had, there were severe cardiovascular diseases, anybody over the age of forty-one. I actually, with a cardiologist, put on a treadmill just so we can assess their cardiac function and their ability to handle stress. So we’ve identified patients with cornier that required bypass surgery. When you use opiates it numbs the entire body.

Dwight Hurst: So what are some things that I should, need to be careful of? Let’s say that I am that person that you mentioned and I’m going to try to get clean. And maybe it’s a friend, or maybe it’s even a program that doesn’t have the medical component. They say, OK, come on in and let’s just kind of suffer through these withdrawals. What are my risks in there?

Michael Lowenstein, M.D.: There are risks involved. It’s very stressful on the body. So you can see alarmingly high levels of blood pressure, even levels where you could potentially have a heart attack or a stroke. There is a lot of nausea, vomiting, and diarrhea, and you become dehydrated.

Michael Lowenstein, M.D.: That can also present great risks as far as from a cardiac standpoint. And if you lose electrolytes to the vomiting or diarrhea that could affect heart rhythm in people, it’s important to control those physiological responses of withdrawal. We’re in a place where you can be very carefully monitored and see those symptoms can be treated aggressively to maintain, you know, a normal blood pressure, heart rate, fluid balance, electrolytes and can be replaced if necessary. So I think it’s very important to people that have underlying medical issues that become at much greater risk during the dramatic physiologic changes that take place during withdrawal. I think it’s very important for them to be closely monitored and have their physiology controlled.

Dwight Hurst: Clare, you and I have talked about this before, that everybody in the life of someone who is dependent and who is using just wants to say, well, stop using, stop drinking, stop using and everything. You know, that’s the problem. And in fact, that’s actually. Covering up the problem as we say it as we talk about psychologically, but in this case, too, this is another example of how just stopping the usage is not the beginning of recovery or the beginning of treatment unless I’m actually doing it in a medically oriented way. Does that make any sense? I just feel like I rambled for like a minute. When I’m when I’m trying to say is we think so. We think that people just need to stop using and then they’re already getting better. But you’re describing that, actually. No, in many ways, it starts a heavy process right there.

Michael Lowenstein, M.D.: I think there are two distinct processes that take place with treatment for opiate dependence. Or opiate addiction. You’ve got the dependence portion which, dependence is medical and you stop the opiates and there’s a physiologic response. So I think it’s very important that to address that appropriately. I’m also a huge proponent of using naltrexone, which is a pure opiate blocker, to block the receptors to decrease craving and significantly reduce the risk of relapse. And that’s the part that’s done medically in the hospital. And I don’t think you can’t really address the true underlying behavioral or addiction issues until you’ve really addressed and taking care of the dependence. A large number of people do not make it through the actual detox process because they can’t tolerate the symptoms. If you have a procedure or process where you can treat the dependents and get someone on that blocking medicine naltrexone, then I think the patients have the best opportunity to be successful long term because you’ve gotten the dependence issue out of the way, you’re blocking the cravings and then you can really address the behavioral portion. And so that’s why after the hospital, our patients go to the aftercare, which is a nice, supportive environment. They’re on the right track so they can start to address the underlying behavioral or addiction issues.

Clare Waismann, RAS/SUDCC: So I think, Michael, well, what Dwight is trying to get to as well is that the withdrawal is not just “stop using”.

Clare Waismann, RAS/SUDCC: Our patients that do go through the hospital when they go to Domus Retreat, the reason we built Domus Retreat is because the physiological changes, regardless if we do rapid detox or medically assisted detox, do not stop at the hospital. So the patient can be completely off opiates, but for a few days or even a few weeks. There is a whole transition that affects them physically and emotionally.

Dwight Hurst: Yes, I think you’re seeing that in a much clearer way than I was trying to come out. That wasn’t coming out very clearly.

Clare Waismann, RAS/SUDCC: You’re dealing with a complex human being. They know a lot of different organs trying to match the speed of that detox.

Dwight Hurst: What’s what’s kind of like that recovery process look like from the medical perspective?

Michael Lowenstein, M.D.: What I explain to all of the patients? Is their body used to living on these opiates? And once we’ve treated the dependence, then their body has to find its new “normal”. There are a lot of physiologic changes that take place. So the importance of having them in an aftercare such as Domus Retreat is that number one, it enables patients to transition through the physiological part. So some people may have to reestablish a normal sleep-wake cycle and we can help with that. Some people may have some anxiety, mild symptoms like restless legs, opiates cause significant constipation, so the body has to figure out how to function normally again. So all these physiologic issues as the body finds its new normal, just take time. So that’s the importance of being in a very supportive aftercare environment. And then also the behavioral part starts in the aftercare as well, where you can start to address the true underlying issues that have led to the years of opiate use.

Michael Lowenstein, M.D.: With a therapist, there’s improved nutrition. Start exercising again. A lot of it is once the opiates are out of the picture, is to be able to provide direction as the things they can do to improve their health. A lot of them have neglected just all of their underlying medical issues. So even re-evaluation with their physician. Some of them are under the care of a psychiatrist. Once the opiates are out of the picture, the psychiatrist can better diagnose what’s truly going on and they may require modification of their medications.

Dwight Hurst: Yeah, I was surprised when I started working in outpatient substance abuse to discover how many people coming through or being sober and working through our program did not eat I didn’t eat there out of the habit of eating, which is always remarkable to someone like me who loves eating as much as I do. But to see people have to reacquaint themselves with healthy habits, even just like ingesting the right type and number of calories to not have attending health problems. So there’s a lot of things people take for granted if they haven’t been through this process.

Clare Waismann, RAS/SUDCC: Patients on opiates also eat a huge amount of sugar. So all those are, you know, are major health issues that we see.

Dwight Hurst: That was something I didn’t think about when I worked in that place. I had a little candy dish in my office at first. And it was always empty. Crazy, right? I wonder if it be good to describe just a little bit about how naltrexone works. Basically, what I hear most people at my level of knowledge say is something like, oh yeah, you take that and you can’t get high. So I think that’s all people really associate with it. What can you say about how that actually functions?

Michael Lowenstein, M.D.: Naltrexone is a pure opiate antagonist, which means it blocks opiate receptors without having any of the positive effects that you see with opiates that are used for pain. So you don’t get any of the euphoria associated because it’s a pure opiate blocker. There is no withdrawal associated. It appears that by keeping those receptors blocked, it reduces the opiate cravings and therefore significantly reduces the risk of relapse. It enables people to truly have the opportunity to identify the underlying issues. And I’ll recommend that patients use it for up to nine months. It also gives the body neurotransmitters and hormones and all those other things a chance to rebalance. So I view it as protective, giving the individual’s nervous system a chance to rebalance and find a new “normal”.

Dwight Hurst: So if I’m listening to this and let’s say it’s me or someone that I love and we’re addressing this problem in our own lives and I’m ready, you know, I’m prepared to engage in treatment. What are some things that I should take into consideration, I guess, as I’m about to embark on that process?

Clare Waismann, RAS/SUDCC: Addiction is a symptom. You’re looking for treatments for yourself based on your health needs, based on your emotional needs. If you’re looking for detox, you have to think about your health needs. So what’s good for one is not good for another. You have to seek treatment for you, not where you have to adapt to the only protocol “they” offer. You have to look for somebody that A. Specializes in on your condition and B. Somebody that is going to tailor the treatment to your specific needs.

Clare Waismann, RAS/SUDCC: I think most patients say, “Oh, treatments!” Because rehabs promise them “I’m going to detox here. I’m going to make your wife look prettier. I’m going to make your life greater. Everything is going to be wonderful.” So you know what – they’re going to fail.

Michael Lowenstein, M.D.: It’s really important to pursue a treatment where they are going to look at you as an individual with all your underlying medical and psychological issues or diagnoses and individualize the treatment to you. So a cookie-cutter approach doesn’t work when we’re dealing with opiate dependence. I think it’s important for people to seek treatment where. All of the underlying medical issues are addressed and that treatment is customized to your specific medical needs and as well as the specific underlying psychological needs, whether it includes depression, anxiety, bipolar or whatever the issues are, customize it to the individual needs of each person.

Dwight Hurst: That’s kind of where I was. I was rambling a little bit earlier. But a big part of this whole conversation that I’m taking away from it is the fact that while many people view stopping, just just like I said, just stop, just stop taking that and then all the work starts. But what’s the description here? Is it from a medical perspective, from a real treatment perspective, getting the drugs out of my system? Not, you know, just starting that one is a very multi-layered and multi-step process in and of itself. And in many ways, it sets you up for success or failure with all the other treatment protocols and therapies and everything you can do down the line.

Dwight Hurst: And we’re going to leave it there for today. Thank you, all of you, for listening. If you have questions, please e-mail those questions to us at info@opiates.com or @opiates on Twitter.

Dwight Hurst: So until we’re there with you next time, remember to keep asking questions, because whenever you have questions, you get answers. And when you get answers, you get hope. Thanks again for being here.

Dwight Hurst: Waismann Method podcast is a production of Waismann Method, offering medical detox and individualized treatment options for opioid dependence, go to opiates.com to learn more. Our music is the song Medical by Clean Mind Sounds. The show is produced by Popped Collar Productions, a company where we find interesting and exciting solutions to your business goals through podcasts. Find out more about us at poppedcollar.net.