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Understanding

I have gained an empathy for public figures and others who announce that they have a problem with prescription drugs.  It is all too easy to develop a dependence and so very difficult to withdraw.

Text Box: Understanding
I have gained an empathy for public figures and others who announce that they have a problem with prescription drugs.  It is all too easy to develop a dependence and so very difficult to withdraw.

Drug Withdrawal

 How I detoxed after three months of maximum dose Lortab® use

 (LORTAB® Hydrocodone Bitartrate and Acetaminophen Tablets)

There is something visceral about the prospect of experiencing excruciating pain.  Humans are hard-wired in the brain to avoid it at all cost.  My shattered hip gave me a lesson in pain and the frantic search for relief offered by narcotics.  When my orthopedic surgeon went on vacation and my Lortab® prescription (generic equivalent) supply started to dry up I was scared!  The exact two-step process I used to detox follows on this page.

Now as I write this five months after the crushing fall and a month and a half after my last narcotic dose I want to tell you about how I got off the drugs.  It was not easy.  I tapered off over 24 days of withdrawal and suffered in the throes of kicking the physical dependence that influenced me from head to toe for about 6 weeks in all.  My mind is now clear enough to write, my bowels started to work after 3 days, and it was weeks before I had just one good night’s sleep between the insomnia, muscle pain all over my body, splitting headaches, and heartburn.  My hip hurts but I’m using time-release acetaminophen to keep going.  I’m so glad to have my mental clarity back.

When I was transferred out of the hospital after four days of morphine drips and other injectables I had to change pain medications.  The doctor at the residential rehabilitation center prescribed a four hour alternating regimen of hydromorphone (Dilaudid®) and oxycodone (Percocet®) because neither alone would suffice.  Despite one dose every two hours I was hurting about half the time.  I was too dopey to realize that the general malaise, drenching cold-sweats and Sahara-dry mouth I experienced for the first week were withdrawal symptoms from the morphine.  Dopey, sick and hurting is a tough combination.  I was getting a taste of the dark side of narcotics.

I was terrified at the long term prospects for dealing with these drugs. 

The information with my prescription warned “Do not discontinue use abruptly.”  Stopping the use of narcotics can trigger significant withdrawal symptoms.[1] These symptoms and the desire to avoid pain can cause one to not only restart using the drugs but to possibly increase the dose.  This is a potentially harmful cycle that could lead to abuse.

My surgeon seemed afraid of my becoming addicted to the Lortab®.  He doled out prescriptions in one-week increments and advised me to “Get off it as soon as possible.”  Thank God my personal physician gave me hope.  He prescribed an adequate amount of the Lortab® to get me through the anticipated months of painful physical rehabilitation and told me how to wean myself off the drugs to avoid an opiate addiction.  He also told me that he was there to help.  The method of withdrawal I used is based on my physician’s advice and may be a model for you but I strongly recommend that you talk to your doctors to build a plan that works for you!

Here is the two-step drug withdrawal method I used:

I was on the maximum prescribed dose of Lortab® prescription (generic equivalent) which meant that every six hours my timer went off and I took one 10 milligram tablet – 24 hours a day, 7 days per week.  I did not sleep through the night for over 4 months.  If I didn’t take the pill on time in the middle of the night either the pain or the withdrawal would wake me up.  I managed the process with a timer and a written log of every pill I took.  I used these same tools to withdraw.

This method is a gradual reduction in the narcotic dose over a period of time that gives the body some time to adjust.  This should result in less severe symptoms.  It gives one a chance to find out how the underlying pain is doing and thus manage both pain and withdrawal.

Step one: Extend the time between doses and stay at the new time interval for 2 or 3 days.  This will step your total daily dose down from baseline.  Each time you extend the time, you will reduce the total daily dose.

Step two: When the time between doses reaches a point where you are feeling really uncomfortable, reduce the dose size but take it more frequently.  Target a daily dose lower than the last step but that is tolerable.  Stay at the new lower dose for 2 or 3 days and then extend the time.  Continue with this stepping down process.  The process takes some work and discipline but will reward you with success.

Prior to starting this you must keep a log of what you are taken and when you are taking it.  This set of information gives you the powerful information you need to manage the process.  I also noted the progress of my pain and the side effects of the drugs.

I quickly realized that it is not very easy to figure out the time and dose combinations that actually allowed me to ease off the total dose.  That is why I created the following dosing options table that allowed me to engage the two-steps.  I was using 10 milligram tablets that I could break in half and cut into quarters using a pair of wire cutters.  That gave me all the multiple combinations of 2.5 milligrams (10, 7.5, 5, 2.5) to work with.  Lortab®.  The drug comes in 10, 7.5, 5 and 2.5 milligram pill sizes that you can break into ½ pill and sometimes even ¼ pill increments. The table includes the dosing rates ranging from 10 milligrams every 4 hours down to 1.5 milligrams every 8 hours.  Please note that this table is provided only to help calculate what theoretical dosing rates are NOT TO RECOMMEND DOSING for you.  Dosing is up to your doctor.

 

1

2

3

tablet

hour

milligrams

milligrams

interval

per day

10

6

40.00

10

7

34.29

10

8

30.00

7.5

4

45.00

7.5

5

36.00

7.5

6

30.00

7.5

7

25.71

7.5

8

22.50

5

4

30.00

5

5

24.00

5

6

20.00

5

7

17.14

5

8

15.00

3.25

4

19.50

3.25

5

15.60

3.25

6

13.00

3.25

7

11.14

3.25

8

9.75

2.5

4

15.00

2.5

5

12.00

2.5

6

10.00

2.5

7

8.57

2.5

8

7.50

1.5

4

9.00

1.5

5

7.20

1.5

6

6.00

1.5

7

5.14

1.5

8

4.50

How to read and use this drug withdrawal table:

Tablet milligrams is the pill size.

Hour interval is the time between doses.

Milligrams per day is the total dose per day if the pills are taken at that hourly interval.

To use the table, pick the tablet size you are using from column 1,  find the hour interval in column 2 and then read across column 3 to find the total dose per day (milligrams per day). 

Your objective is to find your current (baseline) dose per day.  Once you have the baseline dose, you want to gradually reduce your milligrams per day by:

  1. Increase the time between doses every two to three days or so as long as you feel comfortable. And then
  2. Drop to a lower dose with a shorter hourly interval.  And then repeat step one with that lower dose (increasing the time interval)

My personal withdrawal table and experience:

Here’s my personal example of how I used this table and the withdrawal process:

I started at the maximum prescribed dose allowed of 40 milligrams per day and had been there for about three months.  A quick test showed me that a drop of 10 milligrams per day was way too fast when I was at the higher level so I picked doses that would drop about 5 milligrams per day.  My progression was 40, 34, 30, 24, 20, 15, 10 and then 0.

1

2

3

 

tablet

hour

milligrams

 

milligrams

interval

per day

notes

10

6

40.00

My baseline dose – day zero = start

10

7

34.29

New dose days 1-3 after start

10

8

30.00

New dose days 4-51/2, withdrawal at about 6 hours

5

4

30.00

New dose days 5 1/2 - leg still hurt in PT so I stayed here

5

5

24.00

New dose days 12 - 19 - leg hurt so I stayed here

5

6

20.00

New dose days 20 - 21

2.5

4

15.00

New dose days 22 - 23

2.5

6

10.00

New dose day 24 - last day

I had hoped to get through this process in about two weeks staying at each level for only 2 days or so.  The dosing actually worked pretty well for the withdrawal symptoms but I ran into problems at days 5 through 19 as I had to pause twice to manage the residual pain so I could continue physical therapy.

I learned that the withdrawal symptoms increased significantly after about 6 hours from my last dose after I dropped to 30 milligrams per day so I limited the next dosing schedules to no more than 6 hours.  You may have to adjust yours depending on how you feel.  The lower the daily total dose you are on the faster and easier it should be to withdraw.

I ran out of dosing options at day 24 (2.5 milligrams every 6 hours) because I couldn’t break the pills any finer and I was hitting my personal 6 hour limit where withdrawal set in.  I was also pretty uncomfortable so at that point I jumped into the pool and went to zero at 7PM that night after just one day.  Heartburn woke me up at 1:40 the next morning to kick off the final stages of withdrawal.  The next three days were miserable with insomnia, massive headaches, muscle pain and malaise.  That turned the tide and by day 7 I actually had a good night’s sleep.  The various resources say that symptoms will increase for up to three days after stopping and will continue to fade for a couple of weeks.  By day 14 I was feeling essentially back to normal other than hip pain and actually moved from my hospital bed downstairs in the TV room back to the master bed room for the first time in 4 about months.  My mental clarity continued to improve and within a month I felt as normal as ever. 

You can find a blank table that you can print and use here.

What I finally found after the fact:

The following are the few firm recommendations I found in my research long after I completed my withdrawal.  They are consistent with what I did although I used a dose reduction of starting at 13% and moving up to 25%.  In any case the tables make it easy to calculate the doses.

"The opioid withdrawal syndrome is preventable. Patients treated with opioids of more than one to two weeks should be instructed to gradually reduce the dose of opioid before discontinuing use. Dose reductions of 25% every day or two will generally prevent signs and symptoms of withdrawal. An alternative recommendation is: give half the previous dose for the first 2 days and then reduce the dose by 25% every 2 days. When the dose reaches the equivalent of 30mg /day of PO morphine, this dose is given for 2 days, and then the drug is discontinued."[2]  The resources I found indicated that morphine and hydrocodone were equianalgesic.[3]  My experience showed that about 10 milligrams per day was the floor for my tapering.

"Protocol for Tapering:

bulletTaper by 20%-50% per week [of original dose] for patients who are not addicted. The goal is to minimize adverse/withdrawal effects.
bulletThe rapid detoxification literature indicates that a patient needs 20% of the previous day’s dose to prevent withdrawal symptoms.
bulletDecisions regarding tapering schedule should be made on an individual basis. Sometimes faster or slower tapering may be warranted.
bulletSome experts suggest that the longer the person has been on opioids, the slower the taper should be.
bulletRemain engaged with the patient through the tapering process, and provide psychosocial support as needed."[4]

MY NOTES FOR DRUG RECOVERY SUCCESS:

Here are some things to consider:

Consult with your doctors and physical therapists:  There is no substitute for good medical advice.  If they don’t give you a plan of their own, show them this one and get their approval.  I’m not sure that many doctors have necessarily thought this process through to the detail I present in these tables.  I know my surgeon didn’t offer any advice.  Further, if you are in physical therapy, consult with your therapist about the timing for withdrawal.  They should be knowledgeable about your healing process.  The drugs are masking the underlying physical conditions that cause pain so it is very hard for you to estimate what you'll feel without them. 

I understand that some people may use more than the prescribed daily dose.  Medical advice is even more critical in such cases.  Talk to medical professionals.  Check out this link to MedLine Plus for information on opiate withdrawal and the other references at the bottom of the page.

Be aware of possible setbacks:  In my case, my physical healing was behind what I expected so I had to extend the withdrawal out over 24 days rather than what might have been a couple of weeks.  I experienced significant physical pain during withdrawal and twice held the dose constant for a few days to allow for recovery.  I also rescheduled a couple of physical therapy sessions to allow a day or two more recovery time.

Be aware that the narcotics play mind games with you:  Since many narcotics are actually changing your brain chemistry they will have an impact on your mind.  In my case and particularly while I was on the drugs I had issues of motivation (energy loss), short term memory loss, agitation and a loss of mental clarity.  But the worst was the CRAVING for another dose.  That's why I logged every single dose I took and stayed on track both during and before I started to wean myself off.  The log pages were my surrogate memory and were a powerful support for me to keep from taking too much.  When I had a craving I'd look at the log book to see when I was due the next dose.  And I'd wait for it.  I also relied on my support group to help me keep on track with encouragement.  My rational mind told me that the pain would pass as I healed and came off the drugs and that the end result was worth it.  When my leg hurt I'd pack on the ice and think about better days.

Support:  My friends and family were an essential part of my recovery and I am grateful for all of them.  They encouraged me to go forward and held me up when I was sick.  My wife, Kate, in particular, was literally by my side every step of the way.  Use your support group.  There are a number of public support groups to consider as well.

Manage the pressure to perform:  I have to admit that I was very lucky to be in a position where I did not have to work or interact with people outside of friends and family.  The pressure to perform would have made it far more difficult for my withdrawal process.  Manage your need to perform as best you can.  You really won’t feel well for some days and the least you must do the less likely you will be to reach for a pill.  On other days any distraction may be a blessing.  Find what works best for you.

Follow the two-step process:  The process makes it easier to stay on track and keep from losing ground. 

Keep a log:  Believe me you will not remember what you have done every step of this process.  These drugs really impact memory.  You must write everything down.

Recognize the difference between physical and psychological dependence:  I was lucky.  I felt only a physical dependence to the drugs.  I never felt any of the so-called pleasant side effects that seem to draw so many into addiction.  Pain management was the only positive thing that these drugs did for me and I am very grateful.  I do not know how I would have survived this ordeal without them.  I am unqualified to speak to addiction and recommend that you seek out professionals.  Here are some key definitions and information to help you understand dependence and addiction.

Detoxification is an essential component of the entire drug addiction treatment process because it aims to end a patient's physical addiction to any drug.

Do it your own way for physical dependence:  Everyone is different.  I’ve talked with people who decided it was better to just go “cold turkey” and get it behind them.  They just toughed it out.  Others started trying to sleep through the night to extend the time between doses.  You must, however, use professional help to get through the psychological dependence of addiction.

Use alternatives:  I am now using time-released acetaminophen (e.g. Tylenol Arthritis™) to manage the residual pain.  My doctor is monitoring my liver function to make sure that it isn't damaged.  Do NOT combine Lortab® and Tylenol without your doctor's advice because acetaminophen can be VERY TOXIC and is part of the Lortab® formula.

I did run into problems however when I added Ibuprofen into my withdrawal schedule and took one pill with every Lortab® dose.  The Lortab® masked the signs that my stomach was not tolerating the Ibuprofen.  When I finally stopped the Lortab® I found that I had very serious heartburn.  I was put on a 14 week course of acid reducers to see if the ulceration will heal.  If it doesn't resolve, I'll have to have further tests to determine the scope of the problem.  The heartburn finally resolved and I was able to use this same withdrawal method to wean myself of the acid reducers.

Have faith:  The withdrawal symptoms can be very uncomfortable but they are temporary and not life threatening.  Stay on track and you will get through it.  You will feel better off the drugs than on them as long as the underlying physical pain is under control.

 

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Drug Withdrawal Testimonial

I wanted to thank you for sharing your information about weaning off of Lortab.  I had been on Lortab daily since last August and two weeks after surgery in mid-May I felt like I didn't need them anymore and decided to stop taking them (after 9 months of daily use).  It never dawned on me that my body had become addicted to them and by the end of the second day without one I realized I was going through withdrawal - I had all the classic flu-like symptoms and was miserable.  I called two of my doctor's offices asking for a plan but found yours on line while waiting to hear back from them (good thing I found yours because neither office called me back - don't get me started). :)  
 
I was able to be off of them in exactly two weeks and today is my third day without any and I haven't had any side effects thank goodness!  Now I am weaning off of Soma which I don't think should take as long since I've been on them for only 3 1/2 weeks.
 
Thanks again for sharing your information!

June 25


 

[1] http://www.drug-withdrawal.com/lortab.htm

[2]Gordon D and Dahl J. Fast Facts and Concepts #95 Opioid Withdrawal August 2003. End-of-Life Physician Education Resource Center www.eperc.mcw.edu. http://www.mywhatever.com/cifwriter/library/eperc/fastfact/ff95.html

[3]http://www.ohsu.edu/ahec/pain/part2sect3.pdf.

[4]http://www.oqp.med.va.gov/cpg/cot/cot_cpg/content/annotations/annoY.htm "Educate on Withdrawal Symptoms; Taper Medications", United States Department of Veterans Affairs

drug withdrawal

(c) 2006 - 2011 Steven C. Martin www.positive-way.com/recovery All rights reserved.

Disclaimer: Please note that everything here is personal opinion that is not intended as a substitute for medical advice.  It is highly recommended that you review your case with a medical doctor who is familiar with your medical history before you start any narcotic or drug withdrawal process or obtain treatment for any illness or injury.

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