Weaning off drugs like opioids, anti-depressants, sedatives and sleep aids

Weaning off drugs could be tricky, but necessary.

Cognitive Behavioral Therapy, knowledge, owning the situation – taking action – and managing life could very well give you the option to quit some things you’ve used to manage life or symptoms. If you’ve got the situation covered, you could get rid of the crutches. Here are a few words about getting off opioids, antidepressants, and sleep aids.

Weaning off drugs

Weaning off drugs you’re dependent on could be both tricky and uncomfortable. In some cases even dangerous, so ideally, you do this with your prescribing physician. Try to get the help you need from whoever put you on the meds.

Unfortunately, that’s not always possible, so here are a few words about it.

Several of the substances used within these areas are either addicting or make you physically dependent on them, where there’s a slight difference.

Some crave and long for opioids and Benzodiazepine, but I’ve yet to meet someone who longs for their antidepressants or gabapentin. Quitting cold turkey on either might cause various symptoms, and it ought to be done more thought-through than just stopping. Still, you’re unlikely to crave the antidepressants, and… you’re unlikely to find them on the black market.

The substance should be weaned off before quitting unless you’ve used a small dose or just used the drugs for a few days. If you don’t do it that way, the withdrawal will bother you more than necessary. It’s usually a mix of mental and physical effects where the duration and the symptoms vary depending on the substance, previous doses used, speed of weaning off (or not), and the individual.

Some seem to suffer less than others.

Some become complete wrecks.

To avoid withdrawal, one should have a plan and follow it. Your physician should help you plan the process in a perfect world, but everyone doesn’t get that help.

Quitting and getting rid of “drugs” or pharmaceuticals could be challenging, so support is often helpful. Sometimes just in the form of a quick check-in, and sometimes rehab centers are necessary. They’re there for a reason. You’ve heard about the alcoholics who have a hard time. This isn’t at all that different. The difference is “just” the substance. The addiction, the cravings, and the suffering when you’re trying to quit don’t differ that much.

A good enough plan and the will to get through it are often enough. If you’re an average person and haven’t misused the substances and kept to ordinary doses or your own medications, weaning off those is often possible to do yourself with a plan. This is what most people call “using” drugs.

If you haven’t kept to the typical dosages and used other things than “your meds,” things could get trickier. That’s when we’re getting to “misusing or abusing” drugs. If you’re addicted to substances, and this is how they’re used, you’re more likely to require more support. If you’re handling a situation like this, the problem is likely out of hand. The drugs could be a too big part of your life, and it’s more of an addiction to the drugs than a dependence on the medications for quality of life.

Addiction and abuse are different things. Using and misusing are not the same thing. But I sure agree about the fact that there’s a gray area. I’d say drugs are good when the net effect is positive. If you’re getting more out of them than they cost you – you’re using them. If the price is higher than the long-term effect – they’re using you. That’s rather a problem than anything else.

Quitting isn’t easy, but it could be helpful – or absolutely necessary.

Quitting opioids

Addiction, a physical dependence, is natural when using opioids. You’re not necessarily abusing them because you are addicted. Abuse is how you handle them, I’d say. But… Where the line between use and misuse goes could be vague.

If one doesn’t think they’re relieved of their pain enough and doubles the dose, is that abuse?
Is it abuse as soon as one uses more than the prescription?
What if you’ve got pills to take “as needed”, rather than on a schedule?
I’ll leave that little (ethical?) dilemma for you to ponder.

When you’re on this level of “misuse”, it’s likely irrelevant. It’ll be quite clear when you’re abusing the drugs enough for it to be a problem. That’s when the drugs are in control, and you’re not.

This is a millennia-old task; you won’t be first or last. The calming, soothing substance that can relieve pain and anxiety can be quite a hassle to get rid of. It has been, and still is, used a lot as a recreational thing. That’s for a good reason – the brain often loves these. This is why people have become addicted to and abused these drugs for so long. Instant comfort and gratification are addicting even if there isn’t a physical dependence involved. Here, you get everything. There’s less pain, and it’s soothing. You’re comfortable and less worried. Things are just generally better, as if under a warm blanket. Some people I’ve met have even found the dumbing effects positive unless they need to perform something. Fewer thoughts led to fewer worries.

But that’s just the positive parts. The opioids can get the best of you and get an excellent grip on your life.

It’s reasonable to assume that most people begin using opioids to treat pain or as a recreational thing. Regardless of which one, you’ll build tolerance with continuous use. If you like what you’re doing and having, you’ll generally need more of the same substance to get the same effect as last time. That, alongside the fact that opioids don’t seem to work wonders to combat long-term pain, might make people look for more – either a larger dose or a more potent substance.

That’s likely why they’ve ruined incredible amounts of lives. People look for more to get the same, and that spirals out of control. Behaviors go out of control because you’re not in your right mind. You need this.
You’re dependent enough on drugs to become someone else. That could be one good reason to quit.
The fact that it doesn’t do enough for your long-term pain could make quitting a good idea.
Side effects might be another reason. Are you getting what you want from the drugs… or is the price – the effects you’re not looking for – too high?
Bureaucracy could be a reason to quit. Can you get what you “need” (do you need it?) easily enough? Is it a hassle? Is that hassle a good thing because you shouldn’t use it? Or is it just a big enough obstacle for you to consider quitting as a “screw this!”-thing?

The Centers for Disease Control and Prevention and NIDA tell us:

The trend for the darkest outcome doesn’t look good.

Most people don’t die, obviously. Though, side effects are extremely common with opioid therapy.

The most common ones are:

Dizziness, nausea, and vomiting.
Constipation.
Pruritus, or “itching skin”.
Dry mouth.
Sedation and drowsiness, lack of focus, and inability to concentrate enough to be productive.
Confusion.
Slowed breathing.

More serious side effects are mentioned in the study below.

Long-Term Opioid Therapy Reconsidered

By: Michael Von Korff, ScD, Andrew Kolodny, MD, Richard A. Deyo, MD, MPH, and Roger Chou, MD

“Direct risks of long-term opioid therapy are not limited to opioid addiction and overdose. Potential medical risks include serious fractures, breathing problems during sleep, hyperalgesia, immunosuppression, chronic constipation, bowel obstruction, myocardial infarction, and tooth decay secondary to xerostomia. Clinical data suggest that neuroendocrine dysfunction may be common in both men and women, potentially causing hypogonadism, erectile dysfunction, infertility, decreased libido, osteoporosis, and depression (18). Recent studies linked higher opioid dose to increased opioid-related mortality (15, 16). Controlled observational studies reported that long-term opioid therapy may be associated with increased risk for cardiovascular events (19, 20). A descriptive study of 133 persons aged 65 years or older receiving long-term opioid therapy found that 5% were hospitalized for opioid-related adverse events (21).”

Those side effects are some excellent reasons to quit.

So how do we wean off?

You do so by lowering the dose gradually in several steps.

Depending on how hurried you are and how much discomfort you can handle, you could lower the dose every or every other week. Every other week means less discomfort – and so do smaller decreases in dosage.

I’ve weaned off opioids with clients with even less time between the changes in dose. Sometimes without any particularly bothersome withdrawal symptoms, but that is highly subjective and individual. Doing it quickly is generally the more uncomfortable option, but sometimes you’ve got to do what you’ve got to do. What and how you do things depends on your options. I’ve rushed through this with clients earlier because of horrible planning and quick decisions from healthcare. If my client relies on medication and suddenly and without further notice won’t get any more pills prescribed, that’s simply the situation we’re in. If we’re running out of drugs on very short notice, then we’ve got to cope and do the best of it.

It wasn’t long ago I talked to a pain patient with incredible pain who looked for help with something besides the pain. The solution they came up with was to remove all of the drugs on incredibly short notice, even though she’s getting the top-notch stuff you get in this country. You generally don’t get stronger stuff or higher doses than that. That’s another reason to keep the doses low, to begin with, and quit if possible. When these things happen, it’s time to get as much help as possible. In this case, she didn’t get any help from the public healthcare she uses, so she had to solve the problem of weaning off her stuff in another way.

Getting off stuff “like that” in an uncontrolled way makes you react and feel like the horror scenarios you hopefully haven’t seen.

Doing it slowly and – even then – being ready for some discomfort is generally a good idea.

Your brain will likely be slightly more displeased at every decrease in dosage, but with some grit and willpower, it’s generally possible to overcome. If it’s not, the steps are too big. Split pills to make the steps smaller if you have to. If you do have that prescribing doctor helping out, you might get another substance or dose when doing this to make it easier.

Early symptoms of withdrawal

You might be wanting, longing, and craving the drug.
Sweating.
Anxiety.
Headache.
Runny nose and eyes.
Yawning.
Goosebumps.

Later symptoms

You might get more or less flu symptoms.
Having chills or even fever
Diffuse pain
Diarrhea
Heart racing
Nausea
Muscle tension
Trouble sleeping

Quitting your opioids could also reveal anxiety problems being hidden underneath. If that’s just something from withdrawal, that’s fine. It’ll pass. Let them hang around and focus on just surviving the discomfort. You don’t need to medicate those with something else. There might be something else to it as well, however. If you have trouble with anxiety, and opioids are your way of handling it, there ought to be better ways to treat it.

There are probably those who’ve ingested more than you and gotten out. There’s hope for you too, but it might take a lot of patience and willpower. Opioid addiction is a big problem worldwide because of just that. It’s tricky, uncomfortable and generally unpleasant to get out of. But not at all impossible.

Quitting antidepressants, what affects the nervous system and similar

This covers what is bunched as “anti-depressants”, even though the drugs could be used for things other than depression. It’s not uncommon to get it prescribed for long-term pain or sleep disorders.

Medications

Many types of antidepressants are available, including those below. Be sure to discuss possible major side effects with your doctor or pharmacist.

Selective serotonin reuptake inhibitors (SSRIs). Doctors often start by prescribing an SSRI. These drugs are considered safer and generally cause fewer bothersome side effects than other types of antidepressants. SSRIs include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft) and vilazodone (Viibryd).
Serotonin-norepinephrine reuptake inhibitors (SNRIs). Examples of SNRIs include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq, Khedezla) and levomilnacipran (Fetzima).
Atypical antidepressants. These medications don’t fit neatly into any of the other antidepressant categories. They include bupropion (Wellbutrin XL, Wellbutrin SR, Aplenzin, Forfivo XL), mirtazapine (Remeron), nefazodone, trazodone and vortioxetine (Trintellix).
Tricyclic antidepressants. These drugs — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin, trimipramine (Surmontil), desipramine (Norpramin) and protriptyline (Vivactil) — can be very effective, but tend to cause more-severe side effects than newer antidepressants. So tricyclics generally aren’t prescribed unless you’ve tried an SSRI first without improvement.
Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) — may be prescribed, typically when other drugs haven’t worked, because they can have serious side effects. Using MAOIs requires a strict diet because of dangerous (or even deadly) interactions with foods ― such as certain cheeses, pickles and wines ― and some medications and herbal supplements. Selegiline (Emsam), a newer MAOI that sticks on the skin as a patch, may cause fewer side effects than other MAOIs do. These medications can’t be combined with SSRIs.
Other medications. Other medications may be added to an antidepressant to enhance antidepressant effects. Your doctor may recommend combining two antidepressants or adding medications such as mood stabilizers or antipsychotics. Anti-anxiety and stimulant medications also may be added for short-term use.
Gabapentin also fits in this category since it’s generally used for pain – but does so by affecting the nervous system.

When decreasing the dose, it’s generally done quite similarly to when it was increased. Doing it too quickly (or missing doses!) or stopping entirely in an instant here causes discontinuation syndrome. It isn’t pleasant but doesn’t cause the same symptoms as opiates. Different substances have different effects. The most common feeling is often to feel like you’re coming down with the flu. You could experience an upset stomach, headaches, muscle pain and general intangible achiness, lightheadedness, or dizziness where you’re unstable. Some experience a light feeling of unreality, and some get incredibly sleepy.

Quitting too suddenly might also cause a sudden deepening of depression or an increase in neurological symptoms. If the medication did help for something and you removed it – that help is gone now. If your depression got less intense, but you couldn’t stand the side effects of the medication you’re about to remove, you’re back to square one. Be prepared.

Follow more or less the same regimen you used when you increased the dose, and you shouldn’t get much more problems with getting the medication out of your system than you got when you got it in there. Do it even slower if necessary… or possible. You could go longer on the same dose – or use smaller steps when you decrease the dose to decrease the suffering.

These are often the least “dangerous” ones, but those with the vaguest symptoms and most intangible discomfort connected to them. If you expect it to be uncomfortable, at least you won’t get surprised. If you’ve got the option – decrease the dose when you’re in a position where you can handle being a little bit less productive so you can hang out on the couch more. If you’re getting achy and things hurt – use something for the pain if it helps. Suffering isn’t necessary, so do what you can to decrease it… And give this the time necessary. Don’t hurry more than necessary. That’ll increase the discomfort.

Quitting sleep aids.

Getting rid of your sleep aid is often more related to thoughts and behaviors than other medications. With most kinds, you “just have to survive and get through it” – with these, there’s more. All of the pharmaceuticals mentioned here are tricky, but those related to sleep could make you psychologically dependent on a level beyond that in a way. Sleep is something we can learn to manage in a good way. Sleeping pills could mask misbehaviors, thoughts, emotions, and patterns that inhibit your sleep. That could teach you to keep those dysfunctional patterns since they don’t matter – you’re sleeping anyway.

These are more commonly used intermittently; “here and there, when needed and in the case of…”. If that’s how you use them, that makes them more troublesome mentally. Pure physical addiction is affected by dose over time, but the “here and there”-aspect bothers habits and psychological dependence, thoughts, and emotions way more. It’s generally easier to wean off the substance if it’s standardized, so if you’re having trouble getting off these, that’s often a good place to start. Standardize. That will remove many thoughts and emotions around the substance and give you a protocol to follow instead of just winging it.

The standardization is useful because sleep is so very influenced by mood, thoughts, and emotions. The uncertainty that comes with using the pharmacological tool sometimes could influence the nights when you don’t use it. Sleep loves routines and stability.

To standardize:

Start using it every night, regardless.

Pick a “minimum effective dose”, that you’ve found works. Since the dose is standardized, you won’t use more if you wake up at night.

Use the substance at the same time every night. (Since you sleep at the same time every night, that’s not a problem.)

Do this for 7-14 days.

That might show you that some nights are worse even with the substance… or you could notice that you sleep like a baby always. If you are where I think you are, the former is more likely. Keep tracking with the sleep diaries to clarify what affects your sleep except for the substance. It can’t possibly be just the lack of medication, can it? There’s generally way more to sleep than just pills.

7-14 days later, it’s time to reflect… or rather sum up the reflections you’ve done during the period. Reflect as you go, and look at it with perspective after 7-14 days.

Was the sleep worse?

When? Was it at the beginning of the change – or later when you might have built some tolerance?

Why? Was it because of something, except for the pills? Any changes in life, thought patterns, or emotions?

This is where I think you should start decreasing the dose. Doing it randomly is too tricky with these.

The question “how much should I decrease?” depends on the substance, dose, and how it’s administered. Some pills are hard to split, and liquids are obviously easy. It’s rare to require several steps. One or two is most common, and three if you’ve had a hefty dose.

First, you find a standard dose, do that for a week or two, then split it in two and go another week or two before quitting.

Sometimes you do the same thing again one more time.

The important part is that the dose gets lower. How much lower just affects how long it takes to get rid of it entirely. You’re likely not in a hurry, are you? If you are in a hurry because you’re running out of pills, you’ll want to do a crash course, which isn’t beneficial but possible. Small steps are likely easier than big ones, and keeping a new dose for 14 days is easier than 7. Bigger steps and shorter time on each dose if you need to speed things up.

When you do step down a notch – think and think again. You’ll likely sleep slightly worse since you’ve removed something that “helps you sleep”. Can you aid your sleep in any other way than pills? That’s the entire concept of CBT for sleep. Can you manage life better? Could you be more thorough with that jogging you say you want to do? Can you add another meditation session and not just do it in the morning but also in the evening? If sleep gets worse – accept the process. We’re reaching for long-term goals, not short-term comfort.

Evaluate and repeat like this until you’re rid of it. Standardize and just use a smaller dose. If you notice in your sleep diary that you’re sleeping worse for an entire 7-14 day-period I’d stay on that dose for another period and try to get it decent enough before progressing further. The goal isn’t to get rid of it at any cost. The goal with this is to keep the quality of sleep – or rather increase the quality, but keep the quantity.

The program ought to fiddle with practically everything related to sleep, but that’s different from succeeding and removing all issues. Perhaps you’re not in control of everything in your situation. Just shining a light on something doesn’t always remove the problem. You might be in a situation where you won’t be able to remove everything stressful, and if the aid you’ve got to fall asleep gives you enough, there could be reason for it to stay. If your sleep gets too bothered when you’ve lowered the dose, perhaps lowering the dose isn’t helpful right now.

A big part of the program is to ask the right questions, analyze and then fix the problems you’ve got so you’ll get into a state where sleep comes naturally. If that’s not possible, the sleep aid might be the tool you need at the moment. If you can’t manage life, lowering the dose is tricky. Perhaps you started weaning off and then got worse in some aspect, or something new showed up. It’s not necessarily a catastrophe that you do use help to sleep. Weaning off is great when you don’t need the help and being OFF gives you MORE. That goes for all medication. You want what gives you the most. If the drug gives you more quality of life, it’s a net positive.

Quitting entirely might be a bigger jump than removing parts and lowering the dose. It’s a habit, and it’s a little piece of safety and comfort before going to bed. Once, it might have been your only weapon to combat the troubles you’ve had. Pills equal sleep. Pills equal relief from anxiety. Quitting could increase anxiety, but the most common way to battle anxiety is to expose to it. See if you can face it. This might be scary, but plenty of people have slept without sleeping aids before. Promise. You could give it a shot and try. Remove the substance for (7-)14 days and see if it works. If it truly doesn’t, go back to the small dose again for a period and then try again when you’re ready.