Narcotic Withdrawal

Periodically patients appear in emergency departments seeking methadone. During my residency I recall one in particular who said he was traveling cross country, but unfortunately had run out of his methadone. My attending and I informed him that most ERs don’t dispense methadone.

He left angrily, and without his suitcase. He must have said something provocative en route, because a short time later the ER was evacuated as the bomb squad arrived. They gently moved his suitcase outside, and with a water cannon they nebulized his skivvies. No bomb.

For those of you unfamiliar, methadone is a narcotic used to help people stop using other narcotics like heroin, or medications like codeine, Percocet, Norco, Oxycontin, MS Contin, Demerol, Dilaudid, etc. It has a long half-life and apparently doesn’t deliver the same highs. It permits those addicted to try to living semi normal lives again, and it falls under the “harm reduction” umbrella… i.e. It’s worse to be injecting an illegal substance than to be addicted to a legal pill.

Methadone has helped many people, but I have mixed feelings about it because the withdrawal is considerably more prolonged and difficult than from heroin. Plus, much like dialysis, life soon revolves around methadone clinics. I remember the debate about giving methadone to addicts in jail when I lived in New Mexico. While free to inmates, it cost $7 a day when they were released independent of dose.

While narcotic withdrawal can be one of the most painful experiences on the planet, it is not considered life threatening (unlike alcohol withdrawal). However, there are some points to consider.

Red Flags:

• Underlying heart disease
• Elderly
• Diabetic
• Dehydrated (not urinating, no sweating, hyperthermic)
• Comorbid psychiatric illness
• “I take 100+mg of methadone per day”

Happy Words

• “I’ve been through this before and just need some clonidine.”
• “I feel better with exercise.”
• “I can still keep liquids down no problem.”
• “I only recently was started on methadone, and currently I’m at 20mg a day.”

The large majority of people who withdraw from narcotics live to tell the tale, and it’s usually harrowing. Expect rapid heart rate, sweating, vomiting, insomnia, cramps, generalized pain and emotional distress.

Our approach in the ER may include IV hydration, clonidine, antiemetics, ibuprofen, sometimes muscle relaxants, sometimes sedatives. I usually congratulate patients for taking their first steps down the road to recovery just to spread a bit of positivity. But once through the withdrawal, a few days to weeks later, then reality and life sets back in… bills, warrants, children, hepatitis, HIV, work, relationships, etc. I believe this is where we as a society often fail.

Pre-R maybe can help through your acute withdrawal. But consider Ken Starr MD Addiction Medicine Group and ENDORPHIN POWER COMPANY for your remaining days.

There is an older video that pretty well captures the prison of narcotic addiction, “Detox or Die“.

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