At-Home Opioid Withdrawal Protocol: The Detox Essentials

How to make at-home opioid detox bearable. I focus on which prescription and OTC comfort medications are must-haves and which should be avoided. I address marijuana and other plant-based remedies, as well, and I touch on non-pharmacologic methods for alleviating detox symptoms.

"Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times."

Mark Twain (19th-century American writer)

Note: This article is a summary of what has worked for me and other opioid addicts who I have known (supplemented with data from medical journals). It is not direct medical advice and should not be used except in consultation with your Primary Care Provider, addiction specialist, or other clinician. When in doubt, a supervised detox in a medical facility is the safest bet.

Post Acute Withdrawal Symptoms (PAWS) can resurface weeks to months after acute withdrawal is over. Sometimes this occurs apropos of nothing, but often it is in response to stress or physical illness, causing a relapse into withdrawal symptoms that can feel almost as intense as those experienced during acute withdrawal. Infographic from the Mandala Healing Center.

A QUESTIONABLE AESTHETIC

I once detoxed in an ultra-low-budget rehab center in Upstate New York that was originally a tuberculosis sanitarium. Each Friday, the dental truck would pull up to a large smokestack attached to the back of the building, which was once the facility's crematorium. Editor's note: If "dental truck" sounds bizarre or even oxymoronic to you, then you are blessed.

This facility was rough. It was a sprawling brick structure on four floors, which were organized by race - similar to how things run in many prisons. This was no coincidence, as probably three-quarters of the guys there were on paper, many for much more serious offenses than your standard possession / dealing / repeated DWI starter pack that you find in most rehabs.

To give you an idea of the vibe around safety, we had to sign out razors to shave with because of past shanking incidents. In fact, a patient from the Papi floor once offered me two Ramen soups if I gave my razor to him rather than returning it. ("You look like you could get away with it," he offered apologetically when I declined to do so).

So, this wasn't a particularly safe-feeling space for a gangly white guy who had never done time. Throw into the mix that I'm gay, which is something that virtually no one discloses in an environment like that, and hopefully you can understand that there were some downright harrowing moments.

I plan to write a more detailed account of my experience in this facility, which will include a description of my first night with my detox roomie Steve, a white guy my age who was a manager at a local pizza shop and a total treatment virgin. For now, let me say that much of my first 48 hours was spent praying for a benzo withdrawal seizure to deliver me from Steve's blubbering, endless threats to go home AMA (as though that would've been a tragedy for me), and requests to accompany him to the bathroom. (Each bathroom had two doors that didn't lock, and Steve somehow felt - after knowing me for six hours - that inviting me into the bathroom with him as his bodyguard was preferable to taking his chances by placing a towel under each door, which is how the rest of us signaled that we were using it). At the end of the first night, the danger-haired nurse on duty gave me my 2 mg clonazepam (Klonopin) dose, then added something unexpected: "I'm not logging this one in the system," she promised sotto voce with a knowing look.

What I'm getting at here is that a supervised detox in a medical facility isn't always a viable option. Furthermore, it's not even necessarily the most effective option. Whether because your addiction is still a secret from friends and family, you're experiencing a gap in insurance coverage, there're no available beds in the programs in your area, or you just don't feel like sharing a bathroom while projectile vomiting and having Jackson Pollock-inspired diarrhea, sometimes at-home opioid detox is the way to go.

If you're undertaking at-home detox, it's imperative to get some comfort meds to help you. Without them, your chances of succeeding are close to zero; true "cold turkey" detox outside of penal contexts is so rare that it's almost a myth. It's best if you can have a loved one* dole them out based on the symptoms that you're experiencing, and it's essential that you be able to adjust your plan to respond to how you feel as you progress through the stages of withdrawal. *Editor's note: Or even an un-loved one, for that matter; just not someone who would rejoice in your suffering.

MINDSET AND INTENTION-SETTING

I've heard some addicts say that they conceptualize withdrawal as a prison sentence - a miserable period that just has to be gotten through, one day at a time, one way or another.

For me, as goofy as it sounds, I preferred a more positive cognitive framework. I told myself that opioid withdrawal was like giving birth to a new me. Just as with labor, there would be more fear and pain than I had ever felt before; but as with birth, in the end there would be new life.

I'm not a possessions person. My grandmother's prayer card and the two tattered volumes of my Norton Anthology of English Literature are the only objects in this world that I have any attachment to. However, I found that keeping both of these close to me during withdrawal was anchoring and motivating. The prayer card reminded me that I am loved miraculously, unconditionally, and helped me to reconnect with the person that I know I am deep down and wanted to return to being. The Norton Antho was a symbol of the truth and beauty that addiction had blinded my soul to; it also recalled my love of learning and my potential as a writer, two things that my addiction posed an existential threat to.

Pictures of loved ones (and of yourself during halcyon times); beloved books, including children's tales; photos from your travels or postcards of places that you long to visit; spiritual objects, such as rosaries and prayer cards: These are your totems, the reminders that will carry you through when things get really gnarly. Gather them around you; keep them close.

Time distribution of withdrawal symptoms during withdrawal from a "typical" opiate / opioid like hydrocodone, morphine, or heroin. The acute phase of withdrawal from fentanyl, oxycodone, morphine, and heroin should be concluded by days 5-7. Keep reading for more information on how the length of withdrawal varies depending on the half-life of the drug of choice. Infographic taken from drstacygreen.com.

A FEW OF MY FAVORITE THINGS

Now for the meat and potatoes of this post: The comfort meds - prescription, over the counter (OTC), and herbal - that will soften the edges of a truly hellish undertaking.

In my experience, the best way to obtain these medications is from your Primary Care Provider (PCP), if you have one. These physicians - or mid-levels such as Nurse Practitioners and Physician Assistants - are much more likely to take into account your overall circumstances and support your decision to detox at home. If you aren't able to see a PCP with whom you already have a relationship, urgent care followed by the Emergency Room are the next best options.

Have your rationale ready - either your insurance won't cover you (some will limit you to a certain number of detoxes within a set period), there aren't available beds at the moment, or whatever else is going on. Most prescribers will view sending you off to a medical facility for a supervised detox as the gold standard plan, so you're going to have to be prepared to push back a bit. Remember that, with the possible exception of gabapentin, depending on where you live, all of the medications listed in this section are non-controlled, so you aren't putting these prescribers out that much by asking for them.

Also keep in mind that if you are coming off of benzos, barbiturates, or alcohol (if you drink to the point of heavy physical dependence), withdrawal can kill you. In these cases, a supervised, medical detox is therefore the only option. So, if you've been regularly mixing your opioids with other substances, at-home detox is probably not the way to go.

Used properly and in conjunction with non-pharmacologic techniques (discussed below), the following meds can decrease the intensity of key withdrawal symptoms by 4-6 points on a scale of 10. In my experience, that is enough to allow you to reclaim sufficient agency so that you won't automatically bolt out the door to score when your withdrawal symptoms peak.

Without further ado...

Gabapentin. Useful for virtually every withdrawal symptom, from anxiety and insomnia to bone and muscle aches, lack of appetite, and nausea. The key is to dose liberally. Start with 300 milligrams every 4-6 hours for the first two doses, then increase by 300 mg every 4-6 hours until you reach 900 or 1200 mg per dose. The maximum daily dose of gabapentin is 2400 to 3600 mg, so you will need to plan accordingly.

Muscle jerks / twitches, especially as you are falling asleep, are a sign that you may need to back off your dosage a bit. Remember that gabapentin affects the seizure threshold, so you will want to taper down after 7-10 days of using it rather than discontinuing this medicine abruptly.

Clonidine. This blood pressure medication is an alpha-adrenergic agonist, meaning that it blocks the flight-or-fight hormones that produce much of the dread and panic associated with opioid withdrawal. It is useful for anxiety, insomnia, and high blood pressure (hypertension) caused by withdrawal, and it will likely help with restless limbs, as well*. *Editor's sidenote: The expression "kicking the habit" originated from the flailing of arms and legs that doctors observed in heroin addicts during detox.

Do not dose more than 0.1 mg of clonidine three times per day. If your blood pressure tends to run low, or if you are on other antihypertensive medications, you will need to be extra careful with this one. A dose of 0.1 mg twice per day is probably safer if you fall into this category.

It's best practice to borrow a blood pressure cuff to make sure that the clonidine isn't dropping your BP too much. If you aren't able to do this, dizziness upon changing position is a surefire indicator that you need to back off on the clonidine. Do not ever take more than 0.1 mg at a time, period. Many an addict in withdrawal has swallowed a few of these pills at once thinking that they are basically equivalent to Xanax or Ativan, which inevitably leads to nasty low-blood-pressure symptoms and a trip to the ER.

If you've taken clonidine for longer than 7 to 10 days, you will want to step down your dosage before discontinuing it to avoid rebound hypertension.

Zofran (ondansetron). This is a wonderful anti-nausea medication. Make sure to ask your prescriber for the sublingual version, which dissolves under your tongue, rather than the standard pill formulation, as you might not be able to keep down a pill and the sublingual formulation works faster, anyway. This med should decrease the nausea enough that you can get down some light soup, a bowl of plain rice, or some crackers.

Hydroxyzine (Atarax). This is a sedating antihistamine that helps with anxiety. In my experience, it is most effective if taken once per day to induce sleep, but many prescribers will recommend taking it every 6 hours during the worst days of withdrawal. Like gabapentin, it will lose its efficacy rapidly if you take it on too many days in a row, so after acute withdrawal is over, it's best if used as necessary (PRN).

Hydroxyzine is prescription only, but doxylamine succinate (Unisom) is an OTC alternative that works similarly. Benadryl (diphenhydramine) should only be taken if neither hydroxyzine nor doxylamine succinate can be procured, as it is not as effective and has worse side effects compared to these two medications. In particular, Benadryl is likely to leave you feeling gross if you take 50-100 mg and then cannot fall asleep.

Do not exceed the recommended dose on any of these medications. They can cause hallucinations (not the fun kind) and a host of other highly unpleasant symptoms.

Loperamide (Imodium). This OTC antidiarrheal is the most effective antidote to the bear carcass diarrhea that is an inevitable part of opioid withdrawal because it is an opioid itself; you are giving the intestinal opioid receptors exactly what they want. However, because it doesn't cross the blood-brain barrier, loperamide won't get you high.*

*I am conscious of the Streisand Effect here, but please heed my warning not to exceed the prescribed dosage of loperamide. It is true that massively exceeding the intended dose can push some of the loperamide across the blood-brain barrier, thereby alleviating some of the symptoms of opioid withdrawal. However, this "poor man's methadone" is liable to induce a cardiac arrhythmia that has killed more than a few. It is simply not worth it. Stick around; I need you for views.

Ibuprofen. This OTC Non-Steroidal Anti-Inflammatory Drug (NSAID) will help to quiet the aches and pains that flare up during withdrawal. I recommend ibuprofen rather than acetaminophen because anyone with a damaged liver should avoid acetaminophen altogether, and most opioid addicts have some degree of liver damage from viral hepatitis and / or taking acetaminophen overdoses for years because opioids such as oxycodone and hydrocodone are primarily available in combined formulations.

Dose every 4-6 hours for the first few days of withdrawal. Watch out for odd bruising or signs of GI bleeding, such as blood in the stool.

This chart from uspharmacist.com shows differences in time to onset and duration of withdrawal symptoms for various opioids. In general, the longer the half-life of an opioid, the longer the withdrawal from it will last. So, acute withdrawal from fentanyl, which has a half-life of perhaps 3 to 7 hours depending on the route of administration, might last 4 to 7 days, whereas acute withdrawal from methadone, which has a half-life of 24-48 hours (highly variable), can last weeks or even months.

STAY AWAY FROM

Alcohol. Contrary to what Trainspotting taught you, drinking alcohol is the absolute worst thing that you can do during opioid withdrawal. As tempting as it may sound to get a few moments of relaxation or perhaps even an hour of sleep, imbibing while withdrawing is entering into a Faustian bargain that will leave you puking, sweating / shaking, and with massively increased anxiety and cravings. It is also very likely to lead to regular drinking after withdrawal, which is a problem that many former opioid addicts contend with after quitting their drugs of choice.

One final warning: Alcohol leads to loss of electrolytes and dehydration, which compromise cardiac function and can land you in the ER. What's more, having screwy sodium and potassium levels induces a malaise that you certainly don't want to add to your existing opioid withdrawal symptoms.

Benzodiazepines (Xanax, Klonopin, Ativan, et al.). If you are one hundred percent sure that you can confine your benzo use to taking the recommended dosage for just a few days, then benzos are probably the most potent way to reduce the anxiety, insomnia, and muscle cramps that accompany opioid withdrawal. However, I recommend steering clear for two reasons:

(1) Benzos are highly addictive, and you are likely to become cross-addicted to them, in which case you've traded one awful addiction for another one whose withdrawal syndrome can actually kill you; and

(2) As with alcohol, benzos induce disinhibition, meaning that the mental barriers that prevent you from giving in and using come down after you take them.

Don't be fooled into thinking that the z-drugs like Ambien (zolpidem) and Lunesta (eszopiclone) are less dangerous than the benzos. They are every bit as addictive; they also cause withdrawal seizures; and they are likely to leave you in an unpleasantly hallucinatory state if you take them during withdrawal and they don't knock you out. All that, and they won't even help with muscle cramps and nausea in the way that standard benzos do.

Kratom. This plant-based remedy, which has been used in herbal medicine in parts of Southeast Asia for at least 250 years, targets opioid receptors and therefore interferes with optimal healing. Moreover, it can induce cramps, nausea, and diarrhea, all of which will exacerbate your existing Gl symptoms.

Trazodone. This tetracyclic antidepressant, which is seldom used for depression these days due to its unpleasant side effect profile, is often prescribed for sleep during opioid withdrawal. I caution against taking it. Even in doses of 100 to 200 mg, it failed to knock me out but left me in a twilit state in which my restless limbs were dramatically exacerbated. This reaction isn't unique to me; I have heard enough other addicts complain of this exact effect to make me wary.

If you need a stronger sleep medicine to use in conjunction with hydroxyzine, I recommend Seroquel (quetiapine), an atypical antipsychotic that I have found both more peaceful and more effective in inducing sleep.

JURY'S OUT ON

Marijuana. Many people find marijuana helpful during withdrawal, particularly those who smoke it habitually before they detox. If you don't regularly use weed, I would advise against edibles because it's too easy to take too much, in which case you're in for a long, uncomfortable ride. While weed can help ameliorate the anxiety, nausea / loss of appetite, and insomnia of withdrawal, it can also cause anxiety in some people, and its hallucinogenic properties can be unwelcome in the midst of withdrawal.

Unless you're a stoner elder, less is more with weed during withdrawal. A couple of tokes of old-fashioned bud is much preferable to smoking concentrate or taking an edible. Indica is preferable to Sativa because of its calming effect.

CBD on its own is also something to consider.

Melatonin. I recommend against taking melatonin during the worst 3-5 days of withdrawal because A) it is unlikely to be strong enough to put you to sleep during this initial period, and B) it can intensify REM sleep, which will exacerbate the uber-nightmares that you're likely already having due to a phenomenon known as REM rebound (basically, your brain catching up on REM sleep after months or years of decreased REM sleep due to opioid use).

Kava Kava. This plant-based medicine, which has a rich history of use in certain Pacific Island cultures, can help with anxiety, insomnia, and other symptoms. It is a subtle drug that induces a unique, lucid high.

I wouldn't recommend starting Kava Kava during acute withdrawal. Like melatonin, it is unlikely to be strong enough to break through severe withdrawal symptoms. Plus - depending on the form that you obtain it in - some adverse GI reactions have been reported. I see occasional use of Kava Kava extract as an excellent option during the several weeks following acute opioid withdrawal, but be aware that there is some risk of psychological dependence or perhaps even addiction with Kava Kava, as well.

Ti Qi, exhausted from relapse after relapse on the part of his daddy. As much as some counselors will tell you that "you have to do it for yourself," I don't believe that this is necessarily true. If I loved myself enough, I wouldn't have tortured and damaged myself almost to the point of death in the first place. But to get better to ease the suffering of the people I love - that thought is easier for me to draw power from.

Because humans are highly visual creatures, I recommend keeping photos of the loved ones who you are doing this for at your side during detox (if you don't have any available, you can close your eyes and picture them when you're really in the thick of it). Imagine how good it will feel when you call them to tell them that you are three months, six months, one year, five years clean and sober! To go from being a source of chaos and stress to one of positivity and resilience.

FINAL THOUGHTS

A hot shower - or better yet, bath or jacuzzi session - can bring down discomfort by 2 to 2.5 points out of 10 on its own. The steam will open your lungs and slow your breathing, helping to calm you.

I found it helpful to have my favorite cologne on hand during withdrawal (bougie, I know). To put it bluntly, opioid withdrawal smells like shit and death. What's more, your newly awakened olfactory receptors will be more sensitive to these smells than under normal conditions, meaning that even a moment's respite from this barrage of unpleasant odors will be a heavenly escape once you're in peak withdrawal. Some fellow addicts swear by aromatherapy with essential oils of lavender and other substances, and I can imagine that this is an even more effective means of olfactory escape.

As your mind and body reawaken and your emotions resurge, music will acquire another dimension, becoming transcendental, ecstatic. For my soothing detox playlist, click here. If music is too much for you at the moment, there are a variety of free and subscription apps that generate custom ambient noise to calm and center you.

I find breathing exercises and other mindfulness techniques to be indispensable during opioid withdrawal. If you can maintain control of your breath, much of the panic-laden emotional overlay dissipates. Likewise, being able to train your awareness on various parts of your body before re-situating yourself in it as a whole (a technique I call "body-dropping") helps you to monitor your symptoms, which, paradoxically, lessens them. Both methods draw your consciousness away from the powerful cravings that will besiege you at all of the worst moments.

The key with mindfulness techniques is that, as with breathing exercises during labor, you can't practice these methods for the first time when you really need them. Rather, you should prepare for days or even weeks before your at-home detox. YouTube is full of wonderful mindfulness meditations for observing and quieting your thoughts and emotions.

Especially after the first 3-4 days, withdrawal is an exercise in distraction. I remember that during my first, cold-turkey Suboxone (buprenorphine) detox from a ceiling dose of 16 mg per day, it took me six full weeks before I could sit down and watch a 20-minute episode of Parks and Rec all the way through. The sooner you can begin to read a few pages of a trashy romance or watch 15 minutes of a sitcom, the better. It will draw you out of yourself, and before you know it, your symptoms will subside into background noise. Creative pursuits - whether it's just coloring a mandala or jotting down some notes in your journal - are powerfully healing as well. Many artists, writers, and musicians have found withdrawal and the weeks that follow it to be times of enormous verve and fresh perspective.

During the worst moments of withdrawal - which will be some of the worst moments of your life, no doubt - get your breathing under control and then bring your mind back to your reasons for putting yourself through this pain. Affirm the wisdom of your decision to stop using as you choose it again and again. Imagine the joyous freedom of feeling good without having to worry about how many hours are left before you need to smoke / snort / swallow / shoot more "good" or face comedown, then withdrawal.

Remember that this can be your last detox: You need never feel this pain again. Observe it carefully, embracing every moment so that you will remember it months from now when the temptation to revert to old ways arises. Finally, remember that smooth seas never made able sailors, and that the young, brawny deckhands aren't necessarily the ones who are most likely to survive the shipwreck; instead, it's the wiry old-timers who've weathered many a past crisis who will get through today's disaster, as well.

I am so proud of you for taking this on! Deciding to quit your drug of choice when your brain and body need it to function is nothing short of heroic. If you can do this, you can truly do anything.

Note: The above recommendations are tailored to the United States' medical system. I will respond to any comments or emails from readers living in other countries; I'm glad to help you research possible alternatives if the suggestions above aren't viable in your area.

Please share your own experiences and recommendations below!

You're all invited to connect with me on Instagram, which will be ramping up in the next several weeks. Also, please remember to subscribe to the Concrete Confessional mailing list, which you can join from our homepage, for access to our soon-to-launch Discord community and to receive a free copy of my Glossary of Opioid Addiction for Patients and Their Loved Ones later this year.