Prescription Painkiller and Opioid Addiction Treatment

Why prescription dependence is harder to recognise

There is no illegal purchase, no obvious paraphernalia and, at the beginning, no visible deterioration. The medicine has a legitimate origin and often a legitimate ongoing justification, so the family has no clear point at which to say that something changed.

The signs that do appear are easy to attribute to something else: irritability, a preoccupation with the supply, visits to more than one doctor, running out early, and increasing distress at the prospect of a gap in supply. By the time it is unmistakable, physical dependence is usually well established.

• Running out consistently before the next prescription is due
• Obtaining the same medicine from several doctors or pharmacies
• Taking it for reasons other than the pain it was prescribed for, such as sleep, stress or low mood
• Distress or anger when the supply is questioned or interrupted
• Withdrawal symptoms — sweating, aches, restlessness — within a day of a missed dose
• Continued use well past the resolution of the original condition

Tramadol, and why it needs particular care

Tramadol is the most commonly involved medicine in this category in Pakistan, and it behaves differently from other opioids. Alongside its opioid action it affects serotonin and noradrenaline, which means its withdrawal has two components: the expected opioid symptoms, and a second set closer to antidepressant discontinuation — agitation, electric-shock sensations, confusion and marked anxiety.

Tramadol also lowers the seizure threshold, and seizures can occur at high doses, on abrupt cessation, and particularly where it is combined with certain antidepressants. For these reasons tramadol withdrawal should be medically supervised and tapered rather than stopped suddenly, even though the dose may look modest on paper.

Codeine cough syrups

Codeine-containing syrups are widely available and widely misused, and because they are sold as a cough remedy they carry no sense of being a drug at all. Quantities consumed are often very large by the time treatment is sought.

Two problems follow. The first is straightforward opioid dependence requiring managed withdrawal. The second is that these preparations usually contain other active ingredients — antihistamines, and in some formulations paracetamol — and sustained consumption at high volume causes its own harm, including liver damage where paracetamol is involved. Assessment includes checking exactly what the preparation contained.

What withdrawal involves

Withdrawal from prescription opioids follows the same broad pattern as heroin withdrawal, with timing that varies according to the particular medicine. Shorter-acting preparations produce symptoms within hours; longer-acting ones take longer to start and take longer to finish.

• Early: restlessness, anxiety, yawning, watering eyes, sweating and disturbed sleep
• Building: muscle and joint pain, abdominal cramping, nausea, gooseflesh and dilated pupils
• Peak: typically between one and three days for shorter-acting preparations, with vomiting, diarrhoea and severe discomfort
• Settling: acute symptoms ease over roughly five to ten days
• Extended: low mood, poor sleep and craving persisting for weeks, alongside the return of the original pain problem

The pain that started it does not disappear

This is the part that distinguishes prescription dependence from other opioid dependence, and the part most often handled badly. Where there is a genuine underlying pain condition, withdrawal returns the person to that pain without the medicine that had been managing it, and telling them simply to stop is neither realistic nor humane.

Assessment therefore covers the original condition as well as the dependence. Long-term opioid use is in any case a poor treatment for most chronic pain — tolerance means the benefit falls while the dose rises, and opioids can increase sensitivity to pain over time. A plan that addresses pain by other means is part of treatment rather than an afterthought.

Treatment

Withdrawal is managed rather than imposed. Depending on assessment this may involve a controlled taper of the existing medicine, transfer to a longer-acting opioid and reduction from there, alpha-2 agonists such as clonidine or lofexidine to reduce autonomic symptoms, and symptomatic treatment for pain, nausea and insomnia.

• Full assessment: which preparation, what dose, how long, and what the original condition was
• Medically supervised taper or detoxification, with the pace set by the medicine involved
• Management of the underlying pain condition by means other than escalating opioids
• Psychiatric review, since depression and anxiety are common alongside long-term opioid use
• Psychotherapy addressing the role the medicine came to play beyond pain relief
• Discharge planning, including how future prescriptions will be handled

Overdose risk after a period without the medicine

Tolerance falls during any break in use, and a dose that was previously routine can be dangerous afterwards. This applies to prescription opioids exactly as it does to heroin, and it is less well understood because the medicine feels safe by virtue of having come from a pharmacy.

Anyone who has completed a withdrawal should understand that returning to their former dose is genuinely hazardous, and should recognise the signs of opioid overdose: pinpoint pupils, slow or absent breathing, blue lips and unresponsiveness. That is an emergency requiring an ambulance.