Drug Holidays.
This is the name given to the period during which the medications are stopped.
Drug Holidays should always be tailored to the pharmacokinetics of the
medication for which it is intended. (e.i.
in the above mentioned example for morphine, they should be 7 to 10 days in
duration while in the case of methadone, they should be 3 weeks in duration.)
During the Drug Holidays, clonidine can be
administered for one week, to help with the hyperactivity of the sympathetic
autonomic nervous system. This medicine will lessen the withdrawals, but will
not completely get rid of them. During the Drug Holidays, because of cross-tolerance, patients should not be
allowed to switch to another opioid. When returning to
the opioid, at the end of the Drug Holiday, the
patient should always be started at a lower dose than the dose prior to the
Drug Holiday. They should be repeated as often as necessary to allow the
patient to control his/her medication intake, rather than allowing the
medication to control the patient.
Whenever you feel that you have developed medication tolerance. When your pain medication
begins to lose effectiveness. When you see that your pain medicine is
not working as well as it use to.
Medication tolerance
is what happens when your medicines are no longer as effective as they use to.
Tolerance may be acquired to the effects of many drugs,
especially the opioids, barbiturates, and other CNS
(central nervous system) depressants. When this occurs, cross-tolerance
may develop to the effects of pharmacologically related drugs. Tolerance to a
pain medication will be manifested as an increase in pain after the frequent
use of the analgesic (pain medication). Tolerance has been described to develop
in as short as 10 days. Although this process may take as long as a year in
some patients, it is safe to assume that it will occur to everybody who takes
this type of medication on a chronic basis. In our practice, we try to assess
the patient's narcotic requirements in as short of a time period as possible.
As soon as the patient admits to be comfortable on a certain dose, we call such
a dose "the patient's requirement". Thereafter, any increases in the pain, within an otherwise stable condition, is
considered to be due to the development of tolerance. A common complaint of
patients is that, "the medications don't seem to work as well as they use
to."
This is a very common
misconception held by
patients, as well as physicians.
It is a common misconception that changing from one
narcotic to another prevents the development of tolerance.
Switching from one narcotic to another does not help with tolerance,
because of cross-tolerance. In fact, it complicates the management of
the patient's condition since it introduces more variables. Essentially, what
happens is that the substituting narcotic is probably been given at a higher,
non-equivalent dose, which gives the patient and the unsuspecting physician the
illusion that it is working, when in fact the only thing that has been
accomplished is an increased in the opioid dose.
When
you develop tolerance to a narcotic or opioid, you
develop it to the entire family, through a process known as ìCross-Toleranceî.
Therefore, even if a pharmaceutical were to develop a new narcotic tomorrow,
you would still be tolerant to it, just because of the fact that it is still in
the same family of medications.
Fact #1.
Most
of the tolerance seen with opioids is due to
adaptation of cells in the nervous system to the drugís action. The use of
increased amounts may in turn enhance the risk of toxic effects or produce
other problems if the drug is expensive or obtained illicitly. Although the
ìlethal doseî is greatly altered in tolerant individuals, a dose always exists
that is capable of producing death from respiratory depression. Tolerance to opioids largely disappears when withdrawals have been
completed, and many addicts have taken fatal overdoses by returning to their
previous dosage immediately after undergoing withdrawal.
Fact #2.
Increasing
the dose will only treat the problem temporarily. Tolerance will again occur at
the higher dose. The higher the dose, the worse the withdrawals, the more money
it will take to buy your medicines, and the more likely that you will have side
effects. In addition to this, the higher the dose, the more likely it is that
your physician will be uncomfortable with prescribing it and the more likely
that you will not find anybody to continue prescribing it for you.
Fact #3.
Most
short-acting narcotics are ìcombination drugsî, meaning that they exist as a
mixture of two drugs. (e.i. Percocet = Oxycodone+Acetaminophen
[Tylenol]; Vicodin = Hydrocodone+Acetaminophen)
Because of this combination, it is dangerous to take them for prolonged periods
of time or in high doses, not because of the narcotic (Oxycodone,
Hydrocodone), but because of the Acetaminophen
(Tylenol), which will permanently damage your Liver. Acetaminophen toxicity can
cause Liver necrosis (organ death), requiring treatment by way of a ìLiver
Transplantî.
Withdrawals
Contrary
to withdrawals from alcohol or benzodiazepine (VALIUM, ATIVAN, XANAX, etc.),
narcotic withdrawals are, for the most part, not lethal. In the case of short
acting narcotics, such as morphine, withdrawals can occur 12 to 14 hours after
the last dose, reaching their peak at 48 to 72 hours, and disappearing in 7 to
10 days. With longer acting narcotics, such as methadone, withdrawals can begin
24 to 48 hours after the last dose, reaching a peak at the 3rd day,
and may not begin to decrease until the 3rd week.
Symptoms
of withdrawal
They
usually consist of lacrimation, runny nose, yawning,
sweating, dilated pupils, loss of appetite, goosebumps,
restlessness, irritability, tremors, insomnia, sneezing, weakness, depression,
nausea, vomiting, diarrhea, abdominal cramps, chills, bone and muscle pains,
increased in respiratory rate, heart rate and blood pressure, muscle spasms,
cold and hot flashes, increase in body temperature, anxiety, and a feeling of
being ready to ìclimb up the wallsî or ìjump out of your skinî. For the most
part, withdrawals are more severe for the short-acting narcotics than for the
long-acting.
Reason #1. (Physiological
Reason).
By
withholding the medication from the receptors, a physiological process of
ìReceptor Down-regulationî occurs, by which ìToleranceî to the narcotics
decreases and occasionally disappears. When the medication is restarted, it
will usually be more effective in controlling the symptoms (pain).
Reason #2. (Medico-Legal
Reason).
Federal
Law defines an ìAddictî as ìsomeone who has lost self-control over their own
medicationsî. Following this definition, it then states that ìit is illegal for
any physician to prescribe narcotics to an ìaddictî. Because of this, any
patients refusing to undergo a ìDrug Holidayî, may be considered as having lost
self-control over their medications, subsequently triggering the permanent
cessation of all controlled substances by the prescribing physician. The other
side of that coin is that by complying with the ìdrug Holidaysî, the patient
proves that he/she continues to have self control over their own medicines, and
therefore, it makes it legal for the treating physician to continue prescribing
the pain medication.
It should be at least two (2) to three (3)
weeks long. The rule of thumb is that it should continue, as long as the
patient continues to exhibit symptoms of withdrawal.
Yes, you may use non-steroidal anti-inflammatory drugs
for that pain; muscle-relaxants for the muscle pain and spasms; and, clonidine or Zanaflex ’ for the withdrawal symptoms. In addition to
this, you may continue to use your other medically indicated medications, for
your other chronic medical conditions (e.i. diabetes,
etc.).
No,
you cannot switch to another narcotic or continue taking any other narcotics
during your ìDrug Holidayî.
It all depends on how quickly you develop
tolerance. Some patients are lucky and may develop it over a period of a year, in
which case they will have to undergo a ìDrug Holidayî once a year. On the other
hand there are some that are not as fortunate and may develop tolerance over
periods as short as twenty-eight (28) days, in which case, they may have to do
one every month. The later, may not be a good candidate to stay on this type of
medication, precisely because of this reason.
As previously stated, you may actually make it illegal for your
physician to continue prescribing the medicine for you. Therefore, you may find
yourself coming off of the medicine forever, rather than just two (2) to three
(3) weeks. In addition to this, if you are not to follow your physicianís
recommendations, then, you should not be seeing that physician.
WHAT HAPPENS IF I AM THE KIND OF PATIENT THAT
DEVELOPS TOLERANCE VERY QUICKLY?
In
that case, you may not be a candidate for Narcotic therapy, at all. Rapid drug
escalation is a sure recipe for disaster. This should be avoided whenever
possible.
No. We do not hospitalize any patients for ìDrug
Holidaysî. If you feel that you will not be able to stop your pain medication without
being hospitalized, then we will need to closely evaluate your case for
possible ìaddictionî issues. Addiction involves psychological craving, and/or
an unsubstantiated fear to stopping the medication. In these cases, you need to
check yourself into a ìDetoxificationî program, such as ìCharterísî. Once you
are completely off of the medication, we would probably avoid going back to it,
since this condition can relapse.