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Dependency and tolerance

Tolerance

Tolerance to the drug is a situation when after prolonged use of the drug you need to increase the dose to maintain the initial effect. For opioids, there is no ceiling for tolerance. Remember that when you develop tolerance to one type of opioids you may also develop tolerance to other opioid painkillers, which is very undesired especially in cases of unexpected surgery, or treatment in hospital. The doctors may simply don't know that you have developed the tolerance to painkillers and they may be unwilling to give you greater doses of the analgesics. It may be very dangerous, eg in case of a car accident.

It has been proved that dextromethorphan (DXM) slightly reduces the tolerance to opiates and opioids.

Addiction

Left/RightOpiates can produce drug dependence of the morphine type. Actually, many substances (including those OTC) available in pharmacies have a dependency potential. Codeine is considered as an opiate with smallest dependency potential (least addictive), while oxycodone has the same dependency potential as morphine. Make sure you control your usage and also keep an eye on your friends who use any opiates.

The opioid dependency may appear after prolonged, usually every-day use. The physical symptoms of dependency may appear after as short as one month or as long as half a year of every day use. The psychological symptoms of the addiction usually may appear earlier.

It is very unwise to stop using opioids suddenly, because of the possibility of acute withdrawal symptoms. Once you decide to quit opiates, you should reduce the dose gradually (weekly reduction by 25% is recommended).

Fergusson syringe, morphine and belladonnaWithdrawal is a very unpleasant experience and many people have difficulties in coping with it. Symptoms of withdrawal include nausea and diarrhoea, coughing, lacrimation, yawning, sneezing, rhinorrhea, profuse sweating, twitching muscles, abdominal and muscles pain/cramps, hot and cold flushes, and piloerection. Increase in body temperature, respiratory rate, heart rate, and blood pressure may also occur. If you experience the symptoms of withdrawal, it doesn't necessarily mean you are addicted (being 'addicted' means drug craving and overwhelming concern with acquisition of the drugs).

Most symptoms usually resolve within 3-14 days; however, there appears to be a secondary or chronic abstinence syndrome that may last 2-6 months, characterised by insomnia, irritability and muscle aches.

Only codeine is not generally approved for the clinical management of substance abuse.

Dealing with withdrawal

The most annoying aspect of withdrawal is the physical pain. There are many drugs that will help you go through the withdrawal 'hell':

There are few herbal remedies helpful in dealing with sleeplessness, anxiety, and stress related to withdrawal, although none of them will alleviate the withdrawal itself:

If you wish to get off relatively strong opioid (eg oxycodone), you may need to use a weaker 'substitute' (eg codeine or dihydrocodeine) to avoid or minimise the withdrawal symptoms.

Do-It-Yourself Detox Guide

© Peter McDermott, 1993

© Lifeline Project, 1993

This guide was first published by Lifeline Project, Manchester, UK. This electronic version may be freely distributed electronically or as hard copy. However, be warned that you are missing out on Mike Linnell's brilliant illustrations.

Why should I do-it-myself?

People often go along to a drugs agency in the hope of finding an easy solution to their drug problem. This is a mistake. There are no easy solutions.

The majority of people stop using drugs without any help. Addiction to smoking is just as difficult to give up as addiction to heroin, but the majority of people stop smoking with out any outside help. Drugs agencies are thought to be in contact with between 10% and 25% of all heroin users. The rest stop using drugs without any help whatsoever. When the U.S. army was fighting in Vietnam, hundreds of thousands of soldiers became addicted to heroin. When they returned to the U.S.A., the vast majority gave up heroin without any help whatsoever.

While a small number of people find that it is harder to stop using unless they are physically removed to a place where they cannot get drugs, i.e., a hospital or a rehab unit. This may be an option for you to consider, but if you do, remember, you still have to face the situation back in the real world when you do get out. Ultimately, nobody else can do your detox for you.

Some people find that support from a drugs worker can be helpful during a detox. Other people's experience is that they are a bunch of know-nothing do-gooders who are about as much use as a blocked needle or a packet of wet skins. There are also other drawbacks associated with attending a drugs agency. They expect you to attend for regular appointments. You can expect to run into other drug users, possibly even dealers, and most drugs agencies keep records of your name, address, date of birth, etc. In some cases, these are passed on to the Home Office and kept on a register. If you decide to use a drugs agency, remember to ask about their record keeping and confidentiality policies.

Ultimately, whether you decide that you want support from a drugs worker or not, the only person who can stop using drugs is YOU. However, the greatest obstacle to your success is fear. This booklet aims to try and remove some of the mysteries that surround drug detoxification, by explaining what will happen, we hope to make you your own expert. You take the credit for success, and the responsibility for your own continued use.

Before you make the decision to detoxify, there are several questions that you should try to answer for yourself.

Who are you stopping for?

In order to succeed in your attempt to stop using drugs, you have to genuinely want to stop. Not for your parents, not for your wife, not for the court or the probation officer, but for yourself. Of course, all those other people may play a role in making you want to stop. If you are upsetting your parents, if your wife is about to leave you, or you stand a good chance of being sent to jail, that may well make you tired of using drugs. However, for many people, it doesn't.

If you aren't really sure about it, perhaps you should think about other options. Some people find it is easier if they attempt to stabilize their drug use before giving up. If you feel that this may be a better option for you, then talk it over with a friend or a drugs worker. If you do attempt to stop using drugs before you really want to, you may be setting yourself up to fail. After several failures, you may lose confidence in your ability to succeed, which can lead you to stop trying. So try to be clear about what it is that you really want, and if you do want to continue using drugs, then focus on trying to reduce the harm associated with your drug use.

Why do you want to stop?

Drug use has both positive and negative aspects to it. Everybody who uses drugs experiences both. People usually only stop when they are aware that the negative aspects outweigh the positive ones. Some people are aware that the negative consequences of their drug use are great, but are still unable to make the decision to stop using drugs. This may be because the positive benefits that they gain from using are even greater, or it may be simply because they haven't thought clearly enough about the consequences. Here is a list of some of the positive and negative aspects of drug use.

Before you decide to give up, make a list of the positive and negative aspects of your own relationship with drugs. Then you can see whether or not you think stopping would be a good idea.

What drugs are you using?

Just as different drugs have different effects, so the attempt to stop using different drugs has very different results. Make a list of the drugs that you are currently using and try to think about which ones might be causing you a problem. Remember, you can lie to parents, employers, teachers, partners and friends, you can even lie to yourself - but given that you are only doing this detox because you want to, what would be the point?

Some drugs are not regarded as addictive, but that does not mean that you cannot become habituated to their use, or that their use is not a problem. Cannabis, L.S.D., Solvents, Amphetamine and Ecstasy may all fall into this category. Some people may experience mental craving if they try to stop using these drugs, but they should not experience any physical discomfort.

Other drugs are quite definitely addictive. This means that when you attempt to stop using them, you might experience physical withdrawal symptoms as well as psychological craving. The drugs that fall into this category include Opiates like Heroin and Methadone, Benzodiazapines like Valium, Temazepam, Ativan or Nitrazepam, Barbiturates like Seconal or Tuinal, and Alcohol.

For a long time, people thought that Cocaine fell into the first category of just being psychologically addictive. However, more recently, scientists have identified changes in the brain chemistry that occur after regular use of coke, and so the severe craving experienced by people with a cocaine problem may well have a physical component as well. Whether it does, or whether it doesn't, cocaine provides us with an example of a drug that produces chaotic and compulsive use patterns prompted by psychological craving rather than fear of withdrawal.

Make a list of the drugs that you currently use regularly. If all the drugs that you use fall into the non-addictive category, then you will not need to detoxify gradually. You can stop using immediately without experiencing any physical symptoms whatsoever.

If you find that you use more than two types of addictive drugs regularly, then you will probably find it easier if you seek professional help with your detox.

If you are just using one of the addictive drugs or one addictive drug and one or more of the non-addictive drugs, then you may well be a good category for a do-it-yourself detox.

What is your source of supply?

If you are dependent on drugs that are prescribed by a doctor, then you have an ally in your detoxification project. Talk over your plans with the doctor and tell him or her what you are planning to do.

If you feel that you are dependent upon Benzodiazapines or Barbiturates, and are on high doses, or have been using them for a long time, then it may be unwise to attempt to stop without medical supervision. Both drugs can cause severe fitting when they are withdrawn, and deaths have been caused by barbiturate withdrawal so it is not a good idea to attempt to stop immediately. With the Barbiturates, it is usual to change over to Phenobarbitone before attempting a gradual reduction, whereas with the Benzodiazapines, it is usually best if the prescription is changed to Diazepam.

If you are dependent upon an Opiate, then many people find it helpful to change over to either Methadone or Dihydrocodine (DHC or DF118) for detoxification. Again, if you are receiving your supplies from a doctor or a clinic, talk your plans over with them. They can help you by rationing your supplies for you. during the course of your detox, and by offering more flexible options should you experience difficulty with your plans.

If you are dependent on black-market drugs such as heroin or cocaine, you may find it difficult to persuade a doctor to prescribe for you. This can be a good thing, as if you go on a script, it can make it too easy to continue using for a long time. Once again, it is crucial to stress that you need to know what you want. If you want to stop using, then it may be easiest to attempt a home detox. Should you find it too difficult, then you can always seek help from a doctor or drugs agency afterwards. If you wish to continue using, then you may well benefit from a visit to a drugs agency in order to discuss ways of stabilizing your drug use or reducing the risks that you run.

What will the withdrawals be like?

Withdrawal symptoms will differ with the drugs that you use. Cocaine users will not experience physical withdrawals, but they may experience intense craving, irritability, inability to sleep, mood swings and panic attacks.

Heroin users, on the other hand, will experience all of the psychological symptoms, accompanied by physical withdrawal symptoms. Some clever- dick drugs workers claim that withdrawal is no worse than a dose of bad flu. That might be true, except when did anybody suffer a dose of flu that stopped you from sleeping or even getting comfortable for more than a minute at a time? A dose of flu that can be cured in minutes by the consumption of a little bag of powder?

With opiate withdrawal, although the symptoms are the same for everybody, everyone seems to focus on one particular aspect as the thing that they experience as the worst. For one person it may be pains in the muscles or joints, for others it could be the inability to get comfortable. Others have difficulty coping with the lack of sleep. The range of symptoms for opiate withdrawal includes sweating, restlessness, nausea, diarrhoea, stomach cramps, muscle pains, sleep disturbance, hot and cold flushes. It is undoubtedly unpleasant. However, fear of withdrawals makes them seem worse than they actually are. Almost everybody can cope with the severity of their withdrawal, regardless of how much they have been using.

Some people do really stupid things and claim the fact that they were in withdrawal is an excuse. It isn't that they can't deal with the sickness though - the real reason that they do these things is because they aren't really committed to stopping. It's hard to sit and suffer if you know that as soon as you get money, you are going to get sorted, and therefore you'll have to go through the whole thing again. You, on the other hand, are different. If you have decided to stop using drugs, this will be the last time that you suffer this way. Not only will you feel the pain, you will embrace it as you kiss it goodbye, safe in the knowledge that after you have finished your detox all that will be behind you.

How do I go about it?

Once you have decided to stop using, don't just say "that's it, no more" as you are bound to fail. You need to plan your detox properly. Decide a time when you are going to do it. It could be relatively soon, or it could be some time in the future. Whenever it is, put aside at least two weeks when you don't need to do anything stressful and you don't have any responsibilities. If you have children, send them to their grandparents or to a friend for a holiday. They won't enjoy spending this time with you, and you'll be glad not to have to worry about them.

Tell everybody about your decision to stop using. People who love and care about you will give you support through this period. Other users may resent your ability to break the habit and try to tempt you into using. If you suspect that this is the case, explain what you are doing, and tell them that you would rather they didn't come around during this period. You can decide later whether you still want to see them, but if they insist on trying to tempt you, you can be certain that they don't really care about you, so don't feel guilty about excluding them from your life.

Try to put some money aside. You need to be able to pamper yourself with rewards during this period. Giving up drugs is a very brave and difficult decision, so you shouldn't feel guilty about indulging yourself in other, less destructive ways. If you are unemployed, perhaps you could avoid paying the rent for a week and make up the arrears a bit at a time later on.

Finally, find a comfortable place in which to do your detox. One of the main reasons for doing a detox as an in-patient is that some people don't have anywhere comfortable that they can detox. For most people though, detoxification is much easier if you can make a drink in your own kitchen, watch your own T.V., read your own books and listen to your own stereo. If the place where you live isn't very nice, see if you can go back home to your parents, or if you can stay with non-addicted friends for a couple of weeks.

Personally, I think you should regard a detox as being like a prison sentence. Rather than focussing how long you have felt lousy, focus on how much closer you are to feeling better. Make a calendar and tick off the days, or keep a diary and write down how you feel. Identify landmark points so that you can look back over it and see how much progress you have made. Stopping using drugs is one of the major decisions in your life - it will be nice to look back and see how you managed to overcome each of the obstacles, or even just how much you suffered without quitting.

Every time you complete a certain period, congratulate yourself for having made it. Give yourself a reward. For each day you complete it could be something small, like something special to eat or drink. For each week that passes, do something really nice for yourself. Buy yourself something to wear or go out for a meal. Think about both the detoxification and the rewards as investments in the new you - the person that you want to become rather than the person that you were.

One of the most difficult aspects of opiate withdrawal is the lack of sleep. Some people might be tempted to use sleeping tablets in a desperate attempt to get some respite. Personally, I find that they don't really help, they just dope you up so that rather than lying around withdrawing, you are lying around feeling doped-up and withdrawing. You still won't sleep and benzodiazapines are addictive too, so you could end up replacing one habit with another. Remember, there are no easy solutions, you've just got to bite the bullet and ride it out.

Finally, don't get hung up thinking about the length of time that a detox is going to take. Like they say in Alcoholics Anonymous, just try to get through one day at a time. It's difficult trying to imagine a life without drugs, but far easier to make it through to the end of a day. Then you can again start afresh tomorrow. Remember, every day that you manage to stay clean is an investment in your own future - and if you can't be bothered to invest in yourself, you can be pretty damn certain that nobody else will.

How long does it take?

How long is a piece of string? It all depends what drugs you use, how much you've been using, how long you've been using for and what your own particular metabolism is like. Somebody who has been using benzodiazapines might take months to feel normal. Heroin usually takes anywhere between three days and two weeks. Methadone seems to take much longer than heroin. It can last anywhere from two weeks to a month before you start to feel normal again.

However long it takes, don't let it get to you. Three days without sleep will begin to feel like a week. A week without sleep will feel like a month. A month without sleep and you start to feel as though you're going mad. You aren't. Your mind and body will snatch some sleep as you need it. It might only be the odd five minutes here and there, but it's better than none. Remember, the longer you've been clean, the more you've actually got invested in your detox, so when the going gets tough just congratulate yourself for the success that you've achieved so far, and try to make it through to the next morning. And then start again, doing it one day at a time.

When will it all be over?

A detox is never over. After a few weeks, your mind and body will be free of the drugs that you've been taking, but your problems are only just beginning. Ask any veteran junkie, they'll all tell you the same thing - getting off drugs is easier, staying off is far harder. Detoxification lasts a couple of weeks, staying drug free takes a lifetime of effort.

There are a number of points that you should bear in mind:

  1. Stay busy.

    Boredom is one of the main reasons why people go back to gear. If you can't get a job, take up some voluntary work, or a hobby. Go back to school and train for a new career. Do anything that will stop yourself sliding back into your old patterns of behaviour.

  2. Avoid other drugs.

    Some people think that because they were addicted to say, heroin, they won't have a problem with other drugs. A number of things happens frequently with ex-users if they use other drugs. Some of them simply transfer their dependency to a different drug, such as alcohol or cocaine that can be just as damaging. Those who use the non-addictive drugs such as amphetamine, LSD or Ecstasy often find that it acts as a spur that allows their resolve to slip. If you must use other drugs, cannabis is probably the safest, but that can also lead you to slip into using other drugs. The safest strategy is to avoid all drugs completely.

  3. Find some support.

    Seek out friends that you can talk to when things are getting heavy. Some people find that organizations like Narcotics Anonymous are useful in helping them stay away from drug use, because people in the organization understand what you are going through. Others feel that the quasi- religious content of the twelve step programmes like A.A. and N.A. is too much to take, or they dislike the way that programme members continually define themselves as addicts rather than moving forward and getting on with the rest of their lives. Good friends, who may or may not be ex-users, can fulfil the same functions. Giving support when you feel low or when you've slipped up and used again. If you don't have any non-drug using friends, go back to point 1, and find something to do with your time. Chances are, you'll make new friends through your new activities.

  4. Avoid drug-using situations.

    Many people find that certain cues make them think about using drugs. It may be a certain person - a friend or a relative. It may be a certain place - a particular pub or an estate, somewhere that you used to score, or it may be something less concrete like the sight of a Jif lemon or a bottle of vinegar. When you can recognize them, avoid them like the plague until you are certain that you have enough strength to deal with them.

  5. Use the money you would have spent on drugs to do something you really want to do.

    If you do stop using, make sure that you get some benefit from having done so. Put the money towards buying something you really wanted, or doing something that you really want to do. Try to avoid having large amounts of surplus cash just lying around putting temptation in your way. Instead, plan a holiday in that country that you've always wanted to go to. (Avoid places like Thailand or Holland.) Take driving lessons, or save for a car. You have already had your first taste of success when you stopped using drugs. Now, anything is possible.

Summary for action

  1. Re-read this booklet
  2. Make a list of the reasons for and against your continued drug use.
  3. Decide whether you genuinely want to stop using drugs or not.
  4. If you don't want to stop, put this booklet away until you do.
  5. Make a list of all the drugs that you currently use. Is a D-I-Y detox viable?
  6. If so, plan a time to stop using. Remember to leave at least two weeks clear with no responsibilities.
  7. Tell your family and friends about your plans.
  8. Accumulate money to pamper yourself with rewards after each stage.
  9. Arrange to have a comfortable place to do it.
  10. Make a detoxification time-table/calendar/diary.
  11. Plan activities to fill up your time after you have completed your detoxification programme.
  12. Begin the detoxification programme.
  13. Don't use any more drugs.
  14. (I couldn't end on 13, could I?) Wish yourself good luck - you'll need it!

Related information: Websites on addiction in the Links