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Tapering Guide for Opiate Based Prescription Painkillers





Withdrawal Aid Lifestyle Guide
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Tapering Guide Notification: This following information is for general educational purposes only, not medical advice. It’s important that you talk with your health care provider or doctor before starting any new vitamins, supplements, exercising routines, or lifestyle changes. It’s just as important to discuss with your doctor if you plan on stopping any of your medications either abruptly or by tapering as there can be adverse reactions. Tapering results vary from individual to individual due to many reasons including age, gender, weight, length of use, amount of use, the type of opiate, metabolism, general health, diet, exercise, and more. In other words, there is no one size fits all when it comes to tapering perfectly which is why it’s important to discuss with your doctor as they know your medical history and your general health and can monitor you while you taper.

Statistics from the Center for Disease Control and Prevention indicate that health care providers in the U.S. wrote more than 259 million opioid prescriptions in 2012, which represents a growing trend over a 15-year period (CDC, 2014). Health care providers have been grappling with the increasing number of patients taking larger doses of opiates in recent years. The major challenge for providers has been managing opiate-based therapy, and when and how to intervene when opiate use becomes an addiction. Opiate abuse has been seen in all types of health care scenarios, ranging from short to long-term use in surgery, to cancer treatment, and other medical uses. Its continued use in non-hospital settings is also a major area of concern for health care providers, especially when individuals become addicted to the drugs at home.

When Tapering Becomes Necessary
As a rule of thumb, tapering is normally done when perceived benefits from using the drug are no longer achievable. Improved quality of life for the patient is one of the key metrics used to measure benefits of tapering (Kral, Jackson, Uritsky, 2005). Other reasons for considering a taper include unacceptable risk posed by continued use of opioids and when the user becomes non-compliant and starts abusing the drugs. Under these circumstances, a taper should be considered to get the individual off of the drug as soon and safely as possible.

Important Factors to Consider Before Tapering
Endorphins are natural chemicals that are produced by the body to control positive feelings such as happiness and pleasure. Opiates imitate this function and gradually lead to a reduction in the amount of natural endorphins that are produced (Schatzberg and Nemeroff, 2009). It is for this reason that tapering is necessary as it helps the body to gradually wean off synthetic endorphins and restore production of natural endorphins without adverse reactions. 

As a rule of thumb, prolonged opiate use normally requires a longer tapering schedule to ensure a slower taper. Someone who has used opiates for a long duration, say 10 years will have physical and psychological problems with a short taper cycle compared with someone who has been on opiates for a shorter time. People who have been on opiates longer will typically express more fear and anxiety when it comes to tapering. An article published in the American Journal of Addiction found that short tapers combined with factors such as low motivation led to a high relapse rate. This underlines the importance of customizing the taper schedule for different individuals. 

Additionally, anxiety and fear play a critical role in reducing the efficiency of tapering. It is vital for individuals to surround themselves with friends, family and care providers who will form a good support network during the tapering process. Another key factor to consider when tapering is the individual’s genuine desire to quit or reduce opiate use. A critical assessment of a person’s real desire to quit is crucial if a taper is going to be successful. In many cases, one may express their desire to quit but are truly not committed to the process. Therefore, a critical assessment of these factors is important before embarking on a tapering schedule. 

Lastly, it is important to consider the biochemistry of the drug prior to tapering. A drug’s half-life is described as the amount of time it takes for half the concentration of the drug to be broken down by the body (Schatzberg and Nemeroff, 2009). Half - life varies from one drug to another and plays an important role in determining the amount of time it will take for a successful taper. For instance, Oxycodone has a half-life of 4 hours. This means that for every 4 hours, the concentration of the drug is halved, meaning it will be eliminated up to 95%+ within 24 hours. Additionally, it is equally important to consider the dosage of an opiate prior to starting the taper. For instance, a patient who is taking 250mg of Oxycodone per day will typically take longer to taper than someone who is taking 30mg per day. 

An in-depth pre-taper assessment will usually increase the chances of a successful taper and reduce the probability of relapse for many users. 

The next section looks at typical tapering plans for five common opiates: Hydrocodone (Vicodin), Oxycodone (Percocet), Codeine, Suboxone, Methadone, together with withdrawal symptoms and conventional uses of each drug.

Hydrocodone - Vicodin
Hydrocodone-containing medications are prescribed over 140 million times each year to relieve moderate to severe pain as well as suppressing coughs for people with whooping cough or pneumonia (FDA, 2013). Hydrocodone remains one of the most abused opiates because of its effects against pain and pleasant feeling that follows its use. Many addiction cases normally start as legitimate cases but then end up as cases of drug abuse. 

Hydrocodone has a half-life of 3-4 hours, which makes it a manageable opiate to taper off. The following schedule indicates a typical taper schedule for someone taking 100mg of Hydrocodone per day in ten 10mg pills at a rate of two pills for every 4-6 hours.

Week 1

  • The taper starts by reducing the intake to eight pills, distributed across the day in the following fashion: two pills at 8am; one pill at 12 noon; two pills at 4pm; one pill at 8pm; and one pill before going to bed.
  • It is important to start small so that the effect of withdrawal is not pronounced.

Week 2

  • The intake is reduced to six pills per day.
  • At this stage, it is important to check for withdrawal symptoms and/or depression. If any withdrawal symptoms are experienced, you can dial up the dosage to seven pills.

Week 3

  • Reduce the pills to four or five per day, depending on how the body has responded so far. 

Week 4

  • Reduce the pills to two or three per day, again measuring the effect of withdrawal on the body. 
  • If there are withdrawal symptoms, take a pill as necessary to curb the symptoms. It is important to remember that the aim of tapering is to avoid withdrawal symptoms while taking care not to get high with the drug.

Week 5

  • Reduce the intake to two pills per day and, in subsequent weeks, reduce the intake to one pill until you can comfortably go a day without taking a pill. 

Many people will have fully tapered from Hydrocodone 1-3 weeks after their last intake and may only experience mild withdrawal symptoms after a successful taper. Depending on your dosage, you can taper down 10% of your dose every week until you are completely off Hydrocodone. 

Oxycodone - Percocet
Oxycodone, like Hydrocodone, is one of the most abused opiates in its class. It has received considerable attention from law enforcement agencies and healthcare providers due to its potential for dependence and abuse. Medications containing Oxycodone are prescribed for moderate to severe pain and are normally available as a combination of other substances such as acetaminophen and aspirin (PubMed Health, 2015). Oxycodone is available in immediate release formulations such as Percocet and Roxicodone and extended release formulations such as Oxycontin. Before tapering, it is important to remember that immediate and extended release formulations for Oxycodone have different half-lives, with the former at 3.2 hours and the latter at 4.6 hours (Gallego, Baron, and Arranz, 2007). Therefore, tapering schedules will have to be amended accordingly to fit the half-life of the respective formulation of Oxycodone.

The best way to taper Oxycodone is to reduce the dosage by 5-10mg every three days to enable the body to tolerate the decrease. Towards the end of the taper, you can lower the dosage by 2.5mg every three days as you prepare to stop the medication completely. Therefore, a typical taper for someone using 40mgs of Oxycodone per day would include six weeks of gradual reduction of daily intake. On the sixth and final week of the taper, one should reduce the dose to 2.5mg and skip some days as the body prepares to wean itself off the drug. In general, one should reduce daily intake of Oxycodone by 20-50% during a taper for the best results.

Codeine
Codeine is a schedule II opiate that is used to relieve moderate to severe pain and to manage coughs and diarrhea. Codeine-containing cough syrup is commonly abused in formulations containing Promethazine, which projects euphoria, relaxation, and sedation when consumed in higher-than-prescribed quantities. Codeine is one of the most easily prescribed medicines, which makes it one of the most abused. Promethazine-codeine cough syrup has high cases of fatalities due to its effect on the central nervous system, the heart, and lungs (NIDA, 2014). Combining the syrup with alcohol, as is common, greatly increases the risk of fatalities. 

Codeine has a half-life of around 2.9 hours, which makes it considerably shorter to taper. However, the length of the taper will depend on other factors such as your metabolic rate, dosage, and duration on the drug. An effective taper plan for codeine will involve a 20-50% reduction rate per week while making sure to check for any withdrawal symptoms that might make the tapering unsuccessful. For instance, assuming you are tapering off 40gm of codeine per day, the best plan would be to start by reducing your weekly intake to 8mg per week and keeping it at a steady reduction rate until the last week. It is always best to reduce the amount you are taking on the last week so that your body is able to absorb the effects of going off the drug when the tapering period ends.

Suboxone
Suboxone is an opiate that was approved by the Food and Drug Administration in 2002 as a therapeutic medication for opiate addition and a replacement for methadone (Ling, et al., 2009). As of 2008, more than 8,000 doctors had prescribed Suboxone as treatment for addiction to other opiates. Suboxone contains buprenorphine and naloxone as active ingredients in a 4:1 formula, which is designed to reduce buprenorphine abuse intravenously (Fudala, et al., 1998). Compared with other opiates, Suboxone has a has low toxicity even at higher doses and has the ability to block the effects of other opioids, thus proving useful in tapers of other opiates.

Suboxone is a popular pharmacotherapy in clinical settings mainly because of its extended half-life and less severe withdrawal symptoms. It has a half-life of between 24 and 60 hours, which makes it ideal for replacing other opiates during a taper. A typical 28-day taper schedule for 24mg taken daily will look like this:

Days 1 - 2: 24mg
Days 3 - 5: 20mg
Days 6 - 8: 18mg
Days 9 – 11: 12mg
Days 12 - 14: 10mg
Days 15 - 16: 8mg
Days 17–19: 6mg
Days 20–22: 4mg
Days 23–25: 2mg
Days 26–28: 1mg

An individual who is tapering from other stronger opiates can choose to complete their tapers using Suboxone because of it is easier to taper from and has a longer tapering schedule with the least side effects. It is also important to note that Suboxone tapers can be adjusted according to the individual’s ability to taper without withdrawal symptoms. 

Methadone
Methadone is a synthetic, schedule II controlled substance that is conventionally used to treat moderate to severe pain in terminal patients and as an alternative for people who are addicted to other serious opiates (NDIC, 2006). Methadone abuse has been a serious health issue for the past few years because of an increase in its use. It is mainly used as a substitute for other hard drugs such as heroin but requires a higher dose than conventional hard drugs to elicit the same euphoric effect. For this reason, methadone-related emergency admissions accounted for over 10,000 cases in 2001 alone (NDIC, 2006). Like most opiates, a taper offers the safest and most comfortable way to come off methadone.

Methadone has a half-life of 10-60 hours, depending on the type of formulation (NHTSA, n.d). Therefore, the taper is usually slower to ensure the least amount of withdrawal symptoms during the taper. The best tapering plan usually involves a 5mg drop every 7 days in order to mitigate any withdrawal symptoms. When the dose is sufficiently low enough, say at 20mg, the interval between each dose can be extended to further slow down the taper to levels where withdrawal symptoms can be minimized.  

Help of Friends and Family
Having a support group in place could be very important in helping one get off of opiates. Having a loved one hold onto your medication and hand it out to you can be extremely helpful. For one, it helps to make sure you control or opiate intake (without cheating), and also helps by being held accountable while receiving the support and encouragement to slowly taper off of the opiates.

Use of Vitamins and Supplements
While going through opiate withdrawal, it's will be important to provide your body with vitamins, supplments and nutrients. Though it may be hard to eat, it's important that you stay hydrated as you may experience diarrhea as well as vomiting which may cause you to become dehydrated. Drinking a sports drink will help to replenish any electrolytes you may lose.

Also adding CalmSupport to your tapering can be paramount in helping to ease some of the opiate withdrawals naturally. CalmSupport was formulated by herbalists and doctors to help ease some of the withdrawal symptoms of opiate withdrawal. By using the finest organic herbal powder (rather than extracts) will provide your body with the full benefit that each specific herb provides. We also only use active versions of vitamins which do not need to be metabolized by your body, allowing for easier digestion and faster absorption. We are the only supplement on the market that uses Active Vitamins plus we offer a 30 Day Money Back Guarantee.

CalmSupport was formulated to help with:

  • Low energy, irritability, anxiety, agitation, insomnia
  • Runny nose, teary eyes
  • Hot and cold sweats, goose bumps
  • Excessive yawning
  • Muscle aches and pains
  • Abdominal cramping, nausea, vomiting, diarrhea
  • Restless Leg Syndrome (RLS)

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      Conclusion
      Tapering is one of the most efficient ways of getting off an opiate. Studies have shown that people who use tapering for an opiate addiction are less likely to experience a relapse than those who opt to go “cold turkey”. Additionally, tapering enables the user to solve an addiction problem without experiencing the nasty withdrawal symptoms associated with an abrupt stop to daily doses. Tapering for many opiates is largely dependent on an individual’s metabolic characteristics, dosage, the duration of use, the drug’s half-life, and their psychological preparation for the taper. It is also important to remember that dose adjustments during a taper should be made according to one’s physical and mental response to reduced drug doses in order to ensure the least amount of withdrawal symptoms during the taper. Adding CalmSupport to your tapering process can help to detox your body and soothe the symptoms of opiate withdrawal naturally.

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      References List
      Center for Disease Control and Prevention [Internet]. Vital Signs. Atlanta, CDC. July 2014.
      http://www.cdc.gov/vitalsigns/opioid-prescribing.

      Food and Drug Administration (FDA) (2013). Drug Safety and Risk Management Advisory Committee (DSaRM)
      http://www.fda.gov/downloads/advisorycommittees/committeesmeetingmaterials/drugs/drugsafetyandriskmanagementadvisorycommittee/ucm337148.pdf

      Fudala PJ, Yu E, MacFadden W, Boardman C, Chiang CN. Effects of buprenorphine and naloxone in morphine-stabilized opioid addicts. Drug Alcohol Dependency, 50: 1–8.

      Gallego, O., Baron, G.M, and Arranz E.E. (2007). Oxycodone: a pharmacological and clinical review. Clinical and Translational Oncology, 9(5): 298-307 http://www.ncbi.nlm.nih.gov/pubmed/17525040 

      Kral, A.L., Jackson, K. and Uritsky, T.J. (2015). A practical guide to tapering opioids. Mental Health Clinician: May 2015-Alternatives In Pain Management, Vol. 5, No. 3, pp. 102-108.

      Ling, W., Hillhouse, M., Domier, C., Doraimani, G., Hunter, J., Thomas, C., Bilangi, R. (2009). Buprenorphine tapering schedule and illicit opioid use. Addiction (Abingdon, England), 104(2): 256–265. doi:10.1111/j.1360-0443.2008.02455.x

      National Institute on Drug Abuse (NIDA) (2014). Drug Facts: Cough and Cold Medicine Abuse.
      http://www.drugabuse.gov/publications/drugfacts/cough-cold-medicine-abuse

      National Highway Traffic Safety Administration (NHTSA) (n.d). Methadone.
      http://www.nhtsa.gov/people/injury/research/job185drugs/methadone.htm 

      PubMed Health (2015). Oxycodone (Oral).
      http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0011537/?report=details

      Schatzberg, A.F. and Nemeroff, C.B. (2009). The American Psychiatric Publishing Textbook of Psychopharmacology. New York: American Psychiatric Pub



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