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Heroin Addiction - Help for Addicts www.helpingaddicts.net
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Detox Handbook
The detox handbook is written for people in the UK and contains useful information for anyone interested in a detox.
Most of the information will apply if you live outside the UK, but the laws, formulations and the way drug services work may be different.
All the information on this page is from the leaflet called 'The Detox Handbook' and is available from drug services in the UK.
Is split into three sections: Part 1: Before you detox
Part
1: Before you detox
It is easy to get completely involved in the issue of what you are going to take during the detox in order to make the withdrawals less severe. But it is important to remember that the detox is unlikely to be successful if you don’t spend some time thinking and talking about how you will cope without opiates and who you will see and what you will do once you are off.
This first section of the handbook is the longest because planning can make all the difference to the success of a detox.
It outlines the things you can do, and the help that might be available, to help you make the changes you want to make to your drug use.
Understanding
why you take drugs
It may be that the reasons you started using opiates are different from the reasons why you are taking them now. Try listing the reasons why you take opiates under these two headings:
'Reasons I started' and 'Reasons I do it now' Look at your lists and see which:
This exercise isn’t something you do to make yourself feel guilty, or to find people to blame. It is something you can do to understand your situation, so that you can start sorting things out.
We may not be responsible for many of the things that have happened to us, but we can choose how much, if at all, drugs are part of our response to them.
Pros
and cons of detoxing
Against
Look through your lists and see what you can do to get the scales to tip in the direction you want them to go.
Alternatives
to detoxing
You may want to consider making other changes, some of which could help set the scene for a future detox. You might want to:
If you are not ready to detox, or the detox doesn’t work, a maintenance prescription is likely to make life much easier and much safer.
Getting
ready to detox If you have detoxed before it can be useful to look back on past detoxes to see what worked - and what didn’t work - to see if there are any lessons you can learn.
The best time is when things are as good as they are likely to get, in terms of support, housing and your state of mind, etc. But if things don’t look like they’ll get any better - the best time may be now.
Giving up opiates is like anything - the more often you do it the better you get at it. Planning will usually increase your chances of success. But if you get an unexpected chance to detox - for instance admission to hospital or prison - or if you decide that enough is enough, you may want to go for it.
The more you want to do it for yourself the more likely you are to succeed. It can help to want to get off for your partner, children, parents or because you haven’t got any money left. But, in the long run, it will probably be the reasons why you want to do it for yourself that will get you through the hard times.
Deciding
how fast to detox
If you aren’t ready to come off that quickly then it might be worth talking to your drug service/doctor about a steady dose prescription to stabilise things until you’re ready to detox.
Who
can help?
Drug
services
Drug services are there to help and are usually understanding and supportive. If you are worried about contacting them you could ring or meet with an outreach worker without giving your name. You can get details of local drug services by ringing the National Drugs Helpline on: 0800 77 66 00.
Friends
and family
If you are planning to stay off, friends who are still using opiates are unlikely to be helpful to you. Even if they want to help, it will probably be very difficult for you to be around them and not use. It also really helps if you can build up a network of non-using friends.
Narcotics
Anonymous
How meetings are run, and who goes, varies from place to place and from time to time: so if you don’t like one - try another. You can get details of local meetings by ringing the national NA helpline on: 020 7730 0009.
Where
to detox
The Rehab handbook contains full information on community and in-patient detox services and may help you decide which, if any, will meet your needs.
At
Home
It can be hard to make changes at home, especially when other people around you are likely to be doing what they’ve always done. The positive side of this is that wherever you detox you are probably going to have to end up staying clean at home, and by detoxing there you can deal with real situations as they happen.
Moving
away
There isn’t really anywhere in Britain where you can’t somehow get hold of opiates. Getting off opiates is about stopping taking what is there - if you don’t want to get off, you can’t move away from it to stop.
Going
abroad
If you want to take prescribed drugs away with you it is important to check out the legal situation regarding getting them out of this country and getting them into the country you want to go to. You can do this by ringing Release on 020 7603 8654.
One pitfall of going abroad can be drinking cheap alcohol and switching dependence from opiates to alcohol. People who get back without any ‘straight’ days under their belt find it really hard to stay clean.
Hospital
A psychiatric hospital isn’t always the perfect place to detox - other patients may have serious mental health problems - but it is warm, there are deep baths and plenty of hot water, the food is free and there are people around to talk to 24 hours a day. Sometimes the staff are understanding and helpful and sometimes they don’t like drug users - usually it’s a mixture of both.
Specialist
units
To be admitted to any hospital you usually have to be referred by a GP and/or your drug service.
Rehab
Not all rehabs offer detox as part of the service and some require you to have been drug-free for a period before you go in. If you are thinking about going into a residential service for people with drug problems, it will probably help if you talk to a drugs worker and/or someone from the rehab you want to go to.
Funding for rehab is provided by social services departments, so if you want funding you will have to be seen by a social services’ approved assessor or care manager - this may be a social worker, drugs worker or a probation officer.
Prison
All prisons have a ‘Counselling, Advice, Referral, Assessment and Throughcare’ (CARAT) service which is responsible for organising treatment and support for prisoners, and helping them make contact with services following release. Some prisons have flexible prescribing regimes which can include:
If you can, suss out the system at the prison you are going to before you get sent there.
Prescribing
services
Services that can prescribe drugs to help with a detox vary from area to area. There are three types of service:
Some areas have statutory services, some have non-statutory services and some have both. Everyone has the right to a GP.
If you have to wait a long time for an assessment, or if you are not happy with the outcome of the assessment process, you can complain. If you want to complain about a service you can go to the manager of the service or to the health authority that funds it.
Your local Community Health Council (CHC) will be able to help and support your complaint. Their number will be in the phone book.
Services
for drug-using parents Children are only taken into care when they are in danger from, or suffering, physical, sexual or psychological harm or neglect, and only after everything possible has been done to enable them to stay at home.
Most drug services have policies saying that they will support parents, and help them care for their children. All drug services are confidential and information about you will usually only be passed on with your consent or if there are real concerns that a child or young person is at risk of serious harm. If you are worried, ask to see their confidentiality policy.
If you are having problems with your drug use, or parenting, the drug service might be able to help you sort them out. The fact that you are in contact with a drug service is likely to reassure social services if your drug use is reported to them by someone else.
Fertility
If you start to cut down the amount of opiates you are taking, your level of fertility will probably increase and you may find that you have an increased desire to have sex. This means that you are more likely to get pregnant when you are detoxing.
So as well as protecting you from HIV, hepatitis and other infections, condoms can stop you getting pregnant - even when you aren’t having periods.
Pregnancy
Opiates alone don’t affect the development of the unborn baby, but whether or not you want to have the baby, it is important for your health - and that of the baby - that you get proper antenatal care from a GP as soon as possible.
Being pregnant can change the way you see things, and often women are able to stop using during pregnancy when they haven’t been able to do it before. But it can also be a very stressful time and confusing too - especially if you are finding it difficult to stop using, or using more to cope with the stress. Either way a sympathetic drug service and doctor could be a big help to you.
If you want to detox, reductions should be monitored by a doctor. Detox can usually be done at any time during pregnancy, although the safest time to do it is the middle three months of pregnancy, when the risk of miscarriage is lower.
If you are still taking opiates when the baby is born it may suffer withdrawal symptoms which can be treated if the doctors know what is going on. Some hospitals admit babies born to opiate-using mothers to the special care baby unit, although this is not usually necessary.
Choosing
a drug to reduce on
Many people get too hung up on which drug they will detox on, and set themselves up to fail with unrealistic expectations of what the treatment can and can’t do for them.
The main options of drugs that may be available for you to take as you detox are discussed on the following pages, with their pros and cons, and how they might affect the process of physical withdrawal.
By each drug is a list of statements that may or may not be true for you. Read through them and see if you can decide, for you, which:
Thinking and talking through these issues may help you make a decision.
Illicit
heroin Detoxing on illicit heroin may mean that:
If you are planning to come straight off heroin without taking anything else, things that might help are:
Methadone
The fact that cravings for heroin are usually much stronger than cravings for methadone means that, overall, it is not much more addictive than heroin.
A detox on prescribed methadone may mean that:
If you go for a prescribed detox the first task is to get off all other opiates and take only the medication - if you don’t manage this the chances of a successful detox are slim.
Other things that might help are:
Lofexidine
It isn’t an opiate and its only function is to prevent the action of extra noradrenaline in your system. This means that you can’t get dependent on it in the same way as you can with opiates, but it also means that you will get none of the psychological effects of an opiate during the detox.
Lofexidine can be taken as part of an inpatient detox programme or at home.
Lofexidine:
A lofexidine detox is much more likely to be successful if you:
You should also take care when you get up out of a chair or bed or out of a bath as lofexidine can lower your blood pressure and make you feel faint.
Buprenorphine
Buprenorphine (which has the trade name Subutex) is now taking the place of DF118 as an alternative prescribed opiate for detoxification.
Subutex gives some opiate effects (but less ‘euphoria’ than heroin or methadone) and can significantly reduce the physical withdrawal symptoms of detox. However, it does not offer a completely pain-free detox and, as with methadone, the different feelings can take some getting used to at the start of treatment.
Subutex is taken once a day, by putting a tablet under the tongue and letting it dissolve - it has no effect if chewed or swallowed.
If people are transferring from methadone they have to be on a dose of 30 mg or less, as the changeover from higher doses can cause withdrawal symptoms.
If you are taking methadone you will have to go at least 24 hours from the last methadone dose before taking Subutex for the first time, and if you are using heroin there should be 4-6 hours between your last heroin dose and your first Subutex tablet. This is because Subutex can send you into withdrawals if you start treatment without waiting for opiates to begin to clear out of your system.
A Subutex detox can be completed in 12-14 days, or it can be done gradually over a longer period.
Part
2: Coming off Research has shown that understanding what to expect during withdrawals actually makes them less severe, and that anxiety makes them worse. So it may help to read this section carefully, and discuss your thoughts and feelings about withdrawals with your drug worker, or someone else you trust.
Withdrawals
- your body
Once you have developed a tolerance to opiates you will experience withdrawal symptoms when the amount of opiates in your system drops below a certain level.
Using opiates makes it harder for the body to produce a chemical called noradrenaline. So your system learns to work extra hard at producing noradrenaline. When you reduce or stop using opiates, the body carries on working extra hard and produces too much noradrenaline. It is thought that most physical withdrawal symptoms are caused by excess noradrenaline overstimulating the brain and central nervous system.
Most of the physical symptoms should begin to fade after 14-21 days, as the production of noradrenaline starts to get back in balance. Withdrawal symptoms are usually at their worst around the second and third day after stopping or reducing the dose.
Another possible physical cause for some of the longer lasting problems following detox, including feeling low and sleeping badly, is lack of natural endorphins. Endorphins are a natural part of the body’s painkilling and ‘feeling good’ systems. It is thought that when you take opiates your body gives up production of endorphins - and that, once stopped, it can take up to six months for them to return to normal levels.
Withdrawals
- your mind and feelings
At first this often seems like being on a long, fast roller-coaster that has all the biggest highs and lows at the beginning. Things usually settle down as you get used to coping with the emotions and feelings - but it can seem like it is taking forever. People react to detoxing differently. People often experience:
All of these things can make you feel like using again. It might help to tell yourself that things are being made worse by the fact that you’ve just made a huge change. There may be things you want to get sorted out, or you may decide to wait a while and see how things settle down before you take action.
Withdrawal symptoms aren’t just physical. If you have ever had withdrawal symptoms start suddenly because you were about to score or just thinking about heroin, you will know that your head is capable of creating withdrawals in no time. Anyone who feels anxious, frightened and/or low may experience withdrawal-like physical symptoms: feeling sick, headaches, stiffness and muscle aches, etc.
The symptoms of anxiety and stress can get added to the physical effects of coming off opiates - this may partly explain why some people suffer much more, or for longer, than others.
Coping
with withdrawals
If you can, plan to:
Alcohol and cannabis will probably not help reduce the withdrawal symptoms.
Stopping
injecting
For some, step by step is better: switching to smoking heroin for a while before the detox can break the process into manageable parts. Another alternative is to switch to methadone mixture for the detox. This can give you a chance to get used to coping without the rush and the ritual of injecting, before you have to cope with being drug-free. Neither option is easy and sometimes it takes time and/or several attempts to stop injecting.
Sleep Getting yourself into a sleep routine is probably the most important part of learning to sleep without drugs. For most people a normal night’s sleep is between 7 and 9 hours, but many people get by on 5 or 6 hours’ sleep. Learning how much sleep you can realistically expect will be an important part of getting into a routine.
Other things you can do to help include:
Using opiates to help with sleeping is one of the commonest reasons for giving up on a detox: if you want to stay off, be prepared to deal with poor sleep.
A short course of sleeping tablets from your doctor may help, but many doctors refuse to prescribe them because it is so easy to get dependent on them and because they can easily put people in the frame of mind to relapse (especially if they take too many in desperation to get to sleep).
Some drug services offer auricular (ear) acupuncture, which can help relaxation and sleep.
Part
3: Once you are off
This section has some pointers to help you avoid the pitfalls and mistakes that can lead to lapse and relapse.
Overdose
Accidental overdose following detox is one of the most common causes of death in opiate users.
Often people mix alcohol and/or tranquillisers which makes even smaller amounts of opiates deadly.
If someone has taken opiates and they can’t be woken, they have overdosed. If they are still breathing, lie them in the recovery position (illustrated below) and watch them. If they stop breathing, mouth-to-mouth resuscitation could save their life. Call an ambulance. Opiate overdoses can be reversed - but only if the ambulance crew get there in time.
Other
drugs
The problems of the benzodiazepine class of drugs (often called benzos, tranquillisers or tranx), such as valium and temazepam, are often underrated byopiate users. If used in doses that are too high, or for too long, they can easily get out of hand. Benzodiazepine dependence can develop within a couple of weeks. The withdrawal symptoms that people can suffer from when they stop include panic attacks, anxiety and fear of going out of the house.
There are a number of drugs that people don’t always realise are opiates such as Temgesic, DF118 or other brands of prescribed medicines and over-the-counter preparations (e.g. cough mixtures such as codeine linctus). These are all best avoided if you are trying to stay clean.
Alcohol
Switching dependence from opiates to alcohol (or benzodiazepines) is not the only risk. A lot of people have lost their resolve to stay drug-free, and slipped back into opiate use, whilst ‘off their heads’ on alcohol, benzos or a combination of both.
If you don’t want this to happen to you, watch your alcohol consumption so you can stop it increasing to ‘replace’ the opiates. If you haven’t sought help before and your alcohol intake increases after a detox, it might be a sign that you need some help now. It might be worth finding out how to count your alcohol consumption in units from your drug worker, GP, practice nurse or local alcohol service.
Staying
off
To start with you’ll probably find that each drug-free day feels like a week. Often, after only a few days, people feel like they’ve been off for ages and deserve a ‘treat.’ If you give in to the desire to have a ‘treat,’ your chances of it being just the once and staying clean are very slim - and the risks of overdose are very high.
People don’t often finish a detox feeling great. In theory you should be free of drugs and have more money to spend on other things. In practice this rarely happens. This doesn’t mean that it isn’t worth coming off!
Being around people who have just given up is often nearly as dangerous as being around people who are still using. If you start remembering your using days together it probably won’t be long before you are both craving and ready to lapse. A lapse with another person happens more easily if you kid yourself by blaming them rather than taking responsibility for yourself.
Use all the help and support you can get. Some drug agencies run groups and relapse prevention programmes to help people following detox - these can increase your chances of staying clean.
Cravings
and triggers
There will be all sorts of things that are linked with using in your mind. These are known as triggers.
There is a list below of the more common ones. Cross out the ones you find don’t apply to you and add on any other things that you know will trigger thoughts about opiates. As time goes on, if you stay off you will probably find more and more. Knowing what they are is the first step to beating them, so it may help to keep adding to the list as you become aware of them.
Common triggers include:
Each time you cope with a triggered craving it may get a little easier next time, but don’t get complacent or test yourself by unnecessary exposure to high-risk situations or people.
You will change from day to day and a situation you coped with easily one day may cause a lapse another. In time you will find the triggers lose their strength, but it is best to allow this to happen naturally.
Just
every now and then?
Generally speaking, the longer the gap since you last used the slower the slide. But if you use again within a year or two in the hope that it will be ‘just this once,’ the chances of relapse are very high. People can quickly get dependent again after five or more years drug-free.
If you have been opiate dependent it is also very unlikely that you will be able to control cocaine use - particularly if you inject it or use crack or freebase.
Lapse
Try not to see a lapse as a disaster, or as proof you can’t do it, but as an opportunity to work out what happened and, more importantly, what you can learn to stop it happening again.
Relapse Many people who have been off opiates for years will tell you that they relapsed several times after their first decision to come off and stay off - so don’t give up giving up. But if you can’t get off, a maintenance prescription may offer a way forward that can get you off illegal drugs, reduce your problems and risk of overdose. Talk to your drug service about the options.
Naltrexone
Naltrexone treatment cannot start until 7-10 days after you have taken your last opiate. This is because taking naltrexone before opiates are completely out of your system causes instant withdrawals. Never start naltrexone treatment without seeking medical advice.
If you find it hard to stay off but are well motivated some of the time, then naltrexone can be ideal: you can take it when you feel strong and have it in your system ‘protecting’ you when you feel weak.
Sometimes people get their partners to give them the tablets in the morning or they go into a drug service to get them. These are ways of increasing motivation although, in the end, there is no substitute for taking responsibility for yourself. You can use it to build up drug-free time, and experience of difficult situations.
However, once you stop taking naltrexone you will be at very high risk of overdose if you lapse/relapse: injecting heroin after a period on naltrexone often kills.
Filling
time
can all help fill the gap and build up your confidence.
It can all seem strange especially if, for a period of time, you feel half way between one way of life and another. The best defence against using again is your pride in being clean and looking forward to the positive things that can follow your detox.
Coping
and the future
If you were using for a long time you may find that the ‘emotional roller-coaster’ takes a couple of years to settle down. Sometimes people feel bad about themselves for a long time too, and this can be made worse by people close to you taking time to accept that you have changed.
You will probably find that the more problems you have, the stronger the urge to use becomes, and the more difficult it is to resist. If you want to stay off it is easier if you are clear with yourself that whatever happens you won’t use. That way instead of asking yourself if things are bad enough to justify using, you’ll be asking yourself how you are going to cope.
People who you can turn to are going to help you more than drugs, and talking things through is usually much better for you than keeping them bottled up or blotted out with drugs.
Building yourself a support network so that you don’t have to cope alone will be a big help.
Credits With thanks to: everyone who has helped with this, and previous, editions of The Detox Handbook, including George Christo, Janie Sheridan, Debbie Preston, Gary Sutton, Jon Derricott and Mary Glover. Thanks also to Len Cretney, Jackie Akhurst and Britannia Pharmaceuticals. Finally, a hello to Todd, Sam and Rachel. Published
by: Exchange Supplies ISBN 1 903346 12 6 The Detox Handbook, Fifth Edition.
The printed edition of this book is printed in the UK on recycled paper made from 100% chlorine-free post-consumer waste. Responsibility for all errors, omissions and opinions lies with the authors. Distributed by HIT, telephone: 0870 990 9702 and DrugScope, telephone: 01235 465500 Exchange Supplies is an independent publisher of information about drugs, drug use and treatment. Exchange publications aim to give drug users the information they need to make informed choices about their drug use, in an easily readable and accessible format. For more information go to: www.exchangesupplies.org The Detox Handbook is updated and revised every year. If there are any comments or suggestions you would like to make, please send them to: Andrew Preston, Exchange Supplies, 1, Great Western Industrial Centre, Dorchester, Dorset DT1 1RD or andrew@saferinjecting.org |
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Source: www.hit.org.uk (HIT) Last updated: 10 August 2004 |
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Detoxing
involves the physical, psychological and social processes of:
For
Help
and support before, during and after a detox can make all the difference.
If
you have to look after children, go to work, want to come off slowly or can’t
find (or get funding for) a residential detox then you’ll probably have to
detox at home, or staying with someone.
Unfortunately
there is no right to a prescribed detox from opiates, but detoxing from opiates
is a ‘health need’ and the NHS health authorities have to ensure that
services are available to meet health needs. You should be properly assessed
and, if necessary, treated within a reasonable length of time.
If
you have children who are under 16, you may have worried about making contact
with drugs services or your doctor about your drug use because you have heard
that children of drug users can get taken into care. However,
drug use alone is never a good enough reason for your children to be
automatically taken into care.
Most
opiate detoxes involve people coming off heroin on their own.
After
a period of daily opiate use your body becomes used to the drugs and needs
higher doses to get the same effect. This is called developing tolerance.
Sometimes this takes only a few days to happen; usually it takes a few weeks.
Stopping
injecting can take as much effort and willpower as detoxing. You can do both
together and deal with everything at once. Although this is hard, you know where
you stand and with no ‘half measures’ it can feel like the only way to do
it.
Not
being able to sleep during and after a detox can be one of the worst parts of it
all. People always get enough sleep to survive, but it doesn’t always feel
like it; and sleep doesn’t always come when you want it.
The
desire to take opiates can feel overwhelming especially if it takes you by
surprise. If you want to overcome cravings it helps to be prepared: plan to do
something active when you get a craving. They do pass, and can be controlled.
For
many people using opiates is a ‘full-time job,’ and once they stop the
endless rush of getting money together, scoring and using there are many
unfilled hours in the day. It is important to find something to fill this time.
Things such as: