How to wean off Percocet?

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Posted on Mon, 8 Jun 2015 in General Health
Question: HI! Very long story short, but I had my 2nd child 2 years ago. I developed painfully debilitating abdominal pain after. After having my gallbladder removed, a huge cyst removed, I finally got a positive diagnoses for sphincter of oddi dysfunction after 2 years of living with it. Something I knew I had after 1 month and reading GI text books. My best friend is also a neuroradiologist and mentioned it immediately. Because of living with horrible pain with eating and the worse than labor attacks for over 2 years, I was put on a combination of percocet and levsin daily. I finally had an ERCP/manometry and sphincterotomy 3.5 weeks ago and NO PAIN SINCE. Well surgery pain, but my SOD attacks are completely gone. It's a miracle. I want to get off all meds ASAP for many reasons, but would love another child and to get pregnant this fall. I am failing. Failing. And it's been the most stressful 3 months of my life on top of this: buying and selling homes, moving, loan issues (since my hubby and I are both self employed), my daughter had surgery, I had surgery, our brand new finished basement flooded, XXXXXXX On top of running my own consulting business (since I couldn't work FT in an office anymore because of the SOD attacks). It's the busiest time of year for my clients and I'm working 60 hours a week, taking care of a household, a 2 and 4 year old, on top of being a perfectionist and having to keep my house spotless and children picture perfect. I'm breaking down. I guess I didn't realize the percocet was a coping mechanism and crutch, because I did have pain almost daily, if not several times a day. I want to get off ASAP but am failing. I don't feel like I can be honest with my primary care doc because if I ever need pain meds for future surgery, or if SOD comes back (which it can), being labeled as having an addiction problem will effect my care. I know it will. I have a masters, I'm not unintelligent. But I also know I need off and I need help. I've never done recreational drugs or had an addiction problem. I've also always gotten my prescription legally as I have legitimate pain. My doc was working on a fast taper, but I couldn't do it because of the muscle aches. I've been through so much in 2 years that I just can't take anymore: 14 ER visits, 4 surgeries, more hospitalizations, experimenting with medications, and getting my blood taken at least monthly (during attacks they LFTs spike then return to normal). I'm a whimp. I can't go into an in-patient program because of my kids. I'm really hoping I can do this on my own ... I would really appreciate some advice. I've been on percocet on and off 2 years .... and as of late (because of the surgery) eight, 5/325's a day. I'll be out before my refill is due and w/d symptoms are just terrible. What do you recommend I do? I was hoping to find an understanding chronic pain doctor who can work on a longer taper plan. Maybe reduce by 1/2 or 1 pill a week? I realize 50% is physical and the other 50% psychological. My hubby will help me and I think I need to give him the med to control and hand out to me ... but would love advice on who I can talk to. What types of things are confidential (don't want insurance labeling me, their delay in care of me and this condition is what got me here, in addition to me too. I'll take personal responsibility too.) With that kind of a dose (hoping it's not that much?), on and off 2 years, if I go off cold turkey how many days will the really bad w/d symptoms last? What do you recommend I do? Thanks for your time!
PS - I am not opposed to traveling out of state to find the right doctor to help me. I live in CO and it's very strict here. My insurance doesn't have chronic pain docs available either. I've asked many times as my SOD pain wasn't controlled at all Feb-April this year.
doctor
Answered by Dr. Matt Wachsman 43 minutes later
Brief Answer:
Interesting.

Detailed Answer:
I was thinking a biliary issue....

It's best to think of time, circumstances, past history as putting you into a geography... even though most of this 'geography' is a medical context. You can get into other 'spots' based on where the spot you are at.

When someone gets into a bit of drug dependence and tolerance (which are just plain consequences of the medication) the key question is what they do next. Mostly, it is to deny any personal agency in the situation, lie to themselves and others and generally get into a progressively worse spot.

Several possible better alternatives:
Suboxone treatment.
Being honest
12 step programs
Rapid detox with the original medications and other medications to lower/make tolerable withdrawal symptoms (such as clonidine, aspirin, vistaril, anti-nausea medications).
Yes, you will have a label. Yes, if you have an allergy to a medication you would also have a label.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Matt Wachsman 36 minutes later
Two questions. I've heard suboxone is trading one dependent medication for another one that will also have withdrawal symptoms, that could be worse. Is that true?

And I also read the rapid detox can be dangerous (vomiting under anesthesia). Is that true? I was intrigued by this one when I read about it. Do you have a reputable center that you know about?
doctor
Answered by Dr. Matt Wachsman 2 hours later
Brief Answer:
Vry good!

Detailed Answer:
it all depends on the context. Most of the people I treat with suboxone (are already on suboxone), but if they are starting suboxone from percocet, they are on greater than 150 mg a day. The withdrawal from suboxone is less severe than that BUT, it is also less severe... so, nausea, incapacitating abdominal pain, drenching sweats, I've never seen / heard of from suboxone. AND, people have to confront the subtle psychological changes with long term narcotic use more directly when that is the only symptom they are having. The psychological effects are far more long lasting than the acute withdrawal.

There are several rapid detox methods. One is to put someone under heavy sedation and give a narcotic blocker. This is not at all a standard practice. More reasonably is to give blockers of nausea/inflammation/muscle spasm and either give very little of anything narcotic or give suboxone at a low dose and taper it rapidly over 1-2 weeks. The suboxone blunts most of the most serious narcotic withdrawal symptoms and also prevents relapse.

And... the treatments that would be best depend upon a number of factors including how much narcotic someone is taking on a daily basis. Unless it is a high amount you really wouldn't go with anything like an inpatient context.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Matt Wachsman 32 minutes later
Thanks. All really good info. So my dose was basically 8, 5/325 a day for a year (give or take 2 around surgeries or when I was feeling better, so between 6-10/day). I had been on and off it more sporadically and lesser amounts (1-3/day) for the year previous. So 2 years total. Based on my recent dose and the amount of time I've been on it, how long do you think the worse W/D symptoms will be? I went off cold turkey before and thought I was going to die. High BP, pulse, skin crawling, horrible sweats, muscle aches, freezing cold temp. I was on 8, but 6 today and tomorrow, and going to 4 for 4 days. I will have a refill for me next Friday but I do want off this ASAP and am having a hard time sticking to the dose I need to be taking to taper down (have been taking too much). Do you think I should ask my doc about suboxone? For me, I've had mild muscle aches already. I just want to make sure I'm not trading up to something stronger, but if it's trading down and will help the process, maybe that's the way to go?

You also mentioned the psychological effects - do you have a good book or user story online that would help illustrate this? I have seen a psychologists who works in my doctors office, and ironically she used to specialize in people with chronic pain. Which I've learned most people and medical professions hate chronic patients. She was fantastic and warned me that after my surgery, when/if I'm fixed, I might have a little break down since I've been through a lot and was having to hold it together for my family. She finds that many of her patients have the break down after they're fixed, which I found interesting. So far I've been fantastic, but I paying attention to this as well. Only issue is trying to get off these meds. Mentally and physically it's NOT easy.

Oh and you mentioned suboxone helps prevent relapse, what do you mean? Can you elaborate? Sorry to both you, but this is really helpful. Wondering if that's the way I should go.
doctor
Answered by Dr. Matt Wachsman 29 minutes later
Brief Answer:
You tell me.

Detailed Answer:
8 x 5 is 40... but.... more to the point, it's a 4 hr drug. It isn't likely there 24 hrs a day every day. So.....should be into some degree of withdrawal if it is going to be there and... 6 to 4 etc is a taper.. 3 to 7 days at a particular XXXXXXX of dosing is relatively fast 2 weeks at a particular XXXXXXX is slow. Suboxone is in the range of 30 mg... BUT it IS a long acting drug, so... 30 mg as a continuous exposure is more likely to cause a withdrawal set up than 30-40 mg used intermittantly. suboxone, unless it is at the lower doses, is more likely to set up for withdrawal than 30 mg a day of a short acting, intermittant narcotic. On the other hand, if someone is already suffering with addiction... having a really hard time with not only the drug effects, not only the psychological effects but also life being screwed up, then having a drug that blocks recreational lapses of abusing narcotics keeps an addict in a safe milieu. Suboxone is a mixture of two drugs, one is a long acting narcotic that is not fully active. No matter how much you take of it, it has a peak effect that maxes out to about the equivalent of 30 mg of percocet a day. It also has a second drug that blocks other narcotics from working at all. So... the suboxone user is locked into 30 mg percocet equivalent a day regardless of what else they take. It helps reinforce a treatment plan and therefore helps prevent relapses.

Suboxone requires a separate licensure. Unless a doctor is giving it; they likely are not licensed for it.

I don't know how much suboxone or methadone programs would be relevant to someone not in legal trouble, not in big addiction problems, and on a moderate amount of narcotics per day. and walking back from narcotic use under an honest doctor/patient relationship seems a pretty straightforward plan. and you might not need a specialized doctor/regimen/program to taper; just the regular doc.
The main thing is you see what happens with one plan and work on how to deal with any problems taht come up. Other non-narcotic pain drugs for pain that occurs during a taper, anti-nausea medicine, etc.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Matt Wachsman 20 minutes later
Ok, that's really helpful. Yeah maybe I'll just stick with the current taper plan and tough out any withdrawal symptoms. I am very sensitive to medications due to the SOD, can't take SSRIs and most narcotics (cause spasms), although now the muscle is cut. So the thought of trying something new is not ideal. Either way, preference is to get off all meds ASAP. My treatment has always been above board because it's a legitimate issue. Sounds like I don't need to take suboxone and I'll just manage the W/D symptoms with OTC meds and hope to get off soon. I may also ask my doc to slower my taper. The plan/intention was to step down every 2-3 days ... and I'm failing so I thought I was doing something wrong, but maybe it's just too quick of a taper for me or unrealistic? Perhaps it wouldn't be unrealistic to ask for step down every 7-10 days?

Well have a good night. I grew up in a very loving home, my hubby and I are post-grad educated and have a very comfortable life. I used to be pretty judgemental about people who fell into addition. But this process with me, all that happened legally, has really opened my eyes to addiction and how scary and troubling an issue it can become. Thanks for doing what you do in a compassionate manner. I can only imagine the difference you make in your patients lives. Take care and wish me luck!
doctor
Answered by Dr. Matt Wachsman 8 hours later
Brief Answer:
something not exactly in the textbooks....

Detailed Answer:
Ok... what is in the textbooks:
1) There's conditioning... this goes back to Pavlov's dog. You give a reward....it influences things. You have something associated with the reward (a bell), then that also creates an expectation of a reward. You can do this to activities that are occurring randomly (rewarding nose picking) and that activity will increase even if the animal is not conscious of the process.
2) This goes up with positive rewards This goes down with unpleasant rewards.
3) It's the direction (getting more positive or negative) and not the location. So....and textbooks 'forget to mention this' you can have relief of a negative and that is every bit as rewarding as giving a positive.

This is not in the addiction textbook but is in both rather obscure philosophy textbooks (Frege, XXXXXXX XXXXXXX Godel). The levels of abstraction of the reward pathways in people is unlimited.

You can have a stimulus related to a reward. You can have a token able to be traded in for a reward (abstract reward). You can have a mental abstract concept as a reward (even more abstract). You can get used to a reward so that it is not as rewarding over time (habituation; works in the animals too, especially if they're fed and the reward is food!). You can also, habituate to the negatives ("yes, I'm getting blood drawn, I get it drawn every week with the chemo, I'm used to it"--just a theoretical example). And.... you can have a therapeutic milieu with the physician with the abstract reward of having your life back on track (pretty abstract) be a positive, and.... habituate to the negative effects of the withdrawal.

So.... repeatedly doing the same taper will result in less bad and more good with repeating the same process in a therapeutic milieu. (not in the textbooks; but derivable from the textbooks).

In the textbooks: Driving up people's anxiety/fear/self-loathing triggers the parts of the brain that really mess up judgement and triggers automatic behavior.
Almost in the textbooks: having intellectual distance from a situation helps (12 step programs, cognitive behavioral therapy)
Not in the textbooks: humor and journal writing are probably best for this.
Oh, wait, there IS a book on that........
https://www.kickstarter.com/projects/0000/devils-diet
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Matt Wachsman

Addiction Medicine Specialist

Practicing since :1985

Answered : 3565 Questions

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