Opioid Withdrawal Not Deadly? Wrong

Opioid Withdrawal Not Deadly? Wrong | Medpage Today – by Jeffrey E. Keller, MD Nov 2018

I’ve seen enough patients withdrawing from opioids [in a jail medical practice] that I think I am reasonably knowledgeable on the topic. Because of this, I was quite surprised when I ran across this sentence in a recent edition of The Medical LetterOpioid withdrawal is not life-threatening.”

The problem is that although this sentence seems quite self-assured, it is flat out wrong. In fact, it is not just wrong; it is also dangerous.

People do die from opioid withdrawal. I know of several such cases from my work with jails.  

Opioid withdrawal needs to be recognized as a potentially life-threatening condition, just like alcohol withdrawal and benzodiazepine withdrawal.

Evidently, this statement is thought to be “common knowledge.” And, to be fair, I was taught this myself back when I was going through my emergency medicine training back in the 1980s.

I suspect that it was wrong back then, as well. But it is also true that opioid abuse and subsequent withdrawal is different now than it was back then.

Just think about it. Nobody would dispute the fact that patients withdrawing from heroin can get very sick.

  • Some become seriously dehydrated from vomiting and diarrhea.
  • Some get hyperdynamic, including tachycardia and fever.
  • Between the two, some develop significant metabolic acidosis.

Opioid withdrawal can be a serious physiological stressor.

And this is exactly what can make it particularly deadly for chronic pain patients,.

Many of us are already dealing with multiple other health conditions, like heart failure, COPD, or high blood pressure, which the additional physiological stress of untreated pain can dangerously exacerbate.

When heroin addicts are young and otherwise healthy, it is probably true that most can weather the storm of withdrawal. But, in fact, not all heroin addicts in the modern era are young. I’ve seen heroin users in their 50s and 60s. And not all of them are healthy — even the young ones.

Are you going to tell me that opioid withdrawal cannot be fatal in a 55-year-old addict who also has coronary artery disease and diabetes?

Or even that a young but debilitated and malnourished young patient cannot be pushed over the edge by a nasty bout of cold-turkey opioid withdrawal?

There is less pure opioid abuse now than there was “back in the day.”

Nowadays, heroin users commonly abuse other drugs as well. Modern street heroin may be spiked with super short-acting opioids like fentanyl, sufentanil, or carfentanil. Addicts tell me that they shoot up Dilaudid, Suboxone, or whatever else they can get in addition to heroin.

The bottom line is that opioid withdrawal in the modern era is more complicated and more dangerous than the old conventional wisdom would have you believe. Opioid withdrawal may be more than simple opioid withdrawal if the patient has also been using Ambien or carfentanil.

It is poor medicine to say, “Well, heroin withdrawal is not life-threatening” and so do little — or nothing.

Just like they tell us that “no one ever died from pain” and so feel justified to do nothing.

Jail practitioners need to take as much care with detox from opioids as they do with alcohol withdrawal.

My point here is that if you are unwilling or unable to use methadone or Suboxone in your jail to treat your opioid withdrawal patients, then consider the use of lofexidine or clonidine.

Don’t assume that “opioid withdrawal is not life-threatening,” and do nothing! Cold turkey withdrawal is both cruel and potentially life-threatening.

I didn’t realize that considerations of cruelty played any part in medical decisions about treatments; they certainly don’t for the anti-opioid fundamentalists.

They believe our chronic pain either does not exist, isn’t as bad as we claim, or is mostly an attitude problem “in our heads”.

It seems that addicted people are getting the same callous treatment we usually get for chronic pain: first, deny the problem exists by spouting counter-factual “common knowledge”, and if that fails, invalidate the individual’s consequential suffering.

I previously posted a scholarly article about this: Yes, people can die from opiate withdrawal

Author: Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.

21 thoughts on “Opioid Withdrawal Not Deadly? Wrong

  1. Laura P. Schulman, MD, MA

    This jail doc has got it right.

    I have, indeed, seen a lot of punitive neglect from medical personnel, in situations where the patient’s condition is considered to be due to self-harm. I myself was taught to let drunk teenagers experience their hangovers in the ER without the softening effects of IV hydration, so that they would “learn from their mistakes.” I mean, I was TAUGHT that from the attending physicians. Anyway, I heard John Lennon’s song “Cold Turkey” on the radio the other day and thought it was so right on about the experience of withdrawal, which I am very fortunate never to have experienced myself, but I am sure that forcing someone to go through this in jail or anywhere, certainly falls under the international definition of torture. Here are the lyrics.

    https://genius.com/John-lennon-cold-turkey-lyrics

    Liked by 1 person

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  2. peter jasz

    Dr. Kellar: Beautifully written, articulated.

    Thx,

    pj
    (RE: ” …Just like they tell us that “no one ever died from pain” and so feel justified to do nothing.”)
    Complete BS. And, how do “they” know?

    Liked by 1 person

    Reply
  3. louisva

    I posted the following on this article on Medpage:

    You are so right, Dr. Keller. Everyone that uses opioids, whether an addict, or a chronic pain patient like myself, should be treated with dignity and respect. I tire of seeing comments on Twitter and Facebook where pain patients seem to think the whole so-called “opioid crises” is the fault of addicts. I am a former patient of Dr. Forest Tennant, whom you may know was forced out of business by the DEA but still has not been charged with ANYTHING. Dr. Tennant was famous for using high doses when needed to get people out of pain and I am no exception. For over eight years I’ve been on 1950mg MED and have had the best years of my life with pain greatly reduced and a high quality of life. My pharmacist in Virginia was served with a charge from the Virginia Pharmacy Board for negligence – ALL because of me and my high dose. How can anyone be charged with negligence when no one was harmed? Now I am staring at a forced taper and I’m very concerned about this. I’m admittedly quite frightened as I am 68 yrs. old and not ready to give up on life.

    Liked by 1 person

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    1. peter jasz

      louisva:
      The DEA, Virginia Pharmacy Board (and ALL other assholes involved in the incomprehensible crusade against chronic pain patients) should be charged with Crimes Against Humanity.

      It surprises me that no blood-thirsty, hungry laywer is unaware of the abuses belted out by such organizations ? It’s time for one of them, to step up in defense of pain patients -but ultimately make a name for themselves in what I foresee to be a precedent setting case.

      peter jasz
      (P.S. 1,950 MED?)

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      1. louisva

        Peter, I had a meeting today with my state senator and will be seeing my delegate next week. My wife and I are fighting this battle asking for a grandfather clause for “legacy patients” that, on many cases, have been on high doses. We have found two other Virginia patients of Dr. Tennant that have had their meds cut by Virginia doctors. Over the last 8 years of receiving high dose meds, I was able to save extras so I’m getting by as of yet.

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        1. peter jasz

          I’m pleased to know things are progressing for you -and I wish you success. But, to think we must visit (beg?) our politicians regarding medical issues (pain mitigation) is one seriously sad state of affairs.

          pj
          (P.S. Previous MME “charts” were simply to be used as guidelines -not “law”. The wording by the CDC was such that drew confusion (or an opportunity) for many government organizations to limit (or refuse refills) that essentially made/makes life unimaginably worse for those already suffering; some, taking their own lives in desperation -for some pain relief.)

          We all must stop, read that last sentence, and think upon it.

          Liked by 1 person

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      1. louisva

        No Peter, it is not a misprint – 1950 is the correct number. It was well over 2000 when I was also fighting oral cancer. This was not unusual for patients of Dr. Forest Tennant who took only patients whose previous therapies had failed and got them out of pain – no matter what the dose. He got busted by the DEA and has left his practice but still NO charges were ever filed against him. He has had some patients at 5000 MED – folks that could not metabolize because they had no intestines for instance.

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        1. peter jasz

          Hi louisva: Thank you for the clarification.
          So, if one experiences nasty pain despite 150 MED (clearly not enough) it appears it’s really just the ‘entry-level’ of opiate therapy ?

          Regarding the disruption of Dr. Tennant’s practice, I remind everyone to start a crowd-funding program in effort to pay for legal fees for such crimes (against Dr. Tennant) and the overarching Crimes Against Humanity -perpetrated by all those involved in tapering/canceling opiate therapy dosing for millions of sufferer’s.

          A legal challenge must begin.

          pj

          Liked by 1 person

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          1. louisva

            There is no real entry level. Each person needs individualized treatment. In my case, I have a genetic defect (CYP2D6 I think, cannot remember name of gene) but it makes me a lousy metabolizer. I take a long-acting med, Oxycontin, and used to get by on half of my current dose until they changed the formula to make the drug abuse-proof. I had to double my intake at that point.

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            1. peter jasz

              Such Government interference is not only abusive, it’s criminal. As a result of the grave consequences that resulted, such illegal abuses must be regarded as Crimes Against Humanity. Yes, the nation itself (those involved in perpetrating these crimes) must be held accountable -and charged accordingly. Sentencing, appropriate to the gravity of the crimes itself; severe.

              peter jasz
              (P.S. RE: “DEA is watching me and other former Tennant patients. He retired at the advice of his attorneys”. What kind of country does this to those so desperately struggling simply for some desperately needed pain relief ?)

              Crowd funding must be sought in response to such abuses -a legal challenge. It really surprises me that there are no courageous attorneys that see both the severity of the abuses/crimes, nor the (professional) precedent-setting opportunity that exits.

              Liked by 1 person

            2. peter jasz

              Hi louisva: Interesting (and unfortunate) regarding the ‘tamper-proof’ new-ish slow-release Oxycontin/OxyNEO formulation; its known (by millions) not to be as effective as the prior formulation.

              pj

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            3. Zyp Czyk Post author

              …and I thought I was imagining the new formula’s decreased effectiveness!

              Hang around pain patients long enough, and you’ll find out there are others who’ve had all the same experiences you’ve had with pain and opioids – the ones doctors tend to say are impossible (like not being able to get the same relief from the new OxyContin).

              So many doctors over so many years told me that some of my reactions are “impossible”, but when I found my “tribe” of other folks with chronic pain online I heard so many stories just like mine! Even though knowing my pain is “real” isn’t going to lead to any cure, I was beginning to feel like I was losing my mind until my pain was validated by so many others.

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            4. peter jasz

              louisva: the vast majority of “Doctor’s” I’ve had he unfortunate experience to meet (here in my neck-of-the-woods) aren’t particularly ‘sharp’; like loyal dogs they follow the rants/bullshit of their governing body. At any cost.
              Tagging along the party line is an apt descriptor of these guys/gals; they don’t do the research, they don’t appreciate the corrupt nature of their very own “peer reviewed” research papers they read as it was the 11th commandment -infallible, and not to be questioned. Most are mere puppets. And such a high level education; it makes one realize there’s a clear distinction between a ‘formal’ education and intelligence. The two are not mutually inclusive. Far from it.

              pj

              Liked by 2 people

  4. louisva

    About Dr. T, after being raided, they could find NOTHING to charge him with. I do have a copy of the search warrant and it says that all his patients are suspect of misuse or selling. So not only is Virginia on my ass but I’m quite sure the DEA is watching me and other former Tennant patients. He retired at the advice of his attorneys but committed no crime. He was known as the doctor of last resort that only took the most serious patients. My meeting with my state Senator went well and still have my state delegate coming up!

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