Detoxification
H.
Hooshmand, M.D.
Neurological Associate Pain Management Center
1255 37th Street, Suite B
Vero Beach, FL 32960
PHILOSOPHY OF DETOXIFICATION
The whole philosophy of
detoxification is to allow the brain to continue the formation of endorphins so
that the patient would have better pain control. For example if the patient is
on Lortab, an opioid agonist. Lortab, similar to Morphine, Methadone, Codeine,
etc., has a tendency to occupy the cerebral opioid receptor sites. There are
three main opioid receptor sites, i.e., mu, theta, and kappa receptors. The
opioid agonists have a tendency to occupy all three opioid receptor sites. As a
result, the formation of cerebral endorphins comes to a halt because there is no
receptor to receive the endorphin. As a result, the patient becomes dependent
upon any opioid agonists. Moreover, this dependency is complicated by
fluctuation of the drug dosage. Every time the patient takes Lortab after 3 - 4
hours, the plasma level of Lortab drops, and as a result, the patient develops
rebound (withdrawal) pain. Even after the original pathology has cleared up, the
rebound phenomenon continues to fluctuate the dosage of opioid in the brain and
continues to cause withdrawal pain in absence of the original pathology because
of the fact that the brain depends on endorphines for its normal function.
On the other hand, the opposite
group of opiates which are called opioid antagonists, in a therapeutic dose they
do not occupy all the opioid receptors. Usually, the kappa receptor, which is
the larger receptor, is left intact. The availability if the kappa receptor
allows the endorphins to be formed and to occupy the kappa receptors. Hence, the
patient received pain relief both from the opioid antagonists as well as the
natural endorphins. Only in toxic dosages, the opioid antagonists occupy the
kappa receptors and they act exactly similar to opioid agonists with similar
side effects.
The main problem with
detoxifying the patient in an accelerated fashion, is that the patient becomes
very jittery, nervous, shaky, tremulous, as well as nauseated.
During the detoxification,
things may go smoother if the following precautions are taken:
1. To increase the dosage of the
antidepressant, specifically Trazodone which is an excellent analgesic
depressant in and of itself. Wellbutrin on the other hand, does not have the
analgesic property and can contribute to the patient’s agitation. For example
the dosage of Trazodone can be increased up to 2 ½ -3 tablets at night.
2. Increasing the dosage of
Klonopin® is extremely helpful in prevention of agitation, tremor, jerky
movements of the extremity (myoclonic jerks) due to withdrawal, and tremor.
If the patient is agitated and
not drowsy, then the patient should be allowed to take two Klonopin even every 2-3
hours as needed. The moment the patient becomes drowsy, then the patient should
hold off the Klonopin. Obviously, the generic Clonazepam is not as affective,
and only causes more drowsiness and feeling of depression. Klonopin is probably
the most affective tool against the complication of rebound (withdrawal)
symptoms.
3. The withdrawal also has a
tendency to be accompanied by nausea, even vomiting as well as excessive
drooling from the mouth and runny nose. Vistaril is the treatment of choice for
this complication with the dosage being 50 mg every four hours as needed.
As long as the patient is
motivated, with the above schedule the dosage of Lortab can be dropped by one
tablet every five days instead of every seven days.
Finally, another precaution may
become necessary while the patient is going through detoxification. If the
patient acts agitated, confused, and forgetful which are common complications of
opioid agonist withdrawal, there should be a relative or a friend supervising
the patient’s intake of medications to make sure that the patient is taking the
right dosage of medicine. Otherwise, the patient will forget and will take
either too much or too little dosages of medication.
DETOXIFICATION PROTOCOL
We have a strict
protocol of detoxifying the patients from the habituating drugs that they have
been on before. In our experience, simple detoxification of the patients from
addicting drugs such as Codeine, Vicodin, Morphine sulfate, etc., is enough to
provide complete relief of pain in more than 20% of the patients.
Codeine a
Class II and Vicodin a
Class III
are opioid agonists, strong narcotics. The Class I being the
street drugs such as Heroin, etc. The Class II is quite a restricted type of
drug because the Class II group such as Morphine, Codeine, and Vicodin
a (Class III) are
opioid agonists meaning that they flood the brain with strong opioid narcotic,
and as a result the brain stops forming endorphins (natural cerebral
analgesics). As the endorphin formation is ceased, they every 4-5 hours after
taking Vicodin or Codeine, the patient will have a severe rebound (withdrawal)
pain because of the fact the level of the drug (Codeine or
Vicodin) has dropped
to a negligible amount and the brain realizes that there is no endorphin. This
causes a severe pain and a marked generalized pain not limited to the area of
pathology, but from head to toe. This is what is called iatrogenic (medication
or treatment originated) pain. Such complex chronic pain patients can never have
a day of rest unless they are detoxified from Codeine, Vicodin, or Morphine.
Instead, the patients should be treated with opioid antagonists. The opioid
antagonists are limited in number, and their characteristic is the fact that the
brain does not recognize the opioid antagonists as a Morphine type of drug. As a
result, endorphins keep forming and will not become suppressed. Endorphin uses
three opioid receptors in the brain to naturally relieve pain. These are called mu, theta, and kappa receptors. The opioid antagonists such as Nubain, Buprenex,
and Butorphanol, in therapeutic doses, only occupy mu and theta receptors, but
not the kappa receptors. As they leave the kappa receptors alone, endorphins
will keep forming to fill the kappa receptor. Hence, the patient will have the
benefit of the opioid antagonist pain relievers plus the patient’s own
endorphins.
It is essential
to preserve the function of the endorphin because it is totally opposite to the
synthetic pain medications. It increases the level of ACTH which is important
for counteracting stress, it increases the level of sex hormones, and it has an
antidepressant and strong analgesic effect. The other synthetic opioid agonist
medications do the opposite. They suppress the sex hormone, cause depression,
and also have only temporary pain relieving effect.
There are two
choices. Either to go according to the financially-driven decisions by the
insurance carrier - and have the cheaper medications in the form of opioid
agonists, Vicodin, or Codeine, or on the other hand to use the opioid
antagonists such as Nubain, Buprenex or Butorphanol, which are the treatments of
choice medically.
We also have to
realize that opioid antagonists in therapeutic doses provide excellent pain
relief and do not cause depression. On the other hand, opioid agonists or
antagonists, any one of these medications if given in higher than therapeutic
range causes suppression of endorphin and will have the same type of adverse
side effect. Fortunately, when the patients are on opioid antagonists, these
medications act similar to Antabuse in regard to the fact that if they mix
opioid antagonist and agonist, they become severely nauseated, vomit, and learn
not to sneak in the wrong kind of medications.
For almost 30
years, the treatment of choice for chronic pain has been the use of
antidepressants.
TYPES OF
PAIN
There are
three different types of pain:
1.
Acute pain:
such as a heart attack or bone fracture or appendicitis. It is acute and has a
duration of less than one week. For the acute pain, the only treatment that will
save the patient’s life is strong Morphine derivative. If I have a heart attack
or a blood clot in my lung in acute stages, the only thing that will get rid of
the pain and keep me alive for the first week or ten days is Morphine.
2.
Chronic pain:
with a duration of usually six months or longer, the use of Morphine derivatives
will cause serious side effects as outlined above. The Morphine derivatives
cannot be used on these patients as the sole agent for pain management.
In chronic pain,
the most effective form of pain treatment is antidepressants-not because the
patient is depressed, but because the antidepressants improve the exchange of
biogenic amines in the nerve cells and improve the function of the nerve cells
and as a result, the brain itself with the help of endorphin and with the help
of inhibitory nerve cells in the brain completely controls the pain. The most
ideal medications of the anticonvulsants family for pain is first of all
Trazodone, and secondly Elavil.
3.
Cancer pain:
a combination of acute and chronic pain. In this condition, any palliative
treatment is justified on humane basis. The cancer pain treatment should not be
mistaken for benign chronic pain treatment.
CONCLUSION
In conclusion,
we are not going to sit back and regress back to the 1950's or
1960's and treat
patients with addicting pain medications (opioid agonists), and discontinuing
the nonaddicting antidepressants which help prevent pain, provide normal natural
sleep, and a better quality of life for the patient. The patient does not have
to chase their pain away with addicting pain medications.
