Tapering Off Fentanyl: Following a Safe Schedule

A powerful and potent synthetic opioid drug, fentanyl is a medication that leads to physical dependence with regular use, even when taken via a medical prescription. The Mayo Clinic warns that any use of an opioid drug for two weeks or longer can lead to dependence, which means difficult withdrawal symptoms can occur if someone stops taking the drug.

While opioid withdrawal symptoms typically are not considered to be life-threatening, they can be intense and cause significant physical and emotional discomfort.

As a result, fentanyl is not a drug to be stopped suddenly or without medical intervention. At-home detox is not recommended.

Fentanyl is an extremely powerful opioid drug that can quickly become habit-forming, making it difficult to stop taking the drug successfully without professional help. Fentanyl overdose is a real health risk of continued use, and it is being dubbed the “third wave” of the opioid epidemic. CNN reports that more than 20,000 Americans died from a synthetic opioid overdose in 2016, and the majority of the deaths were attributed to fentanyl.

A medical detox program offers the safest method for allowing fentanyl to process out of the brain and body, and ultimately helping someone to stop taking the powerful drug. During medical detox, trained health care professionals will often set up an individual tapering schedule. Medications can be used to manage the side effects of withdrawal, and individuals can be monitored and supported while fentanyl use is discontinued.

The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that acute opioid withdrawal generally lasts between four and 10 days.

The Withdrawal Syndrome

When someone takes fentanyl, the drug works by binding to opioid receptors along the central nervous system, helping to essentially turn off pain sensations and suppress the central nervous system. Body temperature is lowered. Heart rate, blood pressure, and respiration rates are depressed, helping to reduce stress and make a person feel relaxed, drowsy, and mellow.

Brain chemistry is altered due to the drug’s interaction. Levels of some neurotransmitters—which are the brain’s chemical messengers used to send signals around the central nervous system regarding how to feel, move, and think—are changed with fentanyl’s presence. Dopamine—the chemical responsible for helping to regulate emotions, thought processes, sleep functions, and movement abilities—floods the brain when fentanyl fills the opioid receptors. Elevated levels of dopamine create the high associated with opioid abuse.

When dopamine levels drop after fentanyl wears off, a crash can occur that brings opposite effects. A person is likely to feel depressed, anxious, irritable, and restless. They will have problems thinking clearly when fentanyl wears off. Physically, many of the fentanyl withdrawal symptoms mimic the flu; nausea, stomach cramps, muscle aches, sweating, chills, runny nose, watery eyes, vomiting, diarrhea, dilated pupils, and insomnia are common.

When the central nervous system is no longer depressed by fentanyl, it can have a kind of rebound effect. Heart rate can speed up, causing an irregular heartbeat; respiration can be erratic; muscle twitches and tremors can occur; fever can spike; and pain can return.

Tapering Off Fentanyl

Agitation, memory lapses, drug cravings, concentration problems, fatigue, weight loss, goosebumps, and possible hallucinations are all additional potential side effects of fentanyl withdrawal.

The National Library of Medicine (NLM) publishes that withdrawal symptoms typically begin within 12 to 30 hours of the last dose of an opioid drug. Acute opioid withdrawal generally lasts between four and 10 days. Symptoms usually peak on day two or three and begin to lessen over the span of a week or so.

Some of the emotional distress and cognitive difficulties, as well as cravings and sleep issues, can continue for a few weeks or months. This is an average timeline, as biological, genetic, and environmental factors can influence the duration and intensity of fentanyl withdrawal. It is, however, most significantly affected by how dependent a person is on the drug.


Factors to Consider With a Fentanyl Taper

Instead of stopping fentanyl cold turkey, the drug is usually weaned off in a slow and controlled manner through a taper.

The tapering schedule is set according to the individual and can depend on certain factors, such as:

  • Individual metabolism and other biological factors
  • How long a person has been taking fentanyl
  • How fentanyl was taken and in what dosage
  • If other drugs or medications are also being taken
  • Any medical or mental health concerns
  • Family or personal history of drug abuse or addiction

Fentanyl comes in several forms: a lollipop or lozenge form that is ingested and dissolved in the mouth; an injectable form given in a hospital setting; a transdermal patch that is placed on the skin, allowing for continual pain management; and a powder form that is often manufactured illicitly in underground laboratories for recreational abuse.

Typically, fentanyl is a rapid-acting opioid that takes effect quickly upon using it. The way a person takes fentanyl can influence how fast it enters the bloodstream and starts working. The patch is an extended-release formulation that gives out small doses of the drug over a period of three days; injecting fentanyl will send it directly into the bloodstream and across the blood-brain barrier. Rapid-release fentanyl takes effect quickly and also wears off pretty fast, which means that withdrawal symptoms can begin quickly. With the extended-release formulations of fentanyl, it may take up to a day or so before withdrawal symptoms kick in. A fentanyl taper will need to take all these factors into account.

Tapering Specifics

The journal the Mental Health Clinician recommends reducing the fentanyl dosage by half every six days or by a quarter every 15 days until the drug can be safely discontinued. The prescribing information for Duragesic, the brand name for the transdermal patch form of fentanyl, warns that withdrawal symptoms can still occur during a taper, and medical professionals may need to adjust dosage as needed. This can mean that the dosage will need to be decreased more slowly, or a person may even need to go back to the previous amount for some time to control the side effects.

Since fentanyl is a potent and rapid-acting opioid, it also may regularly be replaced with a longer-acting and less potent opioid during a taper. As a result, a lowered dosage can be given in fewer doses. A long-acting opioid like methadone or buprenorphine stays in the body for a longer period than fentanyl does, meaning these medications won’t need to be taken as often as fentanyl would. These opioids are also not as potent as fentanyl, so they are less likely to be targeted for misuse. Buprenorphine is only a partial opioid agonist, which means it doesn’t fully activate the opioid receptors in the brain, and therefore does not cause the same high that fentanyl can.

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The idea of an opioid taper is to allow the brain to regulate without fentanyl after it has become dependent on it. The brain will need time to heal and learn how to balance its chemistry without the interaction of the powerful opioid. Keeping a small dosage of an opioid in the system during a taper can help to minimize the withdrawal symptoms. A medical professional can best determine how much and what type of opioid to use during a taper.

How Medical Detox Helps

Medical detox is a structured program in which a person generally will stay in a controlled environment for about a week or longer, depending on the severity of the addiction. It is the safest way to discontinue fentanyl. As an extremely potent opioid with a high risk for overdose, it is not safe to attempt to control dosage at home. The odds for overdose and relapse during withdrawal are high.

Addiction is considered to be a relapsing and chronic disease. The National Institute on Drug Abuse (NIDA) warns that relapse rates for drug addiction are as high as 40 to 60 percent – the same as they are for other chronic illnesses like asthma and hypertension.

medical professional providing detox

After stopping fentanyl for any period, the brain will begin to rebalance itself. A return to taking it at previous levels can quickly lead to a life-threatening overdose. Medical detox can provide the time and space for brain chemistry to regulate safely while working to minimize relapse through encouragement and therapeutic support.

Medical detox can provide many benefits during a fentanyl taper. Among them are:

BENEFITS OF MEDICAL DETOX

  •  Constant supervision and medical monitoring of vital signs and symptoms of withdrawal
  •  Mental health support
  •  Relapse prevention tools and coping skills
  •  Management of any complications, including those brought on by the presence of additional drugs and/or alcohol
  •  Medication management for the control of withdrawal symptoms and cravings
  • A safe, stable, and secure environment
  • Management of any complications, including those brought on by the presence of additional drugs and/or alcohol

This kind of detox provides a high level of medical and mental health support during a fentanyl taper, and it helps a person to reach a safe level of physical stability. Once physical balance is achieved through medical detox, admission into an addiction treatment should be the next step.

Many comprehensive and specialized addiction treatment facilities allow for seamless transitions between detox and treatment that will include supportive and therapeutic methods for recovery. In this way, medications can continue to be monitored and managed as needed during treatment. Drug cravings and some of the emotional side effects of fentanyl withdrawal can persist beyond medical detox, and an inclusive treatment program can manage these going forward.

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SOURCES

(January 2018) Tapering Off Opioids: When and How. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/tapering-off-opioids-when-and-how/art-20386036

(October 2017) This Is Fentanyl: A Visual Guide. CNN. Retrieved from https://www.cnn.com/2017/10/24/health/fentanyl-visual-guide/index.html

(August 2018) Opiate and Opioid Withdrawal. National Library of Medicine. Retrieved from https://medlineplus.gov/ency/article/000949.htm

(2010) Protracted Withdrawal. Substance Abuse and Mental Health Services Administration. Retrieved from https://store.samhsa.gov/shin/content/SMA10-4554/SMA10-4554.pdf

(May 2015) A Practical Guide to Tapering Opioids. Mental Health Clinician. Retrieved from http://mhc.cpnp.org/doi/full/10.9740/mhc.2015.05.102?code=cpnp-site

(July 2018) Drugs, Brains, and Behavior: The Science of Addiction. National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery