EXITING TREATMENT: GETTING OFF THE OTP
Everyone is going to have different expectations about being on the Opioid Treatment Program (OTP), depending on who they are, their circumstances, and what they want to get out of it. There is no ‘right’ amount of time to be on OTP – some are happy to stay on the program for a long time or even forever, while others plan to leave it behind them once they have achieved their specific treatment goals.
Just remember – opioid dependence is a legitimate medical condition, and OTP medications are used to treat it. There is no shame in being on the program, and you should stay on it for as long as it’s still working for you.
Many people don’t come off the program even if they really want to, because they are worried about how difficult it might be. Knowing what to expect from withdrawal and how to reduce the discomfort will make the idea of coming off your OTP medication a lot less scary.
It’s important to remember there is an increased risk of overdose if you start using opioids again after exiting the program due to reduced tolerance. If you do decide to start using heroin or other opioids again, keep in mind that your tolerance will be greatly reduced – an amount which you would’ve hardly felt before may now be enough to kill you! For this reason, always have naloxone on hand if you are using opioids. Talk to your doctor/prescriber about getting a script for take-home naloxone (for the PBS discount) or buy it over the counter at a pharmacy. If money is a major issue, ask a drug and alcohol service if they are running free overdose courses where they give you naloxone to take away with you.
Are you ready?
There are a lot of good reasons why people think about leaving treatment – you might have had enough of the stigma from being on the program, or it could be about the amount of time that appointments and dosing take. All reasons are valid, but you should think carefully about your choices. Be honest with yourself – are you ready?
The best reason for leaving OTP is that you feel in charge of your drug use (whatever that means for you) and feel that your life would be easier and better if you were no longer on the program. For most people it takes at least a year or two on the program to get to this point.
You might ready to leave treatment if you:
Are on top of your mental and physical health
Have stopped using illicit drugs
Have stable housing and support from friends or family
Have important commitments to focus on such as study, family, or work
Have an interest or hobby to focus on (like art, music, or sport)
If you have some of these things in place, you’re much more likely to successfully exit OTP and not relapse into problematic drug use. If you leave the program before you are ready, you could be undoing months’ or years’ worth of hard work.
If you are thinking of leaving OTP, you should ask your prescriber and other healthcare staff, such as your nurses or psychologist, for their advice. They can look at your situation can let you know what they think – they may be concerned it’s too early, or they could completely support your attempt. If they are concerned, find out why and what they think you need to change before you leave treatment. At the end of the day, you get the final say as to whether to stay on the program – your prescriber is not allowed to refuse to help you exit.
Ways to come off
You have several options if you want to leave treatment.
Going ‘cold turkey’ is quitting something abruptly. For OTP, this would mean one day just stopping taking your regular dose, without coming down from it at all. We all know someone who has done it, and some don’t use again but most do. Going cold turkey is strongly discouraged – the withdrawals are really bad and last many months. Stopping treatment suddenly means you’re more likely to start using other drugs or end up back on the program, usually because you finally give in.
There are residential rehabilitation programs which can help you in exiting from the program. Residential rehabs suit people who feel they need to get right away from their lives in order to get their drug use under control. These are medium to long-term options, and often include a support period – perhaps at a half-way house after you leave. There are two options – staying on the program and stopping all illicit drugs and alcohol (called selective withdrawal) or reducing off the program as well as other drugs. Sometimes people start by coming off illicits then decide to go the whole way once their head clears a bit.
Slowly reducing your dose, AKA tapering or titration, while still “on the street”, living your normal life, is the most commonly used, and most successful, approach for exiting the program. Every time you drop down on your dose you will experience some level of withdrawal symptoms, which will increase in severity as your dose gets closer to zero and will usually peak between 1-4 weeks after your last dose.
As you stop taking methadone or bupe, you will go through withdrawals. These are often more uncomfortable and last longer than withdrawing from other opioids because ‘done and bupe stay in your system much longer.
Common symptoms include sweating, restlessness/poor sleep, muscle/bone/joint pains, anxiety, aggression, depression, diarrhoea, and flu-like symptoms such as fevers, runny eyes and nose, and sneezing. If you slowly reduce your dose, every step down will bring on a new round of withdrawal symptoms, which will usually last between four and 14 days. Towards the end, it can get harder because while you may be coming down at only 5mg a time, your start up reduction of 5mg out of 100mg is a twentieth of your dose, whereas 5mg out of 20mg is a quarter of your dose! It makes sense that you will feel it more and maybe need to go slower at the end.
If you’re on methadone, you might want to consider swapping over to bupe while reducing your dose because the withdrawal symptoms are often easier to deal with. Most people who do this reduce their methadone dose to around 30mg and then swap to a low dose of buprenorphine. From there, you can continue going down on your dose. Remember though, it’s a myth that withdrawal from bupe is a walk in the park (read Clyde’s story, coming up next).
When you stop dosing completely, some withdrawal symptoms might linger for months. A lot of people feel depressed and have trouble sleeping after this final dose reduction. One option is to consider going on a short course of anti-depressants. You also may benefit from staying at a detox centre or rehab while making the last reduction – here, you can receive the support you need from trained healthcare professionals while going through withdrawals. Talk to your doctor about how to manage this final jump – they can help point you in the right direction.
If you’re having trouble with the withdrawal but still want to exit, there are ways to deal with the problems or feelings that are coming up. Your prescriber or GP can help you with working through withdrawal symptoms, and you can always wait until you get used to a smaller dose to start reducing again.
Withdrawing from opioids is never going to be pleasant, but it’s not the scary thing we build it up to be either. There are ways you can make it easier. First thing is talk to your doctor. Tell them you are worried and a bit scared and need them to do everything in their power to make this a success for you – and that means helping you manage the withdrawal symptoms.
You also need to make the time to be unwell. Check out how many sick days you are owed at work so you know what you have to play with. Talk to your doctor about writing medical certificates (you can get these from chemists too for around $15 to $25). Get them to write “medical condition” as the reason! There are few workplaces where confessing to coming off an OTP is a good option. Work out what times of the day you feel least well and schedule your activities – maybe come to work later or leave earlier if you can.
Non-opioid painkillers such as paracetamol, aspirin or ibuprofen (Nurofen) and anti-inflammatory medication such as Voltaren can help ease aches and pains in your muscles and bones. We get in our heads that only opioids will do the job, but it’s honestly not so. Sports cream like Deep Heat and Tiger Balm can also help with sore muscles. There is also medication that your doctor can prescribe to help with nausea, stomach aches and diarrhoea.
Making sure that you’re eating well is also important, as your body will be under a lot of strain. Taking a multi-vitamin supplement will make sure you’re getting the nutrients you need, as well as having a diet with lots of fruit, vegetables, whole grains and legumes.
You can also try natural remedies. Echinacea is available at most chemists and can help with the head-cold symptoms of opioid withdrawal. Taking ginseng will ease your fatigue and give you an energy boost. Some people try other alternative medicines like acupuncture.
Your sleep will be affected for some time. Valerian root or a melatonin supplement will make falling to sleep easier, but it's also important to get into a normal sleep routine. That means training your body to go to bed at a reasonable hour and wake up around the same time each day. You might want to talk to your doctor about seeing a sleep specialist. There has been a lot of research about “sleep hygiene” and there are many tips and tricks associated with improving your sleep patterns.
While exiting treatment is hard, staying off opioids completely is harder – your schedule will change, and it might feel like the withdrawals and cravings will never end or that you’re missing something in your life.
Having a solid support network makes staying off opioids a lot easier. This support network could include your friends, family, prescribing doctor, or caseworker. Your prescribing doctor and/or caseworker should continue to see you after you’ve exited treatment to make sure that you’re coping okay. You could also attend support groups if there are any running in your area.
Most important is that you maintain the benefits you got from being on the program. For some, being on OTP means having stable living arrangements or holding down a job for the first time in many years, or it could mean that your personal relationships (friends, family) have improved. These improvements in your quality of life are the long-term goal of being on OTP, and it’s important to keep focused upon them once you have left the program.
Changing your mind
Some people find that when they’ve started reducing or completely stop dosing, they wish they hadn’t! You might not be coping with withdrawals, could be feeling like you’re losing control of your drug use, or may simply miss the benefits and routine of being on OTP.
It’s totally okay to change your mind and stop reducing or start back on the program – there is no need to be ashamed or discouraged. The best option for you might be staying on OTP or starting again. There is no shame in returning to treatment, and it may result in better outcomes for you. A lot of people take multiple attempts to come off the program, and you can always try to exit the program again later if you choose, or you may benefit from being on OTP for the rest of your life.
Talk to your prescribing doctor about how you are finding exiting treatment, or if you have already left the program completely, arrange an appointment with your GP or another prescriber to discuss your options. Don’t be afraid to ask for help from friends, family, or your doctor. Seeing a psychologist or counsellor can also help you adjust to life off the program.