What’s it really like to withdraw from heroin and painkillers?

Frank Sinatra didn’t get it quite right in “The Man With the Golden Arm” (1955), and neither did Leonardo DiCaprio in “The Basketball Diaries” (1995). Their depictions of heroin withdrawal — from frenzied and frothing to debased and pleading — both exaggerated and fell short of conveying the real agonies that opioid addicts face, say those who’ve been through it. Not to mention the prolonged and concentrated effort it requires to gain a foothold in recovery.

“I think one of the most difficult parts is the mental withdrawal,” said Dr. Marc Myer, director of the Health Care Professionals Program at Hazelden Betty Ford Foundation in Center City, Minn. It’s a combination of “a severe depression and feeling that you’re never going to pull out of that state. It’s pretty well known among [treatment] providers that, because of that feeling of hopelessness, the anticipation of the withdrawal is oftentimes worse than the actual thing.”

Here are excerpts from interviews with four people who live and work among us, who became addicted to opioids (prescription painkillers or heroin), who went through withdrawal, stopped using for a while, then relapsed and went through it again and again until they began to achieve some peace in their lives.

Maybe it’s not movie material, but it’s material for serious reflection as we process the tragic and lonely death of Philip Seymour Hoffman — and the deaths of one too many like him these days.

Dan Cain, longtime president of RS Eden

I’ve withdrawn from heroin, albeit 41 years ago, on several different occasions. The experience hasn’t changed much in the course of 41 years.

It’s important to remember that withdrawal with heroin, as with many of the other substances, is both physical and psychological. The actual physical withdrawal from heroin, first off, is unlike what people are led to believe — no one has ever died from withdrawal from heroin to my knowledge and in my experience. People have died from withdrawal from alcohol, people have died from withdrawal from barbiturates and benzodiazepines, but no one has ever died from withdrawal from heroin.

And, in fact, it’s like a sustained case of the flu that can go on for a while, with minor chills and sweats and diarrhea. But the actual physical part is less the issue than the psychological part.

I have seen people who, when they were out on the street and there were no drugs available, go through extreme machinations of withdrawal. Their drive to make this pain go away was extreme. I’ve seen the same people with the same habit go to jail. Interestingly enough, in jail you grab yourself … a bucket [to sit on]. You bring it into the shower, you turn the water on hot, and you just sit there. It’s not nearly as extreme or as painful. That’s a reflection of when you’re out on the streets, you have a chance or an opportunity to go and get some more drugs, so the drive is a lot stronger and the psychosomatic symptoms are a lot stronger. When you take people out of that environment … there’s a certain amount of discomfort. But it’s far from unbearable.

People use drugs to change the way that they feel. Some drugs produce tissue tolerance — that’s a byproduct. But you’ll often find people, if they’re addicted to heroin, if they can’t take heroin, they’ll go take benzodiazepines, or they’ll take Seroquel or they’ll take Sinequon or they’ll take other drugs to try and lessen the symptoms because they’re afraid of what they don’t know. A lot of people quite frankly have never been in full heroin withdrawal. Even the addiction piece for some people can be psychosomatic. They believe they are addicted before they are addicted, they start to feel things that may be a little bit odd, and they equate that with withdrawal, and immediately go out and do something to address it and have never been through a full withdrawal cycle. People who have been through a full withdrawal cycle  — be it from heroin or other narcotics or methadone or Suboxone or whatever — that’s not medically managed find out that it’s a pain, it really is, don’t get me wrong, it’s not anything that anybody would willingly go through. But it’s also not the end of the world.

There is this constant tug-of-war that goes on in the addiction world. Part of the problem is that addiction is not easily categorized. It has biological, psychological, social, behavioral and even spiritual implications caused by people feeling deficient in one area or another. But those of us who treat addiction and probably, just as importantly, those of us who do research who wouldn’t know an addict if one came and tapped them on the shoulder, will try and pigeonhole it into one of those particular areas. So consequently you have the medical profession trying to identify it as a brain disease, treatable with normal medical interventions. The social workers identifying it as a social disease and trying to treat it with social interventions. The faith healers or the faith-based programs identifying it as a spiritual deficiency and trying to treat it with spiritual things. The corrections system identifying it as a behavioral issue, trying to treat it with incarceration. And so on, and so on, and so on.

Unfortunately, no one seems to recognize that it’s not one or the other — it’s all of the above. There are many paths to addiction. And I think we do our clients a disservice when we try and pigeonhole it into one area or another and give them the false hope that by addressing this and this alone, it’s going to solve the problem. George Carlin had the quote, “Just because the monkey’s off your back doesn’t mean the circus has left town.”

Hoffman had 23 years of sobriety. And he did some incredible things during that time, including putting together a family and all of his success in the acting world. I think as a society we tend to view recovery as lifelong abstinence and discount things that ultimately turn out bad. I think it’s tragic that Philip Seymour Hoffman died. I understand it. But I’m not one to say that his recovery wasn’t successful, because 23 years, with the kind of success that he had, is something that a lot of people would trade for.

Dr. Marc Myer, treatment provider

One of the real struggles for opioid-dependent people is that the acute symptoms can go on for weeks, depending on the substance being used. And then the prolonged symptoms, which are a kind of general malaise or mild to moderate depression, can go on for months and months. Sometimes patients will ask, “Doc, when am I going to feel better?” And I sometimes don’t want to tell them that it’s going to be awhile. It’s hard to ride that line between being realistic and not removing hope.

One time I [went] on a continuing medical education conference to Mexico [in 2003]. One of the reasons why I chose to go was in the hope that I could remove myself from access [to painkillers] and have time away from work to detoxify, thinking that I could get back on track. I had planned to wean myself, to do a kind of a scheduled taper. But, of course, because I was so active in the disease, I used up that supply within the first 24 to 48 hours and then started going into immediate withdrawal. And it was awful.

I felt lonely and hopeless, just in the disease. But then going through withdrawal by myself in a motel room in Mexico was just a feeling of emptiness and despair. I had … runny eyes, runny nose, diarrhea, dehydration, complete lack of appetite, overwhelming nausea, pain in every part of my body.

The other punishment involved with opioid withdrawal is that you can’t sleep. So there’s no respite. There’s anxiety and panic and feelings of dread and thoughts of this never getting better. And the depression, the inability to function at all. I didn’t leave my room for five or six days until I had to [in order] to fly home. I felt so awful, so dehydrated, overwhelmed with feelings of cravings to use again just to feel better. I got off the airplane, immediately went to an emergency room and complained of headache and other pain symptoms so that I could get opioids.

It took repetitive attempts to cease my opioid use. And [it took] the intervention of co-workers who finally recognized that I had a problem and needed help. Once my career was threatened, I found a willingness to self-report and seek the help I needed. I went to treatment, relapsed, came back, relapsed. My license ended up being restricted and then suspended. I finally entered long-term recovery starting in August of 2008.

In early recovery from any illness, there are days when it requires simply putting one foot in front of the other. Recovery may not happen immediately. A person may not feel all the way better immediately or on their timeline, but it does happen. It always happens. And with the Twelve Step program of recovery, the relief that we seek can be hastened by doing the work of the steps of recovery.

I feel for anyone with opioid addiction or anyone with the disease of chemical dependency, but especially for those celebrities and other political figures, people in the public eye. Because it’s difficult to reach out for help when you’re driven by fear of people’s judgment. We live in a society that minimizes success and magnifies mistakes. It’s just the way things are.

Emily Carter Roiphe, writer and books critic

You’re ill and you’re in pain, your joints ache. You lie down, and then you get up, but you can’t get comfortable. In the beginning, there’s a lot of nausea. But mainly the worst thing is the joint pain and restlessness combined with weakness and sleeplessness. It tends to last for 72 hours, so people often call it the Asian flu.

Some people say that it doesn’t matter whether you’re stopping a $30- or $300-a-day habit. What’s horrible is how badly you miss your drug, because you know it will give you relief. It’s very unpleasant, there’s no doubt about it. In movies, it’s much more dramatic, people are crawling around and screaming — they’ll do anything for another fix. That’s just nonsense. Basically, you just feel like crap. That’s the worst part of it.

Some people feel so good that they feel well enough to go out and start using immediately again. For some people, it’s very scary because they’re used to being somewhat tranquilized all the time. And then all the emotions come back. It’s very common to see people weeping over dog-food commercials and such. People are very raw, extremely raw.

It’s very good for an addict to be in a treatment setting when they’re withdrawing, because as soon as you feel physically better, the disease gets into your mind. You think: I could go for a walk and use once without all this happening again. The withdrawal doesn’t do anything to remove the addiction. The addiction is still there. I don’t know of anyone who all of a sudden just stopped and never went back to it.

A great many people use to self-medicate. And it’s very dangerous because not only will it remove your depression, it will replace it with euphoria. That’s a powerful incentive.

After the immediate withdrawal, the horror can be that you’re facing feeling how you feel with no relief — ever again. That’s why in AA they say, “One day at a time.” If you start thinking about living the rest of your life without a drug or a drink, it’s horrifying to an addict. It’s like saying that you’ll never, ever, ever have a moment of happiness again. You’ll never, ever not be sad, anxious, lonely.

I can’t emphasize enough how important it was to hear that “One day at a time” thing. That for me was everything. If I thought that I could actually achieve something by staying sober for 24 hours, and that people would give me props for that, that was everything. The idea of facing a life without my drug of choice, which was at the time the only thing that provided me any pleasure whatsoever, would cause me to despair. So hearing that if you can get through one day, you’ve done well — that meant everything to me.

Ian McLoone, LACD counselor, U of M grad student

Because we’re dependent on our endogenous opioid systems for so much of our daily experience, when you tinker with it or stop producing your own endorphins, it affects the whole range of your daily experience.

You hear a lot about people who never quite feel totally normal again — even folks who are abstinent for 10 years. I’m on methadone maintenance, so I feel [relatively] normal. I continue to taper down on my medication. I’ll notice that my body kind of catches up. After I lower my dose, I notice it for a couple days, then my body makes up the difference and finds the homeostasis. So I’m hoping it continues to do that as I continue to taper all the way down.

I’m taking it one day at a time, as they say.

In the moment, when you are experiencing the first few stages of withdrawal, even though you know that the worst that’s going to happen is that you will feel like you have the flu, there’s a psychological piece that is so terrifying and so disconcerting. You know that there’s a cure, and you know that it’s out there, and that’s why people will go to such lengths to quell those withdrawal symptoms. Even though it’s ridiculous and it’s weak and it’s pitiful, in the moment, it really seems like it’s the worst thing that can ever possibly happen. Isn’t that weird?

With the flu, you kind of know that there’s no immediate fix. You’re just going to buckle down and hope that you don’t end up in the hospital. But you spend so much time using just to feel normal, and to avoid that sickness that when the sickness comes on — and you know that if you had just saved that last little bit a little bit longer, not spent that money on this other thing, or if you could just get your hands on something you could sell — that you could fix it. Right? It’s that sense that there’s a cure but it’s just out of reach. So you’ll do whatever it takes to “fix” that horrible feeling. I can fix this. It’s just a real psychological component in there. It’s really hard to convey sufficiently what that feels like.

I was facing losing my spouse, my marriage, my child, my home, any semblance of the life I had. And I was thinking that I should get off my medication and just be totally clean. And somebody said, “Ian, you’ve got one chance to get this right, you should use every tool at your disposal to increase your odds of success.” It just helped me not to feel ashamed about using a medication.

People recover. Most opiate addicts who come into treatment know the true despair of that day-to-day grind of just feeding your habit. [As a provider, I can help them by] just offering some hope that there’s another way to live, empathizing with where they’re at, and offering encouragement to try things differently.