Rehab can serve a lot of purposes other than abstinence. For some people the goal is a tolerance break, or short-term affordable housing, or compliance with the terms of their probation. During each of my many, many stints in rehab, abstinence was never my goal. If you’re detoxing from opioids, the way I see it that process calls for as many other drugs as possible.
Prescriptions for an opioid, a benzodiazepine and a muscle relaxant is what the Drug Enforcement Administration calls the “trinity cocktail.” Some rehab programs will prescribe you benzos, and in my case it was always ideal if I could get them on the push—through an IV rather than in pill form. Midazolam (Versed), temazepam (Restoril) and of course diazepam (Valium) all took the edge off of withdrawal, both physically and mentally.
Best-case scenario was getting the “nursing dose”—when you’re getting meds on the push, the ampule they’re coming out of usually has about double whatever your dose is. The extra dose is supposed to go to waste, unless the nurse dispensing it decides you should have it instead.
If benzos weren’t an option, barbiturates like phenobarbitol helped. But if the barbies too were off-limits, then it was down to muscle relaxants, anticonvulsants and blood-pressure medications. Some of which have a lot of nonprescribed value to squeeze out of them, as many people who use opioids have learned to do.
The intake staff who conduct your initial screening call are often of the mindset that it doesn’t matter whether you’ll be detoxing from just opioids, or from opioids plus alcohol plus benzodiazepines plus barbiturates, because you’re gonna get detoxed the same way—cold-turkey from everything. But when they saw me as someone with a really serious opioid problem, who really needed to be saved, they were often eager to steer me toward “non-narcotic” alternatives. Opioid stigma at its finest. If staff weren’t already pushing these options on me, I basically just had to say what they were already thinking.
On the street I’d be getting Dilaudid, but I’m trying to be “good” so I just want a non-opioid option like gabapentin.
I really don’t want anything heavy for my anxiety, I only take clonidine because I’m trying to avoid the narcotics.
Baclofen? I’ve always been on it for my back pain. Heck of a lot better than an opioid, right?
Medications like pregabalin (Lyrica) and gabapentin are invaluable here for the same reason people use them with opioids on the street—they potentiate the effects. Research has shown that short-term use of muscle relaxants combined with opioid analgesics isn’t associated with increased overdose risk, compared to just the opioids alone.
Lyrica is sort of the unofficial gold standard in this context, but has always been under Schedule V of the Controlled Substances Act and is more readily available in some states than others. You’ll more likely get gabapentin, which a handful of states have scheduled according to their own CSA but isn’t a controlled substance at the federal level.
It’s anticonvulsant medication that’s technically for nerve pain, but to hear prescribers tell it gabapentin is a panacea for everything these days. Seizures, anxiety, insomnia, post-surgical pain, menopause, dogs that don’t want to go to the vet. I remember this actually being an even bigger phenomenon back when it was mostly available as the branded version Neurontin. I once saw docs write my detox roommate a Neurontin script when he had a cough and the hiccups.
The muscle relaxant part of the “Trinity” equation used to be synonymous with Soma, the brand name for carisoprodol. It metabolizes into meprobamate, which is basically a barbiturate. Hence the “Soma Coma.” You used to be able to get Soma in Medicaid rehabs but in 2012 it was placed under Schedule IV of the CSA, after which it became less popular with prescribers.
But baclofen, a different muscle relaxant, is still pretty accessible. So is clonidine, the blood-pressure medication that has helped just about every drug user I know through withdrawal at some point. Three times a day, along with your gabapentin and anything else staff will keep on standing orders for you. They won’t make you taper down off non-narcotics like those. And besides, anything’s better than an opioid, right?
Image (cropped) via Vermont Department of Health. Inset graphic (cropped) via United States Drug Enforcement Administration.
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