Extreme difference in withdrawal symptoms

[jersey_emt]

I take morphine sulfate daily for chronic pain. I am prescribed three 60mg MS-Contin per day and 15-30mg MSIR as needed for breakthrough pain (up to 45mg / day). Generally, I only need two of the 60mg MS-Contins and one 15mg MSIR daily, and the rest goes to recreational use. A 'standard' recreational dose is around 200mg, with the MS-Contins crushed of course. All of these numbers are oral dosages.

A couple of times since I stabilized on my current dosage I have run out of meds early, and got to experience opiate withdrawal for a day or two. What is strange is the fact that the onset of withdrawal symptoms and their severity has differed greatly between episodes.

For instance, about two months ago, I ran out of meds 1.5 days early. I started to experience withdrawal symptoms about 12 hours after my last dose, and they quickly escalated and were quite intense by the 36-hour mark when I obtained my refill.

Then, just this week, I ran out of meds, this time 2 days early. I was perfectly fine for over 24 hours, and very mild, almost unnoticeable withdrawal symptoms began to manifest themselves around the 30-hour mark. I was still quite comfortable when I obtained my refill -- 48 hours after my last dose.

Episodes like this are fairly common with me. Sometimes, I feel like absolute hell only 18 hours after my last dose. Other times, even 36 hours after, I am pretty much fine.

What gives? Anyone else experience similar effects?

[RxQueen]

i think that for me, the symptoms vary in intensity each time. the one constant that i've been able to pin down is that if i'm more emotionally unstable than usual when i start into WD's, they end up being way worse. and last longer too. but then again, i tend to be prone to spells of depression in the first place... i just could never understand how my mental state can have such a huge effect on physical symptoms. maybe it's just that i'm more intolerant of the sickness when i'm already off my game. who knows? not me.... either way, WD's suck worse than damn near anything.

[GoddessofRATs]

I don't have an answer for that but my withdrawal is different everytime, it's never the same. Sometimes i have the flu-like withdrawal and other times it's the sweating, anxiety, depression. Everytime it seems like a different degree and intensity. But one thing that is always there for me in withdrawal is darn RLS. I hate that with a passion. It keeps me up all night, it's like torture to me. But, i have found some remedies on the forum for that and i now have xanax to help with that.

I'm not sure why it's different everytime. Maybe it just depends on our systems, how we've been eating, sleeping. Also our emotional state probably can affect wothdrawal. Who knows, but yea i notice it to, it's always different.

Goddessofrats

[AGV10]

Withdrawal syptoms associated with oral morphine often do vary in terms of when the begin after the last oral dose.

The factors that influence it are:

1) stomach contents
- if taken on an empty stomach, contry to what many think, absorbtion is actually slower because:

a) less stomach movement will result in less (read as: slower) distribution of the tablet on the
surface of the stomach and gut to be absorbed.

b) less food in the stomach means less blood supply to the stomach lining - which results in slower
absorbtion through the stomach and gut barrier

c) less food (and the greater the time between taken the tablet and last eating) means less acidity
(actually this last issue is not such a big point as stomach acidity does not play a big role in
breaking down MS Contin - rather it is moisture and enzyms)

2) existing MS Contin in your body - how long your last dose "lasts" is also determined by when you
took it in relationship to the "half life" stage of the preceding dose - also read as how
much was already in your system (from a preceding dose) when you took the last dose.

a) think of it in terms of "half lives" and how much was already in your system - the more that was
there in the first place, the longer it will last - and yes, 200mg can easily carry through 36hrs
before you start to suffer

3) how you took the tablet

a) chew it or crush, and the timed release mechanism is destroyed - making it all avalible for
absorbtion (and if thats what you want, the key here is not to chew it and swallow all at once (it
will coagulate as a soft ball/pellet in your stomach), but to swallow a little bit at a time. Why? -
because absorbtion of MS Contin is VERY dependant on how well it is spread out over the
stomach/gut lining - the more it is spread out the quicker it is absorbed)

And as I think most already know - drink with a glass of grapefruit juice (any high ph type liquid will
do), and the morphine will be absorbed faster - not because of the acidity per say, but because the acidity encourages a whole bunch of enzymes to be released - which stimulates absorbtion.

How to slow down absorbtion? - have or breakfast, lunch or dinner, wait 45 minutes or so most of it to move out of your stomach and fill your gut, then drink a glass of cold milk (the colder the better - milk slows down alot of the enzyms your stomach produces to absorb food ), wait 10 minutes or so, and then swallow the tablet whole.

That all said - sooner or later, no matter how much morphine you have taken or how you took it, it really is only a matter of time before withdrawal catches up - and as I'm sure most of us have experianced at some point in the past, we avoid that by disciplining ourselves to stretch consumption out to last till we get the next refill.

As well - there is no fixed rule as to what is/are the first symptoms of withdrawal (which is the other half of the subject matter of this thread):

You can just as easily start off trying to hide a raging hard-on (in the case of males) as you could be likely to suffer repeated bouts of sneezing. It could also be the dreaded sweats or stomach cramps, but sooner or later most of them will catch up with you. Sleep (and how tired you are when it all starts) has a big effect on how one feels/responds to withdrawal. Food intake is also important (fatty foods should be avoided), as well as liquids (avoid high sugar soft drinks and alcohol). Personaly I have found extended shower time helps a heap (the sensation of the running water - no idea why, but it does help). Anything you can take to relax/knock you out (sedative and/or sleeping pill of somesort) goes a long way as well.

Note*
The above is based on comments made to me by an anethesitist, and bourne out by personal experiance. Over above all this, there is one other important part of withdrawal and how it effects us - it's our pyschological attitude to it (and therein lies the major part of the problem!).

[jersey_emt]

AGV10, thank you for the very insightful and informative response!