Morphine Withdrawal Timelines
According to the United States Drug Enforcement Agency (DEA), morphine is a controlled substance. It is classified as a Schedule II drug, indicating that while it does have significant medicinal uses, it is also a potentially dangerous drug of abuse and likely to result in the development of physical dependence in individuals who use it on a regular basis for more than just a few weeks. The medications placed in this classification are potentially serious drugs of abuse and can be extremely dangerous when used without the supervision of a physician. Anyone who uses morphine can only acquire the drug legally with a written prescription from a physician.Estimates based on survey data collected by the Substance Abuse and Mental Health Services Administration (SAMHSA) show that about 12.5 million people abused some form of narcotic medication in 2015 and approximately 697,000 of individuals in that group abused products that contain morphine, about 6 percent of all individuals abusing narcotic drugs. One such drug of abuse that contains morphine is the drug MS Contin.
Even though the abuse of morphine represents a small percentage of individuals abusing opiate medications, morphine abuses still a significant problem. One of the driving forces that maintains the abuse of drugs like morphine is that individuals develop physical dependence on these drugs rapidly, and this makes it extremely difficult for them to quit the cycle of abuse without professional intervention.
According to sources like the American Psychiatric Association (APA), SAMHSA, and the DEA, physical dependence represents the development of two related syndromes:
- Tolerance: Tolerance is a common occurrence when an individual continually uses a medication or drug. Over time, the individual’s system adjusts to the effects of the drug and the person finds that they need more of the drug (a higher dose) in order to get the effects they once got at lower doses. Tolerance to opiate drugs like morphine often develops rapidly. With repeated abuse, tolerance continues to develop until the individual is taking doses of the drug that would be fatal for individuals who have not developed tolerance.
- Withdrawal: While most drugs taken on a regular basis for more than a few weeks will result in the development of tolerance, withdrawal symptoms represent what many believed to be the most serious manifestation of the development of physical dependence on a drug. When an individual takes certain drugs on a regular basis (e.g., every day), the individual’s system alters its functioning in order account for the presence of the drug in its tissues. This means that certain neurotransmitters, hormones, and autonomic nervous system activities, such as metabolic processes, heart rate, etc., are adjusted over time, such that they only operate efficiently when the drug is present in the system. When an individual abruptly stops using the drug or abruptly cuts down on the dosage, their system is thrown out of balance. This results in numerous negative physical and emotional symptoms appearing. The fastest way for an individual to counter the effects of the withdrawal syndrome is to take their drug of choice.
Withdrawal from Morphine
The withdrawal syndrome from some drugs (e.g., alcohol and benzodiazepines) can produce symptoms that can be life-threatening (e.g., seizures). Withdrawal from opiate drugs does not normally produce these types of symptoms, but the withdrawal process from morphine is extremely uncomfortable, and the individual may have the sensation that they are in great physical danger. In addition, complications associated with the withdrawal process from morphine, such as the risk of becoming severely dehydrated or severely depressed or confused, can lead to situations that can be potentially serious and even fatal.
APA offers diagnostic criteria for withdrawal from opiate drugs, which would include withdrawal from morphine.
- The individual has either stopped or reduced their dosage of an opiate drug (e.g., morphine) that they had been using on a regular basis for a prolonged period, or the individual has been administered an opioid antagonist drug after a period of opiate use.
The individual displays three or more of a group of symptoms that occur within a few minutes to several days after discontinuation of the opiate (e.g., morphine). These symptoms include:
- Nausea or vomiting
- Muscle aches
- Dysphoria (negative mood states, such as depression or anxiety)
- Dilated pupils, sweating, or piloerection (body hair standing erect)
- Teary eyes or runny nose
APA does not specify a specific period of time for the course of the withdrawal process, but does state that it can last from days to weeks. A formal diagnosis of opiate withdrawal requires that the individual’s symptoms cannot be better explained by some other medical condition, medical disorder, or intoxication or withdrawal from some other type of substance (e.g., stimulant medication). The symptoms must cause the individual significant distress or impairment in their functioning.
According to the book Concepts of Chemical Dependency, withdrawal from morphine can present with numerous signs and symptoms that are expressed within the diagnostic criteria of APA. Some of the signs that an individual may be about to express a withdrawal syndrome from morphine or that may occur with the withdrawal syndrome that complement the diagnostic criteria include:
- Extreme restlessness
- Muscle twitching
- A crawling sensation on one’s skin
- Hot and cold flashes
- Pains in the bones and joints
- Anorexia (appetite loss)
- Intense cravings
- An extreme sense of urgency that one should start re-using morphine or they will die
The timeline for withdrawal from morphine can be variable depending on the individual. Some of the factors that can affect the withdrawal timeline include the amount of morphine the individual regularly used, how often they used the drug, whether they mixed morphine and other drugs of abuse, how they took the drug (Injecting the drug, snorting it, or smoking drugs results in significantly more serious withdrawal syndromes than taking the drug orally.), the method that one used when they stopped taking the drug (e.g., abruptly discontinuing it versus gradually tapering down the amount used), differences in individual metabolisms, and the person’s psychological makeup or emotional stability (Individuals with co-occurring mental health disorders, such as depression, anxiety disorders, personality disorders, etc., may display more severe and lengthy withdrawal syndromes than individuals without these co-occurring disorders.).
As a general rule, those who have been using morphine for several weeks or longer will undergo withdrawal processes that typically include three phases:
1. This is often referred to as the acute phase of withdrawal. Some individuals may begin to experience issues with mood swings and jitteriness just a few hours after discontinuing the drug. Most individuals will begin to feel symptoms within 12-30 hours after their last use of morphine.
The most common symptoms that occur in the first phase of withdrawal include nausea, cramps, diarrhea, insomnia, appetite loss, depression, anxiety, and severe cravings. The symptoms typically peak within 36-72 hours, and the first phase will typically last 5-7 days. Once the symptoms peak, they will begin to decline in their intensity.
2. A less intense more prolonged phase of withdrawal will occur after the symptoms have peaked and decreased in their intensity. The second phase will typically last from 1-2 weeks, and symptoms are less intense than in the first phase.
Symptoms include exhaustion, mood swings, chills, cramps, restlessness, sweating, and goosebumps. Cravings will continue, but for most individuals, they will be less intense; however, the experience of a stressful event or being around an environment that is reminiscent of one’s past drug use can increase cravings.
3. The third phase of withdrawal consists of primarily psychological symptoms, such as anxiety, insomnia, restlessness, and depression. Cravings will still intermittently appear. This phase can last for several weeks depending on the individual; however, many individuals in recovery can use techniques learned in therapy to negotiate the effects of this stage and significantly decrease any distress.
Many individuals may find that within 10-14 days the majority of physical symptoms have resolved; however, they still experience some issues with mood, restlessness, insomnia, and cravings. The intensity of the symptoms in the first two phases often results in relapse.
The American Society of Addiction Medicine (ASAM) has been very active in developing protocols to help individuals undergo the withdrawal process with as little discomfort as possible and to significantly reduce relapse rates that occur during the withdrawal period. The strategy typically involves using opioid replacement medications.
With replacement therapy, the medication is administered to the patient by a physician at a dosage that results in the individual not experiencing any withdrawal symptoms. Then, over time, the physician slowly tapers down the dose of the medication to allow the individual’s body to adjust to intermittent decreases in the drug. Eventually, the drug can be entirely discontinued, and the individual has negotiated the withdrawal syndrome without any significant distress or danger.
The most common medications used in the withdrawal management of morphine include:
- Methadone: This drug is also an opiate medication. It has a longer half-life than morphine, meaning that it stays in the system longer, and the effects it produces are not as intense as the psychoactive/euphoric effects of morphine. This allows physicians to use it as a replacement medication for morphine and slowly taper down the dosage. It only needs to be given once a day, and patients can easily be maintained on the drug.
Buprenorphine: This medication is a partial opioid agonist (morphine is a full opioid agonist) that attaches to the same receptors in the brain that morphine does but produces significantly weaker effects. This drug is also administered on a tapering schedule.
The drug Suboxone may also be used. It contains buprenorphine and the opiate antagonist naloxone. The naloxone component is added to guard against abuse of buprenorphine as anyone attempting to grind up the pills and then snort or inject them immediately activates the naloxone, which blocks all effects of opiate drugs and induces an immediate withdrawal syndrome. Naloxone is often used to reverse the symptoms of overdose on extremely dangerous drugs like heroin.
- Naltrexone: This drug may have some utility in reducing cravings for opioid drugs and can be administered with opioid replacement drugs like buprenorphine or methadone. It does not affect the symptoms of withdrawal other than cravings.
- Clonidine: This drug has been used to treat some of the effects of withdrawal from opioid drugs and may be added in the withdrawal management protocol for individuals who still experience some withdrawal effects while on opioid replacement medications.
During the process of withdrawal management or medical detox, individuals will often spend several months tapering down their opiate replacement drug. ASAM suggests specific protocols for withdrawal management; however, there is quite a bit of individual variation in the process.
Individuals undergoing withdrawal management treatment will take longer to get off the drug, but the process will also be much less stressful and far less discomforting. In addition, individuals can initiate a formal substance use disorder treatment program while undergoing withdrawal management, whereas those in the acute stages of withdrawal from morphine may have difficulty participating in formal treatment activities. Thus, it is strongly recommended that anyone who wishes to discontinue their use of morphine or any other opioid medications/drugs first consult with their physician before they stop using the drug. Undergoing a supervised withdrawal management program can make the difference between successful recovery and relapse.
A Final Word
According to SAMHSA, APA, ASAM, and numerous other professional organizations, simply going through the withdrawal process from morphine or just completing a physician-assisted withdrawal management program is not a sufficient approach to recovery. Following the withdrawal process or the completion of a withdrawal management program, individuals need to get involved in treatment programs that include substance use disorder therapy, social support, continued medical management of other issues, and other interventions as determined during an initial assessment in order for them to get on the road to a successful recovery. Not getting involved in a substance use disorder treatment program will inevitably result in relapse.
In addition, after undergoing a withdrawal management program, individuals have significantly less tolerance than they did when they were actively using their drug of choice. This increases their chance for overdose if they do relapse.