See also Frequently Asked Questions About Heroin, Morphine, and the Opiates - Heroin/Morphine FAQ

Dose reduction and even total withdrawal is possible as an outpatient (see chapter 17).

Reductions in dose should be done slowly. Even well motivated patients become unmotivated by the withdrawal effects. Getting used to no more heroin injections and flash experiences is recommended as the first step towards abstinence. Possible slow stamping out with changing to peroral methadone or morphinepentasulphate makes the way to total abstinence easier.

Steady-State-Opioid consumption causes a tightening of the spectrum of feelings, a feeling of being packed in cotton wool, without any distinctive highs or lows, pain or depression. With smaller opioid doses (methadone under 30 mg / day) fluctuations in feelings start to appear after many years of steady-state with methadone , which are unusual and had been forgotten. These fluctuations in feeling when the normal bodily and affective sensations return, are interpreted by many patients as unpleasant and they recognise these otherwise for other people, normal daily feelings as withdrawal symptoms.

Himmelsbach already saw (1968) that the physiological changes in the form of excitability, bad moods and restlessness persist for up to two years in ex-drug addicts after a successful withdrawal, and that these patients have regular fall backs. Even when in these patients, there was no difference in motivation in comparison to successful groups of patients, they still failed more often. Himmelsbach guessed that remaining changes in the central nervous system as a consequence of chronic opioid consumption. Persistent and possibly also irreversible adaptation mechanisms were actually found as a on the basis of neurochemical results after withdrawal from nicotine, cocaine but also from opioids (Dani 1996, Kuhar 1996, Smart 1996).

Following are the fastest possible reduction schemes. These are only limit details for the fastest possible process, where considerable withdrawal symptoms can just be avoided. For dose reduction and withdrawals, a slow patient process is recommended. The schemes are suitable for withdrawal treatments as well as for dose reductions or to stamp on and end long term opioid-supported treatments.

Methadone causes a protecting withdrawal syndrome due to it’s long half-life value. The methadone can be reduced fastest at 10-15% daily- or better even slower – following the scheme in Tab.31. Therefore an outpatient withdrawal from methadone is possible without any considerable withdrawal symptoms, within one month.

Whether outpatient withdrawals from opioids with shorter elimination half-life values can be done better with step by step reduction ahs yet to have been proven. Initial experiences with peroral morphinepentasulphate or with DAM-cigarettes point in this direction. But also in these cases, the patient must be made aware of the reappearance of normal fluctuations in the mood and sensitivities when the ‘Opioid-Cotton Wool-Protection’ falls away.

Following the experiences made in the Prove-Projects it is recommended to change to oral preparations for the withdrawal from injecting heroin. With dose reductions in heroin to inject, the subjective flash experience increases at middle doses (with daily doses of 100 to 300 mg). The flash and even the pain of injecting from the needle are undesired cue stimuli when reducing the dose for withdrawal, and they are also secondary reinforcers which test the motivation of the withdrawal and could influence it. Short-lasting oral opioid preparations are best suited for step-by-step dose reduction with the aim of total abstinence.