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"I'm so worried about dropping down to 20 mg...I think I feel sick already..."

Is it better to schedule dose reductions so you can prepare for withdrawal symptoms or would you rather stay ‘blind’ to the timing and taper rate to minimize anxiety before reductions?

There’s no right answer to this question, it comes down to personal preference, but some people find that a blind methadone taper reduces anxiety and expectation effects – making the detox process a little easier.

Read on to learn more about:

  1. How a blind taper works
  2. How expectation effects can change your withdrawal experience (like a self-fulfilling prophesy)
  3. The arguments for and against a blind taper
  4. Some general methadone tapering advice

What Is a Blind Taper?

Some people feel anxious before dose reductions. Unfortunately, anxiety and expectations of severe withdrawals can intensify symptoms (like a self-fulfilling prophesy).

To minimize this negative influence, some methadone users request a blind taper. In a blind taper:

  1. Your doctor, pharmacist (and other clinic workers) conceal the timing and rate of dose reductions
  2. Since you don’t know when to expect reductions you worry less - and by worrying less you experience milder withdrawal symptoms.1

Blind tapers are voluntary; you still retain ultimate control – after all, it’s your body and your money:

  • With a blind taper, you should retain control to end the ‘blind’ at any time (to find out your current dosage, dosage schedule and estimated tapering completion date.)
  • You should never forfeit your right to learn your current dose or schedule. This is unsafe (you could need this information for a medical reason) and unethical (you have the right to know what you put in your body.)

How Expectations Can Alter Experiences

Can worries about withdrawal symptoms actually worsen your experience?

Well, expectation effects are powerful and just as placebo pills can ease symptoms, negative expectations can reduce a drug’s efficacy.

To demonstrate this effect, scientists in Munich divided a pool of subjects into three groups. All subjects were given the same potent opiate medication (remifentanil) and then subjected to heat pain while in an MRI machine.

  1. Subjects in one group were told that the medication would work really well to control pain
  2. Subjects in the second group were told that the medication would not control pain
  3. Subjects in the third group were told that the medication would worsen pain

 The Results

  • Subjects who expected significant analgesia during the heat pain experiment reported twice the pain relief as those who expected no analgesia.
  • Though remifentanil is a very strong opiate (roughly 100-200 times more potent than morphine)2 subjects who expected worsened pain experienced no pain relief from the medication.
  • Having a positive expectancy effect increased neural activity in areas of the brain associated with endogenous pain management.
  • Having a negative expectancy effect increased neural activity in the hippocampus, a brain area most commonly associated with memory.

Based on the study results, the researchers recommend factoring a patient’s medication expectations into treatment planning to optimize positive outcomes.3

Blind Dose Reductions – Pros and Cons

Blind Tapering Pros

  • You may feel less anxiety preceding scheduled dose reductions (since you won’t know when they’re coming).
  • Expectation effects could intensify your withdrawal symptoms (see above).
  • Without having to worry about your number, you can focus your energy on developing effective coping strategies and generally getting on with life.
  • You can assess your symptoms objectively – how you really feel vs. how you should feel.
  • Certain numbers, like the 20mg threshold, can provoke significant anxiety. In a blind taper you won’t have to worry about this.

Blind Tapering Cons

  • Instead of anxiety immediately preceding scheduled reductions, with blind dosing some people feel anxiety all the time.
  • You can’t make plans to compensate for temporary upswings in withdrawal symptoms. If you know you’ll be feeling unwell for a couple of days after a scheduled reduction you can plan easier tasks for these days.
  • You don’t get to feel the sense of accomplishment that comes with knowing you’ve ‘mastered' a dose reduction.
  • By retaining control over the process you’re more likely to optimize your tapering plan – such as modifying the rate of taper – to really suit your needs.4

Making a Tapering Plan to Reduce Anxiety

Whether or not you choose a blind taper, to reduce anxiety, you should maximize your control over the process. When discussing options with your doctor or counselor, remember:

  • Never feel pressured to start on a tapering plan – blind or not – before you’re sure you’re ready.
  • Slow tapering plans are more comfortable - for example, 5 mg reductions every 3 to 14 days, slowing as you start experiencing greater symptoms at around 20 mg.5
  • You should retain control. With a blind taper this means knowing that you can stop your taper if or when you choose to, for whatever reason.
  • Before you start, learn how to change to your tapering plan. Who would you talk to? How quickly can changes be made? A good tapering plan should include contingencies for dose reduction slowing or dose increases.
  • Discuss ways to temporarily manage overwhelming withdrawal symptoms, especially if it could take a few days to alter your dosing plan.

The Importance of Counseling during the Taper

Whether you choose blind reductions or not, you are more likely to succeed when you replace medication with other effective coping strategies. If you’re not already involved in psychosocial counseling or support groups, the period of tapering would be a great time (if already late) to start.6

  • You were fine during maintenance - it’s during the tapering phase that you really need counseling again! Use counseling to learn coping strategies and stay emotionally balanced while dealing with increased cravings and withdrawal symptoms.
  • In addition to physical discomfort, methadone tapering can cause an organic mood syndrome of dysphoria (the opposite of euphoria), insomnia and loss of appetite. Counseling and other supports can get you over this motivation-sapping hump.7

If you saw a counselor twice a month during your maintenance phase – you might want to bump that up to a weekly or twice weekly meeting during the tapering phase.

References
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Page last updated Nov 20, 2015

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