By Cindy Perlin, LCSW.
It’s happening more and more every day. Doctors are refusing to write opioid prescriptions, even for patients who have been taking them responsibly for decades, or drastically cutting doses. Some patients who do have prescriptions are finding their pharmacies are no longer willing to fill the prescriptions. It’s cruel and inhumane to do this to pain patients, but no one is listening. What’s a patient to do?
Abrupt discontinuation of opioids throws patients into withdrawal. After only a week or two of administration, the human body adapts to the presence of opioids by reducing its production of endorphins, the body’s natural opioids. Adrenaline production is also increased to counteract the sedative effects of the opioids. This adaptation is called physical dependency.
Once physical dependency has occurred, discontinuation of opioids will result in withdrawal symptoms. Severity of these symptoms will vary depending on how long the drug was used, dosage and other factors. Physical withdrawal symptoms include: a sick flu-like feeling with runny nose, sweating, chills, nausea, diarrhea, stomach cramps, fatigue, loss of appetite, and muscle aches and cramps that can become severe. Psychological symptoms include anxiety, irritability, insomnia, depression and difficulty concentrating. Patients may also experience cravings for the drugs.
Withdrawal symptoms usually begin within 24 hours after the last dose of opioids. Severe symptoms usually last for about a week, after which the patient still has to deal with the pain that the opioids were prescribed to treat.
Minimizing Withdrawal Symptoms
The experts I consulted for this article all agreed that withdrawal symptoms are time-limited and not life threatening. But, as Dr. Stephen Grinstead, a chronic pain patient who’s been through opioid withdrawal and founder of A Healing Place – The Estates, noted, “No one’s going to die from it—they just wish they would”.
I asked the experts about medical interventions and self-care strategies that could be helpful in reducing the severity and duration of opioid withdrawal. Dr. Denis Patterson, of Nevada Advanced Pain Specialists, recommends a medical approach, in an inpatient rehabilitation facility or outpatient addiction treatment program. In these programs, physicians are able to prescribe medication that can ease withdrawal symptoms, including buprenorphine, which helps suppress withdrawal symptoms and cravings. The problem with buprenorphine, however, is that it is also an opioid and withdrawal from it can also be problematic. Some patients report that withdrawing from buprenorphine is more difficult than withdrawing from other opioids. It’s also not widely available due to legal caps on the amount of patients each physician can treat.
Dr. Grinstead prefers Suboxone as a medication to ease withdrawal. Suboxone is a combination of buprenorphine and naloxone. Naloxone blocks the effects of opioid medication, including pain relief and feeling of well-being that can lead to opioid abuse. Patients are usually tapered off Suboxone after 6- 8 weeks but they can be continued on the medication for up to a year.
If you can’t get to a medical program to help with withdrawal, Dr. Patterson recommends the following over the counter medications and self-help strategies that can help with the side effects of withdrawal:
- Nausea/vomiting - Medications that contain the active ingredients bismuth subsalicylate (e.g. Pepto-Bismol) and phosphorated carbohydrate solution (e.g. Emetrol) can help.
- Diarrhea - Medications that contain the active ingredients bismuth subsalicylate (e.g. Pepto-Bismol, Kaopectate) and loperamide (e.g. Imodium) can help.
- Dehydration - Water
- Muscle cramping - Fluids that contain electrolytes (e.g. Gatorade, Pedialyte, etc)
- Agitation - Exercise (e.g. yoga), meditation, biofeedback, and sleep. Some people may benefit from using antihistamines such as diphenhydramine (e.g. Benadry). Antihistamines should be used with caution because in some individuals it can have a paradoxical effect and can worsen their agitation.
Herbal and homeopathic remedies that address the same symptoms are good alternatives. Ginger and homeopathic remedy cocculus indicus can be helpful for nausea. Yellowroot, bayberry, comfrey, peppermint, slippery elm, white willow, black walnut and green tea are helpful for treating diarrhea. Homeopathic remedy ipecac treats both nausea and diarrhea.
Dr. Grinstead recommends a dietary detox cleansing protocol for 5-7 days. Stress intensifies symptoms so Dr. Grinstead also recommends relaxation and cognitive behavioral therapy. Exercise for flexibility and mobility can also ease the pain of withdrawal, according to Grinstead. Acupuncture, massage, aromatherapy and spending time in the sun have also been reported to ease withdrawal symptoms.
Many pain patients have found that marijuana helped them to reduce or eliminate their use of opioids. Some physicians are now using medical marijuana to ease withdrawal as well as for long term pain management Dr. Gary Witman of Canna Care Docs in Massachusetts reports he has helped many patients withdraw from opioids through a one-month tapering program using marijuana. Canna Care Docs is a network of facilities that certify patients for medical marijuana in Arizona, Delaware, Maryland, Washington D.C., Massachusetts, Maine, New Hampshire, New York and Connecticut.
CBD oil, derived from hemp, is being used by many pain patients to reduce withdrawal and manage pain over the long term. CBD is a key pain relieving ingredient in both marijuana and hemp. CBD oil is legally available in all states.
Other patients are reporting that kratom, a Southeast Asian herb, is very helpful for easing withdrawal symptoms as well as managing chronic pain. Kratom is widely available on the internet.
WARNING: Be very careful about restarting opioids if you have gone through withdrawal. Withdrawal reduces tolerance to the drugs, so patients who have just gone through withdrawal can overdose on a much smaller dose than they used to take. A large percentage of opiate overdose deaths occur in people who have just detoxed.
The Long Haul
Once you have gotten through withdrawal, the problem of how to treat the pain remains. Many patients are surprised that their pain levels without opioids are not as severe as they expected. This is due to many factors. Pain is exacerbated when opioids wear off between doses, a phenomenon known as rebound, leading the patient to believe the baseline level of pain without medication is higher than it actually is. Pain is also exacerbated by withdrawal, as already noted. In addition, as the level of opioids introduced into the body is reduced, the body starts producing more of its own natural (endogenous) opioids. And, lastly, some opioid users develop a condition called hyperalgesia, where use of opioids actually creates more pain and stopping opioids relieves pain.
Long term management of chronic pain is most successful with a multidisciplinary approach that addresses the underlying causes of the pain and treats the whole person, mind, body and spirit. There are many safe and effective pain treatments including acupuncture, biofeedback, cognitive behavioral therapy, chiropractic, physical therapy, massage, mind/body medicine, nutritional and herbal interventions, low level laser therapy, medical marijuana, neurofeedback, homeopathy and more. Learn about these treatments and find the ones that work best for you.
Although loss of access to opioids can be a devastating blow, don’t lose hope! Many formerly opioid dependent patients have found strategies that actually work better for them than opioids. Read some of their stories HERE.
Cindy Perlin is a Licensed Clinical Social Worker, chronic pain survivor, the creator of the Alternative Pain Treatment Directory and the author of The Truth About Chronic Pain Treatments: The Best and Worst Strategies for Becoming Pain Free.