It seems there are two kinds of opioid-using chronic pain patients these days: those whose doctors have abruptly cut them off from their opioids and those who live in fear of it happening to them. Their doctors are fearful too—of the Drug Enforcement Agency (DEA) arresting them for prescribing “too many” opioids, or losing their licenses for similar reasons. “Voluntary” prescribing guidelines published by the CDC in March, 2016 appear to have exacerbated this problem, as many pain patient advocates had warned it would.
Regardless of the arguments for and against the safety and effectiveness of opioids for treatment of chronic pain, abrupt discontinuation of opioids is a cruel and counterproductive practice. After 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, and increasing production of adrenaline to counteract the sedative effects of the opioids. This adaptation is called physical dependency.
Discontinuation of opioids once physical dependency has occurred will result in withdrawal symptoms which will vary in intensity depending on the length of use, dosage and other factors. Physical withdrawal symptoms include: a flu-like sick feeling with runny nose, sweating, chills, nausea, diarrhea, stomach cramps, fatigue, loss of appetite, muscle aches and cramps that can become severe, particularly in the back and legs. Psychological symptoms include anxiety, irritability, insomnia, depression and difficulty concentrating. Cravings for the drug may also be present.
Withdrawal symptoms may begin within 12-24 hours after the last dose of opioids. Severe symptoms last for about a week, after which a pain patient still has to deal with the pain that prompted the opioid prescription in the first place.
What should a pain patient do?
Short term interventions
All the experts I consulted for this article agreed that withdrawal symptoms are time-limited and not life threatening. But, as Dr. Stephen Grinstead, founder of A Healing Place – The Estates, and a chronic pain patient who’s been through opioid withdrawal, noted, “No one’s going to die from it—they just wish they would”.
There are medical interventions and self-care strategies that are helpful in reducing the severity and duration of opioid withdrawal. Dr. Denis Patterson ,of Nevada Advanced Pain Specialists, recommends a medical approach, if available, 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 an opioid and withdrawal from it can also be problematic.
If you have to go through withdrawal on your own, Dr. Patterson recommends the following over the counter medications and self-help strategies that can help with the various 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, meditation, biofeedback, and sleep. Some people may benefit from using antihistamines such as diphenhydramine (e.g. Benadryl). 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 favors 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 feelings 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.
Dr. Grinstead, whose program includes many alternative therapies, recommends a dietary detox cleansing protocol for 5-7 days. He also recommends relaxation and cognitive behavioral therapy because stress intensifies symptoms and exercise for flexibility and mobility to ease the pain of withdrawal.
Acupuncture, massage, aromatherapy and spending time in the sun have also been reported to ease withdrawal symptoms.
Many pain patients have reported 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.
Other pain patients report that kratom, a Southeast Asian herb that is widely available on the internet, has helped them with withdrawal symptoms as well as chronic pain.
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. Most 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 best achieved with a multidisciplinary approach that addresses the underlying causes of the pain and treats the whole person, mind, body and spirit. Safe and effective pain treatments include acupuncture, biofeedback, cognitive behavioral therapy, chiropractic, physical therapy, massage, nutritional and herbal interventions, low level laser therapy, medical marijuana, neurofeedback, homeopathy and many others.
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