Guidelines for
tapering off opioids recommend gradually reducing 5 to 10 percent of the
morphine-equivalent dose every two to four weeks and switching from
immediate-release opioids to extended-release on a fixed schedule
Research shows
15 percent of complex surgical patients develop severe postoperative
pain leading to extended use of opioids. Implementing a transitional
pain program helped nearly half of those who had not used opioids prior
to surgery to wean off the drugs. Among those who had already used
opioids prior to surgery, 1 in 4 was able to quit
To help
patients manage their pain, the program uses a variety of methods,
including nonopioid medications, exercise, acupuncture and mindfulness
training
Opioids killed
33,000 Americans in 2015 and nearly 42,250 in 2016. The death toll is
still trending upward, as overdose cases admitted into emergency rooms
increased by more than 30 percent across the U.S. between July 2016 and
September 2017
Studies show
addiction affects more than 1 in 4 of those using opioids for chronic
noncancer pain, and 1 in 550 patients die from opioid-related causes
within 2.5 years of their first prescription
Opioids, narcotic painkillers, killed 33,000 Americans in 2015,1,2,3 and nearly 42,250 in 2016 — over 1,000 more deaths than were caused by breast cancer that same year4 — and the addiction trend shows absolutely no signs of leveling off or declining.
On the contrary, recent statistics suggest the death toll is still
trending upward, with more and more people abusing these powerful
narcotics. According to the most recent data5
from the U.S. Centers for Disease Control and Prevention (CDC),
overdose cases admitted into emergency rooms increased by more than 30
percent across the U.S. between July 2016 and September 2017. Overdose
cases rose by:
30 percent among men
31 percent among 24- to 35-year-olds
36 percent among 35- to 54-year-olds
32 percent among those 55 and older
Considering opioid overdose is now the No. 1 cause of death of
Americans under the age of 50, it’s quite clear we need safer
alternatives to pain management and more effective ways to wean off
these extremely addictive drugs.
Risk of Addiction Is Very High
Studies show addiction affects about 26 percent of those using opioids for chronic noncancer pain, and 1 in 550 patients on opioid therapy dies from opioid-related causes within 2.5 years of their first prescription.6
Despite the drugs’ high risk of addiction, a 2016 NPR health poll7
indicated less than one-third of people said they questioned or refused
their doctor's prescription for opioids. The most common drugs involved
in prescription opioid overdose deaths include8 methadone, oxycodone (such as OxyContin®) and hydrocodone (such as Vicodin®).
However, as noted by Dr. Deeni Bassam, board-certified
anesthesiologist, pain specialist and medical director of the
Virginia-based The Spine Care Center, “There’s very little difference
between oxycodone, morphine and heroin. It’s just that one comes in a
prescription bottle and another one comes in a plastic bag.”9
Indeed, many addicts find the transition from prescription opioids to street drugs like heroin
to be a relatively easy one. When a prescription runs out, the cost to
renew it becomes unmanageable or a physician refuses to renew a
prescription, heroin, which is often cheaper and easier to obtain than
opioids, is frequently a go-to solution.
Postsurgical Intervention Lowers Patients’ Risk of Opioid Addiction
Unfortunately, many patients are still under- or misinformed about
the addictive nature of these pills, and are often not told how to get
off them. Addiction can occur within weeks of use, and if a patient is
prescribed a narcotic for long-term or chronic pain, addiction is
extremely likely. In one 2016 Canadian study, 15 percent of complex
surgical patients developed severe postoperative pain leading to
extended use of opioids.10
To minimize the risk of addiction, the Transitional Pain Service at
Toronto General Hospital includes follow-up meetings twice a month for
the first two months following surgery, and then monthly meetings for
another four months. As explained by Science Daily, the goal of these
meetings is to “prevent acute pain from becoming chronic post-surgical
pain and taper opioid use or wean to zero if possible.”11
To help patients with their pain, the program uses a variety of methods, including nonopioid medications, exercise, acupuncture and mindfulness training,
the latter of which has been shown to help patients with pain-related
stress and disability, thereby allowing them to successfully wean off
higher doses of opioids.12
In the U.S., Stanford University offers a similar program, called the
Comprehensive Interdisciplinary Pain Program. These kinds of programs
are really crucial, as expecting patients to quit cold turkey is a
recipe for disaster. Many state authorities and insurance companies are
now cracking down on opioid use, restricting how much a doctor can
prescribe.
While this is needed, it leaves long-term opioid users in a pinch.
Many who are now unable to refill their prescriptions receive no
guidance on how to quit or support to help them find other ways to
relieve their pain.
Little Is Known About How to Safely Wean Off Opioids When You’re in Chronic Pain
As noted in Scientific American,13
“ … [T]here’s very little research on how best to taper opioids for
chronic pain patients. For example, although studies show that drugs
such as buprenorphine can help addicts recover, little is known about
their value in the context of chronic pain.”
One scientific review,14
which included 67 studies on tapering opioids for pain patients found
only three of the studies to be of high quality; 13 were found to of
“fair” quality while the rest were weak. Still, the evidence available
suggested that tapering off the dosage does improve both pain and
quality of life.
However, the strongest evidence was for multidisciplinary care with
close patient monitoring and follow-up — methods that are not widely
available and rarely covered by insurance. Scientific American reports:15
“One thing seems clear from research and clinical experience:
Reckless restriction is not the right response to reckless prescribing.
‘Forced tapers can destabilize patients,’ says Stefan Kertesz, an
addiction expert at the University of Alabama at Birmingham School of
Medicine. Worried clinicians such as Kertesz report growing anecdotal
evidence of patient distress and even suicide.
The brightest rays of light in this dark picture come from a
burst of new research. In May a team led by Stanford pain psychologist
Beth Darnall published the results of a pilot study16
with 68 chronic pain patients. In four months, the 51 participants who
completed the study cut their opioid dosages nearly in half without
increased pain.
There were no fancy clinics, just an attentive community doctor
and a self-help guide written by Darnall. A key element was very slow
dose reduction during the first month. ‘It allows patients to relax into
the process and gain a sense of trust with their doctor and with
themselves that they can do this,’ Darnall says.”
Canadian Study Shows Tapering Dosage Post Surgery Helps Many Patients Avoid Long-Term Opioid Use
A study17
evaluating the success rate of Toronto General Hospital’s Transitional
Pain Service found nearly half of those who had not used opioids prior
to surgery successfully weaned themselves off the drugs. Among those who
had already used opioids prior to surgery, 1 in 4 was successful. As
reported by Science Daily:18
“The study followed patients at high risk for developing chronic
pain and problematic opioid use for six months after surgery. In
patients who did not take opioids for a year before surgery, the study
found that 69 percent were able to reduce their opioid consumption, with
45 percent of them being able to stop completely.
Those patients who were taking a prescription opioid before
surgery reduced their opioid use by 44 percent, with 26 percent of them
weaning off completely.
‘The assumption is that all patients after surgery are fine with
their opioid use, but we have found that in a high-risk segment of
patients, that is not the case,’ says Dr. Hance Clarke, director of the
Transitional Pain Service at [Toronto General Hospital].
‘We need better ways of identifying these patients, and then
helping those who are having difficulty in reducing or eliminating their
opioid use. Otherwise, we run the risk of de-escalating patients too
fast and having them look elsewhere for opioids or other drugs if we
don't guide them’ …
One of the strongest predictors in the study of remaining on
opioids long-term after hospital discharge is the dose upon discharge:
the higher the dose, the more likely the patient will remain on opioids
long-term.
For patients who were on opioids before surgery, emotional
distress factors such as anxiety or depression, and pain catastrophizing
— excessive pain-related worry, along with an inability to deflect
thoughts from pain — were important factors in how well these patients
could wean off opioids.”
Guidance on Opioid Tapering
Guidance on opioid tapering published in the March/April issue of the
Canadian Pharmacist Journal includes the following highlights:19
Adult patients with chronic noncancer pain who are on a 90-milligram
(mg) morphine equivalent dose daily or greater should consider opioid
tapering to the lowest effective dose and discontinue use if possible
Other reasons to consider tapering include lack of improvement in
pain and/or function, nonadherence to the treatment plan, signs of
addiction, serious opioid-related adverse effects or patient request
Prescribers are urged to collaborate with pharmacists to support and monitor patients during opioid tapering
A multidisciplinary approach is associated with success in weaning patients off opioids
Benefits of tapering include relief of withdrawal symptoms (e.g., pain, sweating or anxiety), reduction in opioid adverse effects and improvements in overall function and quality of life
The Guideline urges physicians to discuss tapering with their
patients, and to “prepare them by optimizing nonopioid therapy as
appropriate for their pain and comorbidities.” This includes the use of
acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids20 and cannabinoids, just to name a few. The guideline also recommends:
“… [O]ptimizing nonpharmacological therapy and psychosocial
support, setting realistic functional goals, creating a schedule of dose
reductions and frequent follow-up and having a plan to manage
withdrawal symptoms.”
To taper opioids for chronic noncancer pain, the guideline recommends:
Gradually reducing 5 to 10 percent of the morphine-equivalent dose every two to four weeks, with frequent follow-up
Switching from immediate-release opioids to extended-release on a fixed schedule
Collaborating with the patient’s pharmacist to assist with scheduling of the dose reductions
Two alternative methods include doing a medically supervised rapid
dose reduction at a withdrawal center, as withdrawal symptoms can be
severe and/or dangerous, or switching to methadone or buprenorphine
(naloxone), followed by gradual tapering of these drugs.
How Kratom Can Help With Opioid Withdrawal
Two other alternatives I want to address here are kratom and medical cannabis.
It’s a toss-up as to which one is more controversial, but there’s
evidence to support both. In the video above, I interview Christopher
McCurdy, professor of medicinal chemistry at the University of Florida
College of Pharmacy about the use of kratom for pain relief and opioid
withdrawal.
McCurdy, a former postdoctoral fellow in opioid chemistry at the
University of Minnesota under a National Institutes of Health (NIH)
postdoctoral training fellowship, has spent nearly 15 years
investigating how kratom affects opiate addiction and withdrawal, and is convinced it may be of tremendous benefit.
Kratom (mitragyna speciosa) is part of the coffee family, but has a
very different chemistry than coffee beans. It’s been used in
traditional medicine in Thailand and Malaysia for centuries, both as an
energy booster and opium substitute. The plant contains a number of
alkaloids, a primary one being mitragynine, which has opioid activity.
It and many other alkaloids in the kratom plant were recently called
out as opioids by the Food and Drug Administration (FDA) commissioner.
“A lot of people were upset about that at first, but I think they need
to understand that an opioid is any molecule that can interact with
opioid receptors or those proteins in the body,” McCurdy says.
In other words, an opioid is not identical to an opiate, derived from opium poppy,
such as morphine, oxycodone or oxymorphone. Opioid is a generic term
that includes even endogenous endorphins that bind to opioid receptors
in your body. And, while mitragynine has opioid activity, it’s very
different from other opioid molecules.
McCurdy’s research shows that compared to methadone and buprenorphine
(two drugs used to treat opioid addiction and opioid withdrawal),
kratom had a much cleaner profile and was milder in its action. Whereas
buprenorphine and methadone are full agonists or activators of opioid
receptors, mitragynine appears to be only a partial agonist. McCurdy
explains:
“We initially sent out purified alkaloid of mitragynine for a
screen across a whole panel of central nervous system drug targets …
What we found was a really remarkable profile of this molecule.
Mitragynine binds with opioid receptors … but it also interacts with
adrenergic receptors, serotonin receptors, dopamine receptors and
adenosine receptors.
Adenosine receptors are the target for caffeine. It kind of
explains why some of these alkaloids in the plant might cause this
stimulant-like effect. It also interacts with alpha-2 adrenergic
receptors, [which] are … used in opioid withdrawal. Agents that activate
alpha-2 receptors, like clonidine, are used in opioid withdrawal
treatment to stop withdrawal symptoms such as shaking, sweating and
heart racing …
In all honesty, when I got the report back from the company that
screened the molecule, I thought, ‘Wow. We just found nature's answer to
opiate addiction’ because here it was interacting with many of the same
targets that we would target pharmacologically on an individual basis.”
How Kratom Curbs Opiate Addiction
As explained by McCurdy, there are three traditional opioid
receptors: mu, delta and kappa, all three of which are associated with
numbing or dulling pain. In other words, they’re analgesic receptors.
They block or slow pain signal transmissions at the spinal cord level,
so your brain doesn't process the pain signals as much.
The Mu receptor was named for its ability to
interact with morphine. The mu receptor is responsible for the euphoric
effects associated with opiates. It's also primarily responsible for
respiratory depression.
The delta receptor is also a target for selective
analgesics, and does not appear to have as strongly addictive
capabilities as the mu receptor. Unfortunately, the delta receptor is
linked to convulsions, and many drug trials aimed at the delta-selective
opioid receptor had to be halted due to seizures that could not be
resolved. Kratom does not appear to significantly interact with delta
receptors.
The kappa receptor, while good for killing pain,
causes dysphoria or aversion, meaning when you take a compound that
activates kappa, it makes you feel so awful you don’t want to take it
again. For this reason, kappa-activating pain drugs have repeatedly
failed in clinical trials and people don’t want to continue the drug.
Kratom appears to be a partial agonist for all of these receptors,
only weakly affecting delta and kappa. And, while the mu receptor is the
primary target of kratom, animal trials suggest the abuse potential of
kratom is quite low. To learn more, see “Kratom as an Alternative for Opium Withdrawal” or listen to McCurdy’s interview.
Medical Cannabis — Another Effective Pain Reliever That Is Much Safer Than Narcotic Pain Killers
Medicinal cannabis is another effective pain reliever which, unlike narcotic pain killers, cannot kill you.21
The reason a cannabis overdose remains nonlethal is because there are
no cannabinoid receptors in your brain stem, the region of your brain
that controls your heartbeat and respiration.
Statistics bear this out as well. In states where medical marijuana is legal, overdose deaths from opioids decreased by an average of 20 percent after one year, 25 percent after two years and up to 33 percent by years five and six.
In 2010, the Center for Medical Cannabis Research released a report22
on 14 clinical studies about the use of marijuana for pain, most of
which were FDA-approved, double-blind and placebo-controlled. The report
revealed that marijuana not only controls pain but in many cases, it
does so better than pharmaceutical alternatives.
Cannabis has also been shown to ease withdrawal symptoms in those trying to wean off opioids. CNN Health reports23
Dr. Dustin Sulak, a renowned integrative medicine physician based in
Maine, has helped hundreds of patients wean off opioids using cannabis,
as has Dr. Mark Wallace, a pain management specialist and head of the
University of California, San Diego Health's Center for Pain Medicine
who started studying cannabis in 1999 with a state grant.
“He looked at the literature and realized that pot had a long
history of therapeutic use for many disorders including … pain. Within a
decade, there were enough studies to convince him that marijuana was a
real alternative to use in his practice. He estimates that hundreds of
his patients … have been weaned off pills through pot,” CNN reporter Nadia Kounang writes, adding:
“According to the Drug Enforcement Administration, marijuana is a
Schedule I drug, meaning it has no medical use and a high potential for
abuse. ‘We have enough evidence now that it should be rescheduled,’
Wallace said. Sulak wonders, ‘When will the medical community catch up
with what their patient populations are doing?’"
Nonopioid Pain Relievers Work Just as Well as Opioids for Acute Pain
If a person comes to the emergency room with severe acute pain, most
physicians will prescribe them an opioid to relieve pain. However,
research24
published in JAMA suggests opioid-free options may work just as well.
This is valuable information, considering the fact that many get hooked
on opioids when prescribed an opioid for acute pain caused by a sports
injury or oral surgery, for example.
The study evaluated the effects of four different combinations of
pain relievers — three with different opioids and one opioid-free option
composed of ibuprofen (i.e., Advil) and acetaminophen (i.e., Tylenol) —
on people with moderate to severe pain in an extremity due to bone
fractures, shoulder dislocation and other injuries.
The patients had an average pain score of 8.7 (on a scale of zero to
10) when they arrived. Two hours later, after receiving one of the pain
relief combinations, their pain levels decreased similarly, regardless
of which drug-combo they received.
"For patients presenting to the ED [emergency department] with
acute extremity pain, there were no statistically significant or
clinically important differences in pain reduction at two hours among
single-dose treatment with ibuprofen and acetaminophen or with three
different opioid and acetaminophen combination analgesics," the researchers concluded.
Speaking to Vox, the study's lead author, Andrew Chang of the
department of emergency medicine at Albany Medical College, Albany, New
York, said,25
"Some (not all) physicians reflexively think fractures require opioids,
but this study lends evidence that opioids are not always necessary
even in the presence of fractures."
Considering the steep risks involved — even when taken as directed,
prescription opioids can lead to addiction as well as tolerance, along
with other issues like increased sensitivity to pain, depression, low levels of testosterone and more26
— the less you expose yourself to opioids, the better. For a list of
additional suggestions for how to relieve pain without resorting to
opioids, see “Do We Really Need Opioids for Pain?”
Please understand though that although nonopioid pain relievers are
not likely to cause addiction, they are fraught with their own problems.
Tylenol taken even for a few days can cause severe liver and kidney
problems in susceptible people. Taking N-acetyl cysteine (glutathione
precursor) can alleviate many of the problems though.
It is also important to recognize that opioids do have a legitimate
purpose for those in acute pain, but the evidence is beyond overwhelming
that they are being prescribed indiscriminately in many cases as a
result of greedy drug companies and doctors that are paid to prescribe opioids, resulting in tens of thousands dying from addiction.
These numbers are so high that they have actually resulted in a loss
of two years in the average life expectancy of the average American. So,
if you know someone that is on these dangerous medications, do
everything you can to warn and plead with them to get off opioids as
soon as possible.
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