By Gregory L. Smith, M.D., M.P.H.
In this class you will learn about the devastating opioid epidemic, the challenges of trying to decrease or discontinue opioids, how to enlist a medical professional to help you overcome these challenges, how to set realistic goals and timeframes to decrease or discontinue opioids, the specific details of what you need to do, day-by-day to achieve your goals, what problems or side-effects can occur, and how to handle them, and what to do if you have a relapse or restart opioids.
I usually like to start patient classes like this with some personal story. However, I think that the horrific stories that we hear about daily in the news, are enough to understand the huge waste in human life that is occurring from this opioid epidemic. For a significant proportion of those people, medical cannabis may be the answer. Let’s learn something, shall we?
The Pain and Opioid Problem:
Over past decade there has been an epidemic increase in both chronic pain and opioid use. As it stands the US has only 5% of the world’s population but uses 80% of the world’s opioid medications.
There has been a 4 fold increase in prescription overdose deaths since 2000. 44 deaths a day. Often these deaths are preventable and due to a patient mistakenly taking too much of their prescribed opioids.
To make matters worse, extensive research has not shown long term use of opioids to be effective for chronic pain. The epidemic is due to a marked changes in physician prescribing practices, stimulated by pharmaceutical company marketing efforts. Recent research suggests that long term use of opioids actually increases the patient’s perception of pain, leading to higher and higher doses of opioids.
Added to this, is the fact that patients are regularly being discharged from doctor’s practice because of positive drug test for illicit substances, often cannabis. These addicted patient end up seeking street opioids to address their cravings. They often end up using heroin, the cheapest, easiest way to obtain illicit opioids. Overdoses of heroin contribute an additional 26 deaths a day.
Opioid Tolerance and Enhanced pain perception:
After injury or surgery the use of opioids for pain relief is very effective. However, with long term use of opioids, especially more than a month of continuous use, several significant problems can and often
do develop. For most of these chronic pain patients, the original source of the pain has improved or healed. However, after being on opioids for only a few months the patients may have developed a physical dependency or addiction to the opioids.
Because of the way long term opioid use changes how we perceive pain, even small amounts of residual pain are being perceived as significant pain. This pain perception is controlled by the opioid pathways of the brain. So that long term use of opioids actually leads to magnified perception of pain.
Another phenomena, is called tolerance. With higher doses of opioids, the opioid receptors become less and less sensitive. So larger and more frequent doses of opioids are necessary to achieve the same level of pain control.
Within a few months, the patient can become physically dependent or addicted to the opioids, so that any attempt to abruptly decrease or discontinue opioids, or even delay in taking the next dose of opioids, can result in the onset of significant withdrawal symptoms. These symptoms, can come on within hours, making them feel very “sick”, and crave any source of opioid, even street drugs.
Here is a summary of the early and later symptoms of opioid withdrawal.
Late symptoms of withdrawal include:
These “sick” patients crave opioids to make the “sickness” go away. This makes it very challenging for someone to voluntarily withdrawal from opioids.
If they continue or restart opioids they often develop further tolerance to the same dose of opioids, so that they need to take more and more opioids to get the same effect.
If someone is successful is tapering off opioids and then weeks or months later takes the same dose of opioids that they were taking before, this can lead to a fatal overdose. During the time that they were entirely off opioids, the tolerance that had developed to opioids, has gone away. The opioid receptors have regained their sensitivity, so the dose that they previously could handle, may be enough to cause fatal respiratory depression. Indeed, most of the 44 deaths a day from overdose of prescription opioids, are probably due to this unintentional overdose. This problem is well known by the drug companies, and several prescription opioids are not permitted to be prescribed unless the patient has already developed a documented tolerance to opioids.
If the risk of fatal overdose is not enough, long term use of opioids cause several severe side-effects. The most common side-effect is intractable constipation associated with abdominal bloating, nausea, and abdominal colic. Decreased testosterone in males and the need for testosterone supplementation is a common side-effect. Also depression commonly occurs with long term use of opioids. These side-effects often require the use of other prescription medications, that can further complicate the management of the chronic pain.
Most research is older, small studies, poor quality.
Recent high quality studies coming out.
Lots of population-based observations
85-94% of medical cannabis patients use it for chronic pain
80% patients regularly substitute medical cannabis for opioid medications
What have we learned so far about medical cannabis, chronic pain and discontinuing opioids:
Unfortunately, there is only a small body of good research on the subject of medical cannabis for chronic pain and opioid withdrawal. However, medical cannabis has been legally available in some states in the US for 20 years, and there are now over 1 ½ million legal medical cannabis patients in the US. Because of this there are some good population studies to tell us how effective medical cannabis can be. Also, unlike the opioids and benzodiazepines, medical cannabis is a very safe medication, with few and easily avoided side-effects and no documented fatal overdoses.
Of the 1 ½ million legal medical cannabis patients in the US, 85-94% of them are using it for chronic pain. These figures may be biased by the fact that “chronic pain” is a subjective condition, and easier to document than other Qualifying Conditions in states with medical cannabis laws. Therefore, people may be faking a chronic pain condition, solely to get cannabis for recreational use.
A study showed that 10-15% of chronic pain patients were using medical cannabis in combination with other pain medications, to reduce amount of pain medications. A remarkable 80% of medical cannabis users report regularly substituting cannabis for their prescribed pain medications.
Medical Cannabis States vs. No Medical Cannabis
34% reduction is fatal opioid overdoses
28-35% reduction in hospital admission for opioid addiction
Marked reduction in Medicare and Medicaid prescriptions for opioids and benzodiazepines
A study from 1999-2010 show a 34% reduction in rate of fatal opioid overdose in states that enacted medical cannabis laws. Another study found a 28-35% reduction in hospital admissions for opioid addiction.
A study of Medicare and Medicaid prescription use showed a marked reduction in the number of pain and anxiety medication prescriptions in those states that had medical cannabis laws.
There is also a recent and growing body of clinical evidence of high quality studies that tell us how effective medical cannabis can be.
Effectiveness of Cannabis for Pain
30% reduction in pain with use of cannabis, about same as with opioids
33-44% increase in pain reduction in patients already using other pain medications
39% stopped and 39% reduced opioid dosage after adding medical cannabis
An analysis of 79 studies found a 30% reduction in pain with use of cannabis. This is about the same percentage reduction seen with the use of opioids.
Another study of pain patients already using opioids, showed an additional 33-44% decrease in pain levels when cannabis was added.
A study in 2016 of chronic pain patients showed that using medical cannabis resulted in 64% reduction in use of opioids, fewer side-effects, and 45% improvement in quality of life measures.
A survey of 542 pain patients, showed that 39% reduced opioid dosage and 39% stopped opioids altogether with the addition of cannabis.
The goal of this class is to help you, with the help of your medical provider, get your dose of opioids significantly reduced and possibly stop using opioids.
Doctor’s resistance to cannabis:
The biggest obstacle to getting help using medical cannabis to decrease or discontinue opioids is resistance from the medical community. This is not something you would want to do without advice, support and monitoring by a medical professional. Unfortunately, over 95% of doctors and nurses have never taken a class, or had real life experience recommending medical cannabis to a patient. They have never learned about the THC, CBD, dosing cannabis or the endocannabinoid system in the body. You are about to learn about these. They are also concerned about the stigma of recommending a “recreational drug.”
In my experience, most physicians that are prescribing opioids and benzodiazepines, will not be willing to help their patients use medical cannabis. If you ask your medical provider for this help and they won’t provide it, there are two good websites available that will help you find a licensed, trained and experienced compassionate medical provider in your area. That medical provider can work with your regular doctor to help you add medical cannabis to your chronic pain treatment.
If you get a separate doctor for the medical cannabis, It is very important, that your regular doctor know what you are doing and agrees to work with you, and the other doctor.
If your medical provider is at all willing to think about the possibility of using medical cannabis, you can refer them to my report, “Using Medical Cannabis for Opiate Sparing and Opiate Tapering in Chronic Pain,” available at .
This report provides a very clear, concise and well referenced discussion on the subject and how to use medical cannabis to help their patients on long term opioids and benzodiazepines.
The following are some recommended sites to find a compassionate medical provider, dispensaries in your area, and to learn about how medical cannabis can help your condition.
This is very important. After starting medical cannabis your urine drug test will become positive for THC, and the doctor providing you with opioid medications needs to understand and agree with this. You and your opioid-prescribing doctor will usually need to sign a new Opioid Medication Contract. The doctor recommending the medical cannabis may also have a similar contract to sign.
Medical cannabis as an adjunct medication:
Several medications are already used to minimize the dose of opioids. These are called “opioid sparing” medications. They spare the amount of opioids necessary for the same amount of pain relief. Opioid sparing medications include NSAIDs (such as Aleve, and Ibuprofen), Tylenol, anti-depressants, and anticonvulsant medications.
Cannabis is also an excellent opioid sparing medication, in my opinion better than those I just mentioned, for a variety of reasons.
Cannabis, in addition to being opioid sparing, reduces many of the symptoms that go along with chronic pain and opioid use, such as joint inflammation, muscle spasm, anxiety, depression, nausea, constipation and poor appetite. .
The goal of adding any opioid-sparing medication is to reduce the level of pain, the side-effects associated with opioids, and decrease development of opioid tolerance with constant need to increase doses of opioids. However, the most important the goal is to decrease number of accidental overdoses resulting in hospitalization or death.
If opioid sparing is successful, then after discussion with your medical provider it may be used to completely withdrawal from all use of opioids.
It is important to understand how the ECS is involved with pain:
The ECS is a huge and vitally important system in the body that was only discovered in the 1990’s. Most doctors have never heard of it, or had a class about how it works. It has the more receptors in the brain, than any other neurotransmitter system, such as dopamine, serotonin, histamine, and acetylcholine. The ECS has the second highest number of receptors in the body, predominantly in the immune system cells, liver, spleen and GI tract.
The ECS has to do the maintaining homeostasis or balance of many systems in the brain and body. It is like the braking system for a wide variety other systems. There are at least two naturally produced chemicals in our body that attach to the receptors of the ECS. These are called endocannabinoids. As far as this class is concerned the ECS puts the brakes on how much pain we perceive in our brain centers, and how much inflammation, swelling and muscle spasm we generate in response to injury or illness.
Cannabis works on pain, and helps spare opioids via several mechanisms, not just the ECS. Cannabis has 100s of ingredients, however, for this class it is important to only think of the two most medically active ingredients, cannabidiol (CBD) and Tetrahydrocannabinol (THC). CBD and THC present in cannabis, mimic the natural endocannabinoids chemicals, and cause the same effects on the ECS as endocannabinoids.
THC and CBD
Keep dose to 10mg
Pain perception in the brain, and spasm
Dose can go into 100mgs
Pain at site of injury/surgery caused by inflammation and swelling
THC, causes euphoria or “getting high.” People who become dependent or ‘addicted’ to cannabis, become dependent on the THC. THC is associated with all of the side-effects from medical cannabis. Because of the issues associated with THC we try to keep any one dose of THC to 10mg or less.
CBD, on the other hand does not cause euphoria. It does not create dependency and is very safe, with minimal risks from even 100s of milligrams several times a day. CBD when taken in balanced doses with THC, blocks most of the side-effects and euphoria caused by THC.
For these reasons, medical cannabis, for pain management purposes, is always a balanced combination of THC and CBD. The most common combination is a ratio of 1:1 CBD to THC. For example, 5mg CBD and 5mg THC.
Some strains of cannabis have lots of CBD and very little THC, such as Charlotte’s Web used to treat kids with intractable seizures. Other strains have lots of THC and very little CBD, such almost all recreational strains of cannabis. In order to have a combination of equal parts THC and CBD, strains need to be combined.
Medical cannabis reduces pain using the ECS. THC works on the centers in the brain and nervous system that recognize and magnify pain perception. THC attaches to cannabinoid receptors and decreases the amount of pain that is perceived. This decreases the amount of opioid necessary to block the pain. There is also some evidence that THC helps reduces muscle spasm, that can contribute to the amount of pain.
CBD works in the body at the site of the injury or where the disease is active. CBD attaches to a different set of cannabinoid receptors at the site of the injury to turn down the inflammatory response. This decreases the amount of painful swelling and inflammation.
After cannabis is inhaled, ingested, or absorbed through the skin, the THC and CBD eventually make it into the blood stream, and once in the blood stream they are rapidly transported around the body and across the blood brain barrier into the brain, where they mimic the effects of the natural endocannabinoids.
Another way cannabis reduces pain and the need for opioids, is by improving how opioids work in the brain. Just as we have natural endocannabinoids in our body that attach to the cannabinoid receptors, there are natural chemicals in the body that are designed to reduce pain by attaching to opioid receptors in the brain. These natural chemicals are called endorphins. So opioid medications, mimic
endorphins. Opioid medications attach to opioid receptors and this results in reduced perceived pain. Both THC and CBD work by helping magnify the effect of opioids. So the person gets decreased pain perception with the same amount of opioid, because THC and CBD magnify the effect the dose of opioid.
Opioid receptors are present in large amounts on the brainstem. Because of this, opioid medications can cause life-threatening respiratory depression, by attaching to these receptors, and making the brain stop sending messages to breath. Cannabis does not attach to these brainstem receptors, so cannabis can be used without the life-threatening issues of respiratory depression.
Acetaminophen is also an opioid sparing medication:
Acetaminophen, commonly known as Tylenol is one of the most commonly used OTC pain medications. In fact many of the opioid medications are a combination of opioid and acetaminophen, such as Lortab, Vicodin, Oxycodone, Percocet and Norco. The acetaminophen is added to the opioid, because of the acetaminophen magnifies the pain relieving effects of the opioid. Again, this is what we call ‘opioid sparing.’
Acetaminophen has been used for over one hundred years but it was not known exactly how it worked in the body. A few years ago it was discovered that when acetaminophen is metabolized in the body, it is turned into another chemical, and it is this chemical that blocks pain by attaching to cannabinoid receptors in the brain, and it also blocks an enzyme resulting in increased natural endocannabinoid activity in the brain. So, acetaminophen works, the same way that THC works, by attaching to certain ECS receptors in the brain that decrease the perception to pain.
Unlike NSAIDs such as Advil and Aleve, or aspirin, acetaminophen has no GI, cardiac or renal side effects. But high doses, especially when taken with alcohol can cause severe liver damage. Because many patient using opioids, often take many opioid pills a day, that also contain acetaminophen, the amount of acetaminophen in each tablet was reduced a couple years ago from 500mg to 325mg. However, many chronic pain patients take up to 8 combination tablets a day, which is still 2,600mg a day of acetaminophen!
Beta-carophyllene, is a terpene chemical, often found in large quantities in some strains of cannabis. It can be considered for opioid sparing as well. It attaches to the ECS receptors on the immune system resulting in decreased inflammatory pain and swelling at the site of injury or disease.
Determining if using medical cannabis for chronic pain and opioid sparing is a good idea for you:
DISCLAIMER: I can’t understate too much how important it is to work with a
trained and experienced physician to determine if you should attempt to decrease or discontinue opioids, by using cannabis. The side-effects of opioid withdrawal can get severe, requiring hospitalization, or sometimes fatal cardiac arrhythmias. The physician may need to prescribe certain potent medications for a short period of time during the initial phases of tapering.
Also some persons should not use cannabis because of an increased risk of psychosis, or developing a dependency on cannabis.
In reality, the plan that I describe below is generally very safe, with minimal risks of psychosis, euphoria or dependency. If successful, the long term benefits of substituting cannabis for opioids for pain control, far exceed the theoretical risks. The program uses a gradual, safe tapering off of the opioids, while systematically substituting low doses of THC and CBD. The rate of opioid tapering is slow, minimizing the chance of withdrawal symptoms. Also, the concomitant use of cannabinoids help reduce risk of tolerance, and reduce dose of opioids if they are abruptly restarted.
Preventing opioid dependency in the first place:
An ounce of prevention is worth a pound of cure. Never has a statement been more true than for the long term use of opioids. Short term use of opioids for acute pain, such as after surgery or injury, is very effective and generally safe, with minimal issues of tolerance, overdose or addiction. However, the longer the “short term” use of opioids continues, the risk quickly grows. A recent study showed that half of patients continued on opioids for more than a month, will still be taking opioids three years later.
Since most pain from surgery or injury requires opioids for only a couple weeks, ongoing use of opioids for longer than two weeks, needs to be questioned. There are plenty of non-opioid pain medications that can control the level of pain after the initial two weeks. Unfortunately opioid medications also causes a pleasant euphoria, making their ongoing use pleasurable for the patient, and if the medical provider is not keeping a close eye of the indications for opioids, he may continue opioids long after they are really necessary for medical purposes. Benzodiazepines, which are often prescribed at the same time as opioids, are also associated with euphoria and are also habit forming, further compounding the risk of life-threatening consequences.
If you are started on an opioid for an acute injury, or surgery, you should advise you doctor that you want to stop opioids and want to use non-opioid pain medications as soon as possible.
The usual medical approach to decreasing or withdrawing from opioids:
I want briefly mention the usual medical approach to decreasing or tapering off opioids. There is the quick method, which usually requires the close medical and nursing supervision only available in a hospital setting for several days. The doctor will use several medications to counteract the sometimes severe withdrawal symptoms associated with “detoxing” off opioids.
A more reasonable approach, is to gradually decrease the dose of prescribed opioids by 20-30% each month, until the patient either can’t tolerate the pain without opioids, or the patient stops opioids altogether and uses non-opioid medications to control the pain. This approach usually takes 3-6 months, and can be effective.
Types of Medical Cannabis:
For simplicity, I will only discuss cannabis for quick relief, and cannabis for long term relief. Just as there are opioid medications that are slowly absorbed, and other tablets that are more rapidly absorbed, different methods of taking the cannabis will change how fast or slow it is absorbed.
The following is a list of the various ways to take medical cannabis.
How to take medical cannabis:
There are several means of getting the THC and CBD into the blood stream:
(1) Inhaling, by either smoking or vaporizing
(2) ingesting, by swallowing extracts, tinctures in teas or edibles
(3) oromucosal absorption, by using an oromuscosal spray or holding tincture under the tongue
(4) skin absorption, by applying cream, salve, or patch.
Taking the first step:
So, you have a medical provider that has helped you obtain medical cannabis. Also, the doctor prescribing you opioids is in agreement with the plan to taper opioids using medical cannabis. You are now ready to start.
In general, the best form of cannabis to start with is in a ratio of CBD to THC of 1:1. It is best to have at least two forms of medical cannabis, one that is slow release such as extracts or edibles, or tinctures in teas. These are for use throughout the day and night and last up to 6 hours. The other form, is a fast release form, such as a vaporizer, tincture held under the tongue, oromucosal spray or smoked bud. These are for breakthrough pain. They work quickly within 20 minutes and only last about an hour.
If it is possible, get a cannabis medication that has a high level of beta-carophyllene. The staff at the dispensary should be able to determine this for you. Remember that beta-carophyllene works on the ECS receptors that have to do with inflammation and swelling.
If you have already been using recreational cannabis, it is advised that you stop all cannabis for 6 days, to clear your cannabinoid receptors off, and left them regulate to a healthy level, before starting this program.
Getting adequate pain relief:
The initial goal of adding medical cannabis is to determine how much of a dose of THC and CBD are necessary to get adequate pain relief. If you are able to get good pain relief without taking the next dose of opioid, then that is a very good indicator. However, you do not want to entirely stop taking opioids if you have been taking frequent doses for a long period of time, as you may have withdrawal symptoms and crave opioids.
The plan is to gradually withdrawal from the opioids, over weeks to sometimes months, using three daily doses of slow release cannabis. If the slow release cannabis dose does not control the pain after 90 minutes, take half the usual dose of opioid medication. The combination of cannabis with half the dose of opioid, usually gives the same amount of relief as taking the full dose of opioid.
A good starting dose is 2.5mg each of CBD and THC, in a slow release formulation, three times a day. This is a low dose, and it would be unusual to have any cannabis side-effects. After 2-3 days at this dose, if it is not giving much pain control, increase it to 5mg each of CBD and THC. Do your best to keep taking the doses at the same time each day to establish a rhythm in your body. This dose can be gradually increased every 2-3 days, to 7.5mg each, then finally 10mg each dose.
After reaching 10mg dose of CBD and THC, the goal is to not increase the amount of THC any further. The next step is to add more CBD, so that you will need to obtain CBD to THC in ratio of 2:1 from the dispensary. With this next ratio, you can increase the amount of CBD, and still keep the THC at 10mg per dose.
The goal at this point is to achieve enough pain relief with the cannabis so that you can consistently take half the opioid dose. After several days of consistent pain control, you can cut the opioid dose in half again, gradually tapering off the amount and frequency of opioid pills. This will result in a natural withdrawal from opioids, and is very unlikely to result in opioid cravings or withdrawal side-effects. Your physician can help you by providing you with lower dose opioid tablets, 5mg and 10mg, instead of 20mg or 30mg. This will make it easier for you to gradually taper down on the number of milligrams of opioids that you are taking each time.
If there is not enough pain control with the cannabis alone, instead of taking the opioid pills, take one 500mg acetaminophen tablet (Tylenol.) Remember, that acetaminophen works by getting converted to a chemical that attaches to the same cannabinoid receptors as THC. So this is a nice way to increase the THC effect, without taking higher doses of THC.
Warning, do not take acetaminophen tablets, if you are also taking opioid pills, as they also have acetaminophen in them. Do not drink alcohol when taking acetaminophen, because of the possibility of liver damage.
Some chronic pain patients will get breakthrough pain as their opioid medications wear off. Because cannabis lasts longer in the body than opioid medications, breakthrough pain may not happen. If you
have intolerable breakthrough pain, between doses of the long acting cannabis, take a small dose of fast acting cannabis, such as one to two hits of a vaporizer, a joint, or 2.5mg of a tincture under the tongue. Give this 20 minutes to work, before you consider taking a fast-acting opioid pill. If you still need to take a fast-acting opioid pill, try breaking it in half, to help with the tapering off opioids.
The higher the dose of the opioid medications, and the more frequent the dosing, the longer this process will take. Be patient. Do not rush. It took a long time to this level of opioid medication, it will take a while to gradually discontinue them.
Problems and pitfalls
Some pain conditions will never respond to only cannabis and non-opioid medications. That is a fact and has to be accepted. The initial goal of decreasing the amount of opioids being taken may be all that you can achieve. However, using cannabis and a reduced dose of opioids, should greatly reduce your chance of unintentional overdose, and significantly improve your mood and opioid-associated constipation and other side-effects.
Tapering off opioids
If it is going well, and you and your doctor are happy with the progress, then tapering entirely off opioids may be a reasonable goal. Continue with the same steps we discussed above, using three daily doses of cannabis, and infrequent fast-acting cannabis for breakthrough pain, until the opioids are stopped entirely.
Tapering off other medications
After discontinuing opioids entirely, you may want to discuss stopping other harmful or dangerous medications that you have been taking for the depression, anxiety, and spasms. You need to work closely with your doctor, building on your previous success, as you gradually discontinue these other medications.
It is possible that you can have a relapse of pain or a craving for opioids or benzodiazepines after you have stopped taking them. This is not uncommon. However, you have now been off these medications, and have lost your tolerance to the high doses that you once were on.
Warning, if you attempt to take high dose pills, as you used to, you could have a fatal unintentional overdose. If you have a craving or want to try an opioid or benzodiazepine, after you have been off them, contact you doctor before taking any medication.
App to help with pain, cannabis and opioids
There are several apps at the iTunes and Google Play that can help you during this process. These apps track your levels of pain, function, medication use (cannabis and opioids) and medication side-effects.
Using these apps will help give you the big picture of how you are doing with your efforts to discontinue opioids. Also, usually there is a print out that you can take into your doctor, to help with decisions about changing your medication.
Community-based Support Groups
Support groups, such as Narcotics Anonymous and SMART Recovery, can be enormously helpful to people addicted to opiates:
Narcotics Anonymous: www.na.org
SMART Recovery: www.smartrecovery.org
The following is a brief summary of the most important points in this class.
Initial goal is to decrease dosage and frequency of opioid pills
If successful, consider quitting opioids altogether
Work closely with the doctor prescribing the opioids, may need a separate doctor for the cannabis
Prevent opioid withdrawal symptoms or craving for opioids, while tapering off
Prevent unintentional overdoses of opioids by restarting opioids after they have been stopped.
About the Author:
My name is Dr. Gregory Smith. I am a Harvard-trained physician, specializing in Preventive Medicine. I have been in practice over 30 years. I first trained on medical cannabis 15 years ago and have used it as part of my practice for many years. I wrote the first science-based textbook for doctors, nurses and medical students on medical cannabis. You can find more information about me, my book and other patient education at www. Cannabis-MD.com.