Dr. Pam Squire (biography and disclosures)
Disclosures: Dr. Squire has received financial support from the following companies within the last 2 years: Speakers Bureau/Honoraria: Eli Lilly, Pfizer, Purdue. Consulting Fees: Eli Lilly, Pfizer, Purdue, Astra Zeneca.
What I did before
I am often referred patients who are on high dose opioids but who present with pain scores of 9-10/10 with little functionality. When I tried to explain to them that it seemed like the opioid was no longer working for them, a (somewhat small) group of them would agree but most would disagree. Many (but not all) in the second group would admit to missing a dose of opioid, intentionally or not, notice that their pain would significantly increase and then also notice that when they eventually took the missed dose, their pain would improve. This lead them to conclude that the opioid was “taking the edge off” their pain and made it difficult to convince them to try an opioid reduction. It was also hard to come up with a satisfying answer to the inevitable question “What do I take for the pain then, if I can’t take these?”
What changed my practice
When I realized that many people were mistaking the pain of withdrawal as their usual pain and when they took the missing dose, although they assumed their pain improved because the opioid was relieving their pain, it was more often just relieving the pain associated with the induced withdrawal. Almost 100% of people who take opioids regularly for more than a few weeks will develop withdrawal symptoms when they stop them. In a person with chronic pain, one of the very first symptoms of opioid withdrawal is increased pain. It can be the same pain they are being treated for, as well as total body joint and muscle pains. This can be confusing to everyone.
What I do now
I explain that I suspect that they are actually coping with their pain right now without the help of an opioid. They just don’t realize it. I explain the theory above. I tell them that if I am right, their pain will flare the first week after reducing, but by the second week it will go back to where it was. I then give them some reading information (see below) and write three prescriptions. The first is a three month prescription that reduces their opioids by no more than 10% every 2 weeks. The pills are dispensed every two weeks so they don’t get into too much trouble if they use a few extra in the first week. I try to give them 6 cycles to try before I see them again because a social scientist said it can take a while to change somebody’s paradigm.
Then, if they don’t have any contraindications (like significant cardiac disease or a history of psychosis or paranoia secondary to cannabinoids), I write a prescription for Cesamet 0.25 mg (not nabilone- only brand name is covered at this dose) and suggest they try one at night first, which can be gradually increased to a maximum dose of .5 mg tid (experienced cannabinoid users can go up to 1 mg TID) for withdrawal associated nausea, vomiting, anxiety, insomnia and pain. It’s much safer than benzodiazepines, has no street value and can be stopped abruptly without withdrawal. I also write a prescription for clonidine 0.1 mg ½ to 1 bid prn sweating. The withdrawal symptoms can last up to 3 months after the last dose and the last few milligrams often cause the worst withdrawal symptoms.
Additional reading with references
- Managing Opioid Withdrawal – Information for Physicians, Dr. Roman D. Jovey, M.D. (View)
- Managing Opioid Withdrawal – Information for Patients, Dr. Pam Squire & Dr. Roman Jovey 2013 (View)
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I mostly do this as you have described – but I love the handout. That is a gem and I will add that to what I do. Many thanks, J
I use Dr Squire’s approach to withdrawing patients from opioids when these agents are ineffective or harmful.
I work in a tertiary interdisciplinary pain clinic and find that most patients on high doses of opioids have difficulty contemplating life without opioids, even in the face of poor pain control, poor function and significant side effects.
It is difficult for people to distinguish the pain of withdrawal from the pain of any underlying condition, particularly when they are fearful that their pain may become worse when opioids are withdrawn. Most however are willing to undergo a trial of withdrawal as described by Dr Squire.
I can appreciate Dr Ryder’s concerns about the possible side effects of nabilone. I agree that if a person has experienced these side effects with the use of cannabinoids in the past, this approach might be contra-indicated.
Nevertheless, in the absence of contra-indications, I too have found the short term use of nabilone to helpful in reducing anxiety and improving sleep in people undergoing opioid withdrawal. I have not observed the side effects that Dr Ryder describes in people undergoing opioid withdrawal.
Cannabinoids have a role in the management of neuropathic pain, which is often poorly treated with opioids, they do not cause respiratory depression or worsen central sleep apnoea, and can be stopped without producing their own withdrawal effects.
I am more concerned about the use of benzodiazepines to mitigate anxiety symptoms and insomnia associated with opioid withdrawal.
I think it is also important to realise that opioid withdrawal should not take place as an isolated intervention, but as part of an management plan that considers the person living with pain in a biopsychosocial context and offers a broader range of psychological, social and educational interventions to mitigate pain and its consequences.
Dear Dr Ryder,
Thank you for your comments. I have used nabilone in more than a hundred patients- here is my experience to date. I agree that nabilone has the ability to cause drowsiness (that’s what makes it helpful for the insomnia – one of the worst symptoms of withdrawal to treat and often the last to resolve).Some patients who have felt too fatigued in the daytime have just used it at night, although I have had one patient who had success by taking a very small dose in the daytime (I had it compounded by mixing 5 mg in 50 ml of simple syrup = 0.5mg/5ml.He used 1 ml bid). It can also cause motor impairment – but so do BZD/s, every other drug we use for insomnia, the opioids and even cyclobenzaprine. Most patients can dose it appropriately during the daytime.If they take some extra- at least they are safe as it does not cause respiratory depression and there have never been any reported deaths due to a cannabinoid (unlike BZD which are often prescribed for the same symptoms of withdrawal). Patients with anxiety find it extremely helpful – like BZD’s- they don’t tend to feel sleepy- unless they take too much – and the dysphoria associated with an excessive dose usually prevents this from being a repeat experience. The drug has been around since 1985. To date it has not appeared within the sights of the RCMP/DEA officers as a drug of interest.(Though that may be because they just haven’t discovered yet – it did take them awhile to start abusing gabapentin) That said, to date it does not seem to have the same addiction potential that the plant based cannabinoids do- perhaps this is related to the drug delivery system (it takes 90 minutes to full therapeutic effect). I agree it can and does cause paranoia and psychosis in susceptible individuals but it’s rare that this occurs in a patient who has had experience with cannabis in the past and never had paranoia or psychosis with it then (although that can be dose related) and it seems to be more common to have this effect in adolescents – who are not part of my patient population so I can’t comment on that. One of the most helpful aspects to using nabilone is that it seems to have solved for the problem of “What can I take for my pain while you are pulling me off these opioids?” I am not sure if it’s because the opioid is providing pain relief, in the unique situation of opioid withdrawal mediated pain, or if it just helps them cope better with the pain – but either way in the over 100 patients in which I I have discontinued /reduced opioids and used nabilone, I have never had to prescribe additional analgesics beyond NSAIDS (excepting some acute on chronic pain problems that occurred). I agree it is also possible for cannabinoids to cause depression but again, I haven’t seen it when used to treat withdrawal symptoms. I believe that the worst depression associated with cannabinoids occurred not with a cannabinoid agonist, but the cannabinoid antagonist Rimonabant (which was pulled by Sanofi Aventis just prior it’s launch as a weight loss drug because of this side effect). My friend and colleague Dr Joel Boardman is a pain and addiction expert in Toronto who has also found this to be an extremely helpful drug in his practice. (He just launched a self help website for addition this week – check out opioidrecovery.ca).
I agree with Dr Williamson’s comments regarding the ideal support system for an individual with chronic pain.
Unfortunately the resources for this are already far behind the need making it almost an unrealistic expectation for many patients.
Re the nabilone, apologies for my ignorance but would you mind clarifying this statement for me : “write a prescription for Cesamet 0.25 mg (not nabilone- only brand name is covered at this dose)”. So the brand name is covered but the generic isn’t?
Nabilone is made in 0.25, 0.5 and 1 mg capsules. It is made as the brand name Cesamet and as a generic capsule. PharmaCare covers the nabilone only as a generic tablet for the 0.5 and 1 mg doses. The generic tablet of 0.25 mg is not covered by PharmaCare, only the brand name product, Cesamet is covered at that dose. I am sure this is an excellent reason for this although I am unaware of what it is.
Excellent patient hand-out. Will be useful for reinforcing what we try to communicate to patients during their short office visit. I also appreciate the suggestions for medications for the anxiety and insomnia associated with withdrawal (nabilone, gabapentin and pregabalin). The high rate of death from the combination of opioids and benzodiazepines/sedatives has been well documented in Interior Health. Thanks for this.
Thanks for the summary of your experience Pam. I’ve helped wean patients off opioids using both a slow wean at your suggested rate and with nabilone and clonidine to aid. I’ve used them in the hospital at times as well in acute on chronic pain patients post spinal surgery, which can often be a challenge to manage for the same reasons you outline — patients feeling they need more opioid, not less, especially closer to discharge from hospital when the fear of how they will cope increases. Ironically, the hospital is still one of the most difficult places to change the practice of combining BZD for sleep with high dose opioids.
Thanks for the great article. I have little experience with nabilone. At what point do you discontinue it. I have found that many patients return from seeing pain specialists on cesamet (used for pain and not opioid withdrawal), but don’t have much symptom improvement. Isn’t it also quite expensive?
I agree re: the operant conditioning that occurs with the excellent response of withdrawal -related-increased-pain to narcotics. This is elusive yet obvious and critical to recognize, empathize with and address , rather than feeling that the patient is obstreperous or trying to manipulate or pressure us . I have little experience with the cannabinol analogues but a lot with long-term users of marijuana. I find it a subtly very stultifying drug when used daily . It leads to patients getting stuck blurring out the “big picture ” of their lives, changing and growing. Admittedly In caricature, the whole world becomes narrowed down to ” wow man, look at the light reflecting off the colour of that cool ashtray” rather than: “what am I going to do about my ______ “(fill in the blank: e.g. relationship, finances, smoking, diabetes, housing…..) i.e. not dealing with the difficult, and dare I say developmental challenges that are part of the human condition. So my concern is : is Cesamet any less likely to become the new addiction by providing psychological escape from a different kind of pain?
I am a physician and a chronic pain sufferer who is currently weaning off methadone. As a patient, I was anxious, just as Dr Squire mentioned, of my pain flaring without the help of the opioid. However she is right in that as I decrease the dose, the pain flares briefly and then is back to normal very quickly. I am down to less than a third of my original dose. I have done this by very slow tapering and have not needed to use any adjunctive medication. The one thing that can be communicated to patients is how much better they will feel off the opioid, even if their pain is unchanged. Opioids were very useful for me along my journey as they “got me out of bed” and allowed me to function while I awaited therapies. No other medication did this. However after 3 years and no major therapeutic breakthrough, the efficacy of the opioids was in doubt. When the dose was decreased, I immediately felt much better cognitively, psychologically, my skin dryness and bowels improved dramatically. I was feeling ill from the meds for so long, I had forgotten what it was like to feel normal.