Tapering Off Opioids for Pain Relief with Dr. Gregory Smith
Final notes
Decreasing or quitting opioid medications using medical cannabis.
* The US has 5% of the world's population but uses 80% of the opioid medications prescribed.
* There's been a four-fold increase in prescription opioid deaths since the year 2000, causing over 40 deaths a day, most as a result of a patient taking too much of the opioid medication.
* Research shows that opioids are ineffective for the long-term treatment of chronic pain.
* The epidemic is caused by prescription-writing practices of physicians stimulated by the marketing practices of pharmaceutical companies.
Research has shown the severe problems inherent in current opioid use practices.
- Long-term use actually increases the patient's perception of pain, leading to higher and higher doses of opioids.
- Patients are regularly being terminated by their pain doctors for testing positive for "illicit substances," usually cannabis.
- These opioid-addicted patients end up seeking street opioids to feed their cravings.
- The cheapest street solution is herion.
Overdoses of herion add another 26 deaths a day to the climbing numbers of opioid failure.
Opioid tolerance and enhanced pain perception
- Opioids are useful following surgery or trauma. Short-term use.
- Long-term use brings new concerns.
- After a few months patients develop an addiction to the opioids.
- Perception of pain is enhanced, so that minor pain is percieved as major pain. The patient's mind calls for more opioids.
- Long-term opioid use leads to marked magnification of the pain response.
Tolerance comes into play because over time the opioid receptors become desensitized. Now you need more opioids and more frequent dosing times to achieve the same level of relief.
- After a few months the patient can become so addicted to the opioid medication that discontinuing, or even delaying the taking of a dose, can result in the onset of severe withdrawal symptoms - sickness, pain, undeniable cravings for opioids
Early symptoms of opioid withdrawal
* Anxiety/Agitation
* Muscle aches (profusely, throughout the body)
* Increased tearing for no reason
* Insomnia
* A Clear, Runny Nose
* Sweating for unknown reasons
* Craving opioids
later symptoms of opioid withdrawal
* Intense abdominal pain
* Diarrhea
* Dialated Pupils
* Nausea and vomiting
These sick patients crave the opioids to make the sickness go away, making it difficult for an individual to make the bra peak from opioids on their own.
- If a patient stops and then restarts an opioid regimen they typically require a higher dose to begin again.
A patient who stops opioids successfully and then later starts again on that same dose level can end up dead. During the time away from opioids the tolerance levels reset you won't need as much, so if you take that much it could be fatal.
The side effects they don't advertise
- Severe, intractable constipation, associated with abdominal bloating, nausea, and colic.
- Decreased testosterone in males to the point where it's common for a long-term patient to need hormonal replacement therapy.
- Depression, a common occurance with long-term use.
These side effects call for the use of other prescription medications tha can further complicate the treatment of chronic pain.
There are a million and a half legal medical cannabis patients in the US right now. About 80-90% of them use medical cannabis for chronic pain.
- Chronic pain is a subjective condition, easily faked to get the prescription.
- 10-15% of chronic pain patients are actually using cannabis, in combination with other pain control medications, to reduce the opioid medications.
- 80 % medical cannabis users report regular substitution of cannabis for other prescription pain meds, without their doctor's advice, and it's working for them.
Contrasting medical states with non-medical states
- Study of years between 1999 - 2010 showed a 30% reduction in opioid overdoses in states with medical cannabis laws.
- Another study found 28-30% fewer hospitalizations for opioid addiction in medical cannabis states.
- A study of Medicare and Medicaid patients found a reduction in prescribed pain and anxiety medications in the states with medical cannabis laws.
Studies suggest a patient can expect a 30% reduction in chronic pain using cannabis.
- This is the same effect one can expect from opioids.
- A study of patients already taking opioids found a nearly 30-35% reduction in pain perception when cannabis was added to the regimen.
- A study in 2016 showed that using cannabis resulted in a 65% reduction in the use of opioids, fewer side effects, and a remarkable 45% improvement in quality of life.
- Another stufpdystudy of over 550 pain patients say a 39% reduction in opioids used and
35% quit using prescription pain medications altogether with the addition of cannabis.
The biggest roadblock to using cannabis to reduce or eliminate opioid use is resistance from the medical community.
- Over 90% of doctors practicing in this country have never taken a class on or have any experience recommending cannabis. They're clueless to the biology and chemistry.
- They're concerned about recommending a recreational drug.
- In Dr. Smith's experience, doctors prescribing the opioids and benzodiazepines won't be open to the conversation on cannabis.
- If your doctor won't work with you there are a couple websites that can connect you to qualified, compassionate medical personnel that can work with you and your doctor.
* You'll need to sign a new opioid contract with your pain Doctor as well as possibly one with the cannabis doctor.
Cannabis is an excellent opioid-sparing medication. In Dr. Smith's opinion, better than the standard medications (mostly OTC) typically prescribed or recommended.
- Cannabis, along with being opioid-sparing, will treat a number of symptoms that accompany chronic pain and opioid use, like joint pain and inflammation, muscle spasm, anxiety, depression, nausea, constipation, and poor appetite
The goal of an opioid-sparing medication is to
- reduce the level of pain
- reduce the side-effects associated with opioids
- decrease the development of opioid tolerance and the constant need to increase opioid doses
- decrease the number of accidental overdoses, hospitalizations, and death associated with opioids
After successfully introducing cannabis as an opioid-sparing medication the goal is to get the patient completely off opioids.
***Read Cannabis 101 at
Cannabis-MD for a deeper understanding of how the ECS works with pain.
The ECS is the braking system for a wide variety of other systems in the body. It puts the brakes on
* how much pain we percieve in our brain
* how much inflammation, swelling, and muscle spasm we generate in response to injury or illness
Cannabis helps to spare opioids and to control chronic pain through several mechanisms other than the ECS.
- There are hundreds of compounds found in cannabis.
Dosing is controlled to no more than 10 mg of THC per dose to limit euphoria
CBD is not euphoric, and doesn't cause dependency that we know of, allowing doses of hundreds of milligrams of CBD numerous times a day.
- CBD in proper ratio with THC will temper the euphoric effects of THC.
- Chronic pain dosing is 1:1
THC modulates the way we percieve pain and may be effective in reducing muscle spasm.
CBD works in the periphery, turning down the inflammatory response
- reducing amount of painful swelling and inflammation at the site of injury
Cannabinoids make opioids process more efficiently in the brain
- opioid medications mimic endorphins, and their attachment to endorphin receptors in the brain diminish pain perception
- both THC and CBD work to magnify the effects of opioids
By including cannabis the patient
- gets reduced pain perception
- gets increased relief from opioids at a reduced dose
Opioid receptors are in the brain stem, where life can be swiftly terminated.
- Cannabinoids can't attach to those receptors and there are no eCBRs on the brain stem, so there's no chance of respiratory depression and possibly death.
Tylenol, once ingested, is metabolized in the liver to become another component that attaches to the eCBRs in the brain and decreases pain perception, the same way THC does.
- it also blocks an enzyme that degrades eCBs, increasing the availability of eCBs
- it's opioid-sparing and potentiates the opioids
- has no GI, cardiac, or renal side-effects
-
However, high doses, particularly when taken with alcohol, can cause severe liver damage
Because so many opioids are made with Tylenol included in the formulation, and the fact that many opioid patients take numerous doses a day,
- Federal regulations cut the upper doses of Tylenol OTC from 500 to 325 mg per capsule, but many pain patients take up to 8 combination pills a day.
- Too much Tylenol is being consumed by too many people.
- 8 extra-strength capsules would be 2600 mg a day.
B-Caryophyllenen attaches to eCB2s
- reducing inflammation and inflammatory response
A gradual tapering off of the opioids in concert with a systematic increase of THC and CBD
- slow tapering minimizes the withdrawal effects
- using cannabis reduces tolerance concerns and reduces the opioid dose, if they have to be reintroduced
A recent study showed that patients taking opioids for as little as a month will still be using them three years later.
- Any prescribed use of opioids for longer than two weeks needs to be questioned.
- There are a number of pain meds available that will do at least as good as the opioids, if not more effective.
Because opioids and benzodiazepines cause euphoria they're pleasant for the patient initially, so they keep taking them.
The typical medical approach to opioid withdrawal is detoxification, which requires close medical supervision only available in a hospital setting.
- Potent meds are used to counteract the withdrawal symptoms.
- Such drastic measures are often used for herion withdrawal.
A more gradual approach is used for most opioids
- dropping off 20-30% per month
- until patient can't tolerate the pain without opioids or stops using opioids altogether
This approach usually takes 3-6 months and can be very effective.
It's best to have two types of cannabis, slow release and quick release.
- slow: extracts in edibles, tinctures, etc (through the gut) lasting up to 6 hrs or longer
- quick: vaporizer, tincture used sublingually, spray or smoked (for breakthrough pain), taking effect within 20 minutes and only lasting about an hour
Look for a chemovar high in b-caryophyllen
Before starting this withdrawal a cannabis user is recommended to do the Six-Day Sensitization Protocol to clear the receptors and reset tolerance levels.
Getting Pain Relief: Setting your personal dose of THC
The initial goal is to find the dose of THC and CBD necessary to get adequate pain relief.
- If you're able to get good pain relief without opioids, all the better. This is a good indicator of future success.
- If you've been taking frequent opioid doses over a long time you
don't want to discontinue the opioids cold turkey.
- Do a gradual withdrawal over weeks or months using daily doses of slow-release cannabis.
If the slow-release cannabis dose isn't giving enough relief after 90 minutes
take half the opioid dose.
- This approach will usually give you the same relief you were getting from a whole opioid dose alone.
- Taking the opioid dose along with cannabis in this way three times a day can usually eliminate any withdrawal effects.
A good starting point is 2.5 mg of THC and 2.5 mg of CBD, slow-release, 3 times a day.
- After two or three days, if you're not getting enough relief, increase the cannabinoid dose to 5mg each of THC and CBD.
- Increase every 2 - 3 days in 2.5 mg increments until you're at 10 mg each.
After reaching 10 mg THC/CBD doses the next step is increase the CBD content to - Long-term use actually increases the patient's perception of pain, leading to higher and higher doses of opioids.:1, then 3:1, and finally 5:1.
- The goal here is to increase the cannabinoid doses to be able to control the pain with no more than half the original opioid dose.
After several days of consistent pain control cut the opioid dose in half again, gradually decreasing the dosing times and dose concentrations.
- You're unlikely to have any severe withdrawal symptoms or craving of opioids.
- Your physican can help you by prescribing the opioids in smaller dose tablets. It's easier to drop off small quantities when the pills are 5 or 10 mg instead of 25 or 30 mg.
If you find it difficult to get pain relief without opioids try substituting a 500 mg Tykenol instead of the opioid.
- You'll get the "THC effect" without increasing the THC dose.
- Don't take Tulenol if you're also taking opioids or drinking alcohol to limit the dangers of liver damage.
Breakthrough pain
- Because cannabis lasts longer in the body than opioids, breakthrough pain may not happen.
- If you have intolerable breakthrough pain in between doses of your long-acting cannabis, take a small dose of a fast-acting cannabis, such as 1 or 2 inhallations of a vaporizer, a couple hits of a joint, or 2.5 mg of a tincture applied sublingually.
- Give this 20 minutes to work before taking a fast-acting opioid pill to counter the pain.
- If you need the opioid, try breaking it in half and only taking that much.
The higher your opioid dose and the more frequent you're dosing, the longer this process will take.
Problems and Pitfalls
Some conditions never respond to cannabis or non-opioid medications.
- The goal is to reduce the opioid need as far as is comfortably tolerable for the patient.
Including cannabis will decrease the chance of overdose, improve your mood, and reduce the incidence of constipation and other opioid side effects.
If you stop taking opioids or benzodiazepines and then later get a craving for them, see your doctor. Taking a dose level you used to take before can cause accidental fatal overdose.
Dr. Smith recommends you get an app to track your
- pain level
- cannabis use
- opioid use
- side effects
You can get a printout of the records to take with you for doctor appointments.
Consider a support group of others going through the same process.
SUMMARY
*The initial goal is to decrease the frequency and dose of opioids, with an eye to quitting opioids altogether.
* Work closely with your doctor that prescribes the opioids.
* You may need to get a separate doctor for your cannabis regimen.
* Gradual tapering off of the opioids can spare you the withdrawal symptoms and cravings that usually come with discontinuing opioids.
* You want to reduce the risk of accidental overdose if restarting opioids after they've been stopped.
Q & A Session with Max
The most difficult part of the opioid loop is taking that first step of getting the doctors lined up and on the same page.
- The three of you - cannabis doctor, pain doctor, and you - get the best results if you work as a team.
- The lingering stigma of cannabis makes this step more challenging than it need be, but that's the world we live in.
Beginning doses are 2.5 mg each of THC and CBD, taken through the gut so it's long-acting.
- Although they try to limit THC to 10 mg doses he has seen patients going as high as 15 mg of THC to get the relief they sought.
The advantages of having access to a chemovar that'll give you up to 20 mg CBD, eh? Doesn't it just thrill you to know we're learning to make custom oils? 
Let's have a discussion about "getting high." If you're getting high you're flooding your eCBRs. This doesn't happen in nature, so the supposition is that you're throwing the system out of balance.
- In the ECS the production of endocannabinoids, their attachment and activation of receptors, and their degradation by enzymes happens in a fraction of a second.
- When you take cannabis to get high you have a flood of THC attached to receptors throughout the brain causing euphoria for up to hours.
- Because this doesn't happen in nature Dr. Smith believes this is wrong to subject the ECS to what he apparently sees tolerance buildup as a problem.
- "This is not pain relief by intoxication."
Good point It's pain relief because we turned down the volume on the pain perception.
I wonder if the good doctor has ever used cannabis recreationally?
When you're taking cannabis for pain management you want to avoid euphoria during your treatment phase. This is done by either
- continuious micro-dosing
- balancing the CBD and THC to at least an even ratio.
If you're treating chronic pain and you take too much THC you're working against yourself
- Dr. Smith believes patients are using the euphoria to treat emotional pain. Physical pain, from injury or surgery, is a special category.
- His conclusion is that if you're only treating physical pain, without emotional pain, avoid euphoria.
Why doesn't this come into play with suppositories? Obviously it doesn't. We have members that have pretty much proven this, and more willing to experiment.
I've used balanced ratio chemovars. Some are going to get euphoric when you get up around 10 mg doses. I get euphoric from my 2:1 CBD:THC CBD Critical Cure, and it's about 10-15% CBD. If your looking to eliminate euphoria with doses of THC above 5% in balance with CBD you'd be well advised to start ramping up the CBD.
CBD is an important pat of the pain regimen because
* the entourage effect potentiates the cannabinoids when they're used in concert
* CBD enhances the ECS by blocking the action of the enzymes charged with degrading cannabinoids, allowing the eCBs to circulate
* CBD helps create a more balanced endocannabinoid tone in the brain.
* CBD counteracts the euphoric effects of THC
No one ever approaches the idea that this is in direct contradiction to the explaination just given of instantaneous production, action, and degradation of eCBs. The limitations of a federal chokehold on research in humans.
When GW Pharma tested Sativex internationally through randomized trials they discovered that a 1:1 ratio with low-dose THC mitigates all of the effects politicans want you to believe make cannabis so dangerous
- no one got dependent
- no addiction behavior reported
- no danger in the workplace
It drives me freaking nuts to hear of the "adverse side effects of THC." Give me a fu**ing break.
It's THC that turns down the pain signals sent out from the brain.
All of the studies done on opioids were done for two weeks, the length of time the medications are most effective. It wasn't until a decade ago that the prescribing practices of physicians began changing.
- Previously opioids were for end-of-life conditions or for post-surgery.
- It wasn't until the last couple years, when they were doing studies to show that the opioids could be effective long-term that they discovered the tendency to increase pain perception, the opposite of what they were marketed to do.
- Long-term opioid use causes increased pain.
Pain signalling can be modulated by simply using the power of your mind.
- After a few weeks the tissues are healing, so the cells are quieting. Pain isn't sharp and knife-like, but dull and achy. This is when opioids can begin to ramp up the pain signal.
The most common mistake Dr. Smith sees is the timing of the long-term doses.
- It takes up to 90 minutes before you're going to feel the desired effects.
- When you're in pain 90 minutes can seem intolerably long and there's a great temptation to take an opiod.
- Ex: If you know you usually take your opioid at 9 AM take the cannabis dose by 7:30. In this way the cannabis is active when you'd typically be taking the opioid and you might be able to reduce or possibly skip that opioid dose.
Take 1/2 the planned opioid dose if pain is not reduced to comfortable levels.
Most pain patients on opioids have both slow-release and fast-release pills.
- You mirror this with slow-release cannabis edibles for the base-line meds and fast-release tinctures, bud, or concentrates for breakthrough pain.
- 2 hits from a joint or vape, or 2.5 mg of a tincture under the tongue qualifies as a fast-release dose for breakthrough pain.
- Pain relief will come within 9 - 23 minutes.
Dr. Smith recommends a CBD only vaporizer.
- Get your 30 mg of THC through the edibles in three 10 mg doses and use the CBD vaporizer for breakthrough pain.
Don't forget the value of the 500 mg tablet of Tylenol.
- It'll stimulate the eCBRs in the same way THC will.
- 3 a day is only 1500 mg of Tylenol, a workable dose.
No alcohol
Pain control is the goal. If you can't function as the member of society your life demands - grocery shopping, caring for the children, going to work, etc...you're not getting pain control.
- If you're still in pain and you've reached the 10 mg threshold for THC begin increasing the CBD ratio to 2:1, then 3:1, then 5:1 before you increase THC concentrations.
- The goal isn't to
get to 10 mg of THC, but rather to use it as the upper threshold.
The majority of Dr. Smith's pain patients are using 5 mg in balance 3 times a day.
At 10 mg of THC you begin to feel euphoric. Dr. Smith's contention is that euphoria is a disruption to functionality.
Obviously he hasn't met us.
The worst symptom of opioid withdrawal is opioid craving.
- A patient will do almost anything to get the opioids to feed that craving.
- Cannabis blocks the reward signal triggered by opioids. This works with cocaine, opioids, and gambling. Lol! Anything that triggers the reward system in this way can be tempered by cannabis.
Cannabis tones down the reward response which cuts back on cravings, but it also cuts back on nausea and vomiting, anxiety and agitation at the 1:1 ratio.
Countering the argument that using cannabis as a substitute for opioids is simply substituting one addictive drug for another.
- The GW Pharma studies are indisputable. It tracked several thousand patients on Sativex for a year.
* no dependant behavior was found
* no uncovering of psychosis
* some mild euphoria (wellbeing)
All of the tests done on cannabis were done with recreational cannabis, having at least 25% THC and negligible CBD
- doses were 20-30 mg of THC, multiple times a day
There's no correlation between the studies done by our government and how cannabis is used in the real patient world.
The medical community created this opioid dilemma. This is a step towards repairing the damage.
The most common reason OTC pain relievers are being used is for degenerative arthritis. Headaches are another top use for those meds. Cannabis can be used as a safe substitute for these medications.
There aren't any recommended chemovars, since the gene pool is so polluted. Get test results so you know what's in there.
- Look for b-caryophyllen. Its presence will assist reducing inflammatory response.
- Myrcene brings couch lock, which will interfer with functionality.
Look for low myrcene, high b-Caryophyllene
Initiating the conversation with your doctor
- Bring something from the Internet. It might soften the doctor's stance and encourage further education.
I have a problem with doctors in this day and age who still see cannabis consumers as "potheads," smoking an illicit substance behind your doctor's back. This is 2018. If you're practicing medicine today and haven't taken the time to educate yourself already you're not the doctor I want overseeing my medical care. Just sayin'.
Does long-term cannabis use have any negative side effects?
- There's evidence to suggest that high consumption could negatively impact fetal development, resulting in low birth weight.
Hahaha! I smoked every day of my daughter's pregnancy. She was the larger of the two children I gave birth to. 
- The studies suggesting cannabis can effect IQ were done in the 70s in NZ, with the intent to prove the dangers of cannabis.
Any negative effects presented by research were done with questionable science. The data of the effectiveness of cannabis as a healing herb overwhelmingly overshadows any parinoid percieved problems that've never really materialized.
Finding pro-cannabis doctors : websites.
- WeedMaps.com
- MarijuanaDoctors.com
- Leafly.com
- They can help you find dispensaries too.
Tolerance buildup explained:
- The cells have eCBRs, and when you flood the system with phytocannabinoids they can hang around for long stretches of time.
- After a couple weeks the receptor sites harden (they start off soft and pliable) and sink into the cells. (Going offline)
- It takes about six days, without any external cannabinoid surface activty for the receptors to regenerate, clean themselves up, and resurface.
How long will this withdrawal process take?
Your opioid doctor is the main player in this game. The cannabis doctor is assisting the opioid doctor.
- You and the opioid doctor need to agree on a quit date. This scheduling will depend on how long you've been on opioids, how high the doses are, and what type of opioid you're taking.
- That date can be as close as a month, more likely to be three months, and in some cases will be six months off.
In Dr. Smith's experience 40% of opioid patients may never be able to get completely free of the drugs.
- They will, however, be able to dramatically reduce the opioid dose and mitigate the nasty side effects associated with opioid medications.
Cannabis-MD is a collection of educational materials for medical professionals.
- The site teaches you about the plant, the ECS, how cannabis interfaces with the ECS, and classes on particular disease states and their treatment with cannabis.
Does the good doctor use cannabis, and how?
Yes he does, a CBD-only cream to treat the pain of an old ankle fracture. He says it always amazes him how effectively and quickly it reduces the pain.
I was right. Bet he's never been euphoric with cannabis. Poor kid. 
"Medical Cannabis: Basic Science and Clinical Applications" by Dr. Gregory Smith. A textbook for physicans on what cannabis is and why it's an important therapeutic tool.
Another valuable text by Dr. Smith.
I better put this on my study list. Great find SweetSue, Go Ninja!
