By Ginevra Liptan, MD *Links may generate a commission for this site
Opioids are important, but imperfect, tools to manage chronic pain. Part of their imperfection is due to the physical dependence they cause with chronic use that can make getting off opioids such a miserable experience. Remember that physical dependence does not indicate addiction, it simply means that withdrawal symptoms will occur if the medications are stopped abruptly. Opioid withdrawal symptoms usually occur within 24-48 hours of the last dose and continue for 4-10 days. The symptoms can include:
Nausea, vomiting, diarrhea
Sweats, chills, fast heart rate
Anxiety, restlessness, insomnia
And the suffering doesn’t necessarily end after the 10 days of acute withdrawal. Some patients experience extended withdrawal symptoms of depression, anxiety and poor focus for several weeks to several months after acute symptoms have subsided. However there are some herbal options that can improve both acute and extended withdrawal symptoms. Discovering CBD, passionflower and corydalis has really revolutionized my medical practice around opioids, and I wish more health care providers and patients knew about these options.
Treating opioid withdrawal
In my clinic, I try to avoid acute withdrawal by slowly tapering dosages, but even with that I often see patients struggle with both physical and mental symptoms of acute withdrawal. Some patients will experience withdrawal with each dosage lowering even during a slow taper. I often prescribe medications to lessen specific symptoms, including anti-nausea medications such as ondansetron and promethazine, anti-diarrheals such as loperamide, and anti-anxiety agents such as clonidine or hydroxyzine. But these medications do little to address the mental and emotional symptoms of acute withdrawal.
Extended opioid withdrawal (also called protracted or subacute withdrawal) can last several weeks to several months after acute symptoms have subsided. Extended withdrawal symptoms occur because it can take months to normalize the molecular brain changes caused by chronic opioid usage. During that time the brain can show mood disturbances such as depression, irritability, anxiety, decreased ability to experience pleasure, and poor focus. Even when you are still on opioids but just go down to a lower dosage, I see some mood-worsening for a few weeks after a dosage reduction until the brain adapts the new levels.
Conventional medicine has very little to offer to treat extended withdrawal other than antidepressants. Since most health care providers and patients are not aware that protracted opioid withdrawal occurs it is rarely recognized or treated. But this is where herbal options can really shine! I have seen great results when continuing CBD plus herbal extracts for a few months after stopping opioids to improve mood and focus and give the brain time to reset.
Herbal Options to Lessen Opioid Withdrawal
The three botanical agents that have research supporting their use in opioid withdrawal are CBD, passionflower and corydalis. Clinically I have been so impressed with these herbs that I developed a tonic to use in conjunction with CBD to make tapering opioids easier.
Cannabidiol (CBD), a non-psychoactive component of cannabis, lowered opioid-seeking behavior in physically dependent rats. In this study CBD showed a long-acting effect, with benefits starting at 24 hours after administration and lasting up to two weeks. The behavioral changes were paralleled by brain alterations in the glutamate and endocannabinoid system. The study authors concluded “CBD may be a potential treatment for heroin craving and relapse”. Another rat study found that CBD activated serotonin receptors in the brain that blocked reward mechanisms around opioids.
Passionflower (Passiflora incarnata) is a flowering vine traditionally used for insomnia and anxiety. One study found that passionflower eased the mental symptoms of opiate withdrawal: “the passiflora plus clonidine group showed a significant superiority over clonidine alone in the management of mental symptoms. These results suggested that passiflora extract may be an effective adjuvant agent in the management of opiate withdrawal.”
Corydalis yanhusuo is also called the Chinese Poppy and is one of traditional Chinese medicine’s chief herbs for relieving pain. Its active ingredient is l-tetrahydropalmatine which was found to improve mood, lessen insomnia and drug cravings, and increase abstinence rates in opioid users.
Of course, talk with your health care provider about your specific case, but here is what I typically do for my patients that I am trying to get off or down to lower dosages of opioids.
Reduce opioid dosage by 5% - 10% every month
Use prescriptions if needed to address any physical symptoms of acute withdrawal
Add CBD 5-30mg up to four times daily
Add Frida Botanicals Herbal Taper Tonic No. 2, start with 0.5ml three times daily, and as you taper down on the opioids, slowly increase up to 2ml three times daily.
If coming completely off opioids, continue CBD and Taper Tonic No. 2 for 2-3 months after stopping to lessen any mood disturbance from extended withdrawal.
As I have said many, many times, until we have better tools I strongly believe opioids must stay in the chronic pain toolkit. Of course, I advocate for using opioids as safely as possible, which means screening for signs of misuse or addiction, using the lowest effective dosage while maximizing non-opioid treatments. But my view is atypical, and many pain patients are being forced to drastically lower or come off opioids as a kneejerk response to the rising rates of opioid overdoses. This has resulted in a new epidemic of undertreated chronic pain, and added the misery of opioid withdrawal to many chronic pain patients lives. My hope is that other health care providers will learn about these herbal options that can lessen the misery of opioid withdrawal.
Author Bio: Ginevra Liptan, MD, developed fibromyalgia while in medical school. She is a graduate of Tufts University School of Medicine and board-certified in internal medicine. Dr. Liptan is the founder and medical director of The Frida Center for Fibromyalgia and the author of The FibroManual: A Complete Fibromyalgia Treatment Guide For You...And Your Doctor and The Fibro Food Formula: A Real-Life Approach to Fibromyalgia Relief.