MEDICAL CANNABIS: AN ANTIDOTE TO THE OPIOID EPIDEMIC?

Naturopathic Doctor New & Review
In Detoxification Medicine, Pain Medicine

Jamie Corroon, ND, MPH

NATUROPATHIC PERSPECTIVE

In the absence of a few basic statistics, the significance of the opioid epidemic in the United States can be easily underappreciated. In 2015, the most recent year for which the Centers for Disease Control and Prevention (CDC) has published data, over 2 million Americans aged 12 years or older had a substance use disorder involving prescription pain-relievers. This estimate increases to 2.5 million when non-prescription opioids are included.1

Why would non-prescription opioids be included? Almost 80% of heroin users report having used prescription opioids before initiating heroin use.2 And often these individuals have their opioid prescriptions discontinued by concerned physicians after dependence has developed. In a 2014 survey, 94% of respondents reported that they decided to use heroin because prescription opioids were “far more expensive and harder to obtain.”3

In 2015, more than a thousand Americans were treated in emergency departments each day across the country for misusing prescription opioids. That’s more than 365 000 visits for the year. Death by a prescription drug is the #1 cause of accidental death in the United States.4 In 2015, drug overdoses accounted for 52 404 deaths. More than 63% involved an opioid, and more than 15 000 of these deaths involved a prescription opioid.5 Put another way, 91 Americans died each day from an opioid overdose in 2015, 44 of whom died from a prescription opoid.1 In the 17-year period from 1999-2015, the opioid overdose mortality rate, and sales of prescription opioids, increased by 500%, while the prevalence of Americans reporting chronic pain remained stable.6,7

In an effort to address this issue, the CDC issued new guidelines for opioid prescribing in March of this year.8

So, what does this have to do with cannabis?

MEDICAL CANNABIS

In a comprehensive 2017 report entitled “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research,” the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine stated, “There is conclusive or substantial evidence that cannabis or cannabinoids are effective…for the treatment of chronic pain in adults.”9

According to a multitude of surveys, the most common medical reason for using cannabis or cannabinoids (compounds contained in the cannabis plant) is chronic pain.10,11 Survey respondents report that cannabis use is an effective means of managing their pain, both as a solo therapy10 and as an adjunctive therapy when combined with opioids.12,13 They also report substituting cannabis for prescription opioids11,14,15 and reducing their dose of opioids, thereby experiencing a reduction in the associated side effects while also reporting a higher quality of life.13,15

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Cannabis as a substitute for prescription drugs – a cross-sectional study

Abstract:

BACKGROUND:

The use of medical cannabis is increasing, most commonly for pain, anxiety and depression. Emerging data suggest that use and abuse of prescription drugs may be decreasing in states where medical cannabis is legal. The aim of this study was to survey cannabis users to determine whether they had intentionally substituted cannabis for prescription drugs.

METHODS:

A total of 2,774 individuals were a self-selected convenience sample who reported having used cannabis at least once in the previous 90 days. Subjects were surveyed via an online anonymous questionnaire on cannabis substitution effects. Participants were recruited through social media and cannabis dispensaries in Washington State.

RESULTS:

A total of 1,248 (46%) respondents reported using cannabis as a substitute for prescription drugs. The most common classes of drugs substituted were narcotics/opioids (35.8%), anxiolytics/benzodiazepines (13.6%) and antidepressants (12.7%). A total of 2,473 substitutions were reported or approximately two drug substitutions per affirmative respondent. The odds of reporting substituting were 4.59 (95% confidence interval [CI], 3.87-5.43) greater among medical cannabis users compared with non-medical users and 1.66 (95% CI, 1.27-2.16) greater among those reporting use for managing the comorbidities of pain, anxiety and depression. A slightly higher percentage of those who reported substituting resided in states where medical cannabis was legal at the time of the survey (47% vs. 45%, p=0.58), but this difference was not statistically significant.

DISCUSSION:

These patient-reported outcomes support prior research that individuals are using cannabis as a substitute for prescription drugs, particularly, narcotics/opioids, and independent of whether they identify themselves as medical or non-medical users. This is especially true if they suffer from pain, anxiety and depression. Additionally, this study suggests that state laws allowing access to, and use of, medical cannabis may not be influencing individual decision-making in this area.

Authors: Coroon JM, Mischley LK, Sexton M

Clinical Trials, Studies and Publications (click to access):

Journal of Pain Research 2017:10 989-998

Medical Cannabis Decreases Use of Pharmaceutical Agents for Pain, Anxiety and Sleep

Abstract

A prior epidemiological study identified a reduction in opioid overdose deaths in US states that legalized medical cannabis (MC). One theory to explain this phenomenon is a potential substitution effect of MC for opioids. This study evaluated whether this substitution effect of MC for opioids also applies to other psychoactive medications. New England dispensary members ( n = 1,513) completed an online survey about their medical history and MC experiences. Among respondents that regularly used opioids, over three-quarters (76.7%) indicated that they reduced their use since they started MC. This was significantly ( p < 0.0001) greater than the patients that reduced their use of antidepressants (37.6%) or alcohol (42.0%). Approximately two-thirds of patients decreased their use of anti-anxiety (71.8%), migraine (66.7%), and sleep (65.2%) medications following MC which significantly ( p < 0.0001) exceeded the reduction in antidepressants or alcohol use. The patient’s spouse, family, and other friends were more likely to know about their MC use than was their primary care provider. In conclusion, a majority of patients reported using less opioids as well as fewer medications to treat anxiety, migraines, and sleep after initiating MC. A smaller portion used less antidepressants or alcohol. Additional research is needed to corroborate these self-reported, retrospective, cross-sectional findings using other data sources.

Clinical Trials, Studies and Publications (click to access):

Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep.

Authors: BJ Piper, RM DeKeuster, ML Beals, CM Cobb, CA Burchman, L Perkinson, ST Lynn, SD Nichols, AT Abess

J Psycopharmacology 2017 Mar 1 (Epub ahead of print)

Use of Medical Cannabis as a Substitute for Prescription Drugs in Canada

271 patients, enrolled  with the Marijuana for Medical Purposes Regulations in Canada responded to a survey to evaluate the number of patients who substituted medical cannabis (MC) for prescription drugs.  Results are shown in the table below. Medical cannabis patients in Canada are decreasing the use of several classes of proscription drugs by substituting at least part of their drug intake with medical cannabis.

 Percent
63% Substitute for all Rx drugs
30% Substitute for opioids
16% Substitute for benzodiazepines
12% Substitute for anti-depressants
25% Substitute for alcohol
12% Substitute for cigarettes and tobacco
3% Substitute for illicit drugs

Clinical Trials, Studies and Publications (click to access):

Medical Cannabis Access, Use and Substitution for Prescription Opioids and other Substances: A Survey of Authorized Medical Cannabis Patients.

Authors : P Lucas and Z Walsh

Int J Drug Policy (2017) 42:30-35

Cannabis and the Management of Chronic Pain

This review will provide the reader with the foundational basic and clinical science linking the endocannabinoid system and the phytocannabinoids with their potentially therapeutic role in the management of chronic pain.

Abstract

The endocannabinoid system is involved in a host of homeostatic and physiologic functions, including modulation of pain and inflammation. The specific roles of currently identified endocannabinoids that act as ligands at endogenous cannabinoid receptors within the central nervous system (primarily but not exclusively CB 1 receptors) and in the periphery (primarily but not exclusively CB 2 receptors) are only partially elucidated, but they do exert an influence on nociception. Exogenous plant-based cannabinoids (phytocannabinoids) and chemically related compounds, like the terpenes, commonly found in many foods, have been found to exert significant analgesic effects in various chronic pain conditions. Currently, the use of Δ9-tetrahydrocannabinol is limited by its psychoactive effects and predominant delivery route (smoking), as well as regulatory or legal constraints. However, other phytocannabinoids in combination, especially cannabidiol and β-caryophyllene, delivered by the oral route appear to be promising candidates for the treatment of chronic pain due to their high safety and low adverse effects profiles. This review will provide the reader with the foundational basic and clinical science linking the endocannabinoid system and the phytocannabinoids with their potentially therapeutic role in the management of chronic pain.

Authors: PG Fine, MJ Rosenfeld

Rambam Maimonides Medical Journal (2013) 4:1

Clinical Trials, Studies and Publications (click to access):

The endocannabinoid system, cannabinoids, and pain.

Cannabis in Pain Treatment: Clinical and Research Considerations

In this article important considerations in the use of cannabis are presented to better prepare clinicians to care for patients who use if and needed directions for research are identified.

Abstract: Cannabinoids show promise as therapeutic agents, particularly as analgesics, but theirdevelopment and clinical use has been complicated by recognition of their botanical source, cannabis,as a substance of misuse. Although research into endogenous cannabinoid systems and potential cannabinoidpharmaceuticals is slowly increasing, there has been intense societal interest in making herbal(plant) cannabis available for medicinal use; 23 U.S. States and all Canadian provinces currently permituse in some clinical contexts. Whether or not individual professionals support the clinical use of herbalcannabis, all clinicians will encounter patients who elect to use it and therefore need to be prepared to

advise them on cannabis-related clinical issues despite limited evidence to guide care. Expanded
research on cannabis is needed to better determine the individual and public health effects of increasing
use of herbal cannabis and to advance understanding of the pharmaceutical potential of cannabinoids
as medications. This article reviews clinical, research, and policy issues related to herbal cannabis to support
clinicians in thoughtfully advising and caring for patients who use cannabis, and it examines obstacles
and opportunities to expand research on the health effects of herbal cannabis and cannabinoids.
Perspective: Herbal cannabis is increasingly available for clinical use in the United States despite
continuing controversies over its efficacy and safety. This article explores important considerations
in the use of plant Cannabis to better prepare clinicians to care for patients who use it, and identifies
needed directions for research.
ª 2016 by the American Pain Society

Authors: SR Savage, A Romero-Sandoval, M Schatman, M Wallace, G Fanciullo, B McCarberg and M Ware

The Journal of Pain (2016) 17:654-668

 

Clinical Trials, Studies and Publications (click to access):

Cannabis in Pain Treatment: Clinical and Research Considerations

 

 

 

 

Marijuana can help treat opioid addiction, study shows

According to a new study published in Drug & Alcohol Dependencecannabis helped subjects manage withdrawal symptoms while undergoing treatment for opioid dependence—and made them more likely to complete outpatient treatment.

Abstract

“Evidence suggests that the cannabinoid system is involved in the maintenance of opioid dependence. We examined whether dronabinol, a cannabinoid receptor type 1 partial agonist, reduces opioid withdrawal and increases retention in treatment with extended release naltrexone (XR-naltrexone)…The severity of opioid withdrawal during inpatient phase was lower int he dronabinol group relative to placebo group…participants who smoked marijuana regularly during the outpatient phase had significantly lower ratings of insomnia and anxiety and were more likely to complete the 8-week trial.”

Authors: A Bisaga, MA Sullivan, A Glass, K Mishlen, M Pavlicova, M Haney, WN Raby, FR Levin, KM Carpenter, JJ Mariani, EV Nunes

Drug and Alcohol Dependence (2015) 154:38-45

 

Clinical Trials, Studies and Publications (click to access):

The effects of dronabinol during detoxification and the initiation of treatment with extended release naltrexone

THC/CBD, an endocannabinoid system modulator, has demonstrated efficacy in the treatment of Central Neuropathic Pain in patients with Multiple Sclerosis

Abstract

Central neuropathic pain (CNP), pain initiated or caused by a primary lesion or dysfunction of the central nervous system, occurs in ~28% of patients with multiple sclerosis (MS). Delta(9)-Tetrahydrocannabinol/cannabidiol (THC/CBD), an endocannabinoid system modulator, has demonstrated efficacy for up to 4 weeks in randomized controlled trials in the treatment of CNP in patients with MS.

Clinical Trials, Studies and Publications:

Oromucosal delta9-tetrahydrocannabinol/cannabidiol for neuropathic pain associated with multiple sclerosis: an uncontrolled, open-label, 2-year extension trial

Cannabis and Cannabinoids (PDQ®) National Cancer Institute – Questions and Answers About Cannabis

Clinical Trials, Studies and Publications:

 

Cannabidiol (THC:CBD) extract relieved pain in patients with advanced cancer

Abstract

“…study showed THC:CBD extract is efficacious for relief of pain in patients with advanced cancer pain not fully relieved by strong opioids.”

Clinical Trials, Studies and Publications: