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

Read More ->

Rationale for cannabis-based interventions in the opioid overdose crisis

This paper presents an evidence-based rationale for cannabis-based interventions in the
opioid overdose crisis informed by research on substitution effect, proposing three important windows of
opportunity for cannabis for therapeutic purposes (CTP) to play a role in reducing opioid use and interrupting the
cycle towards opioid use disorder: 1) prior to opioid introduction in the treatment of chronic pain; 2) as an opioid
reduction strategy for those patients already using opioids; and 3) as an adjunct therapy to methadone or
suboxone treatment in order to increase treatment success rates.

Authors: P Lucas

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

Harm Reduction Journal (2017) 14:58

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

Medicinal Cannabis and Epilepsy – Two New Articles

Two new articles published in Epilepsy Behavior describe the effects of cannabis on the frequency of epileptic seizures in the US and Australia.

Epilepsy Action Australia conducted a nationwide online survey on the use of cannabis-based products for the treatment of epilepsy. 976 responses were obtained. Their results showed that 15% of adults with epilepsy and 13% parents/guardians of children with epilepsy were currently using or had previously used cannabis products to treat epilepsy. 90% of adults and 71% of parents reported reductions in seizure frequency after using cannabis products.

In a US study of 272 epilepsy patients from Washington State and California who used cannabis, a decrease in seizure frequency was also observed.  54% of patients experienced a greater than 50% decrease in overall seizure frequency with 9.5% experiencing no seizures at all. Overall, adverse side effects were mild and infrequent while beneficial side effects such as increased alertness were reported.

These data support the many reports in the literature that show cannabis is useful in decreasing frequency of epileptic seizures.

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

The Current Status of Arisinal Cannabis for the Treatment of Epilepsy in the United States.

Authors: D Sulak, R Saneto, B Goldstein

Epilepsy Behavior 2017 Feb 18 doi:10.1016/j.yebeh.2016.12.032

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

An Australian Nationwide Survey on Medicinal Cannabis Use for Epilepsy: History of Anti-Epileptic Drug Treatment Predicts Medicinal Cannabis Use.

Authors: AS Suraev, L Todd, MT Bowen, DJ Allsop, IS McGregor, C Ireland, N Lintzeris

Epilepsy Behavior 2017 Feb 23 doi: 10.1016/j.yebeh.2017.02.005

Tasty THC: Promises and Challenges of Cannabis Edibles

“Edibles are food products infused with cannabis extract. Edibles come in many forms—including baked goods, candies, gummies, chocolates, lozenges, and beverages—and may be homemade or prepared commercially for dispensaries.”

While there is a place for edibles in the administration of medical marijuana, great care must be taken to determine correct dosage and timing of administration due to the increased behavioral effect of medical marijuana that is eaten verses inhaled. 1 mg of THC that is contained in an edible produces a behavioral effect of 5.71 mg of THC that is inhaled. In addition, the onset of behavioral effects are delayed 60 to 90 minutes when THC is eaten compared to the 20 to 30 minute delay when THC is inhaled.

“Anecdotal reports attribute increased interest in edibles to several perceptions shared by users: (1) edibles are a discreet and more convenient way to consume cannabis; (2) edibles offer a “high” that is calmer and more relaxing than smoking cannabis; and (3) edibles avoid the harmful toxins and health risks that come with smoking cannabis. However, scientific evaluation of the accuracy of these perceptions is incomplete.”

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

Tasty THC: Promises and Challenges of Cannabis Edibles

Authors: DG Barrus, KL Capogrossi, SC Cates, CK Gourdet, NC Peiper, SP Novak, TW Lefever, JL Wiley

Methods Rep RTI Press. 2016 November

Medical Cannabis Relieves Behavioral and Psychological Symptoms of Alzheimer’s Dementia

Abstract.
Background: Tetrahydrocannabinol (THC) is a potential treatment for Alzheimer’s disease (AD).
Objective: To measure efficacy and safety of medical cannabis oil (MCO) containing THC as an add-on to pharmacotherapy, in relieving behavioral and psychological symptoms of dementia (BPSD).
Methods: Eleven AD patients were recruited to an open label, 4 weeks, prospective trial.
Results: Ten patients completed the trial. Significant reduction in CGI severity score (6.5 to 5.7; p < 0.01) and NPI score were recorded (44.4 to 12.8; p < 0.01). NPI domains of significant decrease were: Delusions, agitation/aggression, irritability,
apathy, sleep and caregiver distress.
Conclusion: Adding MCO to AD patients’ pharmacotherapy is safe and a promising treatment option.

Authors: A Shelef, Y Barak, U Berger, D Paleacu, S Tadger, I Plopsky, Y Baruch

Journal of Alzheimer’s Disease (2016) 51: 15 – 19

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

Safety and Efficacy of Medical Cannabis Oil for Behavioral and Psychological Symptoms of Dementia: An-Open Label, Add-On, Pilot Study

 

Cannabinoids in Medical Practice

Abstract
Many patients with chronic medical illnesses use cannabinoids. There are two FDA-approved cannabinoid products,whereas medical marijuana purchased at legal dispensaries is not FDA regulated and may contain uncertain concentrations of various compounds. Cannabinoids have shown efficacy in treating chemotherapy-related nausea and vomiting, poor appetite in advanced HIV, some pain states, and multiple sclerosis-associated spasticity. Recreational cannabinoid use has many known potential serious harms. Physicians should be knowledgeable
about cannabinoids and should inquire with their patients about cannabinoid use. Practical suggestions for clinical approaches are included.

Author:  TB Strouse

Cannabis and Cannabinoid Research (2016) 1:38

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

Cannabinoids in Medical Practice

 

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.