America's Opiate Crisis: How Medical Cannabis Can Help

Dr. Dustin Sulak on a neglected treatment option for opioid addiction: medical marijuana.

BY DR. DUSTIN SULAK ON JULY 25, 2016

Dr. Dustin Sulak on a neglected treatment for opioid addiction: medical cannabis

Dr. Dustin Sulak is the founder and director of Integr8 Health, a network of holistic health clinics specializing in cannabis therapeutics with offices in Maine and Massachusetts. His educational work is featured on Healer.com, a free online patient information resource. This article is adapted from a recent talk given by Dr. Sulak in Portland, Maine, where he discussed the staggering scope of opioid abuse in America and explored a neglected treatment option for opioid addiction: medical cannabis.

Dr. Sulak: The United States is in the midst of an opioid addiction crisis. How big is this problem? Forty-four people in the United States die every day from prescription opioid overdose; the number increases to 78 every day when we include heroin. Almost 7,000 people are treated in emergency rooms in the United States every day for misuse of a prescription opioid.

In 2010, one in 20 people over the age of 12 used opioid medications non-medically or had used it other than as prescribed. Between 1999 and 2010, the sales of prescription opioids quadrupled, and so did the rate of opioid overdose deaths. Enough opioids were prescribed in 2010 to give a one-month supply of 5mg of hydrocodone every four hours to every adult in the United States.

And since then the problem has only gotten worse. One in three prescriptions filled for opioids are currently being abused. The estimated cost of opioid abuse is $56 billion per year. Baby boomers are four times more likely to abuse opioids than millennials. In terms of geography, the states with the worst opioid addiction problem are in the South. But Maine is following closely behind in rates of opioid prescriptions that are filled.

While America claims only 5 percent of the world’s population, we consume 80 percent of the world’s opioids. We’re using opioids far more than any other country—to the extent that some countries actually have trouble accessing opioids for important reasons like post-surgical or end-of-life treatment. Analgesia can be hard to come by in some Third World countries—while we’re using it all up.

In the United States, nearly 50 percent of people who take opioids for more than 30 days in the first year continue to use opioids for three years or longer. Half of them are being prescribed short-acting opioids, the type that Big Pharma opioid manufacturers say is more likely to lead to addiction and abuse. Nearly 60 percent of U.S. patients are taking opiates in combination with other drugs that are known to make the opioids more dangerous, to make an overdose more likely.

The Doctor’s Dilemma

 

 

Prescription opioid abuse and addiction is actually a much bigger problem than heroin addiction in this country. In 2014, for example, there were around 19,000 overdose deaths from opioid prescriptions and around 11,000 overdose deaths from heroin. Many of these heroin users started with prescription opioids.

That year in Maine, where I practice medicine, sixty-nine percent of drug overdose deaths were caused by a prescribed opioid. Maine had the highest per capita prescription rate of long-acting opioids in the United States—more than double the national average. Maine had the most long-term opioids prescribed per capita.

It’s a nationwide problem. Nearly 80 percent of heroin users in the United States reported using prescription opioids before initiating heroin use. And 45 percent of heroin users are currently addicted to prescription opioids. So this problem is largely starting in the doctor’s office.

Adding cannabis to opioids makes the opioids safer. Cannabis can prevent opioid tolerance building and the need for dose escalation. Cannabis can treat the symptoms of opioid withdrawal. And cannabis is safer than other harm reduction options for people that are addicted or dependent on opioids.

 

When a doctor is face-to-face with a chronic pain patient who says, “My pain is worse, the opioids aren’t working, I need more. If I don’t get them I’m not going to be able to go to work, I’m not going to be able to support my family, I’m not going to be able to function”—it’s hard for that clinician to say no, because they don’t have another tool.

Well, in some states with medical cannabis laws, physicians do have other treatment options. But many doctors aren’t aware of this. As a clinician, I see many people suffering with chronic pain and, like other physicians, I want to do something to help them. Fortunately, I have an alternative. I have an option that I know is safe and effective in the treatment of chronic pain.

Adding cannabis to opioids makes the opioids safer. Cannabis can prevent opioid tolerance building and the need for dose escalation. Cannabis can treat the symptoms of opioid withdrawal. And cannabis is safer than other harm reduction options for people that are addicted or dependent on opioids.

Opiates for the Masses

 

 

We’re prescribing so many opioids and consuming so many opioids – but to what extent do these pharmaceuticals actually help with chronic pain? A 2015 review from the Annals of Internal Medicine summarized, “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain in function.” This review analyzed 34 studies on adult chronic pain patients who were using opioids for more than three months. The authors of this review were unable to find a single study that assessed outcomes after one year related to pain, function, or quality of life. There were no studies that compared opioid use for more than a year to placebo or compared opioids to non-opioid treatments or to no therapy.

The article in the Annals of Internal Medicine found no evidence supporting the use of long-term opioids as an effective treatment modality. But the authors did find an increased risk of serious harm associated with long-term opioid use—overdose, fractures, heart attacks, sexual dysfunction. In contrast, the American Academy of Neurology reported in 2014 that an oral cannabis extract can be used to treat chronic neuropathic pain in multiple sclerosis with the highest level of evidence. This is a very particular group of neurologists that rate their evidence on a scale from A to D, and they got category A evidence for the cannabis extract. There have been extensive scientific, randomized controlled trials showing that cannabis oil extract can effectively treat chronic pain.

How do cannabis and opioids work together? What are we seeing in the clinic and how can we explain what we’re seeing? Opioid and cannabinoid receptors are both present in pain areas of the brain. Receptors can be thought of as keyholes. And when the drug – the cannabinoid or the opioid – comes in, it fits into the receptor and it has some effect on the cell, changing its physiology. Opioid and cannabinoid receptors are also both present in other areas of the brain that have to do with addiction and behavior. We know that these receptors talk to each other. And researchers have found that administering opioids and cannabis together results in a greater-than-additive anti-pain effect.

Using cannabinoids and opioids in combination results in a synergistic reduction of pain. There’s peer-reviewed animal research as well as human data to support this. Dr. Donald Abrams treated 21 patients in a hospital setting who were using opioids for chronic pain in quite high doses, and they received cannabis from the National Institute of Drug Abuse, at 3.56 percent THC. For anyone that’s familiar with cannabis potencies, that’s incredibly low potency cannabis. (It would probably be hard to find cannabis with that low a potency, even if you looked for it.) The patients were vaporizing the cannabis three times daily, and their pain significantly decreased by 27 percent. Perhaps if they used a better preparation of cannabis and a more suitable delivery method, they would have gotten even better results than what Dr. Abrams reported in 2011.

Cannabis is Safer

 

 

Can cannabis be used to replace opioids in chronic pain patients? It can certainly be used to enhance the effects of the opioids. A 2016 study surveyed 244 medical cannabis patients in Michigan, where medical cannabis use was associated with an overall 64 percent decrease in opioid use, a decrease in the number and side effects of other medications, and a 45 percent improvement in quality of life. An Israeli study from the same year found that 44 percent of 176 opioid-using patients were able to discontinue opioid therapy entirely seven months after they began smoking cannabis or eating cannabis-infused cookies. They had been given titration instructions—basically start low and gradually increase the amount of cannabis consumed each day.

So, yes, cannabis can be used to replace opioids. But is it safe to use them together? Consider the ratio of the fatal dose to the effective dose of various medications. Heroin has a very narrow therapeutic index. If you were to take five times the dose of heroin that you can use to relieve pain, it could kill you. If you were to take 10 times the dose of alcohol that might get you a little bit relaxed, that dose could kill you. But there’s no lethal dose of cannabis. So what happens when we use cannabis and opioids together? Well, the problem with using too many opioids is that they stimulate opioid receptors in the cardio-respiratory centers of the brain, which can be fatal. This is the part of the brain that controls your heart rate and your breathing. There are virtually no cannabinoid receptors present in these areas of the brain, whereas in the pain areas of the brain there’s a lot of cannabinoid and opioid interactions. This is key: By adding cannabinoids to opioids, we actually get a widening of the therapeutic index. The lethal dose stays the same, but the effective dose goes way down because cannabis potentiates the opiates. So now we’re playing in a much safer range.

Passing a state medical cannabis law on average reduced opioid overdose deaths by 24.8 percent—Journal of the American Medical Association.

 

How about retention of efficacy? One of the biggest problems with long-term opioid treatment is that it stops working. People build up tolerance to opioids, they come back every three to six months saying, ‘I want more, I need more.’ I saw this in my medical training, especially during residency. It was kind of the bane of the primary care provider’s existence. What to do about these patients that we don’t have a better solution for. And every once in a while I’d see a patient that came in on a stable dose of opioids that never asked for an increase – maybe 5mg of oxycodone three times a day for a decade. No change in dosage. So I started to wonder, and I asked why are these patients so different from all the other patients that are taking opioids. I asked the patients and they told me that they were using cannabis in combination with the opioids, that it made the opioids more powerful, the cannabis made it so that these patients didn’t need more.

Once again, there’s solid science behind this. It’s been shown in mice that opioid receptors are actually upregulated in animals that are treated with both morphine and THC (the main psychoactive component of cannabis). This is the opposite of what happens when they’re treated with morphine alone. The mice are able to avoid building tolerance and retain the anti-pain effects of the morphine even when they were given a low dose of THC—a dose so low that on it’s own it wouldn’t relieve pain. But that tiny dose is enough to preserve and potentiate the function of the morphine.

Harm Reduction

 

 

While we would like to imagine that everyone who’s addicted to any substance could successfully get off substances all together, we recognize that that’s not practical. Abstinence just doesn’t work for everyone. So instead of focusing on abstinence, we take a safer substance and use it to replace a more harmful substance. This is the practice of harm reduction.

What are our current harm reduction options for treating opioids? Two main harm reduction approaches for opioids are accepted in mainstream medicine right now. One is Buprenorphine which, when combined with an opioid blocking drug called Naloxone, is sold as Suboxone. And we also have Methadone, although it’s debatable whether Methadone is safer than heroin. A 2014 review in the Cochrane Database assessed the efficacy of these approved heroin substitution options and found that only high-dose Buprenorphine was more effective than placebo in suppressing illicit opioid use. Low dose and medium dose Buprenorphine in trials did not suppress the opioids better than placebo. Methadone maintenance was found to be superior to Buprenorphine in retaining people in treatment.

Sometimes these treatments can help, but they’re not enough. We need something more. So what about cannabis? First of all, cannabis has a much better safety profile than Methadone or Suboxone. There’s no lethal overdose with cannabis. You can have a fatal overdose on Methadone; the same for Suboxone, especially if you’re taking it with a Benzo (like Valium or Clonazepam) or another agent that suppresses cardiorespiratory function. Yet these drugs are often prescribed together.

Cannabis, by comparison, has a lower risk of dependence than any other psychoactive substance. It also has a low risk for abuse and diversion, especially in nonsmokable forms. There’s currently over 30,000 patient years of data, mostly in randomized control trials using a cannabis extract, a sublingual spray called Nabiximols, usually tested for the treatment of pain and spasticity. It’s already approved in 27 countries. In that huge data set, there’s been no evidence of abuse or diversion. That’s really impressive. What’s more, most people who stop using cannabis are able to do so without any formal treatment.

Saving Lives

In 2014, the Journal of the American Medical Association published a study that looked at various interventions to address the opioid problem, to see how many opioid overdose deaths these interventions could prevent. Some states have implemented a prescription drug monitoring program so medical providers can log in, look up a patient, and find out which controlled substances they’ve been prescribed, where and when they filled them, how many pills they got, and so forth. But implementing such monitoring program did not have any significant effect on reducing opioid overdose deaths. Increased state oversight of pain management clinics had no significant effect.

But simply passing a state medical cannabis law on average reduced opioid overdose deaths by 24.8 percent. What’s more, the AMA article reported that each year after the medical cannabis law was passed, the rate of opioid overdose deaths continued to decrease.

We’re currently seeing patients in our clinic who tell us that they’re using cannabis with their opioids to reduce their dose and get off their pain meds. Unfortunately, we’re also seeing patients who are telling us, “My pain management doctor found THC in my urine, and they kicked me out of their practice.” Or, “They cut off my prescriptions abruptly.”

What’s going on here? It doesn’t make any sense. It’s well documented that cannabis is a good replacement for illegal and prescription drugs. There’s a 2015 Canadian survey of 473 medical cannabis patients, 87 percent of them were using cannabis as a substitute for something else—prescription drugs, illicit drugs, or alcohol. Eighty percent reported substituting for prescription drugs; 51 for alcohol; 32 percent for illicit substances. And the reasons they gave were consistent: more effective, less side effects, less risk of dependence and addiction.

“Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain in function.”

 

Cannabis has been shown to improve Naltrexone treatment retention. Naltrexone is an opioid blocking drug. If a person takes Naltrexone, they’re going to be less tempted, hopefully, to abuse opioids because the opioids aren’t going to do anything to them when they take them. A 2009 study found that intermittent cannabis users were staying in that treatment program for 113 days, on average, compared to abstinent users – people who weren’t using cannabis at all—who only lasted 47 days. They also found that intensive behavioral therapy helped those who also used cannabis, but didn’t help the non-cannabis users at all.

Cannabis does something to help patients stay in recovery, to stay out of that addictive chapter of their life and to move on to something new. There’s evidence elsewhere in the scientific literature that suggests cannabinoids can promote neuroplastic changes in the brain, changes literally in the structure of the brain related to new behavior, new thought patterns. That’s exactly what we need to get someone out of that addictive cycle into a new phase of life.

Kicking With Cannabis

In addition to keeping people in treatment, replacing and reducing the opioids, improving the pain relief that opioids provide, and preventing opioid dose escalation and tolerance, cannabis can also treat the symptoms of opioid withdrawal: nausea, vomiting, diarrhea, abdominal cramping, muscle spasms, anxiety, agitation, restlessness, insomnia, and also minor symptoms like runny nose and sweating. Cannabis can treat all of these withdrawal symptoms.

In residency, I learned about a 4-drug cocktail—a muscle relaxant, an anti-hypertensive agent, a diarrhea agent, an anti-nausea agent—we used them all together to get someone through withdrawal, four pharmaceuticals each with their own safety issues. But with cannabis we have a non-lethal herb that can do all of that. Cannabis users experience decreased opioid withdrawal severity.

People often ask, what about the gateway theory? What about getting addicted to cannabis? Aren’t we just replacing one addiction with another? Well, we’ve already discussed harm reduction, but let’s look at how addictive cannabis actually is. According to the National Institute of Drug Abuse, lifetime risk for dependence on cannabis is 9 percent. That’s less than alcohol, opiates or any other drugs of abuse. But that 9 percent figure is exaggerated; it includes people who were in court-mandated treatment programs. Quite a few people who get busted for cannabis are not addicted to it; they’re using it recreationally, or even medically, and because of their legal issues they end up in drug treatment. That skews the numbers.

Medical cannabis should be a first-line treatment for opioid addiction, not a last resort if it’s permitted at all.

Indeed, abruptly ceasing chronic cannabis use can cause withdrawal symptoms. People can become dependent on it. Cannabis withdrawal symptoms include irritability, nervousness, anxiety, anger or aggression, decreased appetite, weight loss, restlessness, sleep difficulty, strange dreams. Symptoms appear one to two days after stopping chronic cannabis use and last at most two weeks. But our patients consistently report that cannabis withdrawal is relatively mild, very similar to caffeine withdrawal.

A 2015 study from the Journal of American Medical Association looked at the data of actual medical cannabis instead of illicit cannabis. Indeed, medical cannabis can have unwanted side effects. But these side effects were typically quite mild and they can be mediated by dosage. So when you use programs like healer.com or when you have a cannabis clinician who knows what they’re doing, they can walk you through how to use cannabis and get the right dosage. It’s possible to use cannabis without any side effects at all. Many of our patients do that.

Enter CBD

The whole conversation around cannabis side effects, cannabis addiction and dependence changes quite a bit with the emergence of CBD-rich cannabis. During the decades of prohibition, cannabis breeders grew strains that had more and more THC [The High Causer] and less and less of the sister cannabinoids because that’s what sells on the black market. People want to buy something that’s pleasantly intoxicating. But recently there’s been a shift, a complete reversal, where people who are medical patients want serious symptom relief, they want the medical benefits, but many people don’t want to get high or impaired.

Significant medical benefits are attributed to a non-intoxicating sister molecule of THC called CBD or cannabidiol. CBD has been shown to reduce the side effects caused by THC and to enhance the benefits of THC. In some animal studies, CBD has been shown to decrease addictive behavior; medical scientists found that the heroin-seeking behavior of self-administering rats decreased when the animals were given CBD.

While CBD is generating a lot of excitement and hope within the medical community, concerns persist about how medical cannabis laws might impact young people. If we pass medical cannabis or adult-use legalization, aren’t more adolescents going to start smoking marijuana? If they perceive cannabis as safe, aren’t they’re going to get into it at a younger age?

Several studies have addressed this question with encouraging results. A 2015 study in the Lancet Psychiatry Journal found, “There is no evidence of a differential increase in past month use in youths that can be attributed to state medical marijuana laws.” And a 2016 study in The International Journal of Drug Policy that found “no evidence for an increase in adolescent marijuana use after the passage of state laws permitting use of marijuana for medical purposes. Concerns that increased marijuana use is an unintended effect of state marijuana laws seem unfounded.”

Patient Survey

 

 

Integr8 Health, my clinic, recently sent a survey to all of our patients and everyone that was one our mailing list. The survey asked basic questions about whether or not they had used opioids for more than three months, if they used the opioids in combination with cannabis, and what happened when they did. We had over 1,000 responders, 48 percent female. Seventy percent of people who responded had used opioids for more than three months in a row. Fifty percent of responders had used medical cannabis in combination with their opioids. Of these, 39 percent had stopped using opioids completely after starting cannabis; 73 percent had sustained the reduction of opioids for over a year; and an additional 39 percent had reduced their dose, but were continuing to use opioids.

That’s big. Thirty-nine percent off opioids entirely and another 39 percent reduced their dose. Forty-seven percent reported a reduction in pain greater than 40 percent. Finding a medication that can reduce pain more than 40 percent—that’s considered very effective in the medical literature. Eighty percent reported improved function; and 87 percent reported improvement in their quality of life.

Luckily in Maine and in other states where medical cannabis is legal, patients with chronic pain have a choice. Cannabis can help them. But there are a lot of people who are dependent on opioids and addicted to opioids who can’t legally access cannabis because medical marijuana isn’t allowed in their state or their state doesn’t include chronic pain or opioid addiction among the conditions for which a physician can recommend cannabis.

States with medical marijuana laws should add opioid addiction to the list of conditions that can be treated with cannabis. And states that have yet to recognize the medical utility of cannabis should revise and update their policy given the extent of the opioid crisis and the considerable scientific and clinical data that highlights the potential of cannabis as a lifesaving treatment for opiate addiction. Medical cannabis should be a first-line treatment for opioid addiction, not a last resort if it’s permitted at all.

In summary, the opioid problem is lethal and growing. Prescription opioid abuse is actually worse than heroin abuse; it’s a bigger problem, and it starts in the doctor’s office. Cannabis can replace and reduce opioid use. Adding cannabis makes opioids safer by widening the therapeutic index. Cannabis can prevent opioid tolerance-building and the need for dose escalation. And cannabis can treat the symptoms of opioid withdrawal. Finally, cannabis is safer than the other harm reduction options.

Key Facts About Cannabis & Opiate Addiction

  • Forty-four people die every day from prescription opioid overdose in America. Almost 7,000 people are treated in emergency rooms in the United States every day for misuse of a prescription opioid.

  • States with medical cannabis laws on average reduced opioid overdose deaths by 24.8 percent. And each year after the medical cannabis law was passed, the rate of opioid overdose deaths continued to decrease, according to a report in the Journal of the American Medical Association.

  • Prescription opioid abuse is actually worse than heroin abuse. In 2014, there were around 19,000 overdose deaths from opioid prescriptions and around 11,000 overdose deaths from heroin. Nearly 80 percent of heroin users in the United States reported using prescription opioids before initiating heroin use.

  • Extensive scientific, randomized controlled trials have shown that a cannabis oil extract can be an effective treatment for chronic neuropathic pain.

  • Cannabis improves the pain relief that opioids provide. Medical scientists have found that administering opioids and cannabis together results in a greater-than-additive anti-pain effect, a synergistic reduction of pain.

  • Cannabis makes opioid therapy safer by widening the therapeutic index so that a patient needs less opioids to get a strong analgesic effect.

  • Cannabis can prevent opioid tolerance building and the need for dose escalation.

  • Cannabis can treat the symptoms of opioid withdrawal—nausea, vomiting, spasms, cramping, insomnia. Cannabis users experience decreased opioid withdrawal severity.

  • Cannabis can replace and reduce the use of opioids and other substances. Many patients use cannabis as a substitute for prescription drugs, illicit drugs, or alcohol.

  • Cannabis therapy is safer than the other harm reduction options.

This piece was reprinted by Project CBD. It may not be reproduced in any form without approval from the source.

Sources

  • Abrams D, et al, “Cannabinoid-opioid interaction in chronic pain,” Clin Pharmacol Ther, Epub 2011 Nov 2.
  • Bachhuber, Marcus A, et al, “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010,” JAMA Intern Med, 2014 Oct.
  • Boehnke KF, et al, “Medical Cannabis Use is Associated With Decreased Opiate Medication in a Retrospective Cross-Sectional Survey of Patients with Chronic Pain,” J Pain, 2016 Jun.
  • Chou, Roger, et al, “The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop,” Annals of Internal Medicine, 17 February 2015.
  • Haroutounian S, et al, “The Effect of Medicinal Cannabis on Pain and Quality of Life Outcomes in Chronic Pain: A Prospective Open-label Study,” Clin J Pain, 2016 Feb 17.
  • Hasin, Deborah S, et al, “Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated, cross-sectional surveys,” The LANCET Psychiatry, July 2015.
  • Koppel BS, et al, “Systematic review: efficacy and safety of medical marijuana in selected neurological disorders: report of the Guideline Development Subcommittee of the American Academy of Neurology,” Neurology, 2014 April 29.
  • Lucas, Philippe, et al, “Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors,” Drug and Alcohol Review, 14 Sept 2015.
  • Mattick RP, et al, “Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence,” Cochrane Database Syst Rev, 2014 Feb 6.
  • Raby WN, et al, “Intermittent marijuana use is associated with improved treatment retention in naltrexone treatment for opiate-dependence,” Am J Addict, 2009 Jul-Aug.
  • Wall MM, et al, “Prevalence of marijuana use does not differentially increase among youth after states pass medical marijuana laws: Commentary on and reanalysis of US National Survey on Drug Use in Households data 2002-2011,” Intl J Drug Policy, 2016 Mar.
  • Whiting PF, et al, “Cannabinoids for Medical Use: A Systematic Review and Meta-analysis,” JAMA, 2015 Jun 23-30.

Legalizing Marijuana Decreases Fatal Opiate Overdoses, Study Shows

According to the American Academy of Pain Medicine, more than 100 million Americans suffer from chronic pain. In an effort to relieve that constant pain, the number of opiate prescriptions has nearly doubled over the last decade. Today, opiates like hydrocodoneoxycodone, and morphine flood the streets, driving up addiction rates and fatal opiate overdoses.

The Centers for Disease Control and Prevention has officially labeled the problem an “opiate epidemic.” As experts scramble to come up with a plan that combats the nation’s dependence on opiates, a new study published last week in the journal JAMA Internal Medicine indicates medical marijuana might be the key.

Over the past two decades, deaths from drug overdoses have become the leading cause of injury death in the United States. In 2011, 55 percent of drug overdose deaths were related to prescription medications; 75 percent of those deaths involved opiate painkillers. However, researchers found that opiate-related deaths decreased by approximately 33 percent in 13 states in the following six years after medical marijuana was legalized.

“The striking implication is that medical marijuana laws, when implemented, may represent a promising approach for stemming runaway rates of nonintentional opioid-analgesic-related deaths,” wrote opiate abuse researchers Dr. Mark S. Brown and Marie J. Hayes in a commentary published alongside the study.

Getting Down to the Numbers

Researchers looked at medical marijuana laws and death certificate data in all 50 states between the years of 1999 and 2010. During that time, only 13 states had medical marijuana laws in place. Researchers quickly noticed that the rates of fatal opioid overdoses were significantly lower in states that had legalized medical marijuana. In 2010 alone, states with legalized medical marijuana saw approximately 1,700 fewer opiate-related overdose deaths.

“We found there was about a 25 percent lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” lead study author Dr. Marcus Bachhuber said.

Marijuana and Chronic Pain

About 60 percent of the nation’s fatal opioid overdoses occur among patients who have legitimate prescriptions for their medications. In states where medical marijuana is legal, however, a legitimate opiate user is able to significantly decrease his or her dosage, making overdose less likely.

Currently, 23 states and the District of Columbia have passed medical marijuana laws. Use of medicinal cannabis is approved for a number of conditions, including cancer, HIV, multiple sclerosis, and glaucoma. Despite the diagnosis, medical marijuana is primarily used to relieve chronic or severe pain. It’s that pain-relieving effect that decreases the number of fatal opioid overdoses.

Major Pain-Relieving Components of Cannabis

In a 2011 study published in the journal Clinical Pharmacology & Therapeutics, researchers suggest the following medical marijuana components offer pain-relieving properties:

  • Delta-9 Tetrahydrocannabinol (Delta-9 THC)
  • Cannabidiol (CBD)
  • Cannabinol (CBN)
  • Tetrahydrocannabivarin (THCV)

Learn more about the signs and symptoms of prescription drug abuse.

Role for Cannabis in Treatment for Opioid Addiction?

Nancy A. Melville

February 06, 2017

The ever-increasing severity of the opioid addiction epidemic provides more justification than ever to pursue the largely overlooked potential of cannabis in the treatment of addiction, and the spread of medical marijuana laws around the country may help give those efforts a needed boost, experts say.

"It is important to move with a deep sense of urgency to leverage the opportunity presented by increased legalization of medical marijuana to expedite the development of cannabidiol for therapeutic interventions for opioid use disorder, thus curbing the opioid epidemic," writes Yasmin L. Hurd, PhD, of the Friedman Brain Institute, Departments of Psychiatry and Neuroscience, Icahn School of Medicine at Mount Sinai, Center for Addictive Disorders, Mount Sinai Behavioral Health System, New York City.

In a review article published this month in Trends in Neurosciences, Dr Hurd notes that although evidence involving humans is sorely lacking due to the continuing status of marijuana as a Schedule I drug, studies in preclinical animal models, particularly involving the phytocannabinoid cannabidiol, show promising improvements in opioid withdrawal symptoms and heroin-seeking behavior that need to be pursued in larger studies.

Research includes a study published in Addiction Biology in 2013 showing that cannabidiol inhibited the reward-facilitating effect of morphine, but not cocaine, in rats.

"Our results suggest that cannabidiol interferes with brain reward mechanisms responsible for the expression of the acute reinforcing properties of opioids, thus indicating that cannabidiol may be clinically useful in attenuating the rewarding effects of opioids," the authors wrote.

Another study, published in the Journal of Neuroscience and conducted by Dr Hurd and colleagues, showed an important effect of cannabidiol in normalizing heroin-induced impairment in the endocannabinoid system and glutamate receptors in the striatum, suggesting a possible effect of normalizing synaptic plasticity in the region.

Among the scant research in humans is a pilot study, also conducted by Dr Hurd and colleagues, showing similar results in reducing heroin-related cue-induced craving in heroin abusers.

The strongest effects in that study were seen in reducing anxiety related to heroin cues. Similar to effects seen in animals, the reduction in general craving lasted for up to 1 week after the last administration of cannabidiol.

"[The study] serves as an important foundation, along with accumulating evidence in animal models, to warrant expedited efforts for additional clinical studies to evaluate the potential therapeutic benefits of cannabidiol as a treatment for opioid use disorders," Dr Hurd writes.

Most evidence suggests that the mechanisms behind cannabidiol's effects relate to its modulation of the 5-HT1A (5-hydroxytryptamine 1A subtype) receptor, consistent with many antianxiety drugs, which have partial agonist properties at the 5HT1A receptors.

For the study involving humans, the researchers used a cannabidiol solution and an oral formulation of cannabidiol (Epidiolex, GW Pharmaceuticals, Plc), which has been shown to have a strong safety profile and is used in the treatment of children with epilepsy.

The formulation allows for cannabinoid treatment without the inclusion of tetrahydrocannabinol (THC), the psychoactive ingredient responsible for the "high" that results from cannabis use and is linked to an increased risk for opioid use.

Furthermore, in contrast to many existing opioid addiction medications, cannabidiol has a low risk for diversion to the black market and retains a safe profile when combined with a strong opioid agonist.

Marijuana a "Safer High"?

Dr Hurd noted that early data coming out of states where marijuana laws have been passed suggest that even as conventionally used, marijuana may be playing a role in offsetting the opioid addiction epidemic.

 

One report, for instance, suggests there is a trend toward reductions in prescriptions for opioid painkillers, as well as a reduction in opioid overdoses and lower opioid-positive screens associated with car fatalities, in states where medical marijuana laws have been passed.

Although emphasizing that any benefits would apply solely to people who are already addicted to opioids, Dr Hurd said that cannabis could feasibly represent a "safer high."

"It's important to note that the data are very clear that early marijuana use does associate with a risk of opioid use later in life," she stressed.

"However, the findings suggest that when opioids are already consumed, marijuana could be a safer replacement for opioids, since marijuana doesn't induce overdose," she said.

As more epidemiologic research becomes available on trends in states where marijuana laws have been passed, a clearer picture of those effects should emerge.

But the stronger evidence that can come from more rigorous studies and clinical trials regarding cannabis or individual phytocannabinoids remains elusive as long as federal restrictions are in place, and, paradoxically, only strong evidence can change those policies.

"We are in a ridiculous catch-22 situation right now," Dr Hurd said. "There has to be some way that research can be done that fits within a federal guideline to allow us to see which components of the marijuana plant could be beneficial and which ones aren't.

"Without that, we will still have these circular debates when we should be having evidence-based decisions and medicine."

She added that the growing tendency of states to loosen their marijuana laws, combined with the opioid use crisis, should help generate action to try to take research to the next level

"We could actually move very quickly if there was a federal mandate to put together a consortium that can quickly investigate this for opioid use disorder," Dr Hurd noted. "We could really answer all the questions that are there. It doesn't have to be 10 or 20 years from now."

Combating Anxiety

Researchers in Montreal are currently evaluating the use of cannabidiol in the treatment of addiction in a clinical trial involving patients with cocaine addiction.

According to senior investigator Didier Jutras-Aswad, MD, psychiatrist and director of the Addiction Psychiatry Unit, the Centre hospitalier de l'Université de Montréal, in Quebec, Canada, the double-blind, placebo-controlled study has enrolled 110 persons who will be studied for 3 months.

"All subjects have cocaine use disorder, and half will be given cannabidiol and half given placebo," he told Medscape Medical News.

The primary outcome of the study is drug-induced craving and number of days to relapse. Secondary outcomes are stress-induced craving and assessment of cocaine use during the postdetoxification phase.

"The main hypothesis in the field is the mechanism of cannabidiol in the treatment of addiction is in its effect on anxiety, but we need more evidence of this in human trials," he said.

"We're trying to determine if the effect is through anxiety or purely through a reduction in craving."

Dr Jutras-Aswad echoed that the key benefits of cannabidiol over other addiction therapies are in its safety and its low potential for abuse.

"It's not reinforcing of drug-seeking behaviors, and it's not a source of abuse, which is often the case with a lot of antianxiety medications. So for a population already with addiction, it's a very attractive candidate."

Dr Jutras-Aswad's research is being supported by Insys Therapeutics, the manufacturer of the cannabinoid used in the study. He emphasized that the bottom line for the advancement of broader research is the need for more funding.

"Funding is not easy to get in the US, Canada, or elsewhere due to the somewhat controversial nature of this, but I strongly support Dr Hurd's call to action for more support and funding in these efforts," he said.

As reported by Medscape Medical News, the US Drug Enforcement Agency (DEA) denied two petitions to reschedule marijuana under the Controlled Substances Act from Schedule I to Schedule II last August.

But the agency did take the step of expanding the number of DEA-registered marijuana manufacturers to help give researchers "a more varied and robust supply of marijuana," the agency said.

The clinical trial that Dr Jutras-Aswad is conducting is receiving funding from Insys Therapeutics. Dr Hurd has disclosed no relevant financial relationships.

Trends Neurosci. Published February 2, 2017. Full text

Medical cannabis can help reduce our nation's pain epidemic

On Wednesday, Sept. 27, the president’s Commission on Combating Drug Addiction and the Opioid Crisis, lead by Governor Chris Christie (R), held its third meeting entitled: Innovative Pain Management and Prevention Measures for Diversion.

The agenda, which was not released until the day it was scheduled, included testimony from 10 invited organizations, all of which were from the pharmaceutical industry. Consequently, the tone of the meeting came off as a commercial by each of the companies asking for government assistance in getting their medications to market more quickly.

One in three Americans suffer from chronic pain and one in ten have experienced severe pain every day for three months or more. If effective pharmaceutical alternatives to opioids for chronic pain already exist, why aren’t we already using them?

While it is quite possible that innovations from the pharmaceutical industry could be helpful in providing health care practitioners with alternative treatments to chronic pain, these innovations can take years to develop. All of the medications currently on the market the presenters discussed also include a laundry list of side-effects such as nausea, anxiety, insomnia, and impotence. Why not explore what millions of Americans are already using successfully as an alternative or adjunct treatment to pain, with little to none of the side-effects associated with pharmaceutical treatments, medical cannabis?

If the intent of the commission is to truly look at innovations in pain management, then why were pharmaceutical approaches the only ones discussed on this panel? There are numerous non-pharmaceutical interdisciplinary approaches and therapies to pain management that were not discussed at all, and a glaring omission was medical cannabis.

Dr. Francis Collins, director of the National Institutes of Health expressed the need to accelerate the pace of how medicines that may help with chronic pain are researched and obtain FDA approval. However, there was no mention of accelerating research into using medical cannabis to treat chronic pain.

Americans for Safe Access, the country’s largest patient-focused medical cannabis advocacy organization, requested to be included in today’s meeting to provide testimony, but was denied a seat at the table. Innovation is typically associated with new ideas or creativity in application. Although medical cannabis has been used as a treatment for pain for thousands of years, a concerted effort in applying medical cannabis as a tool to help fight the opioid crisis is not only innovative, but has great potential. Ignoring this potential is a grave error by this commission.

Why should medical cannabis be considered a tool to fight the opioid crisis? Thirty states, including those most negatively impacted by the opioid crisis such as West Virginia, New Hampshire, and Ohio, and Washington, D.C. all have medical cannabis programs. Many of these states allow medical cannabis to be used to treat chronic pain.

A study in the Journal of the American Medical Association indicated that in states with medical cannabis programs, there has been a 25 percent reduction in opioid related deaths. This study also showed a 13 percent decrease in hospitalizations from opioid related causes. In a survey of nearly 3,000 pain patients, 93 percet preferred medical cannabis over opioid therapies for pain management. In addition to the data, there are thousands of personal stories of patients who have been able to reduce the number of opioids they take or come off opioid therapies altogether by using cannabis.

The National Academies of Science, Engineering, and Medicines revealed strong clinical evidence that cannabis is highly effective in treating chronic pain. The National Institute on Drug Abuse (NIDA) has indicated that medical cannabis legalization might be associated with decreased prescription opioid use and overdose deaths.

A NIDA funded analysis showed that a areas with a greater number of medical cannabis dispensaries were associated with decreases in opioid prescribing, in self-reports of opioid misuse, and in treatment admissions for opioid addiction. This past week the National Institutes of Health (NIH) indicated that medical cannabis “might be effective for chronic...primarily for neuropathic pain patients.”

Cannabis alone will not end the opioid crisis. Cannabis will not and should not replace the prescribing of opioids or other pain medications. And we recognize, that cannabis, like any other medicine has side effects. But we can not continue to ignore the usefulness of medical cannabis in reducing our nation's pain epidemic. Cannabis is one of many tools that can help fight this epidemic. And it is a tool that this commission should consider carefully and seriously.

Steph Sherer is founder and executive director of Americans for Safe Access (ASA). ASA is the largest national member-based organization of patients, medical professionals, scientists, and concerned citizens promoting safe and legal access to cannabis for therapeutic use and research. Alongside the American Herbal Products Association (AHPA), she has created the first industry standards in the areas of Distribution, Cultivation, Analytics, and Manufacturing, Packaging, and Labeling.

Can Cannabis Help Repair Arthritic Joints?

As our nation’s baby boomers age, they’re facing a multitude of health-related ailments and costs. One of the most prominent concerns is the prevalence of chronic arthritis, an ailment that affects 52.5 million adults today, and that number is expected to increase to 67 million by 2030. There’s no cure for arthritis, and limited treatment options exist for the painful and limiting disease.

 

One alternative that’s gaining popularity among the aging population is the use of cannabis to get full-bodied pain relief and anti-inflammatory properties. Although arthritis is considered a qualifying condition in at least two states, there’s a remarkable lack of data and research behind the effectiveness of cannabis as a treatment alternative for arthritis, osteoarthritis, and rheumatoid arthritis.

Arthritis is an uncomfortable and often unavoidable disease that often results in severe symptoms:

  • Injuries that don’t heal properly
  • Carpal tunnel syndrome and peripheral neuropathies (tingling or numbness in extremities)
  • Plantar fasciitis (inflammation of the forefoot)
  • Persistent joint pain
  • Locked joints
  • Morning stiffness

A study published in the journal Rheumatology from Dr. Sheng-Ming Dai of China’s Second Military Medical University found that CB2 receptors are found in unusually high levels in the joint tissue of arthritis patients. The use of cannabis is shown to fight inflammation in the joints by activating the pathways of CB2 receptors.

Canadian researcher Dr. Jason McDougall, a professor of pharmacology and anesthesia at Dalhousie University in Halifax, has undertaken a new study to find out if medical marijuana can help repair arthritic joints and relieve pain. The study is supported by the Arthritis Society and is awarding a grant for a comprehensive, three-year study to investigate if cannabis is not just dampening the pain in the brain, but also working to fight inflammation and repair the joint itself.

When asked to describe the nerves of an arthritis sufferer, McDougall told CBC Radio’s Information Morning the following information:

“[The nerves are like] wires that have been stripped of their coating. They’re all bare, they’re all raw and responsible for feeling a lot of pain. What we hypothesize is that by locally administering these cannabis-like molecules to those nerves, we’d actually be able to repair them and reduce the pain of arthritis.”

McDougall’s research is focused on non-psychoactive cannabinoids, but so far, his findings has shown that cannabis molecules can attach themselves to nerve receptors and control the firing of pain signals in the joint. Indeed, it’s been proven in certain anecdotal circumstances, such as the case of Katie Marsh of Madawaska, Maine. A sufferer of rheumatoid arthritis, she was on a prescription of prednisone and antibiotics and was encouraged by her doctors to try disease-modifying anti-rheumatic drugs (DMARDS), but the side effects were severe enough that she sought a natural way to ease her pain and swollen joints.

After seeking the advice of a physician that specializes in dietary cannabis, Marsh began juicing raw cannabis, blending it into a smoothie and consuming the whole raw plant. She began to see results almost immediately — within days, Marsh was off the prednisone and even pain killers. After 11 months of regular cannabis juicing, her condition is in remission.

Now that Health Canada has approved the study, titled the CAPRI trial (Cannabinoid Profile Investigation of Vaporized Cannabis in Patients with Osteoarthritis of the Knee), researchers in Halifax and Montreal are seeking volunteers over the age of 50 who suffer from osteoarthritis of the knee to participate in the year study, which will be a randomized, double-blind, placebo-controlled study that involves visits to the physician and exposure to six different types of cannabis through a vaporizer, all with varying levels of THC and CBD.

Two Canadian licensed producers of medical marijuana, Aphria, Inc. and the Peace Naturals Project, contributed $100,000 each to the Arthritis Society to fund the grant, and the research project has been approved by Health Canada. Researchers hope to start the study by September, and preliminary results will be collected by the end of 2016.

If you’re interested in cannabis for arthritis, check out our list of cannabis strains that may help treat arthritis symptoms.

Need Period Relief?

The pain creeps in slow and unexpectedly. Initially, it’s a subtle discomfort, like the prick of a needle stabbing away at your stomach. As the minutes pass by, the discomfort can develop into a crippling pain, making even simple tasks such as standing up straight seem utterly unbearable.

That dreadful feeling has a name: Dysmenorrhea—the medical term for severe period pain commonly referred to as cramps. And it’s something experienced every month by hundreds of women all across America.

While over the counter medicine like Midol can be helpful for many women, some 20 percent of women who suffer from cramps caused by their menstrual cycles each month experience such extreme dysmenorrhea that they can’t perform daily actives like getting out of bed and going to work, according to the American Academy of Family Physicians.

Now, relief may soon be on the way. The New York Assembly's Health Committee passed an initiative Tuesday that would add dysmenorrhea to the list of conditions necessary to qualify for medical marijuana use. If it becomes law, everyday women suffering from intolerable period pain could have legal access to pot with a medical marijuana card.

“This is a woman’s health issue and for years women have suffered in silence. There’s Midol. You can take Advil, but really nothing more,” Assemblywoman Linda Rosenthal, a Democrat, who introduced the bill, told Newsweek during a phone call Wednesday. “Men have really been [the ones] who’ve run state houses, governorships, presidencies, and some issues that are just about women have gotten shortchanged and that’s because it’s not in men’s everyday consciousness.”

The measure, called Assembly Bill 582, was approved in a 21-2 vote by the committee and it’s headed to the Assembly floor next. It would also need the OK from the New York Senate and Governor Andrew Cuomo.

The bill’s only pushback so far came from two Republican Assembly members—both men—but Rosenthal is confident that members of the Senate would be more understanding of how helpful medical marijuana, a drug that people suffering from various types of chronic pain can legally use in New York, can be for women during menstruation, too.

“There is some mild discomfort for some, but some women can’t leave their bed for a week,” Rosenthal said. “People are starting to understand that medical marijuana is a useful tool to relieve suffering and women’s suffering from severe menstrual cramps.”

In New York, only people suffering from cancer, HIV infection or AIDS, amyotrophic lateral sclerosis (ALS), Parkinson's disease, multiple sclerosis, spinal cord injury with spasticity, epilepsy, inflammatory bowel disease, neuropathy, Huntington's disease or chronic pain can get access to medical marijuana—not everyday women who naturally have periods and experience the pain that sometimes comes along with it each month.

Rosenthal has become known as a champion for women’s issues. She worked last year to get a bill that removed sales taxes on feminine hygiene products signed into New York law, and she’s at the helm of passing another bill that would make feminine hygiene products free for women in prisons, homeless shelters and schools. For Assembly Bill 582, she is getting some extra help from a highly regarded medical marijuana advocate, who just so happens to be a well-known movie star and co-host of the daytime talk show, The View.

“I met with a force of a woman named Whoopi Goldberg, and she’s been a longtime expert on medical marijuana. I met with her and spoke with her, and she’s been passionate about easing women’s suffering by using medical marijuana,” Rosenthal said. “I thought this was a great opportunity to create an impact with a passionate supporter and help women access something new that can help relieve what cripples some of them during that time of the month.”

Goldberg introduced her own line of medical cannabis products in 2016 to combat menstrual pain with cannabis industry leader Maya Elisabeth. Under their Whoopi & Maya brand, women in legal marijuana states are able to receive pain relief with a cannabis bath soak, cannabidiol (CBD) and beeswax-infused body balm and organic and raw cocoa infused with either THC or CBD.

Although the bill has a few more steps to go before women could potentially be prescribed medical marijuana for cramps in New York, Rosenthal said the high support so far for the measure is a good sign it could pass into legislation.

“I think we’re a progressive state. It did take 20 years to get medical marijuana to be the law,” she said,” but we’re going to work hard to get it passed.”

“And I’m sure many women will vouch for what they have to go through each month.”

What Are the Best Cannabis Strains for Pain?

One of the most common applications for medical marijuana is pain, whether it’s inflammationheadaches, neuropathic pain, muscle soreness, spinal injuryfibromyalgia, or cramps. Patients have seen varying degrees of success with cannabis in treating various pain-related ailments, depending on the type of pain, the intensity, and the individual’s own physiology.

This guide is informed both by user-submitted strain reviews and chemical profile data, as certain cannabinoids and terpenes are known to have areas of specialization such as pain. Because every person’s experience is so nuanced, we recommend sampling several of these suggestions and maybe even experiment with them in different forms, like topicals, oils, or even transdermal patches. Smoking and vaporizing are great ways to get marijuana’s painkilling properties quickly, but read up on non-smoking consumption methods and cannabis concentrate alternatives to get an idea of the full spectrum of options available to you.

And remember — there are many adept pain slayers out there in the cannabis world. Use our Explorer’s symptom and condition filters to find out what else has worked for other patients, and check the “Availability” tab on their strain pages to see if they’re available at a shop near you!

1. Cannabis Strains That Help Treat Generalized Pain

All hail ACDC, one of the most effective painkilling strains out there due to its one-two punch of cannabinoids CBD and THC. As a general rule, cannabis strains with high amounts of both THC and CBD tend to make the best pain medicines, and there are plenty of high-CBD strains out there offering similar chemical profiles as ACDC.

Unfortunately, high-CBD strains are relatively new to the game and not all patients have access to them, especially those living in states without medical marijuana laws. Luckily, high-THC strains also offer pain relieving benefits, and many people find that heavy indicas such as Blackberry Kushare particularly skilled in the art of killing pain.

Browse more strains suitable for general pain.

2. Cannabis Strains That Help Treat Inflammation and Arthritis

Cerebrally-focused sativa strains aren’t typically a first choice for patients treating pain and inflammation, but Harlequin‘s high-CBD content makes it an exception. Its uplifting and clear-headed effects set it apart from heavier, more intoxicating options and make it a perfect choice for daytime medicating.

Also known as Blue VenomBerry White, and White BerryBlue Widow is a prolific hybrid cross between parent strains Blueberry and White Widow. Leafly user reviews praise Blue Widow for its anti-inflammatory qualities, and perhaps the reason for this is Blue Widow’s rich terpene profile that typically boasts high levels of caryophyllene, or it could be its heavy resin production which gives way to massive amounts of THC and other beneficial compounds.

Browse more strains suitable for inflammation and arthritis.

3. Cannabis Strains That Help Treat Headaches and Migraines

Purple Arrow hits the target somewhere between heavy pain relief and uplifting euphoria, making it a great choice for headache sufferers needing swift relief without the couchlock effects typical of indica varieties.

Headband hybrids are commonly described as “cerebral” with effects that go straight to the crown of your head. Blueberry Headband lives up to its name, delivering focused headache relief and a sweet berry flavor.

Browse more strains suitable for headaches and migraines.

4. Cannabis Strains That Help Treat Cramps

With effects that relax tension in both mind and body, Redwood Kush is known to deliver a woody forest aroma alongside hefty amounts of THC to help ease muscle cramping.

Dynamite is another high-THC indica strain that blows pain and cramping out of the water, but be wary: Dynamite is also known to incite the power of the Munchie Beast.

Browse more strains suitable for cramps.

5. Cannabis Strains That Help Manage Spinal Injury Pain

Cataract Kush is a heavy-hitting hybrid cross between powerhouse classics LA Confidential and OG Kush. This strain’s potency may not be for the novice consumer, but it’s perfect for patients needing a strain that can expertly annihilate pain associated with spinal injury.

Descending from some of the earliest indicas of Afghanistan, Mazar I Sharifis a relentless painkiller with a potency you can see on her heavy blanket of crystal trichomes. Afghani indicas have a reputation for their high cannabinoid contents, so it isn’t hard to imagine that so many patients have found relief from stubborn pain in Mazar.

Browse more strains suitable for spinal injury.

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