Is Marijuana a Viable Replacement for Opioids in Managing Chronic Non-Cancer Pain?

According to surveillance data from the Centers for Disease Control and Prevention (CDC), mortality from drug overdose has steadily increased since the dawn of the new millennium. More than 600,000 overdose deaths were reported from 2000 to 2016. According to the CDC, the first wave began with increased prescribing of opioids in the 1990s and then though the pill mills until approximately 2010. The second wave began shortly thereafter with increased overdose deaths involving heroin as the cost of prescription opioids increased when the pill mills were shut down. The third wave began in 2013 with increased overdose deaths involving synthetic opioids – particularly when illicitly manufactured fentanyl was first used as an additive to Mexican heroin. The illicitly manufactured opioid market continues to change, and is still found in combination with heroin, counterfeit “look-alike opioid prescription medication, spiked marijuana, and now cocaine.

In spite of this changing data, legally prescribed opioid use remains the focus of the most recent opioid “epidemic”. To wit, approximately 63% of the 52,404 overdose deaths in 2015 involved an opioid—but which one? By 2016, the trend was clear– heroin and fentanyl killed the majority of the 42,000 people who overdosed in 2016, more than any year on record. Further, 40% of opioid overdose deaths involved a prescription opioid. This does tell us whether the prescription opioid was attained legally or illegally. Pop star Prince died from an overdose of counterfeit oxycodone tablets, spiked with fentanyl.

Although various strategies have been introduced to address the crisis, including implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain, as well as efforts to improve prescription drug monitoring programs and better access to treatment for opioid use disorder.

Figure 1 CDC Clinical Guidelines for Physicians Prescribing Opioids (CDC 2017):

The CDC Guideline addresses patient-centered clinical practices including conducting thorough assessments, considering all possible treatments, closely monitoring risks, and safely discontinuing opioids. The three main focus areas in the Guideline include:

1. Determining when to initiate or continue opioids for chronic pain 

  • Selection of non-pharmacologic therapy, nonopioid pharmacologic therapy, opioid therapy
  • Establishment of treatment goals
  • Discussion of risks and benefits of therapy with patients

2. Opioid selection, dosage, duration, follow-up, and discontinuation

  • Selection of immediate-release or extended-release and long-acting opioids
  • Dosage considerations
  • Duration of treatment
  • Considerations for follow-up and discontinuation of opioid therapy

3. Assessing risk and addressing harms of opioid use

  • Evaluation of risk factors for opioid-related harms and ways to mitigate patient risk
  • Review of prescription drug monitoring program (PDMP) data
  • Use of urine drug testing
  • Considerations for co-prescribing benzodiazepines
  • Arrangement of treatment for opioid use disorder

These recommendations from the CDC are excellent but without adequate training for physicians who deal with chronic pain or addiction on a regular basis, they will likely not produce the change we hope for—and for good reason.  The fear of suspicion and retribution from governing bodies who monitor prescription opioids and all scheduled medications have kept physicians from prescribing these drugs for their patients who need them. Many will recall the latter days of the pill mills, with surveillance videos of sketchy looking characters carrying trash bags full of hydrocodone and oxycodone out of a doctor’s office as part of a covert sting operation–followed by the physician in handcuffs being “perp walked” on the nightly news. These images became iconic in the American psyche and have changed medical practice. Yet for the millions of Americans who suffer from legitimate chronic, non-cancer pain, this is a frightening prospect. Why? Because for most pain patients, opioids have provided a viable means to a quality of life.

The facts are clear; patients with legitimate chronic pain who are cared for by boarded pain or addiction specialists do not abuse their opioid pain medication. In fact, recent data reveal that only between 4 and 10 percent of these patients will ever misuse or abuse their medication. Most of these individuals could not work, achieve self-efficacy, or have any quality of life without the pain relief opioids provide them. We all wish that alternatives were available—but they are not. As the baby boomers are living longer and have more wear and tear and injuries that require expert pain management, there is a legitimate need for these medications—until some alternative to opioids are found. Understandably, many pain patients and their doctors are afraid that government overreach, designed to stop drug dealers and drug addicts, will rob them of the little quality of life they have because opioids provide a temporary respite from severe pain.

In truth, the DEA has done a good job of shutting down the pill mills and most states now allow physicians to access each patient’s pharmacy records online. This process has also shut down “doctor shopping” for controlled substances and takes less than a minute to review all prescriptions for controlled substances for a single patient. Perhaps the epidemic of chronic pain should be the focus of our research efforts.

So why are people still dying from opioid overdose? The CDC report reveals part of the answer. As the pill mills shut down, the price of illicit prescription opioids increased substantially. In response, the Mexican cartel, which was losing billions due to legalized marijuana, flooded the US with cheap, powerful heroin. It was cheap and powerful because the cartel was spiking it with homemade fentanyl, which is approximately 100 times more potent that morphine. It is heroin and fentanyl that are killing thousands of Americans each month.

Cannabis and Pain

Is marijuana really a reasonable alternative to opioids for opioid addicts or for chronic pain? Maybe, but the science is woefully silent on the topic. What little science exists remains inconclusive. The recent JAMA article shows epidemiological trends among Medicare Part D recipients and state Medicaid recipients. The analysis attempts to statistically correlate states with liberal marijuana laws and a decrease in the number of opioid prescriptions written between 2010 and 2015.

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Why Does This Matter?

Correlation is not causation. The conclusions reached by this investigation suggest that merely the decline of filling prescriptions for opioids by elderly infirmed adults is due to liberalized, legal access to cannabis, which is quite a reach in logic. This conclusion assumes these same adults voluntarily switched from their opioids to medical marijuana for pain control.  In truth, there are hundreds of variants, including hordes of untrained and anxious physicians who live in fear that prescribing opioids sends a red flag to licensing boards and invites increased scrutiny and potential retribution. Plus, any physician who believes in evidence-based medicine is unlikely to prescribe medical marijuana for pain. At present, the research does not support this practice.

Double blind, placebo-controlled comparisons between medical marijuana and legally prescribed opioids for debilitating non-cancer pain syndromes will provide the science necessary to determine the efficacy and safety of marijuana as a medication for chronic pain.

Yes, it is feasible that the endocannabinoid system may provide new therapeutics for pain and other disease. However, the well-established risks associated with THC must be accounted for. It hard to believe that elderly patients would choose to be stoned for 3-5 hours and experience the cognitive “dulling” and short-term memory deficits over an opioid that if anything, gives them some energy, plus the best pain relief known.

The recent approval of the Cannabidiol (CBD) based medication Epiolidex by an FDA subcommittee, for treating two debilitating seizures disorders, has provided a model for assessing efficacy and risk for cannabis-based medicines. CBD is non-addictive and non-psychoactive.  Until similar scientific scrutiny proves safety and efficacy of THC products, they should be considered harmful.

Reference:

Bradford AC, Bradford WD, Abraham A,  Bagwell Adams G . Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018 Apr 2. doi: 10.1001/jamainternmed.2018.0266. [Epub ahead of print]