Cannabis: Answer to The Opioid Crisis?
Opioid drugs* like oxycodone, hydrocodone, methadone, and heroin caused over 28,000 deaths in the United States in 2014, more than any earlier year on record, according to the Centers for Disease Control and Prevention (CDC). It was estimated in 2012 that about 2.1 million Americans suffered substance abuse disorders related to prescribed opioids and another half million were addicted to heroin. From 1999 to 2014, the number of prescription opioids sold in the United States more than quadrupled, as did related deaths, “yet there has not been an overall change in the amount of pain that Americans report.” Chronic pain affects 11.2% of US adults (about 100 million), with 3-4% of those receiving long-term opioid therapy at an annual cost of $635 billion.
However, in those states that allow medical use of cannabis (Cannabis sativa, Cannabaceae), opioid-related mortality has declined significantly since enactment of such laws. The use of prescription drugs for which cannabis could be an alternative has also decreased significantly and prescriptions for opioid pain relievers have also been reduced. It is reported that, when used concurrently with opioids, cannabis reduces opioid cravings, adverse effects (AEs), and severity of withdrawal, while adding to the analgesic effects. These effects allow lower opioid doses, reducing the risk of overdosing. Use of cannabis for patients who were addicted to opioid or non-opioid pain relievers was suggested in an 1889 publication of The Lancet, followed by many studies showing the efficacy of cannabis in pain management. Among medical cannabis users with pain-related conditions, 80% report substitution of cannabis for prescribed opioids. “Pain,” as well as more specific conditions (back pain, premenstrual/menstrual pain, fibromyalgia, muscle spasms, and seizures) account for most medical cannabis use both where such use is legal and where it is not. Federal scheduling of cannabis continues to inhibit large-scale clinical trials to determine its actual efficacy in different types of pain. The authors conducted a cross-sectional survey to gather data about the use of cannabis as a substitute for opioid and non-opioid analgesics from patients who have used both.
Invitations to participate were distributed by e-mail to 67,422 medical cannabis patients in California through HelloMD, a digital cannabis health and wellness platform. A self-administered survey instrument queried demographics, conditions cannabis was used for, preferred methods of ingestion, and use of cannabis as a substitute for other medicines. Affirmative responses to the latter query led to more detailed questions about the substitution. Responses were collected for six weeks (dates not given).
Of 2,897 respondents (4.3% response rate), 55% were male, with about 0.4% identifying as transgender individuals. Respondents were mostly young, with 53% between 20-39 years of age, 29% over 50, and 15% over 60. A majority (64%) were white; 14%, Latino/a; 7%, African-American. Most (71%) had attended or completed college. Whites, women, and those having a pain condition were significantly more likely than the entire sample (P<0.001 for each subgroup) to report past six-month use of an opioid or non-opioid analgesic. Age was also found to be significantly related (P<0.001) to such use. General pain and specific pain-related conditions mentioned above were the reasons for which 63% of respondents used cannabis. Cannabis was also commonly used for anxiety (13%), insomnia (9%), depression (5%), and other conditions. Most (50%) used cannabis by smoking (combustion); 31% preferred vaporization; and 10% used edibles. Three percent were not using medical cannabis at the time of the survey.
Among respondents, 841 (30%) had used opioid pain medicine(s) in the preceding six months; 61% of those, with cannabis. Among that group, majorities from 71-97% “strongly agreed” that cannabis helped them reduce the amount of opioids they used, that opioids produced undesirable AEs, that cannabis is more tolerable, that cannabis alone was more effective in relieving their pain than opioids with cannabis together, and that cannabis worked as well as opioids for producing pain relief. Similarly, large majorities strongly preferred cannabis to opioids and said they would choose cannabis over opioids if the former were more readily available. Results for the 1,751 (64%) of the study group who reported the prior six-month use of non-opioid analgesics were also enthusiastic. Majorities of 92-96% of the 76% of that group who had also used cannabis strongly agreed that it reduced other medication use, worked better than their non-opioid analgesic, was preferred for sole use, and would be used more if it were more readily available.
Self-reported surveys are subject to selection and reporting bias and errors, and the California residency of these patients may make results noncomparable to other populations. This study did not inquire into amounts or types of cannabis consumed or about specific opioid or non-opioid analgesics used or their prescription status. Nonetheless, it contributes to a growing body of evidence supporting considerable public health benefits following medical cannabis legalization, and to that demanding well-designed randomized clinical trials of this widely-used pain medication.
Reiman A, Welty M, Solomon P. Cannabis as a substitute for opioid-based pain medication: patient self-report. Cannabis Cannabinoid Res. June 2017;2(1):160-166. doi: 10.1089/can.2017.0012.