PART THREE: 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.
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 up-regulated 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.
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 substation 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 non-smokable 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.
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 is a 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.
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.