PART TWO: The Doctor’s Dilemma
(Click here to read PART ONE)
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.
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.
Opioids 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?
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.
Click here for Part THREE