Here’s a statistic that will certainly make you do a double-take the next time your physician writes you a prescription for a painkiller. The United States uses 99 percent of the world’s entire hydrocodone (the active ingredient in Lortab, Norco) supply and 80 percent of the world’s opioids, according to the Institute of Addiction Medicine. The nation’s painkiller problem is such that Time magazine called it the worst addiction crisis America has ever seen on its June 15th cover.

These are certainly some statistics to give you pause and the curiosity to find out more about how opioids have come to have such a perilous grasp on Americans.

Used to alleviate pain, opioids exert their effects by binding to opioid receptors in the central and peripheral nervous system. Opioids are widely used in the U.S. and their use in the treatment of non-cancer pain is staggering, as mentioned above.

Most clinicians prescribe opioids for treatment of chronic pain. However, there is very little evidence to support long-term use of opioids for treatment of non-cancer pain. In fact, the adverse effects associated with opioids become much more prominent with each escalating opioid dose. The latter occurs as patients develop a tolerance to their current level of medication and find the opioid less “effective” than when they first initiated treatment.

As a nation we have also become used to quick remedies. If someone has pain, they are prescribed opioids; if someone can’t sleep, they acquire a sleeping pill; if someone has anxiety, they get an anxiolytic; if someone has muscle spasms, they obtain a muscle relaxant, and so on.

The Opioid Shift

Since the 1990s there has been a dramatic shift in the medical practice paradigm — from withholding painkillers to treating patients with chronic pain using opioids. This change in the medical model has brought on adverse effects. Opioids produce significant side effects; the most common being divided into two categories, the central effects (nausea, sedation, respiratory depression, miosis [pinpoint pupils], hypotension) and the peripheral effects (constipation, hives, urinary retention, bronchospasms).

But the most concerning part of this trend is that the number of people that die from opioid overdose has increased 300 percent since 1999 and over 15,000 people die of opioid overdose per year.1
Furthermore, for every one death there are:

  • 10 treatment admissions for abuse 2
  • 32 ER visits for misuse or abuse 3
  • 130 people who abuse or are dependent 4
  • 825 nonmedical users 4
  • One in 20 people 12 years or older reported using opioids for nonmedical reasons.5,6

Do opioids and medicinal cannabis make an effective cocktail?

There is a real challenge in controlling pain while at the same time allowing patients to function. With the passage of medical cannabis laws in 23 states and the District of Columbia, clinicians now face another challenge: Addressing patients that are on chronic opioid therapy and use medical cannabis. How safe is the combination of these two controlled substances? Does the combination of these medications lead to abuse of other substances such as alcohol and illicit drugs?

Can medical cannabis be used as a substitute or adjuvant therapy to opioids?

Two of the most cited concerns with the use of medical cannabis relates to the psychoactive properties of the plant and the possibility of it leading to more serious drug use, especially among users of opioids. Recent studies have attempted to address these concerns and found that in the states where medical cannabis is legal, there is an upside in the form of a significant decrease (24.8 percent) in the opioid overdose mortality rate.7

Furthermore, a recent study concluded that concomitant use of medical cannabis and opioids did not correlate with subsequent increase in alcohol and other drug use such as cocaine, sedatives, street opioids, and amphetamines. In this study, the patients who used medical cannabis reported better pain management and a desire to reduce their opioid intake.8

Can medicinal cannabis turn the tide on opioid use?

Cannabis exerts its effects by interacting with the body’s endocannabinoid system. This complex system is an important part of human physiology as most of the organs in the body have some association with this system. There is evidence that activation of this system in certain areas can decrease several types of pain perception, including new onset pain (acute), pain related to nerves (neuropathic), and pain associated with ongoing inflammation. 9

Additionally, the body also produces its own molecules that interact with the endocannabinoid system.

This is similar to the body producing its own pain molecules, such as endorphins, that help reduce pain. Studies have proposed that interaction of the endocannabinoid system can alleviate pain on its own and separate from how opioids work.10

The molecules produced by the body that act on the endocannabinoid system are called endogenous cannabinoids. These molecules act in many of the brain’s pain centers to alleviate pain. In addition to working separately from opioids, research has shown improved pain relief when an artificial cannabinoid is added to the regimen of subjects already taking opioids.11,12 This is consistent with earlier studies that demonstrated tetrahydrocannabinol (THC) releases the body’s own opioid molecules which helps decrease pain. Combination therapy with THC and opioids exhibits synergistic properties in animal models.13

Further research in these and several other aspects of medical cannabis and opioids are needed to accurately address the concerns of a combination therapy. Human trials are absolutely necessary to provide answers to some of these pressing questions faced by healthcare providers, as well as patients. As a clinician, these are very exciting times for the prospects of new cannabinoid therapies to help alleviate pain and lessen the side effects of opioid therapy.

Pouya Mohajer, M.D.

Diplomate of the American Board of Anesthesiology
Subspecialty in Pain Medicine
Founder, Nevada Cannabis Medical Association

Sources:

  1. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008. MMWR 2011; 60: 1-6.
  2. Substance Abuse and Mental Health Services Administration. Substance abuse treatment admissions by primary substance of abuse, according to sex, age group, race, and ethnicity 2009 (Treatment Episode Data Set). Available from URL: http://wwwdasis.samhsa.gov/webt/quicklink/US09.htm
  3. Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network: selected tables of national estimates of drug-related emergency department visits. Rockville, MD: Center for Behavioral Health Statistics and Quality, SAMHSA; 2010.
  4. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011. Available from URL: http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16
  5. CDC Vital Signs: Prescription Painkiller Overdoses in the US. November 2011.
  6. CDC Policy Impact: Prescription Painkiller Overdoses. November 2011.
  7. Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10)1668-1673.
  8. Perron, B. E., Bohnert, K., Perone, A. K., Bonn-Miller, M. O., & Ilgen, M. Use of prescription pain medications among medical cannabis patients: Comparisons of pain levels, functioning, and patterns of alcohol and other drug use. J Stud Alcohol Drugs, 76(3), 406-413.
  9. Guindon J, Hohmann AG. 2009. The endocannabinoid system and pain. CNS & Neurological Disorders Drug Targets. 8(6):403.
  10. Meng ID, Manning BH, Martin WJ, Fields HL. An Analgesia Circuit Activated by Cannabinoids. Nature. 1998;395 (6700):381-383.
  11. Abrams DI, Couey P, Shade SB, Kelly ME, Benowitz NL. Cannabinoid-opioid interaction in chronic pain. Clin Pharmacol Ther. 2011;90(6):844-851.
  12. Narang S, Gibson D,Wasan AD, et al. Efficacy of dronabinol as an adjuvant treatment for chronic pain patients on opioid therapy. J Pain. 2008;9(3): 254-264.
  13. Cichewicz DL. 2004. Synergistic interactions between cannabinoid and opioid analgesics. Life Sci. 74(11):1317- 24.