Cannabis and Opioid Reduction

The United States is in the midst of an opioid addiction crisis. How big is this problem? Forty-four people in the United States die every day from prescription opioid overdose; the number increases to 78 every day when we include heroin. Almost 7,000 people are treated in emergency rooms in the United States every day for misuse of a prescription opioid.

Between 1999 and 2010, the sales of prescription opioids quadrupled, and so did the rate of opioid overdose deaths. Enough opioids were prescribed in 2010 to give a one-month supply of 5mg of hydrocodone every four hours to every adult in the United States.  While America claims only 5 % of the world’s population, we consume 80 % of the world’s opioids.  One in three of these prescriptions are currently being abused. The estimated cost of opioid abuse is $56 billion per year.

Prescription opioid abuse and addiction is actually a much bigger problem than heroin addiction. In 2014, for example, there were around 19,000 overdose deaths from opioid prescriptions and around 11,000 overdose deaths from heroin.  Nearly 80% of heroin users in the United States reported using prescription opioids before initiating heroin use.

The opioid 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, and 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.  It’s their job to relieve suffering and they simply don’t have any safer and more effective tool.

Despite their widespread use, opioid drugs have not been proven to 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.” But the authors did find an increased risk of serious harm associated with long-term opioid use – overdose, fractures, heart attacks, sexual dysfunction, and more.

In contrast, two systematic review articles evaluating the use of cannabis and cannabinoid compounds for the treatment of non-cancer chronic pain were published in 2011 and 2015.  Together, they found that 22 of 29 high quality randomized, controlled clinical trials demonstrated safe and effective treatment outcomes with cannabis.

How do cannabis and opioids work together?  Opioid and cannabinoid receptors are both present in pain areas of the brain, and we know that these receptors talk to each other.  Researchers have found that administering opioids and cannabis together results in a greater-than-additive anti-pain effect.  Both animal and human research has demonstrated that adding cannabinoids like THC to opioids, even after the developing tolerance to the opioids, provides significant additional pain relief.

Beyond enhancing the pain relief, can cannabis be used to replace opioids in chronic pain patients? A 2016 study by Kevin Boehnke and colleagues surveyed 244 medical cannabis patients in Michigan; cannabis use was associated with an overall 64% decrease in opioid use, a decrease in the number and side effects of other medications, and a 45% improvement in quality of life. An Israeli study from the same year found that 44% of 176 opioid-using patients were able to discontinue opioid therapy entirely seven months after they began smoking cannabis or eating cannabis-infused cookies.

So, yes, cannabis can be used to replace opioids. But is it safe to use them together?  The problem with using too many opioids is that they stimulate opioid receptors in the cardio-respiratory centers of the brain, which can fatal suppression of breathing and heart pumping.  While the opioid and cannabinoid receptors are abundant and work together in pain areas of the brain, there are virtually no cannabinoid receptors present in the cardiorespiratory centers.  This means that using cannabinoids and opioids together decreases the required dose of opioids without decreasing the lethal dose, improving the safety and therapeutic window of the opioid drugs.

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.’ An ideal adjunct to opioids would prevent this – which cannabis does.  It’s been shown in mice that opioid receptors are actually up-regulated in animals that are treated with both morphine and THC. This is the opposite of what happens when they’re treated with morphine alone.  In my clinical practice, I’ve observed patients use low dose cannabis and opioids for years without ever needing a dosage increase.

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, patients can 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? Suboxone and methadone.  A 2014 review in the Cochrane Database assessed the efficacy of these approved heroin substitutions and found that only max-dose Suboxone and was more effective than placebo in suppressing illicit opioid use.  Methadone maintenance was found to be superior to Suboxone in retaining people in treatment.

Sometimes these treatments can help, but they’re often not enough.

Cannabis has a much better safety profile the approved treatments. There’s no lethal overdose with cannabis, unlike Suboxone and methadone. Cannabis has a lower risk of dependence than any other psychoactive substance. It also has a low risk for abuse and diversion, especially in non-smoked forms as demonstrated in the 30,000 patient-years of Sativex trial data.

In addition to replacing and reducing opioids, improving the pain relief that opioids provide, and preventing opioid dose escalation and tolerance, cannabis can also treat all the symptoms of opioid withdrawal: nausea, vomiting, diarrhea, abdominal cramping, muscle spasms, anxiety, agitation, restlessness, insomnia, runny nose and sweating.

In 2014, the Journal of the American Medical Association published a study that looked at various interventions intended to prevent opioid overdose deaths, e.g. prescription drug monitoring program and increased state oversight of pain management clinics – neither had any significant effect.  The same study found that simply passing a state medical cannabis law on average reduced opioid overdose deaths by 24.8%!

My colleagues and I often see 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, so we conducted a survey.  Of 542 patients who added cannabis to opioids, 39% were able to stop taking opioids completely, and another 39% were able to reduce their opioid dosage.  80% reported improved function and 87% reported improvement in their quality of life

In summary, the opioid problem is lethal and growing. Prescription opioid abuse is actually worse than heroin abuse; it’s a bigger problem, and it starts in the doctor’s office. Cannabis can replace and reduce opioid use. Adding cannabis makes opioids safer by widening the therapeutic index. 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 the other harm reduction options.  We do have a solution to this deadly epidemic – it’s time for clinicians and patients to take advantage of the incredible potential of medical cannabis for treating chronic pain and opioid addiction.

Dr. Sulak is cannabinoid medicine expert practicing in Maine, and is the co-founder of the patient education website Healer.com.  Dr. Sulak’s in-depth video guide to Cannabis and Opioids, including treatment guidelines, can be found for free on Healer.com.