Stemming the Opioid Epidemic with Medical Cannabis

The Tennessee General Assembly will soon reconsider the issue of medical cannabis (marijuana). This is timely, as Tennessee Bureau of Investigation’s Director Mark Gwyn said in late 2016, "We had more overdose deaths in the state last year than we had traffic fatalities." Most reasonable people agree it's time to do something about this public health crisis.

The prudent and pragmatic approach focuses on harm reduction, and regulated medical cannabis can be part of the solution.

The experience of Colorado is instructive. After 10 years of medical cannabis and 3 years allowing all adults to possess cannabis and grow plants at home, there has been no significant increase in teen use, drunk or drugged driving, or increase in the use of "hard drugs". 

The status quo—criminalization—has resulted in unintended harm to public health, and the well being of patients. For example, the current general practice of pain management clinics is to withhold opioid medication from patients who test positive for cannabis. This is counterproductive because cannabis is an alternative to the use of potentially dangerous narcotics such as oxycodone and fentanyl. Cannabis is not a narcotic, and there have been no recorded deaths due to a cannabis overdose. 

Adding cannabis treatment to prescribed opioids makes the opioids safer by increasing the therapeutic index, decreasing the dose of opioid needed for therapeutic effect. 

A review published in the Journal of the American Medical Association found "30% or greater improvement in pain with cannabinoid compared with placebo" across the 79 studies it surveyed.

Using cannabinoids and opioids in combination yields a synergistic reduction of pain. A 2011 study published in Clinical Pharmacology and Therapeutics used cannabis with a very low potency of THC and found: “Pain was significantly decreased (average 27%) after the addition of vaporized cannabis. We, therefore, concluded that vaporized cannabis augments the analgesic effects of opioids without significantly altering plasma opioid levels. The combination may allow for opioid treatment at lower doses with fewer side effects.”

An article published in JAMA Internal Medicine found that states with medical marijuana laws have rates of anticipated opioid-related deaths 25% lower than states that don’t have such a program.

A study published in Health Affairs found that doctors in states that allow medical cannabis write significantly fewer prescriptions for opioids. The annual average number of opioid doses prescribed per physician was 31810 in states without medical marijuana, and 28166 in states with the option, a difference of 11%.

Research published in the journal Drug and Alcohol Review found that 80% of medical marijuana users reported substituting cannabis for prescription painkillers, and 52% said they drank less when taking medical marijuana.

A study published in the February 2016 Clinical Journal of Pain examined the long-term effect of medicinal cannabis treatment on pain and functional outcomes. Overall, pain symptom score improved from a median of 83.3 to 75.0 and opioid consumption at follow-up decreased by 44% .

Cannabis can prevent opioid tolerance from building, and the need for dose escalation with the resultant risk of overdose. This is because opioid receptors are up-regulated in animals that are treated with both morphine and THC. This is the opposite of what happens when they are treated with morphine alone. Mice are able to avoid building tolerance and retain the analgesic effects of the morphine.

In order to combat opioid overdoses, we should support legal cannabinoid use for Tennessee chronic pain patients and those with opioid addiction.

There are several possibilities that may be politically feasible.

Physicians prescribing opioids might consider adding an off-label prescription for a small dose (2.5 mg) of Marinol at bedtime. Marinol is an FDA-approved prescription medication whose active ingredient is dronabinol, a synthetic form of Δ9-tetrahydrocannabinol (THC), the naturally occurring psychoactive constituent in cannabis.

Criminal penalties could be eliminated for persons who have been diagnosed with chronic pain syndrome or opioid addiction. This could include both simple possession of cannabis, and growing up to 6 cannabis plants (3 adult plants) as has been done in several states. Persons with such a diagnosis could submit medical documentation allowing them a medical cannabis card that protects from criminal prosecution.

Please watch this entertaining video of my recent testimony before the Tennessee general assembly task force, which features an interview with Dr. Larry Wolk, Colorado Medical Director of Public Health. It presents a great deal of recent information that will likely change the debate.

ArticleMatthew Hine