Despite having only 20% of the world’s population, the United States ingests 99% of the world supply of hydrocodone, a commonly used opioid medication. Opioid overdose has now surpassed car accidents as the leading cause of accidental death in the United States, and many of those deaths originated with prescribed medication. Forty-nine percent of pain patients leave their doctor’s office with an opioid prescription, and there’s been a four-fold increase in prescriptions since 1999.
Sixty percent of overdose victims have an opioid prescription, and most of those prescriptions are for treating pain. In addition to being treated with opioids, chronic pain is one of most commonly cited qualifying conditions for obtaining a medical marijuana patient card. Both medicines work by blocking pain signals in the nervous system, but as medical marijuana becomes more prevalent, we are learning more about how they differ, how they interact and how cannabis could be part of the solution to the ongoing opioid epidemic.
Evidence shows that patients dealing with pain can find greater relief from combining opioid treatment with medical marijuana, due to the synergistic effect of the two drugs in the human body. In fact, studies have shown that THC, when combined with opioids, works to reduce pain even in extremely low doses that wouldn’t be effective when used alone. Cannabis enhances the efficacy of opioids by preserving and potentiating the function of the medication, which can reduce the harms associated with using opioids by lowering the effective dose. The therapeutic index is widened as the effective dose is lowered, while the lethal dose remains the same. Using opioids alone, patients can develop a high tolerance, leading to a higher effective dose for treating their pain. Put simply, higher doses are linked to higher risks of overdose, and by lowering one’s effective dose, cannabis can help some patients move away from relying on opioids for pain management. [Note: Because everyone responds to cannabis medicine differently, it remains important to choose strains and consumption methods carefully, to “start low and go slow” when it comes to dosing and to always consult a doctor before drastically altering one’s treatment plan.]
Cannabidiol (CBD), in addition to its anti-inflammatory and pain-reducing properties, has been shown to reduce the rewarding effects of opioids by binding to the brain’s serotonin receptors, curbing cravings and even diminishing the symptoms associated with withdrawal (eg, nausea, vomiting, insomnia and muscle spasms). A 2016 University of Michigan study of 244 patients using both cannabis and opioids found decreased side effects from other medications, improved quality of life in 45% of participants and a 64% average reduction in opioid use overall. In the same year, an Israeli study of 176 patients showed that 44% were able to discontinue opioid use entirely after 7 months of cannabis treatment.
This is not to say that cannabis can replace opioid use for all pain patients; rather, some patients may be able to choose cannabis as a safer, less addictive option for pain management, which can be effective both for weaning them off of opioid medication and for treating their chronic pain issues. The Drug Policy Alliance states that one recent study found “80% of medical marijuana patients reported substituting marijuana for prescribed medications, particularly among patients with pain-related conditions.” Cannabis has been proven to have an extremely low risk of dependence and diversion, especially compared with the side effects and risks associated with long-term opioid use.
To this end, researchers also have seen measurable results on a larger scale. In states that have some form of legalized cannabis, there has been an average of a 25% reduction in opioid overdoses, with overdose rates continuing to decrease each year after medical marijuana laws were passed, according to the Journal of American Medical Association. In 13 states, opiate-related deaths decreased by 33% in the following six years after medical marijuana was passed. In 2018, a study found that “states with medical dispensaries saw 3.7 million fewer daily doses of prescription opioids and states that allowed for home cultivation of marijuana saw 1.7 million fewer daily doses” and that “legal access to medical marijuana has been associated with a 23% reduction in opioid dependence or abuse-related hospitalizations and 15% fewer opioid treatment admissions” (Drug Policy Alliance).
The bottom line is that when it comes to the opioid epidemic, all possible pieces of the solution need to be considered, especially ones with as low of a risk-to-reward ratio as medical marijuana. Ninety-eight percent of Americans live in states with some form of legal access to marijuana, but state policies can differ greatly, and until broader legalization opens up access to more people, we rely on state medical marijuana programs to meet the needs of pain patients. Currently, only four states (NY, IL, PA and NJ) consider opioid dependence to be a legitimate qualifying condition for medical marijuana, and although patient advocates in RI have been pushing to add opioid use disorder to the qualifying conditions list, it will not be an easy victory. A hearing was held at the Department of Health on the topic in February, but was opposed by several community “health experts.”