The state of Colorado has joined Illinois and New York in adding all conditions for which a doctor would prescribe an opioid for as a qualifying condition for medical cannabis. This includes acute pain occurring after an injury or surgery in addition to the longstanding chronic pain conditions which most states permitting medical cannabis currently recognize. The idea is that by decreasing the exposure of the population to opioids and by decreasing the amount of opioids dispensed and potentially available to be diverted for misuse, that opioid abuse and addiction can be reduced.
There is data that shows over an 11 year period from 1999-2010 states with medical cannabis programs had more than a 20% decrease in opioid overdose deaths. Colorado, Illinois and New York point to this as an argument for making the change. Of course, there is another study using data through 2017 which finds an increase in narcotic OD death rates for these states. The newer data covers the time period in which the extremely potent synthetic opioids like fentanyl, which are associated with large increases in overdose fatalities, substantially entered the black market. The CDC doesn t separate out statistics for illegal opioids versus legal opioids confounding the conclusions of this rebuttal study.
Currently, medication assisted treatment (MAT), consisting of the administration of methadone or buprenorphine (Suboxone) with psychological counseling, for opioid addiction is the most effective and only approved therapy. It has been shown to greatly improve an addicts abstinence from street opioids and decrease the risk of overdose by essentially replacing the dangerous street drugs with safer opioids. The safety and effectiveness of this mode of treatment makes MAT the recommended treatment for those afflicted. There are some issues with MAT, though. Restrictions on who can treat opioid use disorder (OUD), special requirements with DEA registration, limits on the number of patients which can be treated by a single practitioner, intense scrutiny of those treating such patients by medical boards and the DEA, the stigmas patients face as an addict and the high cost of medication limit the number of patients who actually have access to MAT.
There has been some encouraging data regarding the use of cannabinoids, specifically CBD, in the treatment of opioid addiction. CBD has been shown to reduce anxiety symptoms, depression, physiologic responses to “triggering” stimuli and most significantly the intense craving for opioids heroin users experience.
Patients in Pennsylvania and New Jersey with the diagnoses of opioid use disorder may also qualify for medical cannabis in an effort to combat the high rates of abuse and addiction those states have been experiencing. The difficulties in obtaining MAT, the safety profile of cannabis, anecdotal reports of success of addicts using cannabinoids to treat their OUD all suggest this may not be a bad idea even though there is not yet evidence demonstrating long term abstinence.
Where does that leave things today? As with most things medical cannabis, more research is needed. That said, policy is being made and patients must make decisions on their care based on information available. The addition of adding any conditions for which a doctor would prescribe opioids as a qualifying condition is certainly appropriate. It may decrease the amount of opioids dispensed and possibly available for diversion to the illicit market. The use of cannabis, particularly CBD, has shown promise in treating OUD but is not a replacement for the proven effectiveness of MAT. With the difficulties in patient access to MAT programs, the demonstrated safety profile of cannabinoids and the possibility that CBD can help with some of the symptoms of OUD, patients should consider this as a viable option. It can be considered in addition to MAT after discussing such use with their addictionologist. For those attempting to fight it without methadone or buprenorphine MAT, there is little at this time to argue against using CBD for a disease with such devastating consequences
Cannabis as a medicine seems quite new. With a majority of states now allowing its use, patients, many of their doctors, society at large and certainly to law enforcement and government are searching for information. The information available online is vast and often confusing. Much of it is incomplete, far too detailed and technical for most people to sort through, clever marketing or just plain wrong.
Medical cannabis patients are certified by a physician as having a qualifying condition. The patient is issued a card and then, too often is left to decide for themselves as to the best treatment. Dispensary employees are usually the cornerstone of giving patients advice on strains and how to use cannabis. Sometimes they are very good at giving recommendations. Sometimes, not so much.
Modern medicine treats disease with the drugs that are effective for the majority of patients, forgetting that we are all very different individuals. What is a good choice for one patient may be ineffective or cause side effects in another. Although most patients see some improvement in using cannabis, getting the best result is a bit more complicated...
I have seen patients without much knowledge or direction experience lukewarm results of medical marijuana. I have also seen those so-so results turn into remarkable improvement under the knowledgeable direction of a doctor that treats the individual patient using the correct combination/forms/amount of cannabis.
It is my hope to sift through all the noise, marketing, agenda driven studies, politics and stigmas encountered when one tries to be an informed medical cannabis patient. I want you to get the best result from medical cannabis you can.
Brian Nichol MD