Medical Cannabis and Treatment for Opioid Use Disorder
We’ll answer the question posed in the title of this article right away:
It’s unlikely that medical cannabis will be a silver bullet or magic cure for addiction to prescription opioids like oxycontin or street opiates like heroin, but preliminary evidence from respected research institutions like Johns Hopkins University School of Medicine indicates that yes, the addition of medical cannabis to the list of medications used to treat opioid use disorder (OUD) is, indeed a viable option.
Right now, with regards to the opioid crisis, we need all the viable options we can find.
Why?
Because during the coronavirus pandemic, the opioid crisis got worse. After making modest progress in reducing the number of opioid prescriptions written and dispensed and decreasing the number of opioid overdose deaths between 2016 and 2019 – with a spike in 2018 – the post-pandemic numbers are not encouraging.
Let’s have a look.
Overdose Deaths 2019-2021: United States
- All drugs:
- 2019: 67,697
- 2020: 78,056
- 2021: 100,306
- Opioids:
- 2019: 50,178
- 2020: 69,061
- 2021: 73,453
We include the data on all drugs so you understand where opioids stand in relation to all drugs. In 2019, opioids accounted for 74 percent of overdose deaths, in 2020 they accounted for 88 percent of overdose deaths, and in 2021 they accounted for 73 percent of overdose deaths.
That’s why we need more viable options to treat opioid use disorder.
Not only have opioid overdose deaths made up the majority of overdose deaths every year for the past decade, but they’re increasing again.
Our most powerful weapon against overdose deaths is addiction treatment, and research shows that medication-assisted treatment (MAT) is most effective treatment available for opioid addiction. Now that four states have legalized cannabis for recreational use, 42 states and territories and have legalized medical cannabis, and 14 states have legalized limited medical use of cannabinol (CBD), it’s both reasonable and prudent to explore the use of cannabis and cannabinoids as a viable component of MAT.
Cannabinoids/Cannabis for Opioid Addiction Treatment: Why Do Researchers Think It Can Work?
There are several evidence-based reasons researchers explore cannabinoids for OUD treatment. The first is related to the reason the prevalence of MAT treatment has gradually increased around the country: compared to traditional, abstinence-only programs, MAT is more effective in preventing relapse.
For opioid use disorder, participants in abstinence-only treatment show high rates of relapse:
- In the outpatient population, 85% of people with OUD relapse within 12 months of the initiation of treatment
- Among the inpatient, residential treatment population, 80% of people with OUD relapse within 2 years of initiation of treatment
In contrast, evidence indicates people with OUD in MAT programs – if they stay in the programs – experience relapse rates of between 11 percent and 22 percent. That’s a significant difference, which justifies further research into how we can augment MAT in any way possible: it reduces relapse, which, in turn, saves lives.
The next reason involves taking a step back and looking at the way we treat pain in the U.S.
For chronic and severe pain, opioids are the go-to medication. However, recent research shows that cannabinoids may be an effective adjunct medication for people with severe and chronic pain. Incorporating cannabis as an accepted analgesic medication can change the way we prescribe and use opioids, which, in turn, can affect the number of people who develop opioid addiction after receiving a prescription.
We’ll call cannabis/cannabinoids for pain relief the first step toward using them to treat OUD.
Here’s why.
Step 1: Cannabis for Pain Relief
The primary use for both prescription opioids and prescription cannabis is analgesia, a.k.a. pain relief. Several studies published over the past several years describe the relationship between opioids and cannabis for pain relief. The following data comes from the study Emerging Evidence for Cannabis’ Role in Opioid Use Disorder, published in 2018:
- 90% of patients in state-level medical cannabis registries list chronic pain as their qualifying condition for the medical program.
- The National Academies of Science and Medicine recently confirmed the efficacy of cannabis for chronic pain in adults. They report:
- When given access to cannabis, individuals currently using opioids for chronic pain decrease their use of opioids by 40-60% and report that they prefer cannabis to opioids
- Patients in these studies reported fewer side effects with cannabis than with their opioid medications
- Patients who use cannabinoids or cannabis experience improved cognitive function
- A better quality of life with cannabis use compared to opioids
- Across studies and across various methods of ingestion/administration, studies show cannabis reduces the amount of opioid medication needed to relieve pain
Researchers also identified various ways that opioids and cannabinoids interact in the brain. The details of the interactions are far too complex for an article like this. However, we can spare you the talk of opioid receptors, endocannabinoids, eliminate words like pharmacokinetics and subanalgesia, and share the following information:
- Cannabis and opioids can work together to provide pain relief
- In combination, the dosage required to reduce pain is smaller for both opioids and cannabis than when administered separately
- This analgesic synergy – i.e. pain-relief teamwork – can be leveraged to provide significant pain relief
With regards to the combined use of cannabis and opioids for pain relief, researchers observe:
“This strategy could have significant impacts on the opioid epidemic, given that it could entirely prevent two of the hallmarks of opioid misuse: dose escalation and physical dependence.”
We agree.
Anything that prevents the negative consequences of tolerance and dependence has the potential to alter the trajectory of not only the opioid epidemic, but the way medical professionals and their patients use prescription opioids. There is near-universal agreement that overprescribing and misusing prescription opioids drove the current opioid epidemic. If combining cannabinoids with opioids in a controlled, clinical setting can reduce dosage and prevent misuse, then that would be a welcome development for everyone involved, including doctors, chronic pain patients, and their families.
Now it’s time to move to what we’ll call step 2: using cannabinoids in OUD treatment.
Step 2: The Use of Cannabinoids in OUD Treatment
Before we talk about the use of cannabinoids in OUD treatment, we should offer a quick refresher about the medications already in use for OUD and talk about why researchers continue to seek new medications to improve our overall approach to MAT.
There are three medications in widespread use for treatment of opioid addiction, which we’ll call MAT for OUD: methadone, buprenorphine, and buprenorphine + naloxone.
Evidence shows all three are more effective in treating OUD than abstinence-only programs, and that when combined with therapy, addiction education, community support, and lifestyle changes, MAT for OUD can:
- Decrease opioid use
- Reduce opioid-related overdose deaths
- Decrease criminal activity
- Prevent transmission of infectious diseases
- Improve social functioning
- Allow individuals in treatment to re-engage in family life, including parenting and active participation in primary partnerships/marriage
- Increase time in treatment
- Increase the ability to seek and gain employment
- Improve birth outcomes for pregnant women with OUD
That’s why an integrated MAT program is considered the gold standard in treating opioid addiction. Researchers confirm that integrated MAT is effective, and that there is “little rationale to deviate from this approach.” However, the use of these medications is highly regulated, and, for the most part, prescribing is limited to physicians with special training and licensure. In some cases, the regulations surrounding the prescription and dispensation of these medications can create barriers to treatment.
Scientists cite these barriers as the primary reasons expanded research on cannabinoids for OUD treatment is necessary. They believe it’s critical to pursue “novel and alternative therapies which improve efficacy, diminish geographical disparities, and eliminate the need for specialty physicians…” in order to bring evidence-based treatment for OUD to as many people as possible.
Let’s take a look at that study from Johns Hopkins Medical School we mentioned at the beginning of this article. A team of scientists asked 200 study participants – all of whom were in treatment for OUD – the following simple question:
Did cannabis improve or worsen opioid withdrawal symptoms?
Here’s what they said.
Cannabis and Opioid Withdrawal: Does it Help?
125 participants in the study used cannabis to treat withdrawal. Of those:
- Over 70% said it help improve symptoms
- 20% said it helped some symptoms, but not all
- 6.4% said it made symptoms worse
- 2.4% said it had no effect
Of the 70% who said cannabis helped improve their symptoms:
- 76.2% said it reduced anxiety
- 54.1% said it reduced tremors
- 48.4% said it improved sleep
- 45.9% said is decreased joint/bone/muscle aches/pains
- 45.1% said it decreased restlessness
- 38.5% said it reduced nausea
- 37.7% said it reduced cravings for opioids
Of the 6.4% who said it made symptoms worse:
- 7.4% said it increased yawning
- 6.6% said it increased runny nose
- 6.6% said it worsened teary eyes
- 5.7% said it made them more restless
- Another 5.7% said it increased nausea
- 5.7% said it gave them hot flashes
We’ll take those stats any day of the week. Honestly, we’re not excited that cannabinoids for OUD treatment may increase nausea. However, if a very small percentage of people report nausea, yawning, runny noses, and teary eyes are the worst effects of cannabinoids in the context of using cannabinoids to treat withdrawal symptoms, we can live with that.
The authors of the study can, too. Here’s what they have to say about the statistics above:
“These results show that cannabis may improve opioid withdrawal symptoms and that the size of the effect is clinically meaningful.”
One of the primary reasons people relapse after initiating treatment for opioid use disorder is the severity of the withdrawal symptoms. Also, one of the main reasons people overdose after spending time in treatment is that their tolerance for the drug decreases dramatically. If adding cannabinoids to an MAT treatment program – in the form or manner allowed by the laws of the particular state – can reduce the severity of withdrawal symptoms, then we think that’s certainly a viable option.
Harm Reduction: Improved Lives
Here’s the equation as we see it: less severe withdrawal symptoms – such as cravings – mean less risk of relapse, which, in turn, means less risk of the negative consequences of active addiction, and most importantly, less risk of fatal overdose.
That line of reasoning, at the very least, means further research into the use of cannabinoids in MAT for OUD is worth the time and effort.
We’ll address one last thing before we finish: the addictive and euphoric properties of cannabis and cannabinoids. We’re sympathetic to the argument that “using one addictive substance to help treat addiction to another addictive substance is illogical.” However, this is a debate we’ve had over methadone and the other medications used in MAT. We’re confident and comfortable with our side of the debate – our side being in favor of MAT – because MAT reduces the harm caused by addiction.
That’s what we mean, in this context, by harm reduction.
It’s true: cannabis can cause euphoria (a high) and create physical dependence. What’s also true is that not all cannabinoids used for therapeutic purposes cause euphoria, and that cannabis addiction, withdrawal, and relapse is not fatal and does not cause the harm caused by addiction to opioids. Are we saying cannabis addiction is okay?
No, not at all.
What we are saying is that, on balance, the benefits of cannabinoids in treatment for OUD far outweigh the harms of opioid addiction. And therefore – after reading the research and considering the pros and cons – we conclude that yes, cannabinoid treatment for opiate addiction is a viable option.