Only six days before Prince’s death, the legendary singer was hospitalized for a possible overdose on Percocet. His death on April 21 was the result of overdosing on another painkiller, fentanyl. Every year, millions of Americans use one or both of these opioids in an effort to alleviate pain frequently requiring ever increasing amounts for effective pain management, at the risk of overdosing. According to the Department of Health and Human Services, the U.S. is in the midst of an opioid epidemic that is the greatest in scope and unlike any other in history.
Between 1999 and 2014, more than 165,000 Americans died from opioid overdoses. It’s estimated that the costs for treatment and other related expenses resulting from opioid abuse could be as much as $55 billion a year. It’s an issue that has experts earnestly searching for a safer solution for pain relief. Much of the research is pointing in the direction of marijuana.
Many physicians began hearing accounts of patients using cannabis for pain relief in place of prescription opioids, as early as 15 years ago. These frequent and widespread reports prompted a research team led by Marcus Bachhuber, assistant professor of medicine at the Montefiore Medical Center in New York City, to analyze whether the legalization of medical marijuana in some states had had any impact on the number of deaths caused by opioid overdoses. The study, published in 2014, showed that between 1999 and 2010, states that allowed medical marijuana had an average of almost 25 percent fewer opioid overdose deaths each year than in illegal cannabis states.
However, the Bachhuber research could not prove that medical cannabis had a direct link to fewer opioid overdoses. Also, the number of overdoses reported included both prescription opioids and illegal heroin. But the study did reveal to many researchers a possible relation between marijuana and painkiller use. Bachhuber felt that marijuana could be used as an alternative for treating chronic pain so that people wouldn’t use opioids or at least use a lower dose of opioids than they would have traditionally.
A large array of new studies supported his findings. In the June issue of the Journal of Pain, it was reported that researchers at the University of Michigan conducted a survey of 185 patients who were patrons of a medical marijuana dispensary in Ann Arbor, Michigan. This particular group of patients reported decreasing their opioid use by over half, in the management of their pain.
There are also animal studies which have shown that the cannabinoid chemical compounds found in marijuana can, in some instances, work to enhance the effectiveness of opioids in mitigating pain.
According to Simon Haroutounian, chief of clinical research at the Washington University Pain Center in St. Louis Medical, cannabis was also a prominent topic at the 2016 meeting of the American Pain Society. He co-wrote research, which was published in the Clinical Journal of Pain, that followed a group of 176 chronic pain patients in Israel, over a seven month period and discovered that within seven months of starting medical cannabis, 44 percent of them discontinued taking prescription opioids.
As promising as much of this research sounds, each of these analyses has its limitations. It is difficult, if not impossible, for studies to reveal certain details such as whether overdose deaths were from patients who were using medically prescribed opioids or those who obtained the drugs illegally and were using them recreationally or for self-medication.
Furthermore, in Haroutounian’s observational study, which was carried out in real time, the study subjects were screened in advance for any psychiatric conditions, as well as the potential for misuse of the drugs. The subjects weren’t any more likely to experience complications from medical cannabis than a general population patients suffering from chronic pain. Haroutounian stated that there isn’t a lot of substantial data for the long term effects or for larger groups that aren’t chosen as carefully.
An additional issue is the safety of medical cannabis as an alternative to opioid medications. A report in the Journal of Pain, published late last year, tracked about 200 patients who used cannabis for chronic pain over a twelve-month period. Unlike many studies in the past, this study compared medical marijuana users with a control group of chronic pain patients who were not consumers of marijuana. The results indicated some increases in users for minor adverse effects in the medical cannabis group, but there was not increase for the risk of serious side effects.
There have been some studies that examine whether the use of cannabis can be substituted for opioids in the use of pain management. Typically, these have been limited to a few hundred patients at most. However, there is a much larger study currently underway. Tilray is a Canadian producer of cannabis products, and is conducting a 1,000-patient study that spans across 20 Canadian clinics over a six month period. Philippe Lucas, vice president of patient advocacy at Tilray, stated that rather than relying on reports from patients, the research will analyze the substitution effect directly in real time.
According to Mark Ware, director of clinical research at the Alan Edwards Pain Management Unit at McGill University and lead author of the Journal of Pain safety study, these experimental clinical trials would provide the most concrete evidence on any cause-and-effect relation between medical cannabis and reduced opioid use. But, because the U.S. classifies cannabis as a Schedule I substance that has “no currently accepted medical use and a high potential for abuse”, experimental studies using medical cannabis continue to be extremely difficult. The majority of other countries have similar restrictions in place, making it a challenge for researchers to obtain marijuana and receive approval for its use in clinical trials.
These types of trials are an unavoidable step because they ensure safety. Although numerous experts view cannabis as a potential treatment for chronic pain, many have concerns about jumping ahead without looking at the long-term effects of marijuana and any potential for substance abuse and unwanted side effects.
Despite several states having legalized medical cannabis, there isn’t really a policy in place that governs the ways in which cannabis can be researched and obtained by the scientific community.
The political climate for cannabis has been evolving rapidly. As recently as last June, Ohio legalized medical marijuana, joining
24 other states and the District of Columbia. The U.S. Drug Enforcement Administration contemplated the approval of two state governors’ petitions to reconsider marijuana’s Schedule I status, but after much deliberation, denied the petitions in an August 11 decision. Despite this, the DEA did announce a policy change, authorizing an increase in the number of marijuana manufacturers, thus encouraging U.S. research.
It’s unlikely that medical cannabis would prove to be a replacement for opioids in every medical situation. One example would be end-of-life care and the treatment of acute pain from cancer or major surgery. But in less severe cases, medical marijuana could be an appropriate choice for pain management. Even many harsh critics would agree that medical cannabis poses far fewer risks for fatal overdosing than opioids.