Image Source: Flickr / Cindy Shebley
As per the CDC’s weekly Mortality and Morbidity report, there were over 63,000 drug overdose deaths in the United States, of which approximately 66% of deaths were attributed to opioid narcotics (e.g. Hydrocodone, Oxycodone, Morphine, Fentanyl, Heroin, etc.…). Furthermore, the amount of overdose deaths from synthetic opioids, not including methadone, doubled between 2015 and 2016 (Seth et al., 2018).
Synthetic Opioids and Statistics
The increasing prevalence of powerful synthetic opioids such as fentanyl (50-100 times the strength of morphine) and even carfentanil (10,000 times as powerful as morphine and strictly used to tranquilize elephants intramuscularly) found to be mixed into or directly sold as heroin, have directly contributed to this drastic and tragic rise in opioid-related mortalities (Seth et al., 2018).
These statistics paint a stark, yet accurate portrait of just how severely the opioid crisis has affected American’s today. Enter cannabis: the “gateway drug” we so fondly remember our D.A.R.E officers warning us about as children. Ironically, cannabis does have the power to serve as a gateway for American’s everywhere to find their way out of the vicious cycle that is opioid dependency and addiction. Indeed, recent data clearly indicates a significant decline in “the use and abuse of prescription drugs”, particularly opioids, in “states where cannabis is legal” (Corroon et al., 2017) (Haroutounian et al., 2016). The alarming rate of opioid overdoses and fatalities in conjunction with the recent data demonstrating the attenuation of such tragedies in states that have successfully implemented a medical cannabis program, seriously warrant further investigation into cannabis as an adjunctive or alternative pharmacological intervention in the management of chronic pain. This review will attempt to illustrate the devastating effects of the opioid epidemic as well as the role of cannabis as a potentially efficacious and markedly safer alternative to opioid narcotics in the treatment of pain.
America’s Problem With Opioids and Chronic Pain
It is estimated that about 11.2% of the U.S. adult population (approximately 25.3 million people), suffer from some form of chronic pain (Nahin, 2015). Americans only make up 4.6% of the world’s population, yet, “have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world’s illegal drugs” (Manchikanti & Singh, 2008). If you are skeptical about the notion that American’s are truly in that much more pain than the rest of the world, you are not alone. We have become a nation of pain pill poppers, thanks to a massively misleading marketing push by Purdue pharma (the makers of Oxycontin, also known as “hillbilly heroin”) in the late 90’s and early 2000’s. Sales reps for Purdue pharma were trained to say that the risk of addiction was “less than 1%” by citing studies that did not analyze the long-term use of such powerful opioids for chronic pain (Zee, 2009).
We now know all too well that this is categorically untrue and the use of such opioids for long-term, non-cancer associated pain carries significant risk of dependency and addiction as well as high rates of abuse and diversion as per several studies cited in Zee’s 2009 article ” (Zee, 2009). Indeed, “3 company executives pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids” and ended up paying “$634 million in fines” (Zee, 2009).
But the damage had already been done and the opioid epidemic was already starting to snowball out of proportion. As regulations on the overprescribing of opioids tightened, dependent and addicted patients began to get cut off from their supply and experienced the horrific experience that is opioid withdrawals. As a result, many turned to heroin (one of the most powerful members of the opioid family of drugs) to combat their pain and stave off withdrawal (Netherland & Hansen, 2017). Thus, the formula for the opioid epidemic had been established (overprescribing of opioids for chronic pain, which then led to increased abuse liability and addiction/dependency in patients, which ultimately resulted in the need to obtain illicit and diverted opioids such as heroin, which is much more readily available, cheaper and of course, doesn’t require a prescription) (Netherland & Hansen, 2017) (Dowell et al., 2016).
Overcoming the Opioid Epidemic and Barriers with Cannabis
Healthcare providers and patients alike now find themselves in a precarious and difficult situation. Many physicians are not adept at handling the safe and proper titration of opioid medications in patients who have become dependent on them over the long term. Furthermore, the giant leap from overprescribing opioids to their strict regulation has made it harder for patients who do need temporary pain relief from getting the medications they need due to the fear of medical professionals jeopardizing their licensure and ability to practice. Clearly, there is a dire need for alternative analgesic options for patients that’s safer and does not carry such a high potential for abuse, addiction and dependency. It is at this point in the story where cannabis plays its starring role as a potential exit strategy from the seemingly never ending cycle of (ironically) pain and misery that is the opioid crises
The safety profile of cannabis along with its efficacy in treating many types of pain is one of the cornerstones of what makes it such a promising alternative to opioids. A 2017 study out of Italy reported “64.7% of patients in the study cohort reported an improvement associated with the therapy” and the researchers reached the ultimate conclusion that cannabis treatment seems to be “effective and safe in the large majority of patients” (Fanelli et al., 2017). Furthermore, cannabis has been shown to be a successful adjuvant to opioid therapy in that it allows a patient to use lower doses of their opioid based pain medications when used in conjunction with cannabis, due to their synergistic pharmacological effects on one another.
Additionally, cannabinoids are able to “prevent the development of tolerance to and withdrawal from opiates, and can even rekindle opiate analgesia after a prior dosage has become ineffective” (Lucas, 2012). Studies have even shown the ability of cannabis to replace opioids entirely in the treatment of long term, intractable chronic pain (Lucas, 2012) (Fanelli et al., 2017) (Sexton et al., 2016). This data exemplifies the novel usage of cannabis as an alternative to narcotic pain medications and makes clear a pathway out of the gates of hell that can be an addiction to opioids.
Establishing cannabis as a novel therapy in the management of chronic pain may indeed eventually lead to the substitution or adjuvant use of cannabis to replace and/or limit the amount of opiates prescribed to an individual for pain. Due to the efficacy of cannabis in attenuating withdrawal symptoms of opioids, it is also possible for patients to more comfortably wean off their opioids, while continuing to use cannabis for long term pain management therapy. With further research and clinical testing, more revolutionized approaches in the utilization of cannabinoids for the treatment of pain may indeed prove to be a vital solution to the dire social dilemma that is this opioid epidemic we as a nation are facing.
What the American Medical Association Has to Say
Bradford and colleagues, in a new 2018 study published in the prestigious Journal of American Medical Association (JAMA): Internal Medicine have reiterated their remarkable findings that “medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population. This finding was particularly strong in states that permit dispensaries and for reductions in hydrocodone and morphine prescriptions” (Bradford et al., 2018).
The sparsity of endocannabinoid receptors and binding activity in the medulla (brainstem), which controls autonomic functions like breathing, very likely contributes to the fact that there has never been a purported overdose from the overconsumption of cannabis itself. This is unlike opioids, which do interact with these functions due to the availability of opioid receptors in the medulla, thus resulting in the classic overdose symptoms opioids present, such as fatal respiratory depression (Fine & Rosenfeld, 2013).
The safety profile alone has allowed patients to take matters in their own hands and seek alternative treatments in the world of cannabis, despite federal laws that completely disregard science, thus keeping cannabis on the list of Schedule I substances.
Nevertheless, the data clearly indicates the number of patients exploring medical cannabis as a treatment option continues to grow around the globe, and this author believes it is high time to deschedule and sufficiently study cannabis in more rigorous, double-blind, placebo controlled clinical trials with large and diverse cohort samples.
Paving a Road to a Better Future
The dire need for solutions to this epidemic has even resulted in the passing of a senate bill in IL resulting in the ability of patients to essentially “trade in” their opioid prescriptions for access to medical cannabis instead. Such measures are exactly what we believe is necessary to combat this epidemic and use cannabis as a gateway drug to better health and recovery from this crisis.
Hopefully someday, cannabis will begin to play an integral role as a first line treatment for chronic pain and, in the long run, undo some of the damage done by the roaring flames of the opioid epidemic in America.
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