Marijuana Legalization and the Opioid Crisis

Marijuana Legalization and the Opioid Crisis
California NORML
November 1, 2017

The evidence is mounting that allowing access to marijuana, used medicinally or recreationally, could be an answer to the opioid crisis. On almost a weekly basis, a new study emerges confirming the pain-killing properties of cannabis, or finding that states with medical cannabis laws have lower rates of opioid use and abuse or opioid-related overdose deaths, as well as hospitalizations, traffic fatalities, and drug treatment admissions related to opioids.

Cal NORML has heard from innumerable patients and physicians who report having substantially reduced or eliminated their use of prescription opioids by substituting cannabis instead. Despite this, we continue to hear regularly from chronic pain patients with severe, debilitating pain who are being ordered NOT to use medical cannabis as a condition of taking opioids or other controlled substances. Hardly a week goes by without our hearing patients complain about being forced to sign “pain contracts” that preclude use of cannabis, or being denied opioid or other medications on account of using cannabis that has been legally recommended by other physicians.

We have launched a patient survey to gather data and input from patients across the state on this topic as part of our campaign to gain pain patients’ rights. Early results show that 17-25% of medical cannabis patients in California have experienced this kind of discrimination by their doctors. If you are a medical marijuana patient in California, please take our 2-minute survey.

US Government Reports and Agencies Agree

In January 2017, the National Academy of Science released a major report on cannabis, which concluded that chronic pain is one of the few conditions for which there is “conclusive or substantial evidence” for cannabis’s effectiveness. NIDA, the National Institute on Drug Abuse, now admits on its website that “data suggest that medical cannabis treatment may reduce the dose of opioids required for pain relief” and “medical marijuana products may have a role in reducing the use of opioids needed to control pain.”

A pair of NIDA-funded studies explored the relationship between marijuana legalization and adverse outcomes associated with prescription opioids. The first found an association between medical marijuana legalization and a reduction in overdose deaths from opioid pain relievers, an effect that strengthened in each year following the implementation of legislation.

A second NIDA-funded study, a more detailed analysis by the RAND Corporation published in November 2015, showed that legally protected access to medical marijuana dispensaries is associated with lower levels of opioid prescribing, lower self-report of nonmedical prescription opioid use, lower treatment admissions for prescription opioid use disorders, and reduction in prescription opioid overdose deaths. Notably, the reduction in deaths was present only in states with dispensaries (not just medical marijuana laws) and was greater in states with active dispensaries.

The US Veteran’s Administration policy is not to deny treatment to patients who are participating in state medical marijuana programs. Nonetheless, this policy is not always adhered to at the local level. (UPDATE December 8, 2017 – The VA has issued VHA Policy Directive 2017-1315 stating, “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.” The directive, signed by Executive in Charge Carolyn M. Clancy, M.D., replaces VHA Directive 2011-004 which had the same language. The new directive is scheduled for recertification on or before the last working day of December 2022.)

California Congressman Lou Correa has introduced a resolution calling for the VA to “conduct a clinical study comparing the effectiveness of cannabis in treating chronic pain in veterans to help stop the opioid crisis.” Democratic members of the House Committee on Veteran Affairs sent a letter to VA Secretary Shulkin encouraging the VA to engage in medical cannabis research. Read more.

The Opioid Problem and CDC Recommendations

According to the US Centers for Disease Control and Prevention, opioids (including prescription opioids, heroin, and fentanyl) killed more than 33,000 people in 2015, more than any year on record. Nearly half of all opioid overdose deaths involved a prescription opioid in 2015, and they rose again sharply in 2016—largely due to deaths involving fentanyl—to over 50,000. At this rate, every day 137 Americans die from an opioid overdose.

The CDC further estimates that in 2014, almost 2 million Americans abused or were dependent on prescription opioids and that every day, over 1000 people are treated in emergency departments for misusing prescription opioids.

The 2016 CDC guidelines on prescribing opioid medications for pain state, “Clinicians should not test for substances for which results would not affect patient management or for which implications for patient management are unclear,” the CDC states. “For example, experts noted that there might be uncertainty about the clinical implications of a positive urine drug test for tetrahyrdocannabinol (THC)…Clinicians should not dismiss patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety.”

Recent Developments

Recently, a study found that the legalization of recreational marijuana in Colorado is associated a 6.5 percent decrease in monthly opioid deaths. Read more.

NFL players have begun to advocate for the use of cannabis for pain and head trauma, and the league has reportedly offered to work with the players’ union to study marijuana for pain management. The former commissioner of the NBA and Warriors coach Steve Kerr have also come out in favor of allowing players to use medical cannabis.

TV Host Dr. Oz recently surprised Fox News commentators by telling them that medical marijuana “may be the exit drug to get us out of the narcotic epidemic,” and has now gone further to state that “I think medical marijuana might offer an option to help prevent you from ever getting opioids in the first place, and maybe help in getting you off of them.” He has started a petition asking the National Institutes of Health to fund more research into medical marijuana as a solution to the opioid crisis, which has gathered over 64,000 signatures.

Trump Administration Response (or Lack Thereof)

The journal Scientific American recently called out Jeff Sessions on his unscientific rhetoric and concluded, “Rolling back protections from federal interference in state legalization laws could worsen the opioid overdose crisis.”

Conspicuously absent from the Trump administration’s plan to address the opioid crisis is any mention of a role cannabis might play. NORML has launched a campaign to educate the ONDCP Commission about the positive role that cannabis access plays in curtailing opioid abuse.

Also see: Trump’s opioid agency fails to cite marijuana’s benefits, despite mounting evidence

Additional references

Cannabis is effective in treating pain

Cannabis and intractable chronic pain: an explorative retrospective analysis of Italian cohort of 614 patients
Fanelli et al. J of Pain Research May 2017
“Even with the heterogeneity of the sample size and limited data available… the treatment seems to be effective and safe in the majority of patients.”

Study: Daily Cannabis Use For Chronic Pain Is Safe, Effective
Researchers at McGill University in Montreal assessed the long-term health of 216 medicinal cannabis users with chronic non-cancer pain who consumed a daily standardized dose (12.5 percent THC) of herbal cannabis compared to 215 controls (chronic pain suffers who did not use cannabis). Pain patients who used cannabis reported a reduced sense of pain compared to controls, as well as reduced anxiety, depression, and fatigue. Investigators reported that daily cannabis consumers possessed no greater risk than non-users to experience “serious adverse events,” including cognitive effects.

Four state-funded studies conducted at the University of California at San Diego’s Center for Medical Cannabis Research found in cannabis was helpful in treating diabetic peripheral neuropathy and painful HIV neuropathy. A separate study determined that ʺsmoked cannabis was superior to placebo in reducing spasticity and pain in patients with MS, and provided some benefit beyond currently prescribed treatments.ʺ Positive results were found with both smoked marijuana and low-dose vaporized cannabis.

Smoked cannabis for chronic neuropathic pain: a randomized controlled trial
Ware et al. 2010. CMAJ 182: 694‐701.
This 2010 McGill University study reported that smoked cannabis significantly improved measures of pain, sleep quality and anxiety in participants with refractory pain for which conventional therapies had failed.

Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers
Cooper et al. 2013. Neuropsychopharmacology 38: 1984‐1992.
This 2013 clinical trial reported that both inhaled cannabis and oral THC significantly decreased pain sensitivity and increased pain tolerance in healthy subjects exposed to experimental painful stimuli.

Cannabinergic pain medicine: a concise clinical primer and survey of randomized-controlled trial results
Aggerwal SK, Clin J Pain. 2013 Feb;29(2):162-71.
ʺOverall, based on the existing clinical trials database, cannabinergic pain medicines have been shown to be modestly effective and safe treatments in patients with a variety of chronic pain conditions.ʺ

Cannabinoids for the treatment of chronic non‐cancer pain: An updated systematic review of randomized controlled trials
Lynch and Ware. 2015. Journal of Neuroimmune Pharmacology 10: 293‐301.
Another review of randomized clinical trial data, published in 2015, similarly reports, ʺ[C]annabinoids are safe [and] demonstrate a modest analgesic effect and provide a reasonable treatment option for treatment chronic non‐cancer pain.ʺ

Cannabis access is associated with lower rates of opioid use

Trauma Patients Report That Cannabis Reduces Their Opioid Intake
Patients who used medical cannabis following musculoskeletal injury report that it relieves pain symptoms and reduces their level of opioid intake, according to a survey of 500 patients at two trauma centers in Massachusetts.

Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep
Piper et al, J. Psychopharmacol, 1 Mar 2017
Survey of 1,513 New England dispensary members reported 76.7% reduced use of opioids starting use of medical cannabis

Cannabis as a substitute for prescription drugs – a cross-sectional study
Corroon, Mischley, Sexton, J of Pain Research, Mar 2017
46% of 2,774 cannabis users reported using it as a substitute for RX drugs, the most common being narcotics/opioids (35.8%).

Cannabis as a Substitute for Opioid-Based Pain Medication: Patient Self- Report
Amanda Reiman et al, Cannabis and Cannabinoid Research Vol 2.1 2017
A survey of 2897 medical cannabis patients found 30-34% used opioids and 61% of those used opioids with cannabis, 97% of whom “strongly agreed/agreed” that cannabis reduced their opioid consumption.

Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain
Boehnke, Litinas, Clauw, J. Pain Jun 2016
Survey of 244 chronic pain patients found medical cannabis use associated with a 64% decrease in opioid use, decreased number and side effects of medications, and an improved quality of life.

Splendor in the Grass? A Pilot Study Assessing the Impact of Medical Marijuana
Gruber et al, Front Pharamacol, Oct 2016
Study of 24 medical cannabis patients found notable decrease in use of conventional pharmaceutical agents, with opiate use declining more than 42%. The use of antidepressants, mood stabilizers and benzodiazepines also decreased, and cognitive performance also improved in the patients.

The Effect of Medicinal Cannabis on Pain and Quality of Life Outcomes in Chronic Pain: A Prospective Open-label Study
Haroutounian et al, Clin J Pain, Dec 2016)
The treatment of chronic pain with medicinal cannabis in 176 patients resulted in improved pain and functional outcomes, and a significant reduction in opioid use.

Among veterans, opioid prescription requests down in step with rise in medical pot
Vancouver Globe and Mail, June 7, 2016
Fewer Canadian veterans have sought prescription opioids and tranquillizers in recent years while prescriptions for medical marijuana have skyrocketed.

University of New Mexico study suggests medical marijuana could decrease prescription opiate abuse
Study by UNM Prof. Jacob Vigil and Prof. Sara Stith
18-month study finds 31% reduction in opioid use among chronic pain patients using medical cannabis.

Care by Design / Project CBD Survey Results
Among 800 respondents, over half reported that they had used both cannabis and opiates for pain management. Of this subgroup, 91 percent said they used fewer or no opiates after beginning cannabis therapy. Sixty-three percent said that they stopped using opiates altogether.

Cannabinoid-opioid interaction in chronic pain
Abrams DI, Couey P, Shade SB, Kelly ME, Benowitz NL.
Clin Pharmacol Ther. 2011;90(6):844-851. doi:10.1038/clpt.2011.188.

Cannabis reduces opioid dose in the treatment of chronic non-cancer pain.
Lynch ME, Clark AJ. J Pain Symptom Manage. 2003;25(6):496-498

Cannabis access is associated with reductions in overall prescription drug spending

Medical Marijuana Laws May Be Associated With A Decline In The Number Of Prescriptions For Medicaid Enrollees
Bradford & Bradford, Health Affairs, Apr 2017
Medicaid prescription drug costs were lower in states with medical marijuana laws in five of nine clinical areas, including pain. Estimated cost savings > $1 billion.

Medical marijuana legalization is associated with reductions in opiate overdose and addiction, with hospitalizations due to opiate use, and with opioid-related traffic fatalities

Do Medical Marijuana Laws Reduce Addictions and Deaths Related to Pain Killers?
Powell, Pacula, Jacobson, NBER Working Paper Jul 2015
States permitting medical marijuana dispensaries experience a relative decrease in both opioid addictions and opioid overdose deaths compared to states that do not.

Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010
Bachhuber et al, JAMA Intern Med. Oct 2014
Conclusion: Medical cannabis laws are associated with significantly lower state- level opioid overdose mortality. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws. In 2010, this translated to an estimated 1729 fewer deaths than expected.

Medical Marijuana Policies and Hospitalizations Related to Marijuana and Opioid Pain Reliever
Y Shi, Drug Alcohol Depend. Apr 2017
Medical marijuana legalization associated with reductions if 23% in hospitalizations due to opioid dependence and 13% due to overdose.

Medical Marijuana States See Reduced Number of Fatal Crashes Involving Opiates
Researchers analyzed federal crash data in 18 states over the period from 1999 to 2013. States that passed a medical marijuana law during this period saw a reduction in opioid involvement in fatal car accidents, relative to states without such a law. The reduction was greatest among drivers aged 21 to 40, the age group most likely to use medical marijuana where it’s available.

Cannabinoids can act as an exit drug for those addicted to opioids

The effects of dronabinol during detoxification and the initiation of treatment with extended release naltrexone

Intermittent marijuana use is associated with improved retention in naltrexone treatment for opiate-dependence

Concurrent Substance Use and Outcome in Combined Behavioral and Naltrexone Therapy for Opiate Dependence

Other reports about the potential benefits of medical cannabis in addressing the opioid epidemic

UCLA professor Dr. Thomas Strouse published an oped in December 2016 stating, “There has been plenty of hand-wringing about how these new laws might harm society, but I believe they have the potential to help in a range of societal issues. Prominent among them is the opioid crisis facing our nation.”

The opioid crisis in America’s workforce

Could Pot Help Solve the U.S. Opioid Epidemic?

Cannabidiol: Swinging the Marijuana Pendulum from ‘Weed’ to Medication to Treat the Opioid Epidemic

Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors

Medical Cannabis in Arizona: Patient Characteristics, Perceptions, and Impressions of MedicalCannabis Legalization

Profiles of medicinal cannabis patients attending compassion centers in Rhode Island

Who are medical marijuana patients? Population characteristics from nine California assessment clinics

Patients Are Ditching Opioid Pills for Weed: Can Marijuana Help Solve the Opioid Epidemic?

Opioids Out, Cannabis In: Negotiating the Unknowns in Patient Care for Chronic Pain

Also see: NORML fact sheet on opioids and marijuana

The Drug Policy Alliance Fact Sheet on marijuana and opiates

ASA’s End Pain Not Lives Campaign

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