Can cannabis help combat the opioid epidemic?

An estimated 50 million people in the United States suffer from non-cancer chronic pain, which “has led to the proliferation of opioid prescriptions and addiction which is currently a public health concern in the USA.” Could cannabis offer a way of easing these patients off opioids?

What is chronic pain?

Chronic pain is defined as pain that lasts longer than three months, and it can make life pretty miserable. According to the Mayo Clinic, chronic pain can make it difficult to work, maintain normal social relationships and even manage day-to-day tasks at home. Chronic pain has a significant negative impact on well-being, and it must be managed with various therapies depending on “your diagnosis, biology and personal history.”

In 2020, researchers published a review assessing whether medical cannabis prescriptions reduced opioid dosage, or even completely replaced opioids, in patients suffering from non-cancer chronic pain. These findings support a general trend that cannabis doctors are quick to note: in states where people have access to medical marijuana clinics, use of prescription opioids or sleep-aids generally declines. They found that for many patients, medical cannabis allowed them to reduce their opioid dosage, and in some cases, medical cannabis completely replaced opioid therapies.

However, the studies that the researchers reviewed all had different designs and limitations, so the evidence from this review “cannot be relied on to promote [medical cannabis] as an adjunct to opioids in treating non-cancer pain,” although it opens up some promising avenues for future research.

Why study non-cancer pain specifically?

Cancer pain stems from the “invasion of a tumor and the interaction of a tumor and the interaction among tumor cells, the nervous system, and an individuals immune system.” Cancer pain and non-cancer pain have different causes and are managed in different ways, so the researchers focused solely on non-cancer pain in their review.

Opioids versus non-opioids?

In 2018, a different group of researchers conducted a 12-month clinical trial on the effects of opioid versus non-opioid medications on patients with back, hip, or knee pain. According to these researchers, “long-term opioid therapy became a standard approach to managing chronic musculoskeletal pains despite a lack of high quality data on benefits and harms. Rising rates of opioid overdose deaths have raised questions about prescribing opioids for chronic pain management.”

In the clinical trial, the researchers studied acetaminophen, NSAIDs, Tramadol, and various other opioid and non-opioid therapies, although they did not study cannabis. They found that non-opioid treatments were associated with much better pain relief.

When compared to a placebo, opioids had a small benefit, but caused a variety of adverse side effects like “poor pain outcomes, greater functional impairment, and lower return to work rates.” Additionally, they found that opioids caused far more adverse side effects than non-opioids, such that “opioids did not demonstrate any advantage over non-opioid medications that could potentially outweigh their greater risk of harm.”

Cannabis and CBD have long been used for pain relieving purposes, and due to the obvious drawbacks of opioids, “cannabinoid medicines are increasingly being considered as opioid substitutes.” A meta-analysis of cannabis as a treatment for non-cancer pain “reported a significant effect on pain reduction.” As a result, the researchers in the 2020 review set out to determine whether medical cannabis as an adjunct therapy to opioids led patients suffering from non-cancer chronic pain to reduce their opioid dose.

What did they find?

Patients with non-cancer chronic pain who used medical cannabis demonstrated a 64-75% reduction in opioid dosage compared to patients with non-cancer chronic pain who did not use medical cannabis. The researchers also found that 32-59% of medical cannabis users completely stopped using opioids and that the medical cannabis group also had a dramatic reduction in emergency room visits and hospital admissions.

While these results are exciting, the review drew on a variety of resources including case reports and observational studies where patients self-reported their reductions in opioid dose. The researchers assessed the included studies as having a serious risk of bias. Additionally, most of the studies included in the review did not discuss the dose of cannabis used, and those that did ranged from using 1.5 mg of cannabis to 2000 mg of cannabis.

The researchers note that further studies need to be conducted to determine the optimal dose of cannabis needed to gradually reduce opioid doses “until an optimal pain relief is attained.” The researchers also call for further studies exploring which routes of cannabis administration would allow for the fastest reduction of opioid dosage. However, due to limitations in the studies reviewed, the researchers were not able to recommend using cannabis as an adjunct to opioid therapy. As always, any changes to your pain management strategy should be discussed with your doctor.

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