Opioids versus medicinal cannabis for chronic pain

In light of the Opioid Crisis, highlighted by The Disney+ series, Dopesick , the debate about cannabis vs opiates as a pain treatment has never been more topical. The opioid crisis, particularly in the USA, has wrecked hundreds of thousands of lives, both directly and indirectly (ie family members and the victims of crime). Can marijuana provide medical patients with a viable alternative to opiate treatment?

Cannabis vs Opioids: An Overview 

Research is showing that cannabis could be a key component to help get us out of the opioid crisis (there are many searches on the topic of what is the best cannabis strain for pain and debate about how to use cannabis for pain relief) and it does so on many fronts.

It is an affordable medicine that helps reduce the need for high opiate doses, reduces dependency on opiates, offers alternative pain relief through the endocannabinoid receptors and does not have the same addiction qualities as opiates.

In 2018, 68,500 Americans died due to overdoses of opiates - including prescription pain killers. In Europe, that rate is about 10 times lower but the US is in the midst of an opiate crisis because, since the 1990s, opiates have been prescribed to deal with a wide range of moderate pain, post-operative pain relief and more severe pain. Prior to this change, physicians were cautious about prescribing opiates for patients and used them as a last resort medicine for chronic pain management, particularly for cancers.

Between 1999 - 2016 about 453,300 Americans died of opiate overdose and, by 2019, there were 14.5 million oxycodone prescription at an average cost of $163/prescription. Despite the harms, and the oversight of government regulators, a deathly cash cow had been allowed to trample over the lives of millions. Moreover, there is no strong evidence that opioids are a good intervention in chronic pain management - in some patients they can prolong recovery and, through opioid hyperalgesia , actually aggravate pain.

Is medical cannabis an alternative to opioids to relieve pain?

So, what are the alternatives to opioids? There are two problems that must be faced - non-opiated pain management and interventions that help people come off opiate medicine or recover from opiate addictions.

Opioids reduce pain by interacting with the opioidergic system, which is distributed in the body in many of the same localities as the endocannabinoid system. The interaction between the two systems is a matter of much research. Although in its early stages, there is evidence that CB1 receptors interfere with opiate uptake in the brain, whereby cannabinoids not only reduce the pleasure reward of opiates (a critical component of addiction) but also reduce the quantity of opiates needed to control pain. This laboratory research is supported by the behaviour of cannabis patients. In the US, 90% of registered medical cannabis patients list chronic pain as one of their symptoms and, in one study, respondents given access to cannabis reduced their use of opiates by 40-60%respondents

Cannabis research on pain treatment  

How does cannabis help pain? In a 2017 study of 271 cannabis users who completed a 107-question survey, 53% (144 respondents) reported pain-related medical conditions , of which 36% (98 respondents) listed chronic pain and 12% (32 respondents) listed arthritis. A higher number, 73% (197 respondents) reported having painful symptoms . Across all reported symptoms, cannabis was found to be 'very effective at symptom relief' in 95% of cases (257 respondents).

The European Pain Federation surveyed clinicians and carried out a literature review to ascertain the effectiveness of cannabis for chronic pain, chronic neuropathic pain, cancer pain and chronic non-neuropathic noncancer pain. They additionally looked into other forms of pain arising from Crohn's disease, fibromyalgia, lower back pain, headache, and rheumatoid arthritis. The study concluded that medical cannabis could be used as part of multi-disciplinary treatment plan for a variety of painful conditions, whether as an adjunct to first and second line therapies or as an individual therapeutic trial. The pain relieving properties of the cannabinoid CBD (Cannabidiol) have been studied by scientists in particular in recent years.

What caused the opioid crisis? 

Two factors have been seen as having a significant contribution to the normalization of opiate use by medical patients in the USA. Firstly, prominent pain specialists promoted the idea that these medications had a low risk of addiction based on very little robust evidence.

These claims were mostly based on just two articles from the 1980s i) a one paragraph letter to the editor of the New England Journal of Medicine reported just 0.03% addiction rates in acute pain patients receiving opioids and ii) a retrospective review of just 38 patients where only two went on to have substance abuse problems after receiving opiate medicines.

Although a fundamental change in policy would normally require far more scientific rigour, there was a second factor driving the use of opiates. What happened is the subject of public scandal and has recently been brought to screen through the Disney+ series Dopesick , starring Michael Keaton.

Opioid manufacturers such as the Sackler brothers' company, Purdue Pharma (marketing a drug called oxycodone which is branded as OxyContin), responded to the 100 million Americans living in chronic pain by getting sales staff to encourage doctors to prescribe more opiates.

The sales drive was supported by the prescription guidelines for OxyContin, that got around FDA opiate guidelines by offering a slow release formula that, according to Purdue Pharma, meant it carried a low risk of addition even though there was evidence that is had euphoric effects and withdrawal symptoms.

In addition to creating a new generation of prescription opiate addicts, oxycodone could also be crushed or dissolved and then injected leading to the drug being used alongside other prescription opiates through street level sales.

The reason for their popularity was that, alongside other prescription opiates, such as fentanyl, they are up to 100 times more powerful than morphine or heroin.

References

1] Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med 1980; 302: 123. doi: 10.1056/NEJM198001103020221 .

Portenoy RK, Foley KM. Chronic use of opioid analgesics in non- malignant pain: report of 38 cases. Pain 1986; 25: 171-186. doi: 10.1016/0304-3959(86)90091-6.

[2] https://www.economist.com/graphic-detail/2017/03/06/americas-opioid-epidemic-is-worsening

[3] https://www.theatlantic.com/health/archive/2020/02/more-people-have-died-opioids-us-thought/607165/

[4] https://clincalc.com/DrugStats/Drugs/Oxycodone

[5] Ayoo K, Mikhaeil J, Huang A, Wąsowicz M. The opioid crisis in North America: facts and future lessons for Europe. Anaesthesiol Intensive Ther. 2020;52(2):139-147. doi: 10.5114/ait.2020.94756. PMID: 32419434.

[6] Wiese, B. and Wilson-Poe, A.R., 2018. Emerging evidence for cannabis' role in opioid use disorder.  Cannabis and cannabinoid research ,  3 (1), pp.179-189  DOI: 10.1089/can.2018.0022 

[7] Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients. Int J Drug Policy. 2017 Apr;42:30-35. doi: 10.1016/j.drugpo.2017.01.011. Epub 2017 Feb 9. PMID: 28189912.

[8] Häuser W, Finn DP, Kalso E, Krcevski-Skvarc N, Kress HG, Morlion B, Perrot S, Schäfer M, Wells C, Brill S. European Pain Federation (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management. Eur J Pain. 2018 Oct;22(9):1547-1564. doi: 10.1002/ejp.1297. Epub 2018 Sep 4. PMID: 30074291.