Substitution or Solution?
How Medical Cannabis Can Alleviate the Impact of the Opioid Crisis
In 2017, a new record was set in Canada, but not one to be proud of. According to government data, nearly 4,000 Canadians died of opioid overdoses, an increase of thirty-four percent over 2016. And 2018 was on pace to exceed those figures with more than 1,000 people dying in the first quarter of the year, up sixteen percent from the same period the previous year.
There have been 8,000 deaths between January 2016 and March 2018 and opioid overdose is now the leading cause of death for people aged thirty to thirty-nine. Each year, more and more people are lost to opioid use disorder (OUD), and the problem will continue to get worse before it starts to get better.
Most opioid overdoses are now linked to fentanyl or carfentanil, a fentanyl analog. Fentanyl is a synthetic opioid that is far more toxic than any other and ranges from fifty to a hundred times more concentrated than morphine, meaning it takes very little to overdose, especially when mixed with other substances or when the drug user doesn’t know it is present. Not everyone who overdoses is an addict. Most opioid overdoses are accidental, and many are linked to the use of non-opioid substances including cocaine, alcohol and benzodiazepines. While some drug users are occasional, fentanyl addiction does not discriminate.
Of the fatal overdoes in Canada in 2017, seventy-two percent of them involved fentanyl. That rate increased to seventy-five percent in 2018. Fentanyl is also linked to an increase in hospitalizations and ultimately, a strain on resources, relationships, families and entire communities.
Many opioid addictions originate with workplace accidents, car accidents, or other injuries that necessitate a prescription for opioid painkillers. Once addicted to opioids it’s an uphill battle that few people understand unless they have been in some way impacted by the tightness of the drug’s grasp. Canada is second only to the United States in use and abuse of opioids, with thirteen percent of the population relying on opioids for pain relief. Of those, two percent suffer from opioid use disorder (OUD).
In the U.S., there were 47,000 overdose deaths in 2014, 19,000 of which were caused by painkillers. The following year, in 2015, the number of overdose fatalities rose to 52,000. Millions of Americans suffer from chronic pain and rely on their opioid prescriptions to be able to function. In 2012, 259 million prescriptions were issued for opioid pain killers.
While opioid prescriptions are down ten percent from 2016 to 2017, the damage is done. It has become a serious problem that is destroying lives. In many cases, where pharmaceutical-grade opioids are no longer available, individuals will turn to the street, as heroin makes for an inexpensive alternative.
That was the case in the U.S. after the 1990s. Painkillers were being readily prescribed in the 1990s, as physicians were under the impression that the drugs were harmless and not addictive. Since the 2000s, when the realization was made that opioids were very addictive and harmful, fewer prescriptions have been issued and as a result, heroin overdoses increased more than five hundred percent.
With the rollout of legal cannabis in Canada and ever-evolving state legislation in the United States, there is public concern that welcoming retail cannabis outlets will exacerbate the drug problems being faced by communities. Critics are also likely to believe that marijuana is a gateway drug, but this couldn’t be further from the reality.
Cannabis is a legitimate medication assisted treatment (MAT) that can help support opioid drug users in the recovery process, though it is very different from methadone or buprenorphine, more commonly used MAT drugs. Likewise, where cannabis is legal, there is a marked decrease in violent crimes, with no associated increase in adolescent use or car accidents.
MAT is used to treat opioid addictions through a program of tapering to reduce the physical effects associated from transitioning off of opioids. Unlike other MAT, cannabis does not cause physical dependency and there are fewer harmful side effects.
There is certainly opposition to MAT. Those who take an abstinence-based approach believe that it is simply replacing one addiction with another, and while there certainly is an element of substitution, cannabis can help to improve rest and appetite during withdrawal, it can reduce nausea, anxiety and cravings, and it can improve creativity and perspective. Most importantly, cannabis will not result in overdose and if it supports sobriety from opioids, for those who intravenously use the drug, it does not come with the risk of transmission of diseases like Hepatitis C and HIV.
When the right strains are accessible and people have a knowledgeable and regulated supply of cannabis, be it medical or recreational, users and patients alike can achieve optimal results by selecting the right strain that produces the desired effects for treatment. Strains with high cannabidiol (CBD) content are regarded for pain relief. CBD is thought to modulate neuronal circuits that play a pivotal role in drug addiction and it has been shown to have anxiolytic, antipsychotic, antidepressant and neuroprotective properties. When tested during the intoxication phases of opioid addiction in animals, CBD dampened the rewarding effects of the opioid. Further, studies have shown that in states where medical marijuana laws exist, where users have access to cannabis, there are fewer fatal opioid overdoses.
Using cannabis as a MAT can also help users achieve sobriety and improves their chances of completing treatment. Cannabis MAT serves as a compassionate, non-judgmental, non-punitive treatment that often meets addicts where they are and helps to soften the blow of detox and the transition to sobriety.
Given the restraints on cannabis MAT programs, there is limited proof as to its efficacy, though studies are starting to emerge with positive results that demonstrate that it has potential to treat those with OUD as well as those suffering from traumas and post-traumatic stress disorder (PTSD). Even where there may not be clear affirmations in the research, there are no negative implications of cannabis MAT when used alongside other treatments. It should be noted, however, that some OUD treatment programs disallow participants who do not pass a drug test, and marijuana will stay in the system for much longer than any other substance, up to thirty days after use, which often disqualifies people from receiving the help they need.
Currently, even where cannabis is legalized in the U.S., it has been disallowed as a MAT, though, as of May 17, 2018, Pennsylvania approved a temporary research program to evaluate the efficacy of cannabis MAT for OUD. Eight universities were able to conduct limited research given the federal constraints being imposed on them. While much of the information gathered was anecdotal, the findings showed that without MAT, an individual’s rate of relapse thirty days after detox was ninety percent. With MAT, where individuals used cannabis and participated in behavioral therapy, after six months the rate of relapse was only fifty percent.
A study conducted in Vancouver by researchers from the University of B.C. and the B.C. Centre on Substance Abuse considered 820 drug users who initiated opioid agonist therapy (OAT) between December 1996 and May 2016 and evaluated their retention in the program. The findings were published in the scientific journal Addiction and showed that daily cannabis use was associated with improved retention in the program. Individuals who used cannabis daily in treatment had improved their odds of success approximately twenty-one percent when compared to those who did not.
Certainly, cannabis can play a role in improving health and wellbeing, community safety and the tax base, and can now help address a small part of the opioid crisis. Not only can it be used as a MAT, it could be prescribed to treat chronic pain instead of opioids or as an alternative to benzodiazepines for anxiety, which are dangerous when mixed with opioids.
Sometimes the best way to bring attention to an issue is a little bit of star power and that’s exactly what Jim Belushi has done. Belushi has made it clear that medical cannabis could have saved his brother John’s life, who was taken in his early thirties from a fatal drug overdose.
Now that we know more about head injuries and the long-term effects of repeated impacts to the head in athletes, it is possible that John could have suffered from chronic traumatic encephalopathy (CET) as a result of his football career. John was known to have seizures and other symptoms that correlated with CET but was undiagnosed as it wasn’t an accepted diagnosis at the time.
Now, Belushi, whose belief in the plant runs deep, has taken to growing cannabis himself, doing so on his own property, Belushi Farms, a full-scale farm in Eagle Point, Oregon where he has a small forty-eight plant indoor/outdoor medical marijuana grow operation.
While more and more states are undertaking legislative reform with regards to cannabis, making it legal both medically and recreationally, more could be done to leverage it as a treatment for OUD. This is true of Canada as well, though legalization is certainly a step in the right direction.
Changes need to take place at the federal level in the U.S. to allow cannabis producers to break out of their state markets into the rapidly growing global market. More needs to be done to loosen restrictions that prevent research activities from taking place that can demonstrate the true efficacy of cannabis as a MAT and more needs to be done to eliminate the stigma associated with drug use. If it can help one out of every four people overcome opioid addiction, it’s worth pursuing.