By: Darrell R. Over, MD, MSc, FAAFP Associate Professor, UAMS (South Central) Family Medicine Residenc
Article originally appeared in the July 2018 issue of The Journal.
For my colleagues who have been practicing medicine for at least 20 years, the path leading to the current opioid crisis is familiar. With the conceptualization of pain as a “fifth vital sign” by the American Pain Society in 1996 and its endorsement by the Veteran’s Health Administration, pain management achieved cause célèbe status. In 1998 the Federation of State Medical Boards assured physicians they would not receive excessive scrutiny for prescribing notable amounts of opioids, and in 2001, the Drug Enforcement Agency announced it would follow a “balanced policy” in evaluating physician prescribing practices. These decisions – coupled with the pronouncement by the Joint Commission on the Accreditation of Healthcare Organizations that pain assessment and treatment of all patients in accredited healthcare settings was mandatory in order to receive federal healthcare dollars – created a “perfect storm” wherein physicians were encouraged to aggressively treat pain and indeed were warned that failure to do so could result in sanctions.
Moreover, physicians were reassured by two influential retrospective studies suggesting low risk for opioid addiction when these drugs were used for the treatment of pain. In a 1980 one-paragraph letter published in the New England Journal of Medicine, Jane Porter and Herschel Jick described narcotic use in nearly 12,000 hospital patients and reported that only four of these patients had become addicted – only one case was considered severe. A 1986 report in the journal Pain by Russell Portenoy and Kathleen Foley described 38 patients treated with opioids for chronic non-malignant pain over a number of years and reported “no toxicity … and management became a problem in only two patients, both with a history of prior drug abuse.” Both of these studies were cited hundreds of times in the peer-reviewed and non-peer reviewed the literature to support the contention that chronic opioid therapy for pain had low addiction risk. This view guided the training of young physicians and other healthcare providers.
An unfortunate consequence of increased opioid prescribing was an acceleration of opioid-related mortality. In 2016 there were >63,600 drug overdose deaths in the United States and the age-adjusted rate of overdose deaths (19.8 per 100,000) was 21% higher than the rate in 2015 (16.3). The rates of drug overdose deaths were highest for persons aged 25-34 years (34.6 per 100,000); 35-44 years (35 per 100,000); and 45-54 years (34.5 per 100,000).1 Interestingly, a public policy option that may have the unintended (but fortuitous) consequence of mitigating against the devastating effects of the opioid crisis is the legalization of medical cannabis.
Two recently published clinical trials from Israel (where medical cannabis is legal) have reported intriguing findings. One trial assessed the safety and efficacy of cannabis in 2736 patients (mean age 74.5 + 7.5 years) with pain (66.6%) or cancer (60.8%). At six months about 94% reported a decrease of pain score from 8 to 4 (10 point scale) and 18% reported either reduction of cessation of opioid use.2 Another study reported the safety and efficacy of medical cannabis in 1211 patients (mean age 59 + 16 years) with differing cancers. At six months about 96% reported an improvement in their condition with 36% reporting cessation of opioid use and almost 10% had decreased their dose.3
Two recent studies evaluated the association between medical cannabis laws and opioid prescribing patterns in Medicare Part D populations4 and Medicaid enrollees.5 Compared to states with no medical cannabis law, access to a medical cannabis dispensary was associated with a decrease in prescribing of 3.742 million daily doses (14.4%) annually in Medicare Part D populations. Among Medicaid enrollees, implementation of state medical cannabis laws or “adult use” cannabis laws were associated with lower opioid prescribing rates of 5.88% and 6.38%, respectively.
The use of medical marijuana is not without controversy. While numerous reputable physicians and professional organizations have acknowledged the observed or potential benefits of medical cannabis, questions and concerns still abound. Marijuana remains a Schedule I agent according to the Drug Enforcement Agency and is illegal under federal law. Numerous physicians are concerned that, even if they could prescribe or recommend cannabis for their patients, uncertainty remains about the most effective strength or dose to use, or which route of administration is most effective. Others have expressed concern that medical marijuana may actually serve as a gateway to opioids. Over time cannabinoid receptors proliferate and tolerance can increase. I share these concerns with my colleagues; however, the studies above are encouraging. If medical cannabis will enable us to fight the scourge of opioid abuse I could become a fan.
- Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States. 1999-2016. . NCHS Data Brief. No. 294. Hyattsville, MD: National Center for Health Statistics. 2017.
- Abuhasira R, Schleider LB, Mechoulam R, Novack V. Epidemiological characteristics, safety, and efficacy of medical cannabis in the elderly. Eur J Intern Med. 2018;49:44-50.
- Schleider LB, Mechoulam R, Lederman V, Hilou M, Lencovsky O, Betzalel O, et al. Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med. 2018;49:37-43.
- Bradford AC, Bradford WD, Abraham A, Adams GB. Association between US state medical cannabis laws and opioid prescribing in the Medicare Part D population. JAMA Intern Med. 2018. doi.10.1001/jamainternmed.2018.0266.
- Wen H, Hockenberry JM. Association of medical and adult-use marijuana laws with opioid prescribing for Medicaid enrollees. JAMA Intern Med. 2018. doi.10.1001/jamainternmed.2018.0266.