Could legalizing marijuana help people shift away from using opioids to manage pain? New research suggests it might be possible.
According to a paper published April 2, 2018, in the journal JAMA Internal Medicine, states with legalized medicinal marijuana have fewer opioid prescriptions. States that allow people to visit marijuana dispensaries show more than 3.7 million fewer daily doses of opioid prescriptions compared with states in which medicinal marijuana is illegal, according to the study.
“One policy option that may have the unintended consequence of ameliorating the opioid crisis is the legalization of medical uses for cannabis,” the researchers conclude in the study.
To reach this conclusion, researchers analyzed the number of daily opioid doses prescribed between 2010 and 2015 under the Medicare Part D program. The program is an optional prescription drug benefit plan available to everyone aged 65 and older, and for people with disabilities. More than 70 percent of Medicare members subscribe to the Medicare Part D program, the researchers write.
Over the five years under review, 23 million daily doses of various opioids were dispensed in the United States, including hydrocodone, oxycodone, fentanyl, morphine, methadone, and other opioids, according to the new data. But among the 24 states with active cannabis dispensaries, the overall number of prescriptions for opioids was less.
It’s important to note that the study looked at overall opioid prescriptions per state and did not survey individuals about their habits of taking an opioid versus a cannabinoid. That means it’s not possible to determine from the research that the association between medicinal marijuana laws and fewer opioid prescriptions is due to what doctors prescribe or other factors.
Because marijuana is a Schedule 1 drug — meaning it has a high potential for abuse, according to the U.S. Drug Enforcement Administration, which gives it that designation — doctors don’t “prescribe” it like other medicines. If a patient meets the criteria in a state which permits medicinal marijuana, doctors can authorize a patient to visit a dispensary to treat conditions such as chronic pain if it cannot be managed by other therapies.
But, the fact that doctors are not part of the actual dispensary visit and the authorization for medical marijuana use is not specific (in terms of dose or usage) means it’s hard to track how exactly medical marijuana is used and what conditions it is used for. (It’s worth noting that this study did not track the number of visits to a dispensary.)
It’s also possible that people in this study who shifted away from opioids did not actually move towards cannabis, according to the commentary supplementing the new paper, which was also published on April 2 in JAMA Internal Medicine. Those individuals may have shifted towards heroin, which is a common occurrence as the country’s opioid epidemic rages on, according to Aleksandra Zgierska, MD, an opioid researcher and assistant professor at the University of Wisconsin School of Medicine and Public Health in Madison, who was not involved in the research or the writing of the commentary.
Still, the research is significant because it suggests that medical marijuana policies may be one way to encourage fewer opioid prescriptions and help in solving the opioid crisis, the researchers note in the study.
Not everyone, though, agrees with that interpretation of the new data. Here are four reactions from addiction experts, physicians who prescribe opioids and medical marijuana, and others.
‘I Do Not Think That Legalizing Marijuana Would Solve the Opioid Crisis’
Marijuana can’t necessarily be swapped for every use of opioids, explains Dr. Zgierska. “I do not think that legalizing marijuana would solve the opioid crisis,” she says.
Zgierska treats patients with opioid addiction, but says she does not authorize medicinal marijuana, which is illegal in Wisconsin where she practices.
“We know now that we have recently prescribed opioids too liberally,” Zgierska says. “But there is a place for opioids in our pharmacological toolbox as long as we exercise caution.”
Opioids are not controversial for short-term pain, such as after major surgery or trauma, she says. But they are a problem when used as a long-term therapy.
“In my experience, the majority of opioid-treated patients would like to be off opioids,” Zgierska adds. But they are often unsuccessful in getting off of them due to debilitating pain that interferes with daily functioning and living. Marijuana won’t necessarily solve those problems, she says. What she says does need to happen: Doctors should prescribe opioids to more carefully selected patients and at lower doses.
‘It’s a Wild West Atmosphere’
Arun Swaminath, MD, gastroenterologist and director of the inflammatory diseases program at Lenox Hill Hospital in New York City, sometimes does suggest medicinal marijuana to his patients to manage chronic pain associated with conditions such as Crohn’s disease or colitis, he says.
His patient population is typically younger than the group analyzed in the new study, and he says it’s extremely rare that he would prescribe an opioid to his patients, as those types of drugs can be more problematic for people with gastrointestinal issues.
The researchers analyzing this new data assume that the reason the number of opioid prescriptions are going down is because these same people are now using cannabis instead, Dr. Swaminath says. “It is definitely interesting that [this study] can show the relationship, but it’s still an assumption.
“What happens after a patient gets a certification for medicinal marijuana is between the patient and the dispensary,” Swaminath adds. “This is very different than me prescribing 81 milligrams of aspirin.”
For example, once someone is authorized to get marijuana for medicinal use, doctors do not always know whether a patient is using oil, purchasing an edible, or whether he or she plans to smoke or vaporize it.
“Value around cannabis exists, and there’s a role for it for the right patient,” Swaminath says, “but it is very hard to study in the United States because it is a Schedule 1 drug,” he says. “It’s a wild west atmosphere.”
The Data Is ‘Overly Simplistic’
To run with the idea that legalizing marijuana can solve the opiate crisis is misleading, adds Torin Finver, MD, addiction researcher and associate professor at the Jacobs School of Medicine at the University of Buffalo in New York.
“Until we have the ability to study [cannabis] compounds, we don’t really have a way to know if we have any relief of pain or what we should really be looking for, which is improved functionality,” Dr. Finver says. It is unclear how many people who were addicted to, say, methadone, are visiting dispensaries now instead.
“[To say medicinal marijuana laws could help solve the opioid crisis] is overly simplistic. This data is based on a population that hasn’t teased out that people have underlying addictive disorders,” he says. “The data is making a leap.”
‘[Medical Cannabis] Is a Great Substitute for Opioids’
Michelle Weiner, DO, MPH, is an interventional pain management physician in south Florida. Many of her patients are over the age of 65, which is the same population associated with the new study.
“I see patients with MS (multiple sclerosis), Parkinson’s, cancer, and neuropathic and serious chronic pain,” says Dr. Weiner. “And my goal [with specific patients] is to incorporate cannabis and decrease opioids.
“[Medical cannabis] is a great substitute for opioids,” she says.
Weiner agrees that marijuana’s status as a Schedule 1 drug makes it challenging to research, but suggests doctors should work closely with patients to create an appropriate cannabis treatment plan, to close the gap between authorization and the trip to the dispensary.