As state governments grapple with ways to curb the opioid epidemic in their own backyard, New York and Illinois took a relatively new approach last summer by modifying existing medical marijuana laws to allow certain patients to substitute their opioids with medicinal cannabis.
In each state, patients with an opioid prescription or a condition for which an opioid is indicated can instead buy cannabis at a registered dispensary with a physician’s written certification.
Problem is, federal law still considers marijuana a Schedule 1 drug, so can doctors prescribe it without fear of being in legal trouble? Check with your state requirements.
the legal risk to doctors of certifying patients for medical marijuana is minimal, primarily because they don't directly prescribe or dispense the drug, says Paul Giancola, an attorney who specializes in regulatory healthcare for Phoenix-based Snell & Wilmer law firm. Physicians merely issue a written recommendation that certifies their patients suffer from one of the conditions for which medical marijuana has been approved in their state, which allows patients to obtain cannabis from a licensed marijuana dispensary or supplier, or grow it themselves in restricted quantities. www.physicianspractice.com/...
Some experts say these laws may be in response to several studies that indicated opioid overdose death rates were lower in states that permit medical marijuana, and that opioid prescribing was lower in Medicaid and Medicare Part D programs in states with legalized medical marijuana. But the studies show an association, not a cause-and-effect relationship, said Ajay Wasan, MD, MSc, vice president of scientific affairs for the American Academy of Pain Medicine. “A lot of those states had other … initiatives to decrease opioid prescribing at the same time,” he noted.
That’s a very important point. Social issues are multifactorial, so one has to see if these studies take any measures to control for many confounding variables. It is always important to remember that correlation does not mean causation.
That reminds me of something. Did aliens build the Great Pyramids?
A recent breakthrough in pseudoscience: the location of the Great Pyramid of Giza encodes the speed of light to seven decimal places. slatestarcodex.com/...
In its 2017 report on cannabis and cannabinoids, the National Academies of Sciences, Engineering, and Medicine concluded that evidence supports using medical marijuana or cannabinoids to relieve pain. But is it an effective substitute for an opioid?
I don’t know, have there been any randomized double-blind trials?
Case reports have shown that medical marijuana helped some patients with pain to reduce their opioid use by 60% to 100%. In a survey examining medical marijuana’s safety in older adults, about two-thirds of 2736 patients past age 65 years used medical marijuana for cancer or nonspecific pain. Among 791 patients who answered questions about their medication changes, 18% stopped using opioids or reduced their dose after 6 months. However, another study of 1514 patients in Australia who used opioids for chronic noncancer pain showed that medical marijuana didn’t improve their outcomes or reduce their opioid use.
Well, case reports and surveys are at the bottom of the evidence pyramid, so let’s look at what’s in the Cochrane library. I see a few studies, some seem to be supportive of this idea, and some not, while others seem to be looking at the effects the other way around. (If you want to look at the abstracts of these studies, click on the pubmed link on the Cochrane page.)
Opioid modulation of marijuana's analgesic, subjective, reinforcing, and physiological effects in non-treatment seeking marijuana smokers
ZD Cooper, SD Comer, G Bedi, D Ramesh, M Haney
Neuropsychopharmacology, 2012, 38, S193 | added to CENTRAL: 31 May 2015 | 2015 Issue 5
Intermittent marijuana use is associated with improved retention in naltrexone treatment for opiate-dependence
WN Raby, KM Carpenter, J Rothenberg, AC Brooks, H Jiang, M Sullivan, A Bisaga, S Comer, EV Nunes
The american journal on addictions, 2009, 18(4), 301‐308 | added to CENTRAL: 31 January 2010 | 2010 Issue 1
No evidence for reduction of opioid-withdrawal symptoms by cannabis smoking during a methadone dose taper
DH Epstein, KL Preston
The american journal on addictions, 2015, 24(4), 323‐328 | added to CENTRAL: 31 July 2015 | 2015 Issue 7
Chronic naltrexone modulates marijuana's reinforcing subjective and cardiovascular effects
M Haney, G Bedi, Z Cooper
Neuropsychopharmacology, 2012, 38, S346 | added to CENTRAL: 31 May 2015 | 2015 Issue 5
Nonreporting of cannabis use: predictors and relationship to treatment outcome in methadone maintained patients
UE Ghitza, DH Epstein, KL Preston
Addictive behaviors, 2007, 32(5), 938‐949 | added to CENTRAL: 31 January 2008 | 2008 Issue 1
Opioid withdrawal suppression efficacy of oral dronabinol in opioid dependent humans
MR Lofwall, S Babalonis, PA Nuzzo, SC Elayi, SL Walsh
Drug and alcohol dependence, 2016, 164, 143‐150 | added to CENTRAL: 31 July 2016 | 2016 Issue 7
However, laws that allow medical marijuana as a substitute for opioids for treating pain should specify the clinical scenarios in which it is allowed, Wasan explained. “We need to have careful patient selection and evaluation and follow-up,” he said.
For example, he noted, neuropathic pain tends to respond better to medical marijuana than does nonneuropathic pain. One of the main cannabinoid receptors, CB1, is abundant in the central and peripheral nervous systems. Small studies have shown that medical marijuana reduced diabetic peripheral neuropathy pain in patients with treatment-refractory pain, and it helped alleviate HIV-associated neuropathic pain.
In other words, it’s not a silver bullet for everyone.
And Cochrane did review the topic, and showed that harms outweigh benefits, but results are not convincing.
However, a recent Cochrane review of 16 studies that included 1750 participants concluded that potential benefits of cannabis-based medications in relieving chronic neuropathic pain may be outweighed by adverse events including somnolence, confusion, and psychosis. Nevertheless, the authors noted that studies in the review were small in size, which could lead to bias, and none produced high-quality evidence to support using medical marijuana for neuropathic pain.
So, as always, we need more research.
“We advocate strongly for more research,” said Jeffrey Selzer, MD, chair of the public policy committee for the American Society of Addiction Medicine. He noted that some animal studies indicate that cannabidiol—a nonpsychoactive component of marijuana—has potential for treating opioid use disorder. Similar studies should be allowed to go forward in humans in well-designed clinical studies with appropriate institutional review board approval and patient protections, Selzer added.
“[W]e need to be able to do the research to help figure out what the best policies should be and what critical care should look like,” Cunningham said.
And as usual, the little president is useless
“Together,” the president told grieving mothers and fathers, cabinet members, lawmakers, and representatives of local law enforcement, “we will end the scourge of drug addiction in America. We’re going to end it or at least make an extremely big dent in this terrible, terrible problem.”
Almost no one who’s studied the legislation and understands the magnitude of an epidemic in which an estimated 72,000 people died from drug overdoses in 2017 thinks it will do any such thing. The bill’s provisions to expand addiction treatment, speed up research on alternative drugs, and provide Medicaid funding to treatment centers with more than 16 inpatient beds will certainly help, as will $6 billion in funding to fight opioids, “the most money ever received in history,” Trump said. But many public-health experts, and some of Trump’s Democratic opponents in Congress, say something closer to $100 billion is needed over 10 years to end or “make an extremely big dent” in opioid addiction. Senator Elizabeth Warren cites “broken promises” by an administration that still does not have a confirmed director of its Office of National Drug Control Policy (ONDCP) after nearly two years in office.