In the United States in 2011, the Centers for Disease Control and Prevention declared an ‘opioid epidemic’. This announcement came on the heels of two decades of medical over-prescribing practices, leading to opioid misuse and abuse, resulting in soaring rates of overdoses across the US. Too little, too late? Addiction isn’t a new problem. The human body is inherently vulnerable to addiction through the action of dopamine in the brain. Dopamine, a prominent chemical messenger, is released in response to rewarding and pleasurable events. Its role is to reinforce biologically relevant and necessary behaviours, including eating, sleeping and sex.
However, humans and other animals are at risk of becoming dependent on the dopamine ‘rush’ and can, therefore, develop an addiction to these behaviours whereby their body becomes dependent on the increased dopamine to function at baseline. Just like food or sex, substances like alcohol and opioids can lead to dopamine release. Opioids are derived from the poppy plant and are a key component of illicit drugs (like heroin) and pain medications (like oxycodone). While opioid medications have been used for many years to treat pain, a few crucial factors converged in the late 1990’s and early 2000’s that led to an opioid-addicted US.
In 1996, healthcare professionals were urged to pay closer attention to the pain reported by their patients – a recommendation bordering on being a requirement, prompting recognition of pain as the ‘fifth vital sign’. The Joint Commission on Accreditation of Healthcare Organisation heightened the urgency to treat pain in their published guidelines and US Congress declared the first decade of the 21st century to be the “Decade of Pain Control and Research”. These events and associated policy changes sent a jolting ripple effect through the medical community that resulted in greatly increased prescriptions for pain medications.
Concurrently, Purdue Pharmaceuticals, the manufacturer of OxyContin®, began aggressively marketing their prescription opioids, spending $200 million on advertising. Their tactics included down-playing the potential risk of addiction and dependency caused by opioid medications. As a result, OxyContin® sales soared from $48 million in 1996 to almost $1.1 billion in 2000. While Purdue eventually faced criminal and civil charges, by then, the damage to America had already been done. In 2017 there were 47,600 opioid-related deaths in the US. While prescription opioids certainly contributed to these statistics, many of these deaths involved heroin; those who take opioid medications are at significantly higher risk of using heroin, due to its lower cost and easier access.
In fact, the nature of the opioid epidemic fundamentally shifted the way addiction is viewed in the US. Government initiatives have invested in strategies to reduce access to prescription opioid medications but this does nothing to help patients with chronic pain who need treatment, nor those recovering from addiction. Fortunately, there is an overwhelming amount of data supporting Cannabis as both an effective agent for pain relief and an aide in helping people recover from opioid addiction. The idea of using Cannabis to treat pain is not new – in fact, ancient Chinese civilisations used Cannabis for joint pain and inflammation before it came to the West (Cannabis is one of the ancient Chinese ‘50 Fundamental Herbs’).
Opioids, derived from the poppy plant, have also been historically used for pain control; however, unlike Cannabis, those who used opioids quickly learned of the risk of addiction. Cannabis shares some physiological similarities to opioids, as short-term use increases dopamine to relieve pain. However, Cannabis increases dopamine via cannabinoid receptors, while opioids increase it via opioid receptors. Additionally, the increase in dopamine levels from Cannabis does not persist over time and, therefore, the risk of possible dependence is significantly lower.
The effects of Cannabis on pain have been demonstrated across many studies. A meta-analysis of 28 clinical trials conducted on Cannabis and pain ranging from 1948-2015 reported positive findings, concluding Cannabis is effective in treating pain with a reasonable safety profile. Cannabis has therefore been approved to treat chronic pain in the majority of US states where its use is legalised. But, what about treating opioid addiction and not just pain? US states with legalised ‘medical’ Cannabis have significantly lower levels of opioid use and opioid-related deaths.
A study in 2016 found a 64% reduction in opioid use in American patients who used Cannabis for their chronic pain. Studies have shown Cannabis may be effective in reducing craving for opioids and easing withdrawal symptoms. Based on this evidence and the unrelenting opioid crisis, New Jersey and Pennsylvania added opioid addiction as a qualifying condition for ‘medical’ Cannabis and other states like New Mexico, Maryland, Connecticut and Ohio are drafting similar policies. New York and Illinois allow patients prescribed opioids to receive ‘medical’ Cannabis instead.
These policies certainly represent tremendous progress toward helping patients use ‘medical’ Cannabis to treat their pain and potentially aid them in recovery as they transition off opioids. However, Cannabis still remains a Schedule I substance at the federal level in the US, which restricts patients’ access to it and continues to slow critical research. Despite growing awareness and recognition of the potential for Cannabis in alleviating the epidemic caused by opioid addiction, ending prohibition entirely is the only way to further progress and alleviate the opioid crisis in the United States.