The ongoing increase of opiate abuse and opiate-related overdoses has led to calls for a reduction in the reliance on opiates for treating pain, especially as reports emerge of people whose addiction to opiates began with a prescription for pain management and later transitioned to illicit use. In Canada, approximately 21 million opiate prescriptions are dispensed annually; in the US, that number is over 237 million.
In response to this situation, a group of medical professionals from the Oregon Health & Science University made a submission to the November issue of the Journal of the American Medical Association reflecting on the potential role of cannabis in reducing our reliance on opiates, and raising critical questions at the forefront of many clinician’s minds.
As has been previously covered by Lift, research has indeed begun to show that cannabis may be an effective option for chronic pain management. And we may be seeing some patients independently substitute opiates with cannabis — studies in the US have shown that legalization at the state level is associated with decreases in opiate addiction and opiate-related overdose deaths.
However, there are still very large gaps in research on the medical uses of cannabis due to the limited number of clinical trials and an accompanying lack of education for medical professionals. This situation becomes more stark when contrasted with the medical uses that have been approved by various states. While research has shown effectiveness in using cannabis for a limited number of conditions including chronic pain and muscle spasticity, individual states have approved its use for rheumatoid arthritis, psychosis, traumatic brain injury, anorexia from HIV/AIDS, Parkinson’s disease, and various other autoimmune and neuromuscular conditions.
This gap has left many medical professionals unable to provide information and support to patients who are curious about cannabis as a potential treatment, and it may put clinicians in the uncomfortable position of advising against a treatment that has apparently been endorsed by a governing body, such as the state’s health department, for lack of scientific evidence.
Additional complications arise with the changing legal status of cannabis. Where it is legal for recreational use, clinicians are placed in “a curious position,” as they are no longer in the gatekeeper role and are often uncertain of when to encourage or discourage use. In a sense, one of the effects of cannabis legalization is that physicians essentially cede agency over the type, frequency, and amount of cannabis their patients use to retail shop owners with commercial interests.
The research gap, lack of education, and the changing legal landscape all raise questions of central importance for health practitioners:
- Should cannabis be treated like alcohol, suggesting a threshold level under which it is safe—even beneficial—and above which it is dangerous? If so, what is the threshold?
- If cannabis is an acceptable substitute for opioids, in what amounts and forms should it be initiated, and how (and for whom) should it be gradually increased as opioids are tapered down?
- How should clinicians guide cannabis prescription or oversight for special populations such as youth and individuals at risk? How is risk defined?
- At what point does treatment of chronic, daily, severe pain begin to look like prescribed (or at least sanctioned) cannabis use disorder? How can clinicians determine if cannabis is treating or causing nausea and vomiting?
Without the appropriate information, guidance, and education, clinicians are also missing out on the opportunity to counsel patients on potential adverse effects, the risk of dependence, possible negative effects on fetal development for pregnant women, dangers of driving under the influence, and more.
In the transition to cannabis legalization, it will be important that adequate resources are allocated so that medical professionals can keep pace with the evolving landscape while guiding their practice in sound science.
For interested readers, the journal submission can be found here.
- Featured image via Wikipedia.