During an opioid epidemic, can cannabis be an alternative pain treatment?
on December 12, 2016
Dani Geen was 18 when she was in a severe accident: the car spun violently and was smashed on all four sides. The force of the seatbelt broke all of Geen’s ribs and caused internal abscesses. She came to in an ambulance, panicking from pain and shock, and felt the sharp stab of a needle—the injection of a tranquilizer.
Her recovery in the hospital and at home was bolstered by Norco and Percocet, to which she built up a hefty tolerance. Zanaflex calmed her muscle spasms. Her insomnia was quieted with Trazodone. With new nerve pain came Gabapentin.
As a result of her accident, over the next five years Geen developed spinal cysts and severe bursitis in her right hip and lower back. She contracted nine kidney infections in one year. She was also diagnosed with fibromyalgia. She needed a cane to walk. Geen said doctors put her on a prescription pill cocktail of 15 to 20 medications at a time and gave her regular steroid injections for inflammation.
The pain treatment itself caused harm, like severe nausea. Geen had made a full recovery from an earlier struggle with bulimia, but found herself vomiting every morning. But the worst consequence of prescription drug use was Geen’s realization that she was growing more dependent on the narcotics each day.
“I was dealing with high amounts of pain,” Geen said of her early regimen. “When your opiate receptors and endocannabinoid receptors are muted as a result of opioid pill use, you need more chronic pain medication. You’ve built up a tolerance to prescription medications.”
The number of prescription pills she swallowed each day astounded Geen. “I’ve seen people in my own life get heavily addicted to the medication, and I never wanted to be a statistic,” she said. She was tired of throwing up all the time. She was worried about addiction. And she felt loopy and distant from the world around her. “I’m only 20, and [doctors were] putting me on so much freaking medication that I’m walking around like a zombie,” Geen recalled.
And so Geen became one of a growing number of people trying to fend off an opiate addiction by using a different drug: pot.
Cannabis advocates and some researchers have argued for cannabis as possible solution to the opioid epidemic because it alleviates pain with less risk of overdose. They say it can be used as a supplement or replacement for prescription opioid pain medications, and to quell opioid addiction withdrawal symptoms.
Dr. Amanda Reiman, a lecturer in the School of Social Welfare at UC Berkeley and the manager of marijuana law and policy for the Drug Policy Alliance, said that cannabis can help someone get through a period of withdrawal, as it eases many symptoms, and can also be used “as a psychoactive substitute for somebody who is not willing, able, or wants to be abstinent completely. It’s a much safer decision, much safer drug to use if someone can move away from using opiates, reduce their opiate use, reduce their heroin use. By substituting in cannabis, they’re going to have much better health outcomes.”
But experts, including Reiman, who agree that long-term opioid use creates a high risk of tolerance, dependency and overdose, raise questions about understanding cannabis as an opioid substitute: research limitations, lack of medical guidelines and the need to consider situations on a case-by-case basis.
“Opioids are among most dangerous drugs available. There are thousands of Americans losing their lives to that class of drugs,” said Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing (PROP), an organization that aims to reduce opioid deaths by promoting cautious prescribing methods. “When used on a long-term basis, the addiction potential increases and the effectiveness of the drug decreases, because you start to get used to the drug. You need higher and higher doses in order to get analgesia [pain relief] or euphoria.”
Kolodny expressed disbelief that patients who have been using opioids for years can completely substitute cannabis for it. “If a patient takes an opioid for 90 days, two-thirds of those patients are still on opioids five years later,” he said. But for those able to successfully able to make a switch, Kolodny said that without doubt, “for long-term use, cannabis is safer.”
In Oakland, where in 2004 the city council voted to make investigation and arrest for cannabis use by adults the city’s lowest law enforcement priority, patients like Geen are able, under their own initiative, to explore medical cannabis treatment plans for their pain. Medical marijuana has been legal in California since 1996, and this November, voters passed Proposition 64 to make recreational use among adults legal as well. As of November, 29 states and the District of Columbia had legalized medical marijuana use, and eight had legalized recreational use.
But this kind of marijuana use is not reinforced by the larger medical profession or uniformly among physicians who treat those with chronic pain. That’s because doctors are federally prohibited from prescribing pot, which is classified as a Schedule I drug, regardless of state medical marijuana laws. The Drug Enforcement Administration (DEA) defines a Schedule I drug is one that has “no currently accepted medical use and a high potential for abuse.”
Today, 11 years after her accident, Geen uses only cannabis to treat what once bound her to a cocktail of pills. “Cannabis was what became my medicine,” she said, and using it “made it easier for me to get off of those pain medications.”
She started by substituting a few doses of pain pills with smoking cannabis flowers, the green bud most often associated with marijuana, but found she had to smoke a large amount to feel pain relief. “When it became a real medical issue, flowers wouldn’t do it. When I was introduced to concentrates, I started feeling better. My pain wasn’t as bad. I got off my medication and focused on the nausea,” she said.
She also got a job at Harborside Health Clinic, an Oakland medical marijuana dispensary, where she gives tours to new patients, leading them around the facility with the help of her cane. She is an ongoing advocate for pot as an alternative to opioids and plans to continue a lifelong cannabis regimen to treat her fibromyalgia and pain from her injuries.
“There are now studies that show that fibromyalgia, IBS and migraines are all linked to an endocannabinoid deficiency, so my body doesn’t naturally produce the cannabinoids that I need to not have pain,” she said. “That’s what cannabis does. It needs to be in my body. It does what it needs to do and I can get on with my life.”
While the process of how marijuana might mimic the effect of opiates isn’t thoroughly understood due to an absence of medical research, it seems clear that it accesses the body’s endocannabinoid system, which regulates mood, appetite, sleep, hormone regulation and pain and immune response. The body produces its own endocannabinoids, but these would be supplemented with the cannabinoids in marijuana.
Marijuana dependency does occur, although the rate of addiction to opioids is much higher, and opioids come with a high risk of overdose. According to Center for Disease Control data, in 2014, an average of 81 people died from opioid overdoses every day—52 from narcotic painkillers and 29 from heroin. No case of marijuana overdose has ever been documented.
Data from the American Academy of Pain Medicine shows that more than 100 million Americans suffer from chronic pain, and in an attempt to relieve that pain, the number of opiate prescriptions has nearly doubled over the last decade. The 2016 Surgeon General’s report on Alcohol, Drugs, and Health, the first of its kind, states: “The increase in prescriptions of opioid pain relievers has been accompanied by dramatic increases in misuse and by a more than 200 percent increase in the number of emergency department visits from 2005 to 2011.”
While it is difficult to measure the number of local patients addicted to opioids for chronic pain, in Alameda County the number of hospitalizations due to opioid overdoses has increased from 83 in 2006 to 131 in 2013, according to data from the California department of Public Health. The California Healthcare Foundation’s 2015 report about its effort to end painkiller misuse states: “In 2013 in Alameda County, enough opioids were prescribed to give every adult and child an average of 180 to 200 Vicodin per year.”
Experts believe that patients most often make the switch from opioids to cannabis on their own, rather than on the advice of a doctor. Reiman, of the Drug Policy Alliance, said doctors often leave medical school with no education on the endocannabinoid system except studying it in terms of substance abuse.
Reiman’s 2005 dissertation on medical cannabis dispensaries as health service providers included a survey of patients that asked whether they were using cannabis as a substitute for alcohol or other drugs. The results showed a very high rate of substitution, which led Reiman to carry out another study in 2009 that dove deeper into patients’ use of cannabis as a substitute.
“We saw rates of substitution for alcohol at about 50 percent, for prescription drugs at about 75 percent, with the reasons that patients were claiming to do this being cannabis was less harmful, it was more effective, there were less side effects, there was less chance of dependence and of withdrawal,” Reiman said.
Reiman, along with UC Berkeley and HelloMD, a digital healthcare organization for the cannabis industry, is now overseeing a much larger and even more thorough national survey study that asks 100,000 patients about cannabis use and how it has specifically affected their use of opioids.
While federal law still prohibits doctors from prescribing pot, there is some evidence that states with medical marijuana laws have decreased their rates of opioid overdoses. According to a 2014 study led by researchers from the Johns Hopkins Bloomberg School of Public Health and the Philadelphia Veterans Affairs Medical Center, and published in the Journal of the American Medical Association, states with medical cannabis laws had a 24.8 percent lower annual opioid overdose mortality rate than those without such laws. The study also concluded that the longer these laws are in place, the lower the opioid overdose mortality rate is.
According to a small 2016 survey of medical cannabis patients with chronic pain, cannabis use was associated with a better quality of life (researchers quantified this by asking patients to rank themselves on a numeric scale) and reduced their opioid use by 64 percent.
But because marijuana is federally illegal, Reiman believes doctors dismiss it as a viable alternative to opioids. “The declaration by the federal government that cannabis has no medical value whatsoever gives doctors a reason not to do the education, gives doctors a reason just to stand on whatever the federal government says,” she said.
“I’m hoping that people kind of get over the stigma of what it means to suggest that someone use cannabis, because we’re all taught ‘Just say no’ and [that] the goal should be a drug free America,” she continued. But, she said, “if we can get over that and really look at cannabis as a valuable treatment option—along the lines of [anti-overdose medication] naloxone and other things we’re using to stop overdose deaths on opiates, that’s when we’re going to be able to have a real conversation. And that’s when we’re going to be able to see the effects.”
Ryan Miller was in the greatest shape of his life as an Army lieutenant during a tour of duty in Iraq when a roadside bomb mutilated his left leg and sent shrapnel into his stomach and intestines. He spent three years in an Army medical facility undergoing multiple surgeries to address the necrosis of his foot and the pain throughout his body.
Miller was initially treated at Walter Reed in Bethesda, Maryland. At the time of his treatment there, the military hospital was extremely overcrowded, and its neglect of patients and dire conditions was the subject of an investigative report by the Washington Post’s Dana Priest and Anne Hull.
“The hospital was so full of people in pain and so understaffed. They were just feeding people opiates,” Miller said. He was put on methadone, a long-lasting synthetic drug often used in detoxification treatment for opioid addictions, but also used to manage chronic pain. While it is an opioid, the risk of developing tolerance to the drug is lower than with other narcotics.
Still, people can develop a dependency on methadone. Miller said he didn’t consider himself addicted to opioids, but that he was physically dependent on the pain relief it provided. “I don’t remember the better part of 3 years during my stay at Walter Reed. My days began about an hour before actually getting up. I would pop 20 to 40 milligrams of methadone and then go back to sleep. It was only after the drugs had taken effect that I could bring myself to get out of bed,” Miller said.
“I sat there with my pills thinking, ‘I need to take this, but don’t want to,’” he recalled.
Miller said he was also socially dependent on the drugs, and used them to feel comfortable around others. “I was limited as to what I could do physically. When you’re disabled and in pain, normal social activity is hard, and you retreat into yourself. I used opiates for that, also,” he said.
There were times, he recalled, that he would save up doses of pills, then slightly overmedicate himself for a day to experience a stronger high.
After those three years of deteriorating health and unrelenting pain, he made the decision to have his injured leg amputated. He vowed to get off painkillers before the amputation, to start his post-surgery life free of a dependence on pills.
He asked the staff at the Center for the Intrepid, where his amputation would take place, to help him monitor every single pill he took, down to the milligram, until he weaned himself off and went through withdrawal. He did this without any supplemental medication.
Then came his surgery. “I woke up feeling like a million bucks,” he said. Doctors had given him Percocet for the acute surgical pain. But when he got home, after just a few days, Miller threw away the Percocet. “Back on Staten Island, where I’m from, that’s worth over $1,000,” he said. He occasionally smoked cannabis to get himself through difficult, sharp pain.
It wasn’t until 2014, when Miller moved to California, that he tried cannabis edibles. “I realized that I slept better. I have arthritis that wasn’t really bothering me,” he said. He now vaporizes cannabis oil and consumes edibles to manage his pain, as well as the stress and anxiety he attributes to the mental effects of years of opioid use.
“I know people who have killed themselves under the influence” of narcotics, he said. “If they had access to cannabis, it would be highly likely they’d be alive. It’s no panacea, but it’s a really positive replacement.”
But not everyone who has considered marijuana as an alternative thinks it is the best choice for someone with an opiate addiction.
Dr. Constance Scharff, the senior addiction research fellow and director of addiction research at Cliffside Malibu, an addiction treatment facility, does not advocate cannabis use to her patients. “We need to be careful not to demonize marijuana as a horrible thing, but we also need to be careful not to think that it is a cure-all,” Scharff said.
“By the time someone gets to us at a residential addiction treatment center, we would not recommend marijuana because of the psychoactive way the substances act in the brain,” she said. Abstinence-only treatment centers like Cliffside refrain from substituting one mood-altering drug with another, in the hopes that patients will learn coping mechanisms and not acquire a new dependency.
One of her concerns is that there just isn’t enough research yet on how well these substitutions work, nor are there enough avenues to implement research. “The other thing that is really tricky is that marijuana is still a Schedule I substance,” Scharff said. “But we can’t do research in this country, and it’s very, very difficult for us to do anything to find out what works about marijuana. And why does it work? And is there a better way to do this?”
Her hope, she said, is for doctors to stop over-prescribing drugs to chronic pain patients. The Surgeon General’s report indicated that opioid pain relievers are now the most prescribed class of medications in the United States—and meanwhile the number of opioid-related emergency room visits has increased 200 percent.
“We’re losing too many people all across the country. Largely the medical community did not know what to do about that,” Scharff said.
In the vacuum caused by the lack of research and advice from doctors, she said, she knows people are continuing to try marijuana on their own for pain relief. In the current system, she said, “You’re making every person who doesn’t want to use opioids and wants to use cannabis instead or try cannabis instead—you’re making them literally experiment on themselves.”
And while she doesn’t actively advocate for pot, she says it’s significantly better than more lethal and more addictive opioid alternatives, like fentanyl, a fast-acting narcotic 50 to 100 times more potent than morphine. CDC data released on December 8 shows that from 2014 to 2015, deaths from synthetic opioids like fentanyl increased by nearly 75 percent. “Prescription opioid misuse and use of heroin and illicitly manufactured fentanyl are intertwined and deeply troubling problems,” wrote CDC Director Tom Frieden in a statement last week.
“If your choice is fentanyl or marijuana, to me there’s an obvious first-line choice,” Scharff said.
Citing the John’s Hopkins study that demonstrated a 25 percent decrease in opioid overdoses in states with legal medical marijuana, she added, “What that tells us anecdotally is that when people have a choice for painkillers that are nonlethal, they will choose that and not die,” she said. “As long as you’re alive, I can treat you.”
Dani Geen swings by Harborside’s dispensary on her way home from work in the nearby Harborside business office. She stops in every few days to pick up medicine, and today she’s grabbing an array of lemony-scented concentrates, a solid substance extracted from the plant that is packed with cannabinoids. She also buys a new bottle of CBD oil, a non-psychoactive, topical substance that she uses on pain hot-spots to relieve inflammation.
She says she’s particularly achy after a long day at her computer, even though her computer station—spaceship-like with a curved computer screen and metal arms that float electronics perfectly at eye level—is carefully and ergonomically designed.
On her way in, she chats with Morgan Tano, a smiley young man with a long beard and plugs in his ears. Tano is a Harborside budtender, working the register and consulting with patients on their product needs. He walks with a slight limp. Tano was also in a horrific car accident, his midsection and pelvis crushed when a drunk driver hit the backseat of the car he was riding in. The crash left him in a coma for 17 days, and he awoke with six fentanyl patches on his body.
After over two years of recovery on narcotic pain medication, he said, “I started realizing I was in this loop. My friends told me about conversations, even fights, that I had no idea I’d ever been in.” Reflecting on those missed moments, Tano said, “I must have been a complete zombie. My depression was at an all-time high. I felt I was as low as I could get.”
His younger brother was the first to give him a cannabis edible to ease his pain, and it worked. But the transition from using pain pills to using cannabis was difficult. “Little did I know how much opiates lifted me up. The crash was very rocky,” Tano recalled.
But overall, Tano said, figuring out the best regimen for himself, including using concentrates for pain and topical ointments for swelling, has been a joyous experience. “This industry is not like pharma. It’s not about screwing you up,” he said. “Cannabis heals.”
“I was told I wouldn’t walk,” he said. “This plant allowed me to dance, walk, have great job, to work 40 hours a week standing up.”
Once she gets home, Geen sits at her dining room table, an array of cannabis inhalation contraptions before her. She turns on a VapeExhale, which looks like the base of a lava lamp. She says it’s great for consuming resin, a slightly crystalized and thick concentrate.
Next, she dabs. She heats the nail, the small quartz cup in her dab rig, a specialized pipe for using concentrates. It’s reminiscent of a chemistry class beaker topped with a tangle of glass tubing. Her heat source is a butane torch, the type you might use to crisp the top of a crème brulee. She melts a concentrate in the hot nail, inhales, and sits back.
Two cats wind around the base of Geen’s chair and she smiles at them. She dangles a toy and plays with them in between dabs. “These are our babies,” she says. “With my health problems I’m not sure I’ll ever have kids. But these are our furry babies.”
Geen cleans up her dining room table and makes a careful stack of her concentrate containers. She says she spends a few hundred dollars on cannabis each week to maintain her pain management regimen. It’s not covered by insurance; cannabis is unlikely to be covered by any insurer until it is federally rescheduled for medical use.
And that doesn’t seem likely in the very near future. In August, DEA Acting Administrator Chuck Rosenberg wrote a letter in response to two petitions to reschedule marijuana, one from Rhode Island Governor Gina Raimondo, and a second from Washington Governor Jay Inslee. The letter stated that marijuana will remain illegal under federal law, and that the DEA will follow FDA protocol to determine its medical value. Rosenberg wrote: “If the scientific understanding about marijuana changes—and it could change—then the decision could change. But we will remain tethered to science, as we must, and as the statute demands.”
Experts like Reiman are hoping that the passage of Proposition 64 will offer a path to that scientific understanding of cannabis. “Revenue from Prop. 64 would go to giving $2 million a year to the center for cannabis research at the UC San Diego,” Reiman said. “We need to embolden these research institutions to do the kind of clinical research the federal government wants to see in order to lift that Schedule 1 status.”
She also hopes that the findings of her current survey, which will be published in January, 2017, will guide scientists’ research into the use of cannabis as an alternative to opioid pain treatments.
Until then, Geen says, she fears that people suffering from pain will be given opioids first, and have to navigate their way into the medical cannabis community on their own. “I am very happy to be steroid and pain med free. I can be normal now. I deal with my pain through cannabis, diet, yoga, working out. You can’t take one special pill to cure everything. It’s a package,” she says.
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