Medical cannabis as an evidence based treatment of opiate use disorder.

A
literature review.

The literature regarding medical cannabis and its potential use to treat opiate
use disorders is poor in quality. The significance of the risk of short and long term
adverse effects from medical cannabis must be weighed against the desired
benefit; in this case abstinence and recovery from opiate abuse.

There are studies that have shown cannabis use appears to increase rather than
decrease the risk of developing prescription opiate abuse (1). Within the general
population, studies have shown cannabis use is associated with an increased risk
for several substance use disorders (2) and policy makers, such as the New
Mexico Department of Health, should take this under consideration when making
policy decisions (2).

Data from pain clinics has revealed a high prevalence of cannabis use and opiate
misuse and cannabis use with other substance misuse. (3) Cannabis use in chronic
opiate patients shows statistically significant associations with aberrant opioid use
(4). Use of cannabis and opiates together is an absolute contraindication to the
operation of a motor vehicle. There is a strong association with recent cannabis
use and psychomotor impairment and motor vehicle crashes. (3) Acute cannabis
use is associated with increased risk of fatal collisions (5).

The literature thus far has yet to show definitively that cannabis may be useful in
the treatment of opiate use disorders. On the contrary, there exists a great deal
of literature over the years outlining the acute and long term negative effects of
cannabis use and the impact of cannabis use on public health. (5)(6).
 There are some recent citations in the literature quoting the possible benefits of
cannabis in reducing cravings, and as an adjunct or substitute therapy for
prescription opiates in the treatment of chronic pain (7) (8) (9). However, giving
another addictive substance like cannabis to opiate addicted patients is risky
compared to current practice of giving cannabis to non-opiate addicted patients
for chronic pain.

There are many studies that don’t support the hypothesis of any beneficial
effects of cannabis in treating opiate use disorders. One study showed there is no
evidence cannabis reduces opioid withdrawal symptoms during methadone taper
(10) and another study showed that cannabis increases the rate of patients
dropping out of medication-assisted treatment for opioid use disorder (11).
Several reports have associated chronic use of cannabis and opiate replacement
therapy with brain hemorrhage and cerebral vasospasm, the use of cannabis
among those on methadone maintenance with adverse outcomes and marijuana
use being associated with a greater risk of relapse to heroin use among those on
methadone maintenance (12).

One article promoted cannabis as a harm reduction strategy for substituting

cannabis for alcohol, illicit drugs or prescription drugs. However, it mentioned
cannabis may have implications for abstinence based substance use treatment
approaches which clearly does not make sense nor fit into any abstinence based
substance abuse treatment strategy since cannabis as a drug of abuse cannot be
part of any abstinence based recovery program (13).

More research, including prospective longitudinal studies, is needed to

determine the validity any findings supporting any beneficial role in using
cannabis for the treatment of an opiate use disorder.
References
(1) Olfson M. Wall MM. Liu SM. Blanco C. Cannabis Use and Risk of prescription
Opioid Use Disorder in the United States. Am J Psychiatry 2018; Jan 1;175
(1) 47-53.

(2) Blanco C. Hasin DS. Wall MM. Florez-Salamanca L. Hoertel N. Wang S.

Kerridge BT. Olfson M. Cannabis Use and Risk of Psychiatric Disorders:
Prospective evidence from a US National Longitudinal Study. JAMA
Psychiatry 2016 April;73 (4):388-95.

(3) Reisfiel GM. Medical Cannabis and chronic opioid therapy. J Pain Palliative
Care Pharmacotherapy. 2010 Dec;24 (4): 356-61.

(4) Reisfield GM. Wasan AD. Jamison RN. The prevalence and significance of
cannabis use in patients prescribed chronic opioid therapy: a review of the
extant literature. Pain Med 2009 Nov;10(8):1434-41.

(5) Karila L. Roux P. Rolland B. Benyamine A. Reynaud M. Aubin HJ. Lancon C.

Acute and long-term effects of cannabis use: a review. Curr Pharm Des.
2014;20(25):4112-8.

(6) Andrade C. Cannabis and neuropsychiatry, 1: benefits and risks. J Clin

Psychiatry. 2016 May;77(5):e551-4.

(7) Lucas P. Cannabis as an adjunct to or substitute for opiates in the treatment

of chronic pain. J Psychoactive Drugs. 2012 April-June;44(2):125-133.

(8) Vigil JM. Stith SS. Adams IM. Reeve AP. Associations between medical
cannabis and prescription use in chronic pain patients: A preliminary cohort
study. PLos One. 2017 Nov 16;12(11).
(9) Vigil JM. Stith SS. Adams IM. Reeve AP. Effects of Legal Access to Cannabis
on Scheduled II-V Drug Prescriptions. J Am Med Dir Assoc. 2018
Jan;19(1):59-64.

(10) Epstein DH. Preston KL. No evidence for reduction of opioid-

withdrawal symptoms by cannabis smoking during a methadone dose
taper. Am J Addict 2015 June;24(4):323-8.

(11) Franklyn AM. Eibl JK. Gauthier GJ. Marsh DC. The impact of cannabis
use on patients enrolled in opioid agonist therapy in Ontario, Canada. PLos
One 2017 Nov 8;12(11):e0187633.

(12) Yatan Pal Singh Balhara. Raka Jain. Cannabis use among opioid-
dependent individuals on opioid substitution therapy. J Pharmacol
Pharmacother. 2014 July-Sept;5(3):203-205.

(13) Lucas P. Walsh Z. Crosby K. Callaway R. Belle-Isle L. Kay R. Capler R.

Holtzman S. Substituting cannabis for prescription drugs, alcohol and other
substances among medical cannabis patients: The impact of contextual
factors. Drug Alcohol Rev. 2016 May;35(3):326-33.