Relationship Between Marijuana and Opioids


Cannabis access is associated with reduced rates of opioid use and abuse, opioid-related hospitalizations, opioid-related traffic fatalities, opioid-related drug treatment admissions, and opioid-related overdose deaths

  • “This study seeks to evaluate patient experience with prescribed medical cannabis obtained through licensed dispensaries in women with gynecologic malignancies. A 43-item survey exploring patient experience with medical cannabis was administered to women with gynecologic malignancies who used medical cannabis prescribed by a gynecologic oncologist. … Of the subset of patients using medical cannabis for pain, 63% reported a reduction in opioid use. … Medical cannabis was well tolerated and may have the potential to improve neuropathic pain and decrease opioid use.”
  • “Patients with chronic pain, licensed to use MC [medical cannabis] in Israel reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC treatment initiation. … At one year, average pain intensity declined from baseline by 20 percent. All other parameters improved by 10 to 30 percent. A significant decrease of 42 percent from baseline in morphine equivalent daily dosage of opioids was also observed.”
  • “[We] evaluated the impact of frequent cannabis use on injection cessation and injection relapse among people who inject drugs (PWID). … [W]e found that at-least-daily cannabis use was associated with an increased rate of injection cessation, and this effect was restricted to the cessation of opioid injection. We did not observe a significant association between at-least-daily cannabis use and injection relapse. … To our knowledge, this is the first longitudinal study to identify a positive association between cannabis use and cessation of injection drug use.”
  • “This review found a much higher reduction in opioid dosage, reduced emergency room visits, and hospital admissions for chronic non-cancer pain by MC [medical cannabis] users, compared to people with no additional use of MC. There was 64–75% reduction in opioid dosage for MC users and complete stoppage of opioid use for chronic non-cancer pain by 32–59.3% of MC users, when compared to patients without additional use of MC. … Given the current opioid epidemic in the USA and medical cannabis’s recognized analgesic properties, MC could serve as a viable option to achieve opioid dosage reduction in managing non-cancer chronic pain.”
  • “The aim of this study was to evaluate the short-term and long-term effects of plant-based medical cannabis (MC) on outcomes of interest related to pain, quality of life, tolerability, and opioid medication use in a large cohort of chronic pain patients using medical cannabis over the course of one year. … Medical cannabis treatment was associated with improvements in pain severity and interference. … In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses. … Taken together, the results of this study add to the cumulative evidence in support of plant-based MC as a safe and effective treatment option and potential opioid substitute or augmentation therapy for the management of chronic pain symptomatology and quality of life.”
  • “In this study, we observed an association between state-level legalization of medical cannabis and opioid prescribing by orthopedic surgeons in the Medicare Part D cohort. We found that overall opioid prescribing by orthopedic surgeons in this cohort was reduced in states permitting patient access to medical cannabis, compared with those who do not. … On examination of prescription data of different opioid classes, we found that prescriptions for hydrocodone, the most commonly prescribed opioid medication, by orthopedic surgeons had a statistically significant negative association with state MCLs.”
  • “We examined the association between the legalization of recreational marijuana and prescription opioid distribution in Colorado. Utah and Maryland, two states that had not legalized recreational marijuana, were selected for comparison. … There was a larger reduction from 2012 to 2017 in Colorado (-31.5%) than the other states. Colorado had a significantly greater decrease in codeine and oxymorphone than the comparison states.”
  • A team of investigators affiliated with the John Hopkins School of Medicine assessed whether or not cannabis availability would hypothetically influence pain patients demand for prescription opioids. One hundred and fifty-five subjects with recent experience using both opioids and cannabis for pain management participated in the survey. Authors reported, “[O]ur demand analyses suggests the availability of cannabis decreased opioid consumption (intensity) and increased the degree to which opioid consumption was influenced by opioid price (elasticity).” They concluded, “These results suggest cannabis may confer an opioid-sparing effect in this population.”
  • “Our study found that the addition of MMJ (medical marijuana) to [cancer pain] patients’ palliative care regimen withstood the development of tolerance and reduced the rate of opioid use, over a significantly longer follow-up period than patients solely utilizing opioids. … MMJ(+) improved oncology patients’ ESAS scores [a measurement of pain, nausea, and anxiety) despite opioid dose reductions and should be considered a viable adjuvant therapy for palliative management.”
  • “This matched cohort study included patients who were admitted with a traumatic injury. … There were 66 patients included: 33 cases and 33 matched controls. Dronabinol [oral synthetic THC] was initiated 55 hours from admission. Cases and controls were well matched. Cases had a significant reduction in opioid consumption with adjunctive dronabinol while opioid consumption was unchanged for controls. This resulted in a ninefold greater reduction in opioid consumption for cases versus controls. … The addition of dronabinol resulted in reduced opioid consumption, … suggesting a beneficial opioid-sparing effect of dronabinol in acutely painful conditions. … Because our study showed that the opioid-sparing effect of dronabinol may be greatest in patients who use marijuana, use of dronabinol adjunctively may benefit nearly half of [Colorado’s] population.”
  • “The evidence reported here presents the most accurate picture of the effect of cannabis access laws on prescription opioid use to date and can therefore inform the ongoing state and national debates over the legality of cannabis as well as other policy options to combat the opioid epidemic. Our analysis of a comprehensive national database on a diverse set of measures of opioid use provides an estimate of the overall net impact of cannabis laws. … In general, we find evidence that both RCLs (recreational cannabis laws) and MCLs (medical cannabis laws) decrease opioid prescribing. … Thus, the evidence presented here suggests that cannabis access laws could be a useful tool in combatting the prescription opioid epidemic. While our data do not allow us to test this potential mechanism explicitly, our results are consistent with a substitution of cannabis for prescription opioids in the treatment of pain.”
  • “We aimed to investigate the longitudinal association between frequency of cannabis use and illicit opioid use among people who use drugs (PWUD) experiencing chronic pain. … We observed an independent negative association between frequent cannabis use and frequent illicit opioid use among PWUD with chronic pain. … We found that people who used cannabis every day had about 50% lower odds of using illicit opioids every day compared to cannabis non-users.”
  • “Results provide evidence that MMLs may be effective at reducing opioid reliance as survey respondents living in states with medical cannabis legislation are much less apt to report using opioid analgesics than people living in states without such laws.”
  • “An initial sample of 131 patients was recruited from a private pain management center’s investigative population. Ninety-seven patients completed the 8-week study. The primary inclusion criteria included patients between 30 and 65 years old with chronic pain who have been on opioids for at least 1 year. Data were collected at three different time points: baseline, 4, and 8 weeks. … Over half of chronic pain patients (53%) reduced or eliminated their opioids within 8 weeks after adding CBD-rich hemp extract to their regimens. Almost all CBD users (94%) reported quality of life improvements.”
  • “[S]ubstitution of marijuana for opioids, which included a substantial degree of opioid discontinuation (~20 percent), was common. Our findings are consistent with prior surveys of American and Canadian marijuana users in which substitution of marijuana for opioids was prevalent due to better symptom management and fewer adverse and withdrawal effects.”
  • “The objective of this study was to determine if the use of medical cannabis affects the amount of opioids and benzodiazepines used by patients on a daily basis. … Over the course of this 6-month retrospective study, patients using medical cannabis for intractable pain experienced a significant reduction in the number of MMEs (daily milligram morphine equivalents) available to use for pain control.”
  • “Using a dataset of approximately 800,000 urine drug test results collected from pain management patients of a time from of multiple years, creatinine corrected opioid levels were evaluated to determine if the presence of the primary marijuana marker 11-nor-carboxy-tetrahydrocannabinol (THC-COOH) was associated with statistical differences in excreted opioid concentrations. Results & conclusion: For each of the opioids investigated (codeine, morphine, hydrocodone, hydromorphone, oxycodone, oxymorphone, fentanyl and buprenorphine), marijuana use was associated with statistically significant lower urinary opiate levels than in samples without indicators of marijuana use.”
  • “We examine the association between opioid prescription patterns in privately insured adults and changes in state cannabis laws among five age groups (18–25, 26–35 36–45, 46–55 and 56–64 years). … [I]n states which implemented medical cannabis use laws (but not other categories of cannabis liberalization laws), lower rates of opioid prescription were seen in the younger age cohorts (18–25, 26–35, 36–45 and 46–54 years).”
  • “A 10% sample of a nationally representative database of commercially insured population was used to gather information on opioid use, chronic opioid use, and high-risk opioid use for the years 2006–2014. … In states where marijuana is available through medical channels, a modestly lower rate of opioid and high-risk opioid prescribing was observed. Policy makers could consider medical marijuana legalization as a tool that may modestly reduce chronic and high-risk opioid use.”
  • “In this research, we have examined the effect of MML laws and the presence of active legal dispensaries on CDC age-adjusted opioid overdose death rates over the years 1999-2015. Our results suggest that states with active legal dispensaries see a drop in opioid death rates over time. … Overall, this research provides evidence that states with MMLs may see a decline in opioid overdose death rates if they enact legal dispensaries.”
  • “A retrospective cohort was evaluated to understand the pattern of care and QOL (quality of life) outcomes with MC (medical cannabis) use across rural multidisciplinary practices in New Mexico. … A total of 133 patients were identified between Jan 2017 – May 2017. … Pain score improved in 80% of patients with cancer and in 75% of non-cancer patients. … MC use led to ODR (opioid dose reduction) in 41% of all patients.”
  • “Analyzing a dataset of over 1.3 billion individual opioid prescriptions between 2011 and 2017, which were aggregated to the individual provider-year level, we find that recreational and medical cannabis access laws reduce the number of morphine milligram equivalents prescribed each year by 6.9 and 6.1 percent, respectively. These laws also reduce the total days supply of opioids prescribed, the total number of patients receiving opioids, and the probability a provider prescribes any opioids net of any offsetting effects.”
  • “[S]tudies demonstrate that when patients replace their opioid prescriptions with medical cannabis, they find its pain relief to side effect profile superior to opioids. Additionally, there has been a significant reduction in opioid-related mortality and morbidity since cannabis has become legally available. … As the world continues to face the opioid epidemic, research into alternatives to opioids for pain relief needs to be prioritized. There is significant evidence that cannabis, and synthetic cannabinoid receptor agonists, may provide patients with a way to reduce their opioid use. With this in mind, there is a foreseeable future of both legalized cannabis and synthetic cannabinoid receptor agonists to help mitigate the burden of opioid-based analgesic regimens.”
  • “This study examined whether statewide medical cannabis legalization was associated with reduction in opioids received by Medicaid enrollees. …For Schedule III opioid prescriptions, medical cannabis legalization was associated with a 29.6 percent reduction in number of prescriptions, 29.9 percent reduction in dosage, and 28.8 percent reduction in related Medicaid spending. … Statewide medical cannabis legalization appears to have been associated with reductions in both prescriptions and dosages of Schedule III (but not Schedule II) opioids received by Medicaid enrollees in the US. … It was estimated that, if all the states had legalized medical cannabis by 2014, Medicaid annual spending on opioid prescriptions would be reduced by 17.8 million dollars.”
  • “Using a unique data set of medical cannabis dispensaries combined with county-level mortality data, we estimate the effect of dispensaries operating in a county on the number of overdose deaths. … [W]ithin MCL (medical cannabis law)-adopting states, counties with dispensaries experience six percent to eight percent fewer opioid-related deaths among non-Hispanic white men, while mortality due to heroin overdose declines by more than ten percent. … Extrapolating our results implies that, for every 100,000 non-Hispanic white men, 10 fewer opioid-induced fatalities would have occurred between 2009 and 2015 if dispensaries were present and operating in every county within each MCL state.”
  • “[T]he most common prescription medications replaced by medicinal cannabis in this study were opiates/opioids in a large percentage within every pain group, up to 72.8% of patients in the chronic pain as primary illness group. … This is notable given the well-described “opioid-sparing effect” of cannabinoids and growing abundance of literature suggesting that cannabis may help in weaning from these medications and perhaps providing a means of combating the opioid epidemic.”
  • “We found no evidence to support the concern that recreational marijuana legalization increased opioid prescriptions received by Medicaid enrollees. Instead, there was some evidence in some model specifications that the legalization might be associated with reduction in Schedule III opioids in states that implemented legalization.”
  • “[T]he use of Trokie® lozenges is associated with a self-reported pain reduction in chronic, non-cancer pain patients. … [T]he proportion of participants reducing or discontinuing opiate analgesics was … 84 percent, similar to what has been previously found in a study based on patient self-reports.”
  • Investigators assessed opioid use patterns in a cohort of 573 patients registered with Health Canada to access medical cannabis products. Among those patients who acknowledged using opioids upon enrollment in the trial, 51 percent reported ceasing their opiate use within six-months. “The high rate of cannabis use for the treatment of chronic pain — and subsequent substitution for opioids — suggests that cannabis may play a harm-reduction role in the ongoing opioid dependence and overdose crisis While the cannabis substitution effect for prescription drugs has been identified and assessed via cross-sectional and population-level research, this study provides a granular individual-level perspective of cannabis substitution for prescription drugs and associated improvement in quality of life over time.”
  • “This cross-sectional study used a quasi-experimental difference-in-differences design comparing opioid prescribing trends between states that started to implement medical and adult-use marijuana laws between 2011 and 2016 and the remaining states. This population-based study across the United States included all Medicaid fee-for-service and managed care enrollees, a high-risk population for chronic pain, opioid use disorder, and opioid overdose. … State implementation of medical marijuana laws was associated with a 5.88% lower rate of opioid prescribing. Moreover, the implementation of adult-use marijuana laws, which all occurred in states with existing medical marijuana laws, was associated with a 6.38% lower rate of opioid prescribing. … [T]he further reductions in opioid prescribing associated with the newly implemented adult-use marijuana laws suggest that there were individuals beyond the reach of medical marijuana laws who may also benefit from using marijuana in lieu of opioids. Our finding that the lower opioid prescribing rates associated with adult-use marijuana laws were pronounced in Schedule II opioids, further suggest that reaching these individuals may have greater potential to reduce the adverse consequences, such as opioid use disorder and overdose.”
  • “Between August 1 – December 31, 2016 a total of 2290 patients were enrolled in the program under the qualifying condition of intractable pain; 45 of these patients were previously enrolled in the program under an additional qualifying condition. This report focuses on the 2245 patients who were certified for intractable pain and enrolled in the program for the first time during this interval. … A large proportion (58%) of patients on other pain medications when they started taking medical cannabis were able to reduce their use of these meds according to health care practitioner survey results. Opioid medications were reduced for 38% of patients (nearly 60% of these reduced at least one opioid by ≥50%), benzodiazepines were reduced for 3%, and other pain medications were reduced for 22%. If only the 353 patients (60.2%, based on medication list in first Patient Self-Evaluation) known to be taking opioid medications at baseline are included, 62.6% (221/353) were able to reduce or eliminate opioid usage after six months.”
  • “To gauge how effective medical marijuana was at managing chronic pain and reducing opioid use, researchers surveyed 138 medical marijuana users with an anonymous 20-question survey focusing on how often they used the marijuana. … When patients were asked if they were able to curb their use of other painkillers after starting medical marijuana, 18 percent reported decreasing their use ‘moderately,’ 20 percent ‘extremely’ and 27 percent ‘completely’.”
  • “We find fairly strong and consistent evidence using difference-in-differences and event study methods that states providing legal access to marijuana through dispensaries reduce deaths due to opioid overdoses. … We provide complementary evidence that dispensary provisions lower treatment admissions for addiction to pain medications. … In short, our findings that legally protected and operating medical marijuana dispensaries reduce opioid-related harms suggests that some individuals may be substituting towards marijuana, reducing the quantity of opioids they consume or forgoing initiation of opiates altogether. … At a minimum, however, our results suggest a potential overlooked positive effect of medical marijuana laws that support meaningful retail sales.”
  • “During the study period, 2736 patients above 65 years of age began cannabis treatment and answered the initial questionnaire. The mean age was 74.5 ± 7.5 years. The most common indications for cannabis treatment were pain (66.6%) and cancer (60.8%). After six months of treatment, 93.7% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0-10 to a median of 4. … After six months, 18.1% stopped using opioid analgesics or reduced their dose. … Cannabis use may decrease the use of other prescription medicines, including opioids.”
  • “We used an interrupted time-series design (2000-2015) to compare changes in level and slope of monthly opioid-related deaths before and after Colorado stores began selling recreational cannabis. … Colorado’s legalization of recreational cannabis sales and use resulted in a 0.7 deaths per month reduction in opioid-related deaths. This reduction represents a reversal of the upward trend in opioid-related deaths in Colorado.”
  • University of New Mexico investigators assessed opioid prescription use patterns over a 21-month period in 37 pain patients enrolled in the state’s medicinal cannabis program compared to 29 non-enrolled patients. Compared to non-users, medical cannabis enrollees “were more likely either to reduce daily opioid prescription dosages between the beginning and end of the sample period (83.8 percent versus 44.8 percent) or to cease filling opioid prescriptions altogether (40.5 percent versus 3.4 percent).” Enrollees were also more likely to report an improved quality of life. “The clinically and statistically significant evidence of an association between MCP enrollment and opioid prescription cessation and reductions and improved quality of life warrants further investigations on cannabis as a potential alternative to prescription opioids for treating chronic pain.”
  • “This paper uses a unique marijuana dispensary dataset to exploit within- and across-state variation in dispensary openings to estimate the effect increased access to marijuana has on narcotic-related admissions to treatment facilities and drug-induced mortalities. [It] finds that core-based statistical areas (CBSAs) with dispensary openings experience a 20 percentage point relative decrease in painkiller treatment admissions over the first two years of dispensary operations … [and] provides suggestive evidence that dispensary operations negatively affect drug-induced mortality rates.”
  • “Medical marijuana policies were significantly associated with reduced opioid pain reliever-related hospitalizations but had no associations with marijuana-related hospitalizations. … Medical marijuana legalization was associated with 23% (p=0.008) and 13% (p=0.025) reductions in hospitalizations related to opioid dependence or abuse and OPR overdose, respectively; lagged effects were observed after policy implementation.”
  • “[The] review of the current literature suggests states that implement medical cannabis policies could reduce prescription opioid medication associated mortality, improve pain management, and significantly reduce health care costs.”
  • Among patients with a musculoskeletal injury who acknowledged having used cannabis to assist in recuperating from injury over the past six months, 90 percent said that it was effective at reducing their pain. Eighty-one percent said that the use of cannabis reduced their intake of opioids. “[I]n the subset of patients who used marijuana during their recovery, a majority indicated that it helped alleviate symptoms of pain and reduced their level of opioid intake.”
  • “State-specific estimates indicated a reduction in opioid positivity for most states after implementation of an operational MML. … Operational MMLs are associated with reductions in opioid positivity among 21- to 40-year-old fatally injured drivers and may reduce opioid use and overdose.”
  • “The current study assessed the impact of 3 months of medical marijuana treatment on executive function, exploring whether MMJ patients would experience improvement in cognitive functioning, perhaps related to primary symptom alleviation. … Results suggest that in general, MMJ patients experienced some improvement on measures of executive functioning. … Patients also indicated moderate improvements in clinical state, including reduced sleep disturbance, decreased symptoms of depression, attenuated impulsivity, and positive changes in some aspects of quality of life. Additionally, patients reported a notable decrease in their use of conventional pharmaceutical agents from baseline, with opiate use declining more than 42%.”
  • “Among study participants, medical cannabis use was associated with a 64% decrease in opioid use (n = 118), decreased number and side effects of medications, and an improved quality of life (45%). This study suggests that many CP (chronic pain) patients are essentially substituting medical cannabis for opioids and other medications for CP treatment, and finding the benefit and side effect profile of cannabis to be greater than these other classes of medications.”
  • “The treatment of chronic pain with medicinal cannabis in this open-label, prospective cohort resulted in improved pain and functional outcomes, and a significant reduction in opioid use. … Opioid consumption at follow-up decreased by 44%.”
  • “Using both standard differences-in-differences models as well as synthetic control models, we find that states permitting medical marijuana dispensaries experience a relative decrease in both opioid addictions and opioid overdose deaths compared to states that do not.”
  • “Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time.”

Cannabis access is associated with reductions in overall prescription drug activity

  • “We study a unique case of unintended liberalization of a CBD-based product (light cannabis) that occurred in Italy in 2017. Using unique and high-frequency data on prescription drug sales and by exploiting the staggered local availability of the new product in each Italian province, we document a significant substitution effect between light cannabis and anxiolytics, sedatives, opioids, anti-depressants and anti-psychotics. … We find that the local availability of [low-THC, high CBD] cannabis [products] led to a significant decrease in the number of dispensed boxes of anxiolytics by approximately 11.5%, a reduction of dispensed sedatives by 10% and a reduction of dispensed anti-psychotics by 4.8%.”
  • “Medical marijuana laws (MMLs) can impact marijuana and opioid use, but the relationship between MMLs and other drugs, such as prescription stimulants, remains unexamined. … We pooled 2015-2017 National Survey on Drug Use and Health data for adults (n = 126 463), and used survey-weighted multinomial logistic regression to estimate odds of past-year (a) medical prescription stimulant use, (b) non-medical prescription stimulant use and (c) non-medical versus medical stimulant use. We stratified by gender, adjusted for sociodemographic characteristics, and tested the interaction between MML state residence and sexual identity. … Medical prescription stimulant use was lower in MCL states versus non-MCL states for heterosexual men (3.7% versus 4.6%) and women (4.2% versus 5.7%). Bisexual men’s medical stimulant use prevalence was 4.2% in MCL states versus 9.9% in non-MCL states: among women, it was 7.3% versus 8.6%. Among bisexual men, non-medical prescription stimulant use was 5.6% in MCL states versus 8.1% in non-MCL states; for bisexual women it was 6.0% versus 7.9%. … The ‘spillover’ effect of MCL enactment on the use of substances besides cannabis should be explicitly tested in future studies.”
  • “This study seeks to understand whether people substitute between recreational cannabis and conventional over-the-counter (OTC) sleep medications. … We measured annually-differenced market shares for sleep aids as a portion of the overall OTC medication market, thus accounting for store-level demand shifts in OTC medication markets and seasonality, and used the monthly changes in stores’ sleep aid market share to control for short-term trends. … For the first time, we show a statistically significant negative association between recreational access to cannabis and OTC sleep aid sales, suggesting that at least some recreational purchasers are using cannabis for therapeutic rather than recreational purposes … [O]ur results indicate that enough individuals are switching from OTC sleep aids to recreational cannabis that we can identify a statistically significant reduction in the market share growth of OTC sleep aids in conjunction with access to recreational cannabis using.”
  • “A retrospective analysis was performed on a cohort of 146 medical cannabis patients who reported benzodiazepine use at initiation of cannabis therapy. … After completing an average 2-month prescription course of medical cannabis, 30.1% of patients had discontinued benzodiazepines.”
  • “We report results from an ongoing, online survey of medical cannabis users with chronic pain nationwide about how cannabis affects pain management, health, and pain medication use. … Consistent with other observational studies, approximately 80% reported substituting cannabis for traditional pain medications (53% for opioids, 22% for benzodiazepines), citing fewer side effects and better symptom management as their rationale for doing so.”
  • “Findings from this systematic review show that MMLs are associated with a modest reduction in opioid prescriptions. Specifically, implementation of MMLs (medical marijuana laws) is associated with a 7% reduction in opioid prescriptions.”
  • “This longitudinal analysis of Medicare PartD found that prescriptions filled for all opioids decreased by 2.11 million daily doses per year from an average of 23.08 million daily doses per year when a state instituted any medical cannabis law. Prescriptions for all opioids decreased by 3.742 million daily doses per year when medical cannabis dispensaries opened. … Combined with previously published studies suggesting cannabis laws are associated with lower opioid mortality, these findings further strengthen arguments in favor of considering medical applications of cannabis as one tool in the policy arsenal that can be used to diminish the harm of prescription opioids.”
  • “This was a retrospective, mirror-image study that investigated medical cannabis’ effectiveness in patients suffering from chronic pain associated with qualifying conditions for MC in New York State. … After 3 months treatment, MC improved quality of life, reduced pain and opioid use, and lead to cost savings. … These results are consistent with previous reports demonstrating MC’s effectiveness in neuropathic pain.”
  • “We conducted a pragmatic historical cohort study to measure the effect of enrollment in a state-authorized United States’ Medical Cannabis Program (MCP) on scheduled II-V drug prescription patterns. … Our pragmatic preliminary study found that enrollment in the NM MCP was associated with significant reductions in scheduled II-V prescription drug activity and associated use of conventional pharmacies and prescribing providers. … 34% of the MCP patients cease to exhibit any evidence of scheduled drug consumption and an additional 36% reduce the number of prescriptions filled for scheduled drugs by the last 6 months of our sample period. … In conclusion, a shift from prescriptions for other scheduled drugs to cannabis may result in less frequent interactions with our conventional healthcare system, and potentially improved patient health.”
  • “Using the variations across state MMLs between 1996 and 2014 of Medical Expenditure Panel Survey (MEPS) this paper estimates the effects of MMLs on prescription drug utilization, with a focus on opioids. I find that MMLs lead to a $2.47 decrease in per person prescribed opioid spending among young adults (ages 18-39) over a year. Most of this decrease results from the intensive margin of use and MML states that allow home cultivation experience even larger decreases.”
  • “Using quarterly data on all fee-for-service Medicaid prescriptions in the period 2007-14, we tested the association between those laws and the average number of prescriptions filled by Medicaid beneficiaries. We found that the use of prescription drugs in fee-for-service Medicaid was lower in states with medical marijuana laws than in states without such laws in five of the nine broad clinical areas we studied. If all states had had a medical marijuana law in 2014, we estimated that total savings for fee-for-service Medicaid could have been $1.01 billion.”
  • “Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented. National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in 2013.”

The adjunctive use of cannabis augments the analgesic properties of opioids

  • “In this exploratory CEA (cost effective analysis) of smoked cannabis for neuropathic pain, we found augmentation of standard therapy agents for neuropathic pain with smoked cannabis to be cost-effective over the short- and long-term. … Judicious use of medicinal cannabis alongside standard therapy agents may be particularly beneficial to patients with refractory pain and to active cannabis users.”
  • “The reduction of opioid dosing when used in combination with cannabis/cannabinoids reduces side effects and allows for easier detoxification and weaning due to less of a tolerance and withdrawal from opiates, and rekindling of opiate analgesia after prior dosages have worn off. Because of the cannabis-opioid synergistic interactions as suggested by available data, cannabis has been suggested as a tool in the opioid detoxification and weaning process. …. Unfortunately, most chronic pain management programs have rules and “opioid contracts” mandating patients to be free of cannabis/cannabinoid use for enrollment and ongoing treatment. Given the abundance of evidence-based medicine and research on cannabinoid-opioid synergy, these policies seem quite outdated and should be re-evaluated. Patients using cannabis/cannabinoids may inadvertently be assisting their own detox and weaning from opiates. Chronic pain management programs should harness this potential benefit within their treatment program and use it to their patients’ advantage.”
  • “This double-blind, placebo-controlled, within-subject study determined if cannabis enhances the analgesic effects of low dose oxycodone using a validated experimental model of pain and its effects on abuse liability. … Although active cannabis and 2.5 mg oxycodone alone failed to elicit analgesia, combined they increased pain threshold and tolerance. … Smoked cannabis combined with an ineffective analgesic dose of oxycodone produced analgesia comparable to an effective opioid analgesic dose without significantly increasing cannabis’s abuse liability.”
  • “[T]hese clinical and pre-clinical data suggest that analgesic synergy produced by coadministered cannabis and opioids could be harnessed to achieve clinically relevant pain relief at doses that would normally be subanalgesic. This strategy could have significant impacts on the opioid epidemic, given that it could entirely prevent two of the hallmarks of opioid misuse: dose escalation and physical dependence.”
  • “Twenty-one individuals with chronic pain, on a regimen of twice-daily doses of sustained-release morphine or oxycodone were enrolled in the study and admitted for a 5-day inpatient stay. Participants were asked to inhale vaporized cannabis in the evening of day 1, three times a day on days 2-4, and in the morning of day 5. … The extent of chronic pain was also assessed daily. … Pain was significantly decreased after the addition of vaporized cannabis. We therefore concluded that vaporized cannabis augments the analgesic effects of opioids without significantly altering plasma opioid levels. The combination may allow for opioid treatment at lower doses with fewer side effects.”

Patients often use cannabis as a substitute for other controlled substances, including prescription medications, alcohol, and tobacco

  • “Among our subjects, over 90 percent of CU [cannabis users] and PU [past users] reported “a little” or “great” relief from symptoms with MC [medical cannabis] and 61.20 percent claimed that MC had allowed them to reduce or discontinue use of other medications.”
  • “RCLs (recreational cannabis laws) and, to a lesser extent, MCLs (medical cannabis laws) reduce the total days supply of NSAIDs, the number of different patients to whom providers prescribe NSAIDs, and the likelihood that a provider prescribes any NSAIDs.”
  • “Participants [in the study] were 93 US military veterans and members of the Santa Cruz Veterans’ Alliance (SCVA). … The majority of participants reported that they use cannabis as a substitute for other licit and illicit substances. … [P]articipants reported a high degree of substitution behavior, particularly for alcohol. … [N]early half the sample reported substituting cannabis for prescription medications. … The current study also confirms the findings of previous studies that have documented a trend in substitution behavior, where cannabis is substituted for other drugs, which, if associated with reduced harm, could be beneficial for overall health.”
  • “The aim of the study was to investigate the characteristics, safety, and effectiveness of medical cannabis therapy for fibromyalgia. … Most patients ceased, reduced, or at least did not change the dosage of their chronic drugs for fibromyalgia while receiving medical cannabis. At six months, 28 out of 126 patients (22.2%) stopped or reduced their dosage of opioids, and 24 out of 118 (20.3%) reduced their dosage of benzodiazepines. … Considering the low rates of addiction and serious adverse effects (especially compared to opioids), cannabis therapy should be considered to ease the symptom burden among those fibromyalgia patients who are not responding to standard care.”

Chronic pain patients are less likely to abuse medicinal cannabis as compared to opioids

Chronic pain patients are less likely to become depressed using medical cannabis

Cannabis use is associated with greater rates of opioid use treatment retention and may mitigate opioid-related cravings

  • “To fill the gap between efficacious OUD [opioid use disorder] treatments and the widespread prevalence of misuse, relapse, and overdose, the development of novel, alternative, or adjunct OUD treatment therapies is highly warranted. In this article, we review emerging evidence that suggests that cannabis may play a role in ameliorating the impact of OUD. … The evidence summarized in this article demonstrates the potential cannabis has to ease opioid withdrawal symptoms, reduce opioid consumption, ameliorate opioid cravings, prevent opioid relapse, improve OUD treatment retention, and reduce overdose deaths. … The compelling nature of these data and the relative safety profile of cannabis warrant further exploration of cannabis as an adjunct or alternative treatment for OUD.”
  • “Many chronic pain patients are prescribed opioids at doses exceeding the current Guideline. Tapering the dose can be difficult, as patients fear a return to a state of overwhelming pain. Several factors can increase the likelihood of success: the patient’s readiness for change, psychological support, pharmacological support and careful monitoring. This pilot study addressed these four factors. Six hundred patients took part. Each was taking daily opioid doses ranging from 90-240 mg morphine equivalent dose (MED). All indicated they were prepared to reduce their opioid dose. Over a six-month period, opioid doses were tapered according to individual needs, usually 10% every 1-2 weeks. … After 6 months, 156 patients (26%) had ceased taking opioids. An additional 329 patients (55%) had reduced their opioid use by an average of 30%. … Medical cannabis provided pharmacological support throughout the tapering process … [and] was very helpful to many patients. … The positive results justify further investigation.
  • “This exploratory double-blind randomized placebo-controlled trial assessed the acute (1 hour, 2 hours, and 24 hours), short-term (3 consecutive days), and protracted (7 days after the last of three consecutive daily administrations) effects of CBD administration (400 or 800 mg, once daily for 3 consecutive days) on drug cue–induced craving and anxiety in drug-abstinent individuals with heroin use disorder. … Acute CBD administration, in contrast to placebo, significantly reduced both craving and anxiety induced by the presentation of salient drug cues compared with neutral cues. CBD also showed significant protracted effects on these measures 7 days after the final short-term (3-day) CBD exposure. In addition, CBD reduced the drug cue–induced physiological measures of heart rate and salivary cortisol levels. There were no significant effects on cognition, and there were no serious adverse effects. CBD’s potential to reduce cue-induced craving and anxiety provides a strong basis for further investigation of this phytocannabinoid as a treatment option for opioid use disorder.”
  • “The evidence summarized in this article demonstrates the potential cannabis has to ease opioid withdrawal symptoms, reduce opioid consumption, ameliorate opioid cravings, prevent opioid relapse, improve OUD treatment retention, and reduce overdose deaths. … Adjunct cannabis use alongside current treatment strategies could help to improve the number of individuals engaging in OUD treatment, as well as increase treatment retention rates.”
  • “The present study found that individuals initiating OAT (opioid agonist treatment) were approximately 21% more likely to be retained in treatment at 6 months if they reported ≥ daily use of cannabis. This finding persisted after adjustment for a range of confounders, including high-intensity concurrent use of other substances and relevant social-structural exposures (e.g. homelessness). … Given the well-known mortality risk reduction benefit of sustained engagement in OAT, findings from the present study alongside prior research evidence support the urgent need for clinical research to evaluate the therapeutic potential of cannabinoids as adjunctive treatment to OAT to address the escalating opioid-overdose epidemic.”
  • “Significant research efforts are still necessary to evaluate fully the development of CBD as a potential therapy for addiction disorders. To date, the evidence appears to at least support a potential beneficial treatment for opioid abuse. The fact that patients with substance use disorders often present with various psychiatric and medical symptoms that are reduced by CBD — symptoms such as anxiety, mood symptoms, insomnia, and pain — also suggests that CBD might be beneficial for treating opioid-dependent individuals. Currently most medications for opioid abuse directly target the endogenous opioid system. CBD could thus offer a novel line of research medication that indirectly regulate neural systems modulating opioid-related behavior, thus helping to reduce side effects normally associated with current opioid substitution treatment strategies.”
  • “Opioid dependent participants were randomized to receive dronabinol 30mg/d (n=40) or placebo (n=20), under double-blind conditions, while they underwent inpatient detoxification and naltrexone induction. … The severity of opioid withdrawal during inpatient phase was lower in the dronabinol group relative to placebo group. … Post hoc analysis showed that the 32% of participants who smoked marijuana regularly during the outpatient phase had significantly lower ratings of insomnia and anxiety and were more likely to complete the 8-week trial. Dronabinol reduced the severity of opiate withdrawal during acute detoxification. … Participants who elected to smoke marijuana during the trial were more likely to complete treatment.”
  • “The present study replicates a previous surprising finding that intermittent cannabis use is associated with improved retention in naltrexone treatment among opioid dependent patients, while both abstinence from cannabis and regular cannabis use during naltrexone treatment are associated with high dropout. … These findings are of interest, because they suggest the hypothesis that moderate cannabis use may be exerting a beneficial pharmacological effect improving the tolerability of naltrexone in the early weeks after induction, and that cannabinoid agonists might have promise for improving the effectiveness of naltrexone treatment for opioid dependence.”
  • “Intermittent use of nonopiate drugs is common during outpatient treatment for opiate dependence and may be a favorable prognostic indicator. This may support a “harm reduction” approach as opposed to a strict abstinence-oriented approach. Further research is needed to identify the optimal therapeutic stance toward other drug use during treatment for opiate dependence.”