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 cohort study of New York State Prescription Monitoring Program data from 2017 to 2019 included patients receiving MC for chronic pain while also receiving opioid treatment. Of these, patients receiving LOT [long-term opioid therapy] prior to receiving MC were selected. Individuals were studied for 8 months after starting MC [medical cannabis]. … The daily MME [morphine milligram equivalent] for the last month of the follow-up period among patients receiving longer MC was reduced by 48% in the lowest stratum, 47% in the middle stratum, and 51% in the highest stratum compared with the baseline dosages. … In this cohort study of patients receiving LOT, receiving MC for a longer duration was associated with reductions in opioid dosages. … These findings contribute robust evidence for clinicians regarding the potential benefits of MC in reducing the opioid burden for patients receiving LOT and possibly reduce their risk for overdose.
“The following review aimed to evaluate the evidence linking population-level health metrics with the implementation of recreational legalization policies. Through a literature review, we identified 32 studies which investigated key metrics, such as cannabis consumption, healthcare-related service use, crime, traffic crashes/fatalities, suicidal behaviors, and other drug use. … One of the most robust associations observed in this systematic review is the correlation between RML and prescription opioids. … These RML data parallel and align with previous medical marijuana legalization data, which report decreases in the number of opioid prescriptions provided to patients; the number of prescriptions filled by patients; the number of prescriptions discontinued early by patients; MMEs prescribed to patients, etc. Most research articles included on this topic were evaluated as having high-quality evidence. As such, the evidence is sufficient to establish a potentially beneficial association between recreational marijuana legislation and prescription opioid patterns.”
“This systematic review summarized published literature on county-level predictors of drug overdose mortality in the United States. … “[M]easures related to cannabis dispensaries, substance use treatment, social capital, and proportions of family households, were generally consistently associated with lower drug overdose mortality outcomes across multiple studies.”
“This cross-sectional study of 38, 189 patients with newly diagnosed breast cancer, 12, 816 with colorectal cancer, and ,7190 with lung cancer found that medical marijuana legalization implemented between 2012 and 2017 was associated with a 5.5% to 19.2% relative reduction in the rate of opioid dispensing.”
“Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey to assess health functioning before and after cannabis initiation. … The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis.”
“Patients undergoing primary THA (total hip arthroplasty) or TKA (total knee arthroplasty) with minimum 6-month follow-up who self-reported cannabis use were retrospectively reviewed. A total of 210 patients (128 TKAs and 82 THAs) were matched by age; gender; type of arthroplasty. … Self-reported perioperative cannabis use appeared to significantly reduce the number of patients that persistently used opioids greater than 90 days after TJA from 9.5% to 1.4%. … As cannabis becomes more widely available and patient interest in its use for pain management continues to increase, further research with higher quality, prospective studies are required to clarify its role in perioperative pain management.”
“This study was a retrospective analysis of patients who were enrolled in the medical marijuana registry through the ambulatory palliative care department at Upstate Cancer Center. Data from June 2017 to June 2020 were analyzed. Patients were included if they had a diagnosis of cancer, were certified by a qualified practitioner in the New York Medical Marijuana Program, and received care at Upstate Medical University. … For patients who took at least one dose of medical marijuana, 48.14 percent experienced an improvement in pain, 44.95 percent used fewer opioids, and 85.11 percent had an improvement in at least one symptom. Adverse effects were low at 3.72 percent.”
“In this work, we followed up prospectively and longitudinally on the effectiveness and safety of MC treatment. Oncology patients reported on multiple symptoms before and after MC treatment initiation at one-, three-, and 6-month follow-ups. … Of the patients in the cohort that reported fully on their analgesic medications’ consumption at T0 and T6, 40% of those who had been using analgesic medications (over-the-counter, non-steroidal anti-inflammatory drugs, opioids, anticonvulsants, and antidepressants) at T0 were no longer using them.”
“In all, 178 patients with chronic pain were treated for a period of 366 days (median; range 31-2590 days). Median age was 72 years (26-96 years). 115 patients (65%) with CAM [medical cannabinoids] also received opioids a median 65 mg/day morphine equivalents. This opioid dosage was significantly reduced in course of time by 24 mg/day morphine equivalents or 50%. This reduction was independent on CAM dosage, age and gender. Patients with chronic pain profit from long-term CAM which safely and significantly lower the consumption of co-medicated opioids, even at low dosages (< 7.5 mg/day). Older patients benefit from CAM, and adverse effects do not limit the (chronic) use and prescription of CAM in the elderly.”
“The primary objective of this study was to evaluate the effects of long-term cannabis-based oil consumption on the distribution of patients with an opioid prescription, within patients with a chronic pain condition. … Analyses by subgroups showed a statistically significant difference in the proportion of female opioid non-users before and after cannabis-based oil treatment (34.1% to 56.1%), as well as in the proportion of under-65 years old opioid non-users before and after cannabis-based oil treatment (32.5% to 55%), in the proportion of opioid non-users with non-severe comorbidity (33.3% to 54.2%), and … in the proportion of opioid non-users with a chronic pain condition (32.6% to 59.2%).”
“Forty patients with chronic OA pain were certified for MC. Average morphine milligram equivalents (MME) per day of opioid prescriptions filled within the six months prior to MC certification was compared to that of the six months after. … Average MME/day decreased from 18.2 to 9.8. The percentage of patients who dropped to 0 MME/day was 37.5%. VAS scores decreased significantly at three and six months, and Global Physical Health score increased significantly by three months. … Our findings support the literature in that MC reduces the use of opioids for the treatment of chronic pain.”
“In this study involving patients with chronic musculoskeletal noncancer back pain certified for MC, opioid prescriptions filled significantly decreased after MC [medicinal cannabis] certification. … [P]atients in the less than 15 MME/day group had over a 35% chance of eliminating opioid use. … These opioid reductions were also associated with improvements in pain scores and daily function. Our findings support the hypothesis that the introduction of MC for chronic low back pain is associated with a decrease in opioid prescriptions filled.”
“This study investigates a proposed clinical context in offering medical cannabis as a treatment for chronic pain for those already using chronic opioid therapy. It then details patients’ daily morphine milligram equivalent (MME) usage. … One hundred and fifteen patients met the inclusion criteria. … There was a 67.1% average decrease in daily MME/patient from 49.9 to 16.4 MME at the first follow-up. There was a 73.3% decrease in MME at second follow-up from 49.9 to 13.3 MME. … After discussing the risks, benefits, and potential side effects of chronic opioid therapy with the patient, the authors of this study present medical cannabis, used with the current study’s paradigm, as a potentially effective class of treatment for chronic pain.”
“In this study, we examined individuals who were provided with legal; medical cannabis certifications in the state of Delaware between June 2018 and October 2019 and were concurrently being treated with opioid medications for chronic pain at a private pain management practice. … For non-outlier individuals with positive baseline opioid use before receiving medical marijuana certification (n=63), the average percent change in opioid use was found to be -31.3 percent. Examining subgroups based upon pain location, individuals with low back pain (n=58) displayed a 29.4 percent decrease in MME [morphine milligram equivalent] units, while individuals with neck pain (n=27) were observed to have a 41.5 percent decrease in opioid use. Similarly, individuals with knee pain (n=14) reduced their opioid use by 32.6 percent. … Since the underlying pathology and their source of pain in the individuals was unlikely to significantly change during the period examined, medical marijuana use could have played a large role in allowing the individuals to decrease their opioid use. … The results of this study indicate that medical marijuana certification is associated with a decrease in prescription opiate use for chronic pain treatment and supports greater use of this adjunct treatment modality. Given the significance of opioid addiction in American society, any treatment or additional resource to reduce opioid overuse can aid in the multifactorial management of chronic pain. Although marijuana use causes a variety of side effects, the findings here suggest that the use of medical cannabis as an adjunct treatment for chronic pain may be beneficial to public health.”
“A retrospective cohort study was conducted using the medical files of 68 Israeli patients with chronic pain using MC [medical cannabis]. Number of prescription medications filled and healthcare services used were recorded separately for the baseline period (6 months prior to the start of MC treatment) and 6 months’ follow-up. … Patients filled less opioid prescription medication at follow-up compared with baseline. … MC may be related to a significant yet small reduction in opioid prescription medication. Further prospective studies with representative samples are warranted to confirm the potential small opioid-sparing effects of MC treatment, its clinical importance, if any, and potential lack of association with other healthcare-related services and medication use.”
“The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada. … A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured … during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis. … Among those prescribed high doses of opioids (OME > 100), there were significant reductions in opioid consumption. … Overall, our findings may contribute ongoing evidence for clinicians regarding the potential impact of medical cannabis to reduce the opioid burden among patients.”
“We investigated whether cannabis usage was associated with reduced opioid usage, and the rates of opioid and cannabis use disorders among chronic pain patients who had been prescribed medical cannabis. … Of the 100 participants aged 18-70 years, 76 ever used opioids. Of them, 93% decreased or stopped opioids following cannabis initiation.”
“We quantified the association between cannabis use and nonfatal opioid overdose among individuals enrolled in methadone maintenance treatment (MMT) for opioid use disorder (OUD). … After imputing missing data and controlling for demographic and clinical factors, the likelihood of self-reported nonfatal opioid overdose in the past year was 71% lower among reporters of frequent cannabis use in the past month. Among individuals enrolled in MMT, frequent cannabis use in the past month was associated with fewer self-reported nonfatal opioid overdoses in the past year.”
“We studied county level associations between cannabis storefront dispensaries and opioid related mortality rates in the US between 2014 and 2018. Our study found that increased medical and recreational storefront dispensary counts are associated with reduced opioid related mortality rates during the study period. These associations appear particularly strong for deaths related to synthetic opioids such as fentanyl. Given the alarming rise in the fentanyl based market in the US, and the increase in deaths involving fentanyl and its analogs in recent years, the question of how legal cannabis availability relates to opioid related deaths is particularly pressing. Overall, our study contributes to understanding the supply side of related drug markets and how it shapes opioid use and misuse.”
“National monthly claims data for public and private payers were obtained from January 2016 to June 2019. The drugs evaluated consisted of morphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, oxycodone, tramadol, and the non-opioids gabapentin and pregabalin. All opioid volumes were converted to a mean morphine equivalent dose (MED)/claim, which is analogous to a prescription from a physician. … Over the 42-month period, the mean MED/claim declined within public plans. However, the decline in MED/claim was 5.4 times greater in the period following legalization (22.3 mg/claim post vs. 4.1 mg/claim pre). Total monthly opioid spending was also reduced to a greater extent post legalization ($Can267,000 vs. $Can95,000 per month). … Our findings support the hypothesis that easier access to cannabis for pain may reduce opioid use for both public and private drug plans.”
“This observational study enrolled patients between 8 September 2015 and 31 July 2018 from community-based cannabis clinics in Ontario, Canada. … Of the 1,000 patients consented, 757 (76%) participated at one or more of the study time points. At six and 12 months, 230 (30.4%) and 104 (13.7%) of participants were followed up, respectively. … The proportion of individuals who reported using opioids decreased by half, from 40.8% at baseline to 23.9% at 12 months. … In this cohort, pain intensity and pain-related interference scores were reduced and QoL and general health symptoms scores were improved compared with baseline.”
“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. … The majority of patients in our study felt that medical cannabis was equivalent or superior in efficacy to other medications (e.g., opioids, antiemetics, anxiolytics, and sleep aids) in relieving their symptoms. … Of the subset of patients using medical cannabis for pain, 63 percent reported a reduction in opioid use. … These data suggest medical cannabis may be a reasonable alternative or adjunct to medications frequently used for cancer or treatment-related symptoms.”
“This article presents findings from a large prospective examination of Canadian medical cannabis patients, with a focus on the impacts of cannabis on prescription opioid use and quality of life over a 6-month period. … Baseline opioid use was reported by 28% of participants, dropping to 11% at 6 months. Daily opioid use went from 152 mg morphine milligram equivalent (MME) at baseline to 32.2 mg MME at 6 months, a 78% reduction in mean opioid dosage. … This study provides an individual-level perspective of cannabis substitution for opioids and other prescription drugs, as well as associated improvement in quality of life over 6 months.”
“We conducted an online convenience sample survey of patients from three medical cannabis practice sites who had reported using opioids. … Overall, 40.4% (n=204) reported that they stopped all opioids [and] 45.2% (n=228) reported some decrease in their opioid usage. … The majority (65.3%, n=299) reported that they sustained the opioid change for over a year. … We believe our results lend further support that medical cannabis provided in a standardized protocol can lead to decreased pain and opioid usage, improved function, and quality of life measures, and even complete cessation of opioids in patients with chronic pain treated by opioids.”
“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 implement two-way fixed-effects regressions and leverage variation from eleven U.S. states that adopted a recreational cannabis law (RCL) between 2010 and 2019. We find that RCLs lead to a reduction in codeine dispensed at retail pharmacies. Among prescription opioids, codeine is particularly likely to be used non-medically. Thus, the finding that RCLs appear to reduce codeine dispensing is potentially promising from a public health perspective.”
“We conducted an anonymous, cross-sectional online survey in May 2021 for seven days with adult Canadian federally-authorized medical cannabis patients (N = 2697) registered with two global cannabis companies to evaluate patient perceptions of Primary Care Provider (PCP) knowledge of medical cannabis and communication regarding medical cannabis with PCPs, including PCP authorization of licensure and substitution of cannabis for other medications. … Overall, 47.1% of participants reported substituting cannabis for pharmaceuticals or other substances (e.g., alcohol, tobacco/nicotine).”
“We use quarterly data for all Medicaid prescriptions from 2011 to 2019 to investigate the effect of state-level RCLs [recreational cannabis laws] on prescription drug utilization. We estimate this effect with a series of two-way fixed effects event study models. We find significant reductions in the volume of prescriptions within the drug classes that align with the medical indications for pain, depression, anxiety, sleep, psychosis, and seizures. Our results suggest substitution away from prescription drugs and potential cost savings for state Medicaid programs.”
“Data were collected between October 2014 and October 2020 from patients who were consulting the Canada-wide network of clinics of a medical cannabis provider and who were willing to answer questionnaires based on their medical status. The current study included older adults (≥ 65 years) who completed questionnaires at intake and first follow-up visits. … Data included that from 9766 older adult users at intake (mean ± SD age = 73.2 ± 6.8 years, females = 60.0%), among whom 4673 (females = 61.4%) returned for follow-up after 90.6 ± 58 days. … Doses of concomitant medications were reported to be unchanged by a majority of older adults although 35.6% and 19.9% reported reduced doses of opioids and benzodiazepines, respectively.”
“[W]e sought to capture the medically relevant features of cannabis use in a population of patients with orthopedic pain and pair these data with objective measures of pain and prescription drug use. … Medical cannabis use was associated with clinical improvements in pain, function, and quality of life with reductions in prescription drug use; 73% either ceased or decreased opioid consumption and 31% discontinued benzodiazepines. … This work provides a direct relationship between the initiation of cannabis therapy and objectively fewer opioid and benzodiazepine prescriptions.”
“Patients with chronic pain, licensed to use MC in Israel, reported weekly average pain intensity (primary outcome) and related symptoms before and at 1, 3, 6, 9 and 12 months following MC [medical cannabis] treatment initiation.. … 43% of the patients who had been using analgesic medications prior to MC treatment initiation were no longer using them. This was true for all classes of analgesic drugs including over the counter analgesics, non-steroidal anti-inflammatory drugs, anticonvulsants and antidepressants. As for opioid use, 24% and 20% of the participants who had been using weak or strong opioids, respectively, at baseline stopped using them by the time they reached the 12-month follow-up.”
“One hundred and fifty-seven MMJ patients completed an online survey regarding their characteristics and use. … Sixty-five percent of 157 patients reported either a reduction or total discontinuation of at least one prescription or OTC drug. Forty-one patients (26% of all surveyed) reported reducing intake of at least one drug, 72 patients (46% of all surveyed) reported discontinuing intake of at least one drug, and 11 patients (7%) reported both a reduction and discontinuation of a drug. … This complements other work, which has similarly found a reduction in the use of opioids, nonopioid analgesics, benzodiazepines, and antidepressants among MMJ patients.”
“The use of CaM [cannabis as medicine] as a substitute for prescription drugs is a leading motive among … users … in our sample. Pain medication was the most prevalent prescription drug substituted with CaM, followed by antidepressants and arthritis medication. … Substitution users reported substantial decrease or cessation of prescription drug use, and a greater effect and far better side effect profile of CaM compared to prescription drugs.”
“A pilot RCT of patients with stage IV cancer requiring opioids was conducted. Thirty patients were randomized 1:1 to early cannabis (EC, n = 15) versus delayed start cannabis (DC, n = 15). … A higher proportion of EC patients achieved a reduction in opioid use and improved pain control. No serious safety issues were reported, and patients reported high satisfaction. … The addition of MC to standard oncology care was well-tolerated and may lead to improved pain control and lower opioid requirements.”
“In this study, we investigated CNCP [chronic non-cancer pain] parameters in patients during prolonged MC [medical cannabis] treatment. … 429, 150, 98, 71, 77 and 82 patients reported fully on their MC treatment regimens at six one-month intervals, respectively. … Analgesic medication consumption rates decreased from 46 to 28% and good Quality of Life (QoL) rates increased from 49 to 62%. … These results may shed light on the long-term beneficial effects of MC on CNCP.”
“We recruited survey participants from seven pain management clinics in Southern California to learn about their knowledge, beliefs, and personal experience with CBD products. … A total of 253 participants answered the survey. … Among participants, 62.0% reported trying a CBD product [including products containing delta-9-tetrahydrocannabinol (THC)]. The majority responded that these products have helped their pain (59.0%) and allowed them to reduce their pain medications (67.6%), including opioids (53.7%). … Taken together, participants report some perceived beneficial effects using CBM [cannabis-based medicines] and CBD products including the reduction of pain medication.”
“In a secondary analysis from a cross-sectional survey, we examined substitution patterns among n = 878 individuals with fibromyalgia who currently used CBD. … The majority (n = 632, 72.0%) reported substituting CBD products for medications, most commonly NSAIDs (59.0%), opioids (53.3%), gabapentanoids (35.0%), and benzodiazepines (23.1%). Most substituting participants reported decreasing or stopping use of these pain medications. … Those who substituted reported larger improvements in health and pain than those who did not.”
“Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2009 and 2015, we studied the effects of medical and recreational marijuana laws on opioid prescribing in employer‐sponsored health insurance. We used a differences‐in‐differences (DD) approach and found that the implementation of medical marijuana laws (MMLs) and rec- reational marijuana laws (RMLs) reduced morphine milligram equivalents per enrollee by 7% and 13%, respectively. The reduction associated with MMLs was predominately in people aged 55–64, whereas the reduction associated with RMLs was largely in people aged 35–44 and aged 45–54. Our ndings suggest that both MMLs and RMLs have the potential to reduce opioid pre- scribing in the privately insured population, especially for the middle‐aged population.”
“A validated patient survey was distributed via Florida medical marijuana social media groups to examine the therapeutic benefits of the cannabis plant for medical conditions and overall well-being. Concurrently, qualitative interviews were conducted to understand barriers and facilitators to accessing medical cannabis and explore preferences for different forms and strains, as well as any unexpected side effects. … Participants shared many details on the substitution of prescription medicines for medical cannabis. Participants reported that they ceased using several prescription drugs for pain, anxiety, and mental problems.”
“From September 2018 to April 2019, we conducted in-depth interviews with 25 people living with HIV who use drugs in Vancouver, Canada to examine experiences using cannabis to manage pain. … Most participants reported that using cannabis for pain management helped improve daily functioning. Some participants turned to cannabis as a supplement or periodic alternative to prescription and illicit drugs (e.g. benzodiazepines, opioids) used to manage pain and related symptoms. … Cannabis use may lead to reduced use of prescription and illicit drugs for pain management among some people living with HIV who use drugs. Our findings add to growing calls for additional research on the role of cannabis in pain management and harm reduction, and suggest the need for concrete efforts to ensure equitable access to cannabis.”
“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 retrospective analysis of MM [low THC/high CBD medical marijuana] treatment forms covering the initial implementation phase of Florida’s MM program provides characteristics and prescription drug utilization information on early registrants who sought treatment with medical cannabis. … Though follow-up information was only available for a fraction of patients, follow-up was mostly characterized by clinical improvements and reported reductions in some prescription medication classes. … In particular, reductions or complete cessation of opioid medications were reported as well as reductions of anxiolytics/benzodiazepines and hypnotics/sedatives.”
“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
“This Phase II study evaluated analgesia, abuse liability, and cognitive performance of hydromorphone and oral delta-9-tetrahydrocannabinol (THC; dronabinol) using a within-subject, double-blind, randomized, placebo-controlled, human laboratory trial. … Analgesia only improved in the hydromorphone + dronabinol 2.5 mg condition. … These data suggest that dronabinol may enhance the analgesic effects of a low dose of hydromorphone, indicative of possible opioid-sparing effects, but that this effect only occurs within a narrow dose range beyond which hyperalgesia, increased risk for AEs [adverse events], and abuse liability are more likely to occur.”
“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.”
“The current study collected narrative information about use of marijuana for medical purposes from medical marijuana card holders in Rhode Island. … Of the 25 participants in this investigation, … 7 participants reported that they were able to cut back on their medications, and 12 reported that they were able to completely stop taking other prescription medications once they started using marijuana for medical purposes.”
“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. … All available daily milligram morphine equivalents (MMEs) and daily diazepam equivalents (DEs) were calculated at baseline and at 3 and 6 months. … Over the course of this 6-month retrospective study, patients using medical cannabis for intractable pain may have expe- rienced a significant reduction in the average MME available for pain control. A non–statistically significant difference in average benzodiazepine dose was observed. The results of this study add to the currently mixed body of evidence suggesting that medical cannabis may be effective for treating pain.”
“A retrospective chart review of 77 patients diagnosed with multiple sclerosis participating in treatment with medical cannabis for symptom management was conducted. … Subjective improvement endorsed by patients was extensive, with alleviation of symptomatology seen most in pain (71%), spasticity (43%), and sleep (42%). In addition, 34% of patients were able to decrease and discontinue other medications including opioids, stimulants, and benzodiazepines, indicative of symptom improvement.”
“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. … 1,321 participants completed the survey. Consistent with other observational studies, ~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.”
“[T]he purpose of this study was to examine the prevalence of cannabis for medicinal purposes (CMP) use for anxiety symptoms. … Overall, 2032 completed responses with a verified user number were collected. Of the total sample, 888 (43.7%) reported CMP authorization to treat anxiety symptoms and completed all psychometric screening instruments. … Nearly half (49%) reported replacing a non-psychiatric (53.7%) or psychiatric medication (46.3%) prescribed to them by their physician with CMP.”
“A 239-question cross-sectional survey was sent out via email in January 2017 to gather comprehensive information on cannabis use from Canadian medical cannabis patients registered with a federally authorized licensed cannabis producer, resulting in 2032 complete surveys. … The most commonly cited substitution was for prescription drugs (69.1%; n = 953), followed by alcohol (44.5%; n = 515), tobacco (31.1%; n = 406), and illicit substances (26.6%; n = 136). … Of the 610 mentions of opioid medications, participants self-reported they stopped using 59.3% completely (100% substitution) (n = 362), and a further 18.4% reduced their use by 75% (n = 112). … Of the 515 respondents who substituted cannabis for alcohol, 30.9% suggested they stopped using it completely (100%) (n = 159), and 36.7% reported reducing by at least 75% (n = 189). … Of the 406 participants who substituted cannabis for tobacco, 50.7% say they stopped using it completely (100% substitution) (n = 206), and 13.8% reported reducing their use by 75% (n = 56).”
“A retrospective analysis was performed on a cohort of 146 medical cannabis patients (average age 47 years, 61% female, 54% reporting prior use of cannabis) 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. At a follow-up after two prescriptions, 65 total patients (44.5%) had discontinued benzodiazepines. At the final follow-up period after three medical cannabis prescription courses, 66 total patients (45.2%) had discontinued benzodiazepine use, showing a stable cessation rate over an average of 6 months. … Patients initiated on medical cannabis therapy showed significant benzodiazepine discontinuation rates after their first follow-up visit to their medical cannabis prescriber, and continued to show significant discontinuation rates thereafter.”
“The research team administered brief hard copy surveys to 450 adults attending an annual public event advocating for cannabis law reform. … Medical cannabis users reported a greater degree of use of medical cannabis and a greater degree of trust in medical cannabis compared to mainstream healthcare. In comparison to pharmaceutical drugs, medical cannabis users rated cannabis better on effectiveness, side effects, safety, addictiveness, availability, and cost. Due to the medical use of cannabis, 42% stopped taking a pharmaceutical drug and 38% used less of a pharmaceutical drug.”
“The aim of this study is to characterize the epidemiology of cancer patients receiving medical cannabis treatment and describe the safety and efficacy of this therapy. … We analyzed the data routinely collected as part of the treatment program of 2970 cancer patients treated with medical cannabis between 2015 and 2017. … A total of 1013 patients responded to the medication chapter before and during treatment. At intake these patients took together 3982 regularly used drugs (medications they take regularly). 35.1% reported a decreased in their drugs consumption, mainly in the following families: other analgesics and antipyretics, hypnotics and sedatives, corticosteroids and opioids. Opioids, for example, was the most prevalent drug consumed by 344 patients (33.9%) at intake, 36% of them stopped taking opioids [and] 9.9% decreased [their] dose.”
“31 patients were involved in an observational cross-over study. The patients were screened, treated with 3 months of Standardized Analgesic Therapy (SAT): 5 mg of oxycodone hydrochloride equivalent to 4.5 mg oxycodone and 2.5 mg naloxone hydrochloride twice a day and duloxetine 30 mg once a day. Following 3 months of these therapies, the patients could opt for MCT (medical cannabis therapy) and were treated for a minimum of 6 months. … The majority of patients elected during MCT to decrease or discontinue pharmaceutical analgesic consumption.”
“We explored patterns of use of cigarette, alcohol, and illicit drugs in HIV-infected people with chronic pain who were prescribed opioid analgesics. … In multivariate analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use. Our data suggest that new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could help to address adverse events associated with opioid analgesic use.”
“[O]ur results indicate that MC (medical cannabis) may be used intentionally to taper off prescription medications. These findings align with previous research that has reported substitution or alternative use of cannabis for prescription pain medications dues to concerns regarding addiction and better side-effect and symptom management, as well as complementary use to help manage side-effects of prescription medication.”
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.”
“[F]indings on cannabis substitution effect and the biological mechanisms behind it strongly suggest that cannabis could play a role in reducing the public health impacts of prescription and non-prescription opioids. … The growing body of research supporting the medical use of cannabis as an adjunct or substitute for opioids creates an evidence-based rationale for governments, health care providers, and academic researchers to consider the implementation and assessment of cannabis-based interventions in the opioid crisis.”
An estimated two out of three medical marijuana patients substitute cannabis in place of opioids, according 2017 survey data compiled by Aclara Research, a Chicago-based consulting firm. Specifically, 67 percent of respondents reported that they ceased their use of opioids after initiating cannabis therapy. Twenty-nine percent of respondents said that they reduced their use of opioids.
“The largest survey on cannabidiol or CBD usage to date found that women were more likely than men to use CBD and once they started using it, were likely to drop their traditional medicine. … Forty-two percent of the CBD users said they had stopped using traditional medications like Tylenol pain relievers or prescription drugs like Vicodin and had switched to using cannabis instead.”
“Ninety-seven percent of the sample ‘strongly agreed/agreed’ that they are able to decrease the amount of opioids they consume when they also use cannabis. … In addition, 80% of patients reported that cannabis by itself was more effective than their opioids. … Supporting the results of previous research, this study can conclude that medical cannabis patients report successfully using cannabis along with or as a substitute for opioid-based pain medication.”
“Among respondents that regularly used opioids, over three-quarters (76.7%) indicated that they reduced their use since they started medical cannabis. This was significantly ( p < 0.0001) greater than the patients that reduced their use of antidepressants (37.6%) or alcohol (42.0%). Approximately two-thirds of patients decreased their use of anti-anxiety (71.8%), migraine (66.7%), and sleep (65.2%) medications following medical cannabis.”
“Findings include high self-reported use of cannabis as a substitute for prescription drugs (63%), particularly pharmaceutical opioids (30%), benzodiazepines (16%), and antidepressants (12%). Patients also reported substituting cannabis for alcohol (25%), cigarettes/tobacco (12%), and illicit drugs (3%).”
“These patient-reported outcomes support prior research that individuals are using cannabis as a substitute for prescription drugs, particularly, narcotics/opioids, and independent of whether they identify themselves as medical or non-medical users. This is especially true if they suffer from pain, anxiety and depression.”
“Substituting cannabis for one or more of alcohol, illicit drugs or prescription drugs was reported by 87% of respondents, with 80.3% reporting substitution for prescription drugs, 51.7% for alcohol, and 32.6% for illicit substances. … The finding that cannabis was substituted for all three classes of substances suggests that the medical use of cannabis may play a harm reduction role in the context of use of these substances, and may have implications for abstinence-based substance use treatment approaches.”
“Participants were 367 patients recruited from four medical cannabis dispensaries located throughout Arizona. … Patients reported using medical cannabis to treat a variety of conditions. … [P]atients reported using other medications less frequently when using cannabis. This is consistent with findings from other studies.”
Chronic pain patients are less likely to abuse medicinal cannabis as compared to opioids
“Generally, rates of problematic use of MC (medicinal cannabis) among MC users seem lower than rates of problematic use of opioids among those prescribed opioids,”
Chronic pain patients are less likely to become depressed using medical cannabis
“Prevalence of depression among patients in the OP (opioids), MM (medical marijuana) and OPMM groups was 57.1%, 22.3% and 51.4%, respectively and rates of anxiety were 48.4%, 21.5% and 38.7%, respectively. … Levels of depression and anxiety are higher among chronic pain patients receiving prescription opioids compared to those receiving MM. Findings should be taken into consideration when deciding on the most appropriate treatment modality for chronic pain, particularly among those at risk for depression and anxiety.”
Cannabis use is associated with greater rates of opioid use treatment retention and may mitigate opioid-related cravings
“CBD has a good safety profile, is well tolerated with opioid agonists, and reduces key withdrawal symptoms. … Easing withdrawal symptoms with CBD could improve clinical outcomes by keeping patients engaged in treatment, facilitating smoother transition to MOUD [medications for opioid use disorder] like buprenorphine or extended-release naltrexone, and helping with tapering of opioid agonist treatment or opioid analgesics.”
“A growing body of research has reported on the potential opioid-sparing effects of cannabis and cannabinoids, but less is known about specific mechanisms. The present research examines cannabis-related posts in two large online communities on the Reddit platform (“subreddits”) to compare mentions of naturalistic cannabis use by persons self-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (e.g., “weed”, “cannabis”, “marijuana”) from December 2015 through August 2019 from an opioid use subreddit and an opioid recovery subreddit. … The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a ‘treatment.’ … The most common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-anxiety and GI-distress “comfort meds.” … Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis use in relation to opioid use identified withdrawal symptom management as a common motivation.”
“Participants receiving pharmacological treatment for OUD (n = 2315) were recruited from community-based addiction treatment clinics in Ontario, Canada, and provided information on past-month cannabis use (self-report). Participants were followed for 3 months with routine urine drug screens in order to assess opioid use during treatment. We used logistic regression analysis to explore (1) the association between any cannabis use and opioid use during treatment, and (2) amongst cannabis-users, specific cannabis use characteristics associated with opioid use. … We found that amongst cannabis users, those who use cannabis daily are less likely to have opioid use than people who use cannabis occasionally. This association was present for both men and women. … Future studies should further examine specific characteristics and patterns of cannabis use that may be protective or problematic in MAT [medication-assisted treatment].”
“[W]e found that among more than 800 participants on OAT [opioid agonist therapy, e.g., methadone and/or naltrexone ) in Vancouver, Canada, use of cannabis was longitudinally associated with a substantially lower risk of being exposed to fentanyl. Given the magnitude of the overdose crisis in the U.S. and Canada and the substantial contributions of fentanyl to the burden of overdose morbidity and mortality, findings from this study support the experimental evaluation of cannabinoids as a potential adjunct therapy to OAT to improve clinical outcomes, particularly to reduce the risk of relapse to illicit opioid use (i.e., fentanyl) and associated risk of overdose and death.”
“Two hundred individuals recruited through Amazon Mechanical Turk with past month opioid and cannabis use and experience of opioid withdrawal completed the survey. Participants indicated which opioid withdrawal symptoms improved or worsened with cannabis use and indicated the severity of their opioid withdrawal on days with and without cannabis. … 62.5% of 200 participants had used cannabis to treat withdrawal. Participants most frequently indicated that cannabis improved: anxiety, tremors, and trouble sleeping. … These results show that cannabis may improve opioid withdrawal symptoms and that the size of the effect is clinically meaningful.”
“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.”
