The Association of Cannabis Specialists would like to offer the following comments on the topic of acute and chronic pain management, per the CDC’s request.

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It remains unclear why Americans experience either more pain or more intolerable pain than people from other developed nations (1). However, it is clear that demand for pain treatment is high in Americans and that Americans consume 80% of the world supply of prescription opioids despite representing only 20% of the world population (1). 

As we are acknowledging more recently, opioid pain relievers are plagued by two problems: they aren’t very efficacious, and they present significant risk of dependence, addiction, or death.

It must also be acknowledged that there aren’t many, or many good, alternatives. Acetaminophen and NSAIDs can be effective for many patients and many conditions, but are ineffective or contraindicated for some.

There are some newer agents that may be helpful for specific conditions, like Gabapentinoids, that remain less proven, and are unhelpful to many. Meditation, or other mind-body exercises, have been shown to reduce pain perception but require significant participation by the patient, and some patients cannot achieve results.

Hence, for pharmacological interventions across a wide range of indications, our options are quite limited.

Cannabis presents an effective and safe addition to our armamentarium. Across a wide range of conditions, including neuropathic, mechanical, and inflammatory pain, cannabis has been shown to be effective (2).

The risk associated with use of cannabis for medical purposes in adults is quite small, with risk of dependence as low as 2-3%, and cognitive benefit, not decrement, in patients (3,4,5). Furthermore, much of the work done to date to assess risk has been done with recreational users, not patients, who use significantly more cannabis than is necessary for therapeutic benefit.

Cannabis can be used as an effective adjunct to opioid treatment. It will augment the analgesic effects of opioids without magnifying the risk of dependence or death. In fact, series looking at cannabis used alongside opioids have shown between 40-80% decrements to the needed dose of opioid (6-10). Since risk from opioids is linear with dose, the use of cannabis adjunctively can significantly mitigate that risk.

The Association of Cannabis Specialists represents cannabis specialists who have treated, collectively, hundreds of thousands of patients globally. It is clear to us that no modern discussion of pain management and opioid prescribing can be had without incorporating cannabis or cannabinoid treatment.

We applaud the CDC’s call for expertise in treating pain, and hope that they will not overlook this proven, safe, and effective medication in this discussion. We welcome any questions or discussion of this topic in greater detail.

1. www.cnbc.com/2016/04/27/americans-consume-almost-all-of-the-global-opioid-supply.html
2. Practice, H., Division, M., & Academies, N. (2017). The Health Effects of Cannabis and Cannabinoids. https://doi.org/10.17226/24625
3. Robson, P. (2011). Abuse potential and psychoactive effects of δ-9-tetrahydrocannabinol and cannabidiol oromucosal spray (Sativex), a new cannabinoid medicine. Expert Opinion on Drug Safety, 10(5), 675–685. https://doi.org/10.1517/14740338.2011.575778
4. Lopez-Quintero, C., Pérez de los Cobos, J., Hasin, D. S., Okuda, M., Wang, S., Grant, B. F., & Blanco, C. (2011). Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence, 115(1–2), 120–130. https://doi.org/10.1016/j.drugalcdep.2010.11.004
5. Gruber, S. A., Sagar, K. A., Dahlgren, M. K., Gonenc, A., Smith, R. T., Lambros, A. M., … Lukas, S. E. (2018). The Grass Might Be Greener: Medical Marijuana Patients Exhibit Altered Brain Activity and Improved Executive Function after 3 Months of Treatment. Frontiers in Pharmacology, 8, 983. https://doi.org/10.3389/fphar.2017.00983
6. Vigil, J. M., Stith, S. S., Adams, I. M., & Reeve, A. P. (2017). Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLOS ONE, 12(11), e0187795. https://doi.org/10.1371/journal.pone.0187795
7. Degenhardt, L., Lintzeris, N., Campbell, G., Bruno, R., Cohen, M., Farrell, M., & Hall, W. D. (2015). Experience of adjunctive cannabis use for chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study. Drug and Alcohol Dependence, 147, 144–150. https://doi.org/10.1016/j.drugalcdep.2014.11.031
8. Carter, G. T., Flanagan, A. M., Earleywine, M., Abrams, D. I., Aggarwal, S. K., & Grinspoon, L. (2011). Cannabis in Palliative Medicine: Improving Care and Reducing Opioid-Related Morbidity. American Journal of Hospice and Palliative Medicine, 28(5), 297–303. https://doi.org/10.1177/1049909111402318
9. Rod, K. (2019). A Pilot Study of a Medical Cannabis - Opioid Reduction Program, 7(3), 74–77. https://doi.org/10.11648/j.ajpn.20190703.14
10. Bulbul, A., Mino, E. A., Khorsand-Sahbaie, M., & Lentkowski, L. (2018). Opioid dose reduction and pain control with medical cannabis. Journal of Clinical Oncology, 36(34_suppl), 189–189. https://doi.org/10.1200/JCO.2018.36.34_suppl.189