If You’re Prescribing Opioids, Why?

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Don’t get me wrong. I am not part of the anti-opioid crowd. My only interest is in patient well-being which, of course, led me to practice cannabinoid medicine. I firmly believe that there are patients who need opioid medication. So the question really isn’t why are you prescribing opioids, but rather why aren’t you prescribing cannabinoids first.

Pain and Opioids

We all know that pain is, well, a big pain. It is the number one chronic complaint to American primary care1, and we really have a very limited range of medications with which to treat pain. Once your patient has tried acetaminophen and/or NSAIDs (or cannot take either of them for myriad reasons), what’s left?

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There’s always mindfulness and CBT, neither of which should be discounted, and some patients will get relief from Gabapentinoids, but these approaches are unpredictable and aren’t particularly successful in general. Quickly we can see how opioids come to the fore. 

Consequences of Opioid Use

Sadly, we’ve become very aware of the consequences of opioid use. Common rhetoric would suggest that everyone who uses opioids will become addicted. In reality, the incidence of opioid dependence is approximately 25% (meaning that 3 out of 4 opioid users will not develop dependence)2. Nonetheless, 25% is a significant number and the fatality rate for prescribed opioids is shocking as well.

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“In 2021, 45 people died each day from prescription opioid overdose, totaling nearly 17,000 deaths. Prescription opioids were involved in nearly 21% of all opioid overdose deaths in 2021.”3 We’re not used to considering our medical interventions as having such a death toll. 

But, we can’t stop trying to treat chronic pain. In the United States alone, there are over 51 million chronic pain sufferers (20.9%)4, for many of whom opioids are their sole source of  relief. Since the Opioid Crisis was recognized, many of these patients have been taken off opioid regimens that have been stable and effective for years or even decades and given little or nothing to replace the opioids. This is not good medicine!

Opioids versus Cannabinoids

Enter cannabinoids. In the scheme of things, cannabinoids are approximately equivalent in efficacy to opioids for mild to moderate pain5-6. Opioids clearly are more effective for severe pain. Further, cannabinoids work by dissociative methods – meaning that they divorce the perception of pain from the emotional response to the pain.

In other words, they do not usually take the pain away as you’d expect Ibuprofen to do with a headache, but they diminish the suffering the patient feels due to the painful stimulus. As such, they do not work for every patient, but what medication does?

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On the other hand, cannabinoids are much safer than opioids. Cannabinoids cannot cause respiratory depression or death. The dependence rate is 7-9% among recreational users, presumably significantly lower than that among patients being actively guided by their physicians2.

Cannabinoids have side effects like all medications. Intoxication is the primary side effect; dry mouth, and lightheadedness are common as well. Like any other medication, it is our job as clinicians to guide our patients’ use in such a way as to minimize these side effects while achieving maximal benefit. Focus on dose, route of administration, and timing – again, like for any other medication, leads to best outcomes. 

Using Cannabinoids Before Reaching for Opioids

Inserting cannabinoids into our hierarchy of pain treatment medications before we reach for opioids expands our palette of medication options significantly. In such cases, we may find that patients do not need any opioids at all. If they do need opioids in addition to cannabinoids, we see their need is dramatically less than if they were prescribed opioids alone7. Any reduction of opioid dose has been shown to decrease risk.

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Further, for patients who are already on opioids for pain, introduction of cannabinoids, particularly if the patient is instructed to take the cannabinoids routinely and use the opioids only for rescue, can dramatically reduce their overall intake of opioids between 40- 80%8-9. Again, any reduction of overall opioid dose is a win.

Lack of Cannabinoid Knowledge Among Physicians

The largest impediment to physicians prescribing cannabinoids for pain seems to be lack  of familiarity and comfort with cannabinoid medication. This is quite understandable as there are no courses on this in medical school (yet), few credible CME courses, and even less time available for practitioners to delve into the science on their own. 

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To make matters worse, despite using the word “prescribe” throughout this article, in fact we don’t prescribe cannabinoids under the current medical cannabis systems. Instead, we “recommend” it, which is really conceptualized as just giving permission – and then the patient is at the mercy of their friends and the industry to sort out what to buy and how to use it. This system, of course, does not help us meet our obligation for Informed Consent, leaving clinicians even more wary of cannabinoid medicines for their patients. 

The Goal of Association of Cannabinoid Specialists

This is why I founded the Association of Cannabinoid Specialists. The goal is to educate clinicians (and lawmakers) using the best human clinical evidence. We provide a range of tools from brief overview videos and helpful-in-the-moment handbooks of therapeutics to collections of seminal studies in our Clinical Reference Library. We also provide access to a peer-reviewed journal Cannabis and Cannabinoid Research, CME courses of both comprehensive and deeper-dive scope, and my favorite, monthly networking events to discuss cases, review studies, and meet our peers. 

You don’t have to be a full-time Cannabinoid Specialist to benefit from and enjoy being an ACS member or participating in our coursework. Stick your toe in the water, learn about how to apply these medications for the benefit of your patients, and you’ll have safer, happier patients without prescribing all those opioids. 

 


References:

  1. Finley CR, Chan DS, Garrison S, Korownyk C, Kolber MR, Campbell S, Eurich DT, Lindblad AJ, Vandermeer B, Allan GM. What are the most common conditions in primary care? Systematic review. Can Fam Physician. 2018 Nov;64(11):832-840.  PMID: 30429181; PMCID: PMC6234945. https://pubmed.ncbi.nlm.nih.gov/30429181/
  2. Robson, P. (2011). Abuse potential and psychoactive e]ects 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
  3. Center for Disease Control. Opioid Overdose. Website: https://www.cdc.gov/drugoverdose/deaths/opioid-overdose.html
  4. Rikard SM, Strahan AE, Schmit KM, Guy GP Jr.. Chronic Pain Among Adults — United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72:379–385. DOI: http://dx.doi.org/10.15585/mmwr.mm7215a1
  5. Jylkkä, J., Hupli, A., Nikolaeva, A., Alanen, S., Back, A. E., Lindqvist, S., … Kantonen, O. (2023). The holistic e]ects of medical cannabis compared to opioids on pain experience in Finnish patients with chronic pain. Journal of Cannabis Research,  5(1), 38. https://doi.org/10.1186/s42238-023-00207-7
  6. Hameed, M., Prasad, S., Jain, E., Dogrul, B. N., Al-Oleimat, A., Pokhrel, B., … Stein, J. (2023). Medical Cannabis for Chronic Nonmalignant Pain Management. Current Pain and Headache Reports, 1–7. https://doi.org/10.1007/s11916-023-01101-w
  7. Okusanya, B. O., Asaolu, I. O., Ehiri, J. E., Kimaru, L. J., Okechukwu, A., & Rosales, C. (2020). Medical cannabis for the reduction of opioid dosage in the treatment of non cancer chronic pain: a systematic review. Systematic Reviews, 9(1), 167. https://doi.org/10.1186/s13643-020-01425-3
  8. 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
  9. Powell, D., Pacula, R. L., & Jacobson, M. (2018). Do medical marijuana laws reduce addictions and deaths related to pain killers? Journal of Health Economics, 58, 29– 42. https://doi.org/10.1016/j.jhealeco.2017.12.007