The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage

Kevin Takakuwa

Jeffrey Hergenrather

Frances Shofer

Raquel Schears

^{Society of Cannabis Clinicians, Sebastopol, California.}

^{Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.}

^{Department of Emergency Medicine, University of Central Florida, Orlando, Florida.}

^{Address correspondence to: Kevin M. Takakuwa, MD, Society of Cannabis Clinicians, PO Box 27574, San Francisco, CA 94127}moc.oohay@awukakatmk

Abstract

Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users.

Design: Retrospective cohort study.

Setting: A single-center cannabis medical practice site in California.

Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed.

Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain.

Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents.

Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75–11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels.

Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.

Keywords: medical cannabis, marijuana, prescription opioid use, opiate abuse, low back pain, chronic pain

Abstract

Abbreviations Used

ICD-10	International Classification of Diseases, 10th Revision
IQR	interquartile range
ME	morphine equivalents
SD	standard deviation

Abbreviations Used

References

1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044 NSDUH Series H-52). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration: Rockville MD, 2017. Accessed February25, 2018[PubMed]
2. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G Drug and opioid-involved overdose deaths - United States, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67:1419–1427 [Google Scholar]
3. Bachhuber MA, Saloner B, Cunningham CO, et al. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999–2010. JAMA Intern Med. 2014;174:1668–1673 [Google Scholar]
4. Powell D, Pacula RL, Jacobson M Do medical marijuana laws reduce addictions and deaths related to pain killers? RAND Corporation. J Health Econ. 2018;58:29–42 [[PubMed][Google Scholar]
5. Russo EB. History of cannabis and its preparations in saga, science and sobriquet. Chem Biodivers. 2007;4:2624–2648 [[PubMed]
6. National Academies of Sciences, Engineering, and Medicine. The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. The National Academies Press: Washington, DC, 2017 [PubMed]
7. Aggarwal SK. Cannabinergic pain medicine: a concise clinical primer and survey of randomized-controlled trial results. Clin J Pain. 2013;29:162–171 [[PubMed]
8. Haroutounian S, Ratz Y, Ginosar Y, et al. The effect of medicinal cannabis on pain and quality-of-life outcomes in chronic pain: a prospective open-label study. Clin J Pain. 2016;32:1036–1043 [[PubMed][Google Scholar]
9. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta-analysis. JAMA. 2018;320:2448–2460 [Google Scholar]
10. Russo EB, Hohmann AG Role of cannabinoids in pain management. In Deer TR, et al. (eds.), Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches. American Academy of Pain Medicine. Springer: New York, 2013, p. 181 [PubMed]
11. Scavone JL, Sterling RC, Van Bockstaele EJ Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal. Neuroscience. 2013;248:637–654 [Google Scholar]
12. Roberts JD, Gennings C, Shih M Synergistic affective analgesic interaction between delta-9-tetrahydrocannabinol and morphine. Eur J Pharmacol. 2006;530:54–58 [[PubMed][Google Scholar]
13. Lynch ME, Clark AJ Cannabis reduces opioid dose in the treatment of chronic non-cancer pain. J Pain Symptom Manage. 2003;25:496–498 [[PubMed][Google Scholar]
14. Abrams DI, Couey P, Shade SB, et al. Cannabinoid-opioid interaction in chronic pain. Clin Pharmacol Ther. 2011;90:844–851 [[PubMed][Google Scholar]
15. Kral AH, Wenger L, Novak SP, et al. Is cannabis use associated with less opioid use among people who inject drugs?Drug Alcohol Depend. 2015;153:236–241 [Google Scholar]
16. Boehnke KF, Litinas E, Clauw DJ Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain. 2016;17:739–744 [[PubMed][Google Scholar]
17. Gruber SA, Sagar KA, Dahlgren MK, et al. Splendor in the grass? A pilot study assessing the impact of medical marijuana on executive function. Front Pharmacol. 2016;7:355. [Google Scholar]
18. Reiman A, Welty M, Solomon P Cannabis as a substitute for opioid-based pain medication: patient self-report. Cannabis Cannabinoid Res. 2017;2:160–166 [Google Scholar]
19. Nielsen S, Sabioni P, Trigo JM, et al. Opioid-sparing effect of cannabinoids: a systematic review and meta-analysis. Neuropsychopharmacology. 2017;42:1752–1765 [Google Scholar]
20. Bellnier T, Brown GW, Ortega TR Preliminary evaluation of the efficacy, safety, and costs associated with the treatment of chronic pain with medical cannabis. Ment Health Clin. 2018;8:110–115 [Google Scholar]
21. Cooper ZD, Bedi G, Ramesh D, et al. Impact of co-administration of oxycodone and smoked cannabis on analgesia and abuse liability. Neuropsychopharmacology. 2018;43:2046–2055 [Google Scholar]
22. Corroon JM Jr, Mischley LK, Sexton M Cannabis as a substitute for prescription drugs—a cross-sectional study. J Pain Res. 2017;10:989–998 [Google Scholar]
23. Lucas P, Walsh Z Medical cannabis access, use, and substitution for prescription opioids and other substances: a survey of authorized medical cannabis patients. Int J Drug Policy 2017;42:30–35 [[PubMed][Google Scholar]
24. NHISSummary Health Statistics: National Health Interview Survey, 2016. Accessed February25, 2018[PubMed]
25. National Ambulatory Medical Care Survey2014 State and National Summary Tables. Accessed February25, 2018[PubMed]
26. Ivanova JI, Birnbaum HG, Schiller M, et al. Real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guideline-concordant care. Spine J. 2011;11:622–632 [[PubMed][Google Scholar]
27. Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319:872–882 [Google Scholar]
28. State of California Health and Safety Code, Section 11362.5. Accessed January26, 2019[PubMed]
29. Nielsen S, Degenhardt L, Hoban B, et al. A synthesis of oral morphine equivalents (OME) for opioid utilisation studies. Pharmacoepidemiol Drug Saf. 2016;25:733–737 [[PubMed][Google Scholar]
30. Ridgeway G, Kilmer B Bayesian inference for the distribution of grams of marijuana in a joint. Drug Alcohol Depend. 2016;165:175–180 [[PubMed][Google Scholar]
31. Campbell G, Hall WD, Peacock A, et al. Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study. Lancet Public Health. 2018;3:e341–e350 [Google Scholar]
32. Karst M, Wippermann S, Ahrens J Role of cannabinoids in the treatment of pain and (painful) spasticity. Drugs. 2010;70:2409–2438 [[PubMed][Google Scholar]