Cannabis Use Motivations among Adults Prescribed Opioids for Pain versus Opioid Addiction
Selena N. Clem, Teresa L. Bigand, Marian Wilson
Pain Management Nursing, 2019, 1-5.
Doi : 10.1016/j.pmn.2019.06.009
a b s t r a c t
Background : Cannabis has been linked to reduced opioid use, although reasons for cannabis use among adults prescribed opioids are unclear.
Aims : The purpose of this study was to determine whether motivations for cannabis use differ between adults prescribed opioids for persistent pain versus those receiving opioids as medication-assisted treatment for opioid use disorder.
Design : A cross-sectional survey design was used.
Participants : Adults prescribed opioids for persistent pain (n ¼ 104) or opioid use disorder (n ¼ 139) were recruited from outpatient settings.
Methods : Data were collected on surveys asking about cannabis use and compared the two populations. A series of regression models examined population characteristics and cannabis use motivations using validated measures of the Marijuana Motives Measure scale.
Results : More than half the sample (n ¼ 122) reported current, daily cannabis use and 63% reported pain as a motivation for use. Adults with persistent pain were more likely to be older, female, and have higher levels of education (p < .05). Adults with opioid use disorder were more likely to report “enhancement” (p < .01) and relief of drug withdrawal symptoms (p < .001) as motivations for cannabis use. The most common reasons for cannabis use in both populations were social and recreational use and pain relief.
Conclusions : Both studied populations have unmet health needs motivating them to use cannabis and
commonly use cannabis for pain. Persistent pain participants were less likely to use cannabis for euphoric effects or withdrawal purposes. Nurses should assess for cannabis use, provide education on known risks and benefits, and offer options for holistic symptom management.
In the last few decades, the public perception in the United States of cannabis use has become more accepting. As of 2019, cannabis has been legalized for both recreational and medical use in 10 states and exclusively medical use in 33 states. Cannabis research shows potential for many medical uses, including the improvement of symptom management for people with persistent pain (Boenke, Litinas, & Clauw, 2016). Persistent, or chronic, pain (PP) is a prevalent medical condition, differing from acute pain in that it persists for longer than 3 months or the otherwise expected period of healing. Currently one of the most common prescription treatments for PP is opioids, a class of drugs that act on receptors in the central nervous system to reduce the perception of pain.
Although effective for treating pain, opioids can have negative side effects, including nausea, vomiting, constipation, excessive sedation, clouded sensorium, and dizziness (Stephan & Parsa, 2016). People with PP can develop tolerance to opioids over time and may need to increase their dosage to maintain therapeutic effects. Opioids can also be an addictive substance. Long-term use of opioids can lead to misuse and possibly fatal overdose. Current statistics support that in the United States roughly 21%-29% of adults prescribed opioids for pain are misusing them, defined as using an opioid medication in a way other than how it was prescribed (Bachhuber, Saloner, Cunningham, & Barry, 2014). Furthermore, approximately 130 people per day die from opioid overdose, which is a 13% increase from the previous year alone (National Institute on Drug Abuse, 2019). Using cannabis as an adjunct treatment for PP may help reduce overall opioid use and risk for these negative associated outcomes.
Evidence suggests that with the concurrent use of cannabis and opioids, individuals with PP report significant decreases in medication side effects, decreases in total number of medications being taken (including 64% lower opioid use), and better quality of life (Boehnke, Litinas, & Clauw, 2016). Similar studies indicate that medicinal cannabis results in improved pain and functional outcomes along with a significant reduction in opioid use of 44% (Haroutounian et al., 2016). Along with reduced mortality related to overdose, research indicates that states that provide legal access to marijuana through dispensaries experience lower treatment admissions for addiction to pain medications (Powell, Pacula, & Jacobson, 2018). The added pain relief effects of cannabis for patients already receiving opioid analgesics may play a role in decreasing opioid dose, thus potentiating a decrease in their risk for opioid-related overdose and other negative outcomes. Additionally, PP can be accompanied by other health problems such as fatigue, sleep disturbance, decreased appetite, and mood changes (Bigand, Anderson, Roberts, Shaw, & Wilson, 2019). Therefore, adults with PP may being using cannabis in an effort to combat a myriad of unpleasant symptoms.
Examining motivations for cannabis use among adults using prescription opioids can help nurses and pain clinicians understand why cannabis is desirable and potentially identify unmet health needs. For instance, if symptom management is a motivation for cannabis use among people with PP, and if it is found to be effective, then there may be indication to include cannabis in treatment regimens or to suggest comparable alternatives. Individuals have also reported using cannabis for recreational purposes such as the desire to seek a new experience or the pursuit of being high and feeling euphoric (Buckner et al., 2015). Additionally, some individuals use edible forms of cannabis to aid in relaxation and reduce anxiety (Giombi, Kosa, Rains, & Cates, 2018). Although cannabis may have therapeutic effects, risk for development of cannabis use disorder is present and occurs in an estimated 9% of nonmedical cannabis users (Savage et al., 2016). The recreational motives for cannabis use and its association with addiction has played a role in the resistance of health care providers to integrate cannabis into medical practice (Zolotov, Vulfsons, Zarhin, & Sznitman, 2018). Until more research is conducted, it is challenging to create evidence-based policy changes and treatment recommendations regarding cannabis use for medicinal purposes (Zolotov et al., 2018).
Certain components of cannabis have gained sufficient evidence to be approved by the Federal Drug Administration. These approved cannabinoids, dronabinol and nabilone, have been used to relieve nausea and vomiting associated with chemotherapy and to stimulate appetite inwasting illnesses such as human immunodeficiency virus infection and cancer (Hill, 2015). Strong evidence also exists for the use of cannabis as pharmacotherapies for persistent/neuropathic pain and spasticity (Hill, 2015). Among those who use cannabis for medical purposes, pain is among the most commonly cited reasons for use (Kosiba, Maisto, & Joseph, 2019; Wilson et al., 2018). Cannabis moderates pain through a different mechanism than opioids, providing relief and reducing the undesirable opioidrelated side effects (Miller & Miller, 2017). Because states with legalized medical cannabis have been found to have 25% lower annual opioid-related deaths (Bachhuber et al., 2014), it has been postulated that the ability to obtain cannabis easily may reduce opioid use (Bradford&Bradford, 2016). Yet more recent research has indicated that legal access to cannabis is related to increased opioid overdose mortality rates (Shover, Davis, Gordon, & Humphreys, 2019). Thus research is urgently needed to assess how cannabis is
being used as a substitute drug and whether it is a viable and safe harm reduction strategy to reduce opioid overdose events.
To understand the use of cannabis as a pain or symptom treatment, it is necessary to examine the motivations behind cannabis use. The purpose of this studywas to investigatehowmotivations for cannabis use differ among adults prescribed opioids for PP versus opioid use disorders (OUD). By exploring how motivations for cannabis use compare between populations of adults who are prescribed opioids, clinicians can better understand how cannabis may relate to opioid use and potentially facilitate opioid dose reductions.