The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain : How Cannabis Diminished Prescription Opioid Usage
Kevin M. Takakuwa, Jeffrey Y. Hergenrather, Frances S. Shofer, and Raquel M. Schears
Cannabis and Cannabinoid Research, 2020, Volume X, Number X, 1-8.
Doi : 10.1089/can.2019.0039
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
In 2016, there were an estimated 11.8 million opioid misusers aged 12 years and older, representing 4.4% of the U.S. population.1 In the same year the Centers for Disease Control reported 42,249 deaths related to opioids, a fivefold increase compared with 1999.2 With rising numbers of deaths each year, there seems to be no easy solution to combat this national health crisis.
Since the publication of an article reporting an association between states with medical cannabis laws and a 24.8% decrease in annual opioid deaths,3 there has been increased interest in medical cannabis as a potential treatment alternative or adjunct. Another study that found an association between states with medical cannabis dispensaries and decreased opioid overdoses concluded that cannabis may be acting as a substitute for opioids.4 Neither of these studies was able to show a direct cause and effect relationship. Cannabis has been used for centuries as an analgesic5 and has been shown to reduce chronic pain.6–9 Although cannabis works by acting on the CB1 and CB2 receptors of the endocannabinoid system and does not bind opioid receptors of the noradrenergic system directly, there is thought that the two systems may overlap synergistically or indirectly function in concert.10,11 It has therefore been postulated that pain relief may be achieved with lower doses of opioids in the setting of concomitant cannabis use.10,12 A number of studies have supported this idea of a combined approach8,13–21 or found cannabis may be used in place of prescription opioids.22,23
To find patients who might be taking opioids, we chose to study patients with back pain. Low back pain
was reportedly experienced by 71 million people surveyed 18 years and older in the previous 3 months during 2016, representing 28.4% of the U.S. population.24 Low back and back symptoms were the reported principal reason for 20.4 million doctors’ office visits in 2014, the most common pain complaint in the survey.25 Because opioids are commonly prescribed for back pain26 (although not shown to be more efficacious to nonopioid medication therapy27), we chose to study patients who had a primary complaint of lower back pain and were given the provisional diagnosis corresponding to the International Classification of Diseases, 10th Revision (ICD-10) code (M54.5). The primary purpose of this study was to determine whether the use of cannabis may be used as an alternative to opioids.
A secondary purpose was to see if cannabis would lower opioid usage in intermittent and chronic opioid users.