Marijuana: An Alternative to Opioid Therapy?

The use of cannabis as an alternative to opioid therapy is gaining serious consideration. Cannabis, also known as marijuana, is still a federal Schedule I drug, meaning it is an illegal drug considered to have a high abuse potential and no medical use. However, acceptance is growing in both medical and societal circles that cannabis may have therapeutic benefit in the treatment of some medical conditions, pain in particular. Many states have legalized cannabis for medical purposes, and many more are currently considering legalization.

Recently, there has been interest in the potential use of cannabis as a replacement for opioid therapy. According to Steven Wright, MD, a consultant on medical pain management and addiction, the absence of respiratory depression is a definite benefit compared to opioids. Neurophysiologically, cannabinoids act at receptors that are involved in analgesia: CB1, CB2, Mu opioid (indirect modulation), Kappa opioid, TRPV1, NMDA, and calcium channels. Given alone, certain cannabinoids benefit certain pain conditions, although it is generally felt there is insufficient evidence to support widespread use – not first line in any case.

He continued, “There is data they may have favorable analgesic synergy when combined with opioids. However, both substance categories pose significant risks including that of addiction which cannot be ignored. In one study recreational cannabis use predicted opioid use disorder over time. Finally, although there is suggestion in animal studies cannabinoids might ameliorate symptoms of opioid withdrawal, research in humans to date does not support this clinical practice.”

The medical use of cannabinoids and cannabis remains controversial, risky, and far from settled. Although these agents can be considered in circumstances when better researched agents are found to be insufficient, caution is advised. It is recommended that medical providers keep up to date on the literature and monitor for cannabis use by patient inquiry and drug testing. Response to identified use should be based on the clinician’s judgement about the potential risks and benefits individualized to the patients in their care.

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