What is opioid dependence?

Opioid dependence is a public health epidemic that affects 20 million Americans and kills 91 people every day in the United States. According to the Centers for Disease Control and Prevention, the number of prescription opioids in the U.S. quadrupled between 2000 and 2015. More than 4,000 people start using opioids every day. Nearly seven in 10 drug overdose deaths are the result of opioids.  

Many people who become dependent or addicted to opioids begin opioids acquired from legal prescriptions written by doctors or dentists following injuries or surgeries. In some cases, prescription drugs are illegally diverted for recreational use.

While opioids are prescribed as pain remedies, they mask pain rather than cure pain, often requiring larger doses over time to achieve similar levels of relief.

Opioid use for pain relief dates to 3400 B.C. in Mesopotamia. But opioid dependence on an epidemic scale is a modern American phenomenon. Historians date opioid dependence to the 19th century following the introduction of morphine to modern pharmacology in 1817.

A new generation of natural and synthetic chemical painkillers created in the mid-1990s set the perfect storm for today’s epidemic. Two decades ago, Medical groups embraced pain as a vital sign and endorsed aggressive treatment. Brand-name opioids like OxyContin and MS Contin emerged. Aggressive marketing and overprescribing occurred.

A class of legal drugs like oxycodone, hydrocodone, tramadol, buprenorphine, fentanyl and methadone, and illegal drugs like heroin, opioids are available in numerous forms: pills, powders, transdermal patches, syrups, suppositories, lozenges and lollipops. In addition to blocking pain, opioids may temporarily reduce tension and aggression, producing feelings of calm and euphoria.

Who’s most affected by opioid dependence?

Drug overdoses are the leading cause of death among Americans under age 50. An estimate of drug nearly 64,000 overdose deaths in 2016 by the New York Times this summer shows the largest annual increase ever recorded in the United States — a 19 percent jump from 2015.

Media attention often focuses on deaths among white, middle-class drug users, but every racial and socio-economic demographic has seen opioid overdoses increase since 1999. While whites and Native Americans were dying at double or triple the rates of African Americans and Latinos, CDC statistics show the latter two groups experiencing as much as a 200 percent increase in opioid-related deaths since 2010.

Adolescents, young adults and adult women have been particularly affected. While most adolescents who misuse prescription pain relievers obtain them from friends or relatives, prescribing rates for opioids among adolescents and young adults nearly doubled from 1994 to 2007.

Women are more likely to have chronic pain, be prescribed opioid painkillers, be given higher doses and use them for longer time periods than men. Prescription opioid overdose deaths among women increased more than 400 percent from 1999 to 2010, compared to 237 percent among men. Heroin overdoses among women tripled from 2010 to 2013.

Another demographic affected by opioid dependence is unemployed Americans. In a meta-analysis of 28 studies published in 12 countries between 1990 and 2015, researchers from the Netherlands recently identified both economic recessions and individual unemployment as drivers of increases in illegal drug use. States with high rates of opioid abuse also have high rates of unemployment, including Connecticut, Florida, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Tennessee, Washington, and West Virginia.

How can cannabis help opioid dependence?

According to certain patient reports, whole-plant, full-spectrum cannabis oil extracts may effectively relieve neuropathic pain. Cannabis also may prevent opioid tolerance building and the need for dose escalation. In addition, research shows cannabis may alleviate the symptoms of opioid withdrawal — nausea, vomiting, spasms, cramping, insomnia and constipation.

A 2014 study published in JAMA Internal Medicine examined data between 1999 and 2010 and found that states with medicinal cannabis laws had 25 percent lower annual opioid overdose death rates compared to states in which cannabis is prohibited.

Recent data from self-reported studies of medicinal cannabis patients in Washington show that cannabis is being substituted for pharmaceutical opioids.

A recent study by the University of California Berkeley and HelloMD found that 97 percent of the medicinal cannabis patients surveyed believe they could decrease their opioid use when using cannabis.

In the United States, total prescription drug spending in Medicare fell by $165 million per year in 2013 after the implementation of medicinal cannabis laws in several states. Opioids were the most commonly reported substituted drug.

How does cannabis integrate with or complement opioids?

According to the UC Berkeley-HelloMD study,

cannabis demonstrates promising potential to alleviate the opioid crisis by helping patients wean off opioid medications and switch to cannabis-based therapies.  

There is also growing evidence that cannabis makes opioid therapy safer by widening the drugs’ therapeutic index so that a patient needs fewer opioids to get a strong analgesic effect, helping patients to lower doses and reduce risks of side effects and addiction.

According to research, cannabis could be used to effectively reduce drug cravings and the chances of relapse. A 2016 University of Michigan study published in the Journal of Pain found that cannabis reduced use of opioids by 64 percent, on average; decreased side effects from other medications such as nonsteroidal anti-inflammatory drugs and antidepressants; and improved patients’ quality of life.

Effective consumption methods for opioid patients using cannabis?

There are four primary consumption methods recommended for patients using cannabis as an adjunct or replacement for opioids: edible, sublingual, topical and inhaled forms of prepared cannabis flowers and cannabis oil extracts.

Each consumption method has its benefits. Oral ingestion provides long-lasting relief with varying onset times. Sublingual and buccal applications act fast. Transdermal and topical applications enter the bloodstream via your skin. Inhalation acts fastest but provides shorter-term relief than other consumption methods. Inhalation, however, allows for smaller and more frequent dosing to help manage pain symptoms as needed.  

Effective dosage and ratios for opioid patients using cannabis?

There are no standard dosages for any cannabis therapies. Everybody’s endocannabinoid system is completely different. The general recommendation is start low, go slow and allow enough time to gauge effects before consuming more. For example, many patients begin cannabis therapies by consuming 1- or 2-mg micro doses of extracts, edibles and other cannabis products and continuing with similar doses or increasing doses as necessary. Other patients with higher tolerances or greater needs dose at higher levels. Doses of 5 mg and 10 mg are often reported.  

Clinical research has shown that cannabis preparations that include an equal ratio of two cannabinoids, non-psychoactive CBD and psychoactive THC, is effective for neuropathic pain and will likely have greater therapeutic benefits in combination than either cannabinoid alone, a concept known as the entourage effect, which some researchers say is the reason cannabis can provide effective therapy for certain conditions while synthetic formulations of only THC or CBD medications may only achieve limited success in some patients.

Some patients report positive results from cannabis preparations rich in THC, the primary psychoactive agent in cannabis that is effective in alleviating chronic pain and can enhance CBD’s therapeutic properties. THC can also help reduce nausea, vomiting and other side effects of opioid withdrawal.

In some cases, patients report positive results reducing opioid use by consuming high levels of CBD, the non-psychoactive cannabinoid that affects neurological receptors responsible for pain modulation, inflammation regulation, and mood and stress management — up to 20:1 CBD:THC in some cases. While rigorous studies are still needed, preliminary clinical reports indicate CBD also has anti-anxiety, anti-psychoactive and anti-convulsant properties.