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Natural Medicine Journal

June 7, 2023

Reduced Opioid Dosages with Long-Term Medical Cannabis Use for Chronic Pain

Results from a retrospective, observational study

Erica Eckstrand

Long-term medical cannabis use for chronic pain may lead to reduced opioid dosages.

Reference

Nguyen T, Li Y, Greene D, Stancliff S, Quackenbush N. Changes in prescribed opioid dosages among patients receiving medical cannabis for chronic pain, New York State, 2017-2019. JAMA Netw Open. 2023;6(1):e2254573.

Study Objective

To compare the length of time of medical cannabis (MC) use with opioid dosage changes

Key Take-Away

Taking medical cannabis for at least 1 month may significantly reduce long-term opioid therapy (LOT) doses compared to those with less than 1 month of MC use. 

Design

Retrospective, observational study of a cohort from the New York State Prescription Monitoring Program (2017–2019)

Participants

Of 8,165 chronic pain patients undergoing LOT included in this study, 4,041 had at least 1 month of taking medical cannabis, and 4,124 took medical cannabis for 1 month or less. 

The investigators used 2 groups for comparison to eachother: 

The investigators used 2 groups for comparison to each other:

  1. Those who took MC for more than 30 days. This group was 41.2% male (58.8% female) and had a median age of 57 (IQR: 47–65) years, and
  2. Those who took MC for 30 days or fewer. This group was 42.5% male (57.5% female) and had a median age of 54 (IQR: 44–62) years.

These groups were stratified into 3 dosage ranges for comparison in this study. The dosages were:

  1. less than 50 morphine milligram equivalents (MME),
  2. 50 MME to less than 90 MME, and
  3. 90 MME or more.

Of those who took less than 50 MME, 2,009 took cannabis for more than 1 month, and 2,002 took it for 1 month or less. Of those who took between 50 and less than 90 MME, 701 took cannabis for more than 1 month, and 2002 took it for 1 month or less. Of those who took at least 90 MME, 1,331 took cannabis for more than 1 month, and 1,365 took it for 1 month or less.

People aged less than 18, terminally ill patients, those with opioid use disorder, people taking over 480 MME, and those with large gaps of MC usage were excluded in this study. 

Intervention

Investigators compared those who took MC for more than 1 month to those who took it for 1 month or less. 

Study Parameters Assessed

The dosage of opioids used (per MME) relative to the time of adopting MC use.  

Primary Outcome 

Investigators assessed opioid-dosage reductions in all patients, comparing those who used medical cannabis for 1 month or less with those who used it for more than 1 month. 

Key Findings

Longer-term (>30 days) use of MC was associated with less dosage of MME in this retrospective review. Looking at the data by stratification of MME dosages: Of those who took less than 50 MME of long-term opioid therapy (LOT), more than 1 month of MC use had an average of 48% reduction of opioid dose compared to 4% in those who used MC for 1 month or less, leading to a total difference MME net reduction of –14.53 (CI: –17.45, –11.61) over 8 months between the 2 groups. The daily MME dose reduction trend was significantly improved in those with more than 1 month of MC use, which was –0.27 (CI: –0.43, –0.11) compared to those with 1 month or less of MC use, which was –0.20 (CI: –0.31, –0.09; P<0.05).

Of those who took more than 50 and less than 90 MME of LOT, more than 1 month of MC use had an average of 47% reduction of opioid dose compared to 9% in those who used MC for 1 month or less, leading to a total difference MME net reduction of –29.49 (CI: –35.94, –23.04) over 8 months between the 2 groups. The daily MME dose reduction trend was not significantly improved in those with more than 1 month of MC use, which was –0.13 (CI: –0.51, 0.25) compared to those with 1 month or less of MC use, which was –0.05 (CI: –0.31, 0.21).

Of those who took at least 90 MME of LOT, more than 1 month of MC use had an average of 51% reduction of opioid dose compared to 14% in those who used MC for 1 month or less, leading to a total difference MME net reduction of –69.81 (CI: –87.09, –52.53) over 8 months between the 2 groups. The daily MME dose reduction trend was not significantly improved in those with more than 1 month of MC use, which was –0.25 (CI: –0.81, 0.32) compared to those with 1 month or less of MC use, which was 0.26 (CI: –0.13, 0.66).

Transparency

This study contained no conflict-of-interest disclosures.  

Practice Implications & Limitations

At least 20% of Americans experience chronic pain, which has been shown to significantly affect disability rates, quality of life, medical expenses, daily functioning, and social activities.1 Cannabis has been used for pain all over the world for thousands of years, with records from 2900 BC in China.2 The criminalization of recreational cannabis, which has colonially racist roots,3 has been a barrier to learning more about its use in the clinical setting.4 With an increasing number of places in North America legalizing medical and recreational cannabis, more adults of all ages are exploring its use.2,5  

When 1,661 American adults, living in states that have legalized medical cannabis, were asked if they used it, 31% said that they have.6 Of those who used medical cannabis, almost 95% claimed to use pharmacological interventions as well.6 More than half of these individuals who used medical cannabis to treat their chronic pain claimed that it helped to reduce the use of pharmaceuticals to treat pain, such as prescription opioids, nonopioids, and over-the-counter medications, while almost 39% claimed it reduced their physical therapy use.6 

Opioids have a number of potential risks and side effects, including opioid use disorder, fatigue, dizziness, dulled emotions, worsened memory,7 and risk of kidney and liver dysfunction,8,9 leading many people to seek out alternatives treating chronic pain. 

In a population study that included approximately 650 chronic pain patients, about half reported that conventional treatment was ineffective.10 This encourages people who treat chronic pain and/or who experience it themselves to analyze current medical cannabis research to have multiple options for those who desire pharmaceutical alternatives. 

Although some may claim that cannabis is an innocuous plant, it is not free of adverse reactions.11 Common side effects of cannabis include cannabis use disorder, fatigue, mental confusion, dizziness, and, rarely, cannabis hyperemesis syndrome.11 The issue with many clinical and observational studies is that the concentrations of cannabinoids, such as delta-9-tetrahydrocannabinol (THC), with its more psychotropic effects, as well as its nonpsychotropic counterpart, cannabidiol (CBD), are not controlled or analyzed, which may lead to significant clinical differences.11 Higher CBD and lower THC doses may significantly reduce many of the adverse effects, which are largely attributed to THC.11,12 Another important factor to be mindful of when considering cannabis for chronic pain in the clinical setting is the route of administration.11,12 Cannabis by mouth, such as edibles, tinctures, and oils, are safer options in terms of reducing respiratory adverse effects, compared to inhalation, such as smoking or vaporizing.11,12 

This study supports a number of others that have shown cannabis use may reduce opioid use in chronic pain patients, but more randomized, placebo-controlled trials are needed.2,11,13,14 Most naturopathic doctors cannot prescribe medical cannabis to patients but can recommend that patients go to professional medical cannabis clinics in the meantime. Cost, health history, risk of addictions, and potential age-related limitations are some considerations to share during informed-consent conversations in order for patients to make the best individualized decisions regarding medical cannabis and opioid use.

Categorized Under

Erica Eckstrand

Erica Eckstrand is a graduate from the Canadian College of Naturopathic Medicine and is currently practicing as an oncology-focused health coach in the Cowichan Valley, British Columbia, while she is in the process of getting licensed as an ND. She graduated from the University of Texas with a bachelor of science, with honors, in biology and chemistry and wrote a research-based thesis in evolutionary genomics. She has a special interest in pediatric oncology and runs a pediatric cancer support group. She is passionate about research and currently works for the KNOW (Knowledge in Integrative Oncology Website) project as a research summarizer. 

References

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  3. Brown A. The criminalization of the cannabis plant: decolonizing the harmful enforcement. Decolonization of Criminology and Justice, 2022;4(2):59-68.
  4. ​​National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda. The current state of evidence and recommendations for research. In: The Health Effects of Cannabis and Cannabinoids. Washington (DC): National Academies Press (US); 2017.
  5. Staton M, Kaskie B, Bobitt J. The changing cannabis culture among older Americans: high hopes for chronic pain relief. Drugs. 2022;29(4):382-392.  
  6. Bicket MC, Stone EM, McGinty EE. Use of cannabis and other pain treatments among adults with chronic pain in US states with medical cannabis programs. JAMA Netw Open. 2023;6(1):e2249797.
  7. Schulte E, Spies C, Denke C, et al. Patients’ self‐reported physical and psychological effects of opioid use in chronic noncancer pain—a retrospective cross‐sectional analysis. Eur J Pain. 2021;26(2):417-427.  
  8. Stedman M, Heald A, Robinson A, Davies M, Harnett P. Associations and mitigations: an analysis of the changing risk factor landscape for chronic kidney disease in primary care using national general practice level data. BMJ Open. 2022;12(12):e064723.
  9. Soleimanpour H, Safari S, Shahsavari Nia K, Sanaie S, Alavian SM. Opioid drugs in patients with liver disease: a systematic review. Hepat Mon. 2016;16(4):e32636.
  10. Smith BH, Elliot AM, Chambersa WA, et al. The impact of chronic pain in the community. Fam Pract. 2001;18:292–299.
  11. Goldstein B. Cannabis Is Medicine: How Medical Cannabis and CBD Are Healing Everything from Anxiety to Chronic Pain. New York: Little, Brown Spark; 2020.
  12. Schecter D, Cyr C. Choosing a product, route of administration, initial dosage, titration, monitoring and management of adverse effects. In: Cannabis and Cannabinoid-Based Medicines in Cancer Care. Springer, Cham; 2022.
  13. M, Phillips T, Radbruch L, Petzke F, Häuser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018;3(3):CD012182.  
  14. Okusanya BO, Asaolu IO, Ehiri JE, Kimaru LJ, Okechukwu A, Rosales C. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. 2020;9(1):167. Published 2020 Jul 28. doi:10.1186/s13643-020-01425-3

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