Easing off opioids: Medical marijuana replaces pain meds, curbs dependence

Carbon County may have a new trick up its sleeve when it comes to the opioid epidemic — medical marijuana.

Chief Business Development Officer Victor Guadagnino and Director of Pharmacy Bradley Carlson of Bethlehem dispensary Keystone Canna Remedies discussed the concept of medicinal cannabis during a recent STEP-Up meeting at St. Peter’s Resource Center.

Though the use of marijuana to alleviate or avoid opioid dependence may seem strange, it is actually a common reason for patients to visit Keystone.

“In our patient base alone, 90 percent of our chronic pain patients, their first desired goal when they sit down for a consultation is to either wean themselves off opiates, or not start them at all,” Guadagnino said.

“We felt that this needs to be a conversation that has to be had, especially in light of the opioid epidemic we are going through now.”

Pennsylvania currently has 15 dispensaries statewide, with three growers up and running. Up to 12 grower-processors will be allowed to provide medical grade marijuana in the state.

State by state, the idea of marijuana as a medical treatment option is growing to be more and more acceptable.

“As of April of this year, 30 states have passed marijuana legislation allowing for the use of it in some capacity,” Carlson said, including states that permit medical and/or recreational use.

The opioid epidemic

Citing information from a study called Project CBD, Carlson said, “Forty-four people in the United States die from prescription overdose every day, and the number increases to 78 daily when we include heroin. Almost 7,000 people are treated in emergency rooms every day for misuse of opioid medications.”

Opioid abuse costs the country about $56 billion.

Carlson said opioids like OxyContin were originally developed to ease the suffering of terminal patients, usually with six months or less left to live. Nowadays, the United States consumes 80 percent of the world’s opioids while representing only 5 percent of its total population, and they tend to use them for extended periods of time.

“It was never the intention that people would be on escalating doses for years and years and years, causing the amount of problems that we’ve been having,” Carlson said.

Cannabis a solution

Some evidence suggests that utilizing cannabis can help curb opioid dependence issues, including tolerance and escalating dosages, that can lead to overdose and death.

A study from 1999-2010 showed that when medical cannabis laws were implemented in a state, opioid overdose rates dropped almost 25 percent, and continued to drop in the years after.

Opioid sparing — where patients use cannabis to limit the amount of opioids they use — is a hot topic currently, though a lack of clinical, double-blind studies limits available data.

However, in a survey from Michigan conducted in November 2014 and February 2015, a group of chronic pain patients that were using medical cannabis showed some promising anecdotal results.

“Sixty-four percent of them reported a decrease in their overall opioid usage,” Carlson said.

“A good majority of the patients we see already are already scared out of their minds about starting an opioid, or they want so desperately to get off them. Marijuana gives people an option for adjunctive treatment that sets them up for success and more robust pain treatment.”

On top of that, the active ingredient THC is surprisingly effective in treating pain by itself.

“Marijuana changes your body’s perception of pain through the neural pathways that pain uses in order to manifest itself, but marijuana is also very anti-inflammatory. In fact, clinical literature has demonstrated that THC is 20 fold as anti-inflammatory as aspirin,” Carlson said, also pointing out that opioids are not anti-inflammatory.

Working together

Even if a patient would prefer to keep using opioids for pain management, adding medical marijuana to the mix can be quite helpful.

“Opioids in combination with marijuana can synergize and cause increased benefits. You may want to have a goal not necessarily to get off opiates altogether, but you may not want to have your dose escalate,” Carlson said.

Withdrawal, a major issue for those looking to quit opioids, can be managed with marijuana, which limit symptoms like nausea, vomiting, sweating, anxiety and sleeplessness.

Dosing strategies have already been developed in order to help opioid users effectively get off their medication. Carlson and Guadagnino both said that Keystone Canna Remedies works with patients to develop a functional strategy to obtain what they want, and that the course of treatment is personalized to that goal.

Carlson said that he wishes to change the perception of medical marijuana as a last-ditch effort, and instead bring it to the forefront of treatment options for various conditions.

“It’s been touted for such a long time that marijuana is a gateway drug. I like to look at it as an exit drug, because a lot of patients that have an opportunity to look into a program that allows them to use it for pain, nausea and vomiting, or an adjunctive treatment, they’re able to downplay some of their other medications to the point that they don’t need them anymore,” he said.

Science and safety

As Carlson explained, when THC was isolated from cannabis in 1964, there was a drive to find what the chemical reacted with within the human body to produce responses. This led to the study of the cannabinoid receptors found throughout the human body, where an interesting connection was found.

“A lot of disease states are actually starting to get recognized as dysregulations of the human endocannabinoid system,” Carlson said.

As it turns out, in many situations, supplementing with an external cannabinoid — like those found in cannabis — can be helpful in treating many conditions, as the cannabinoids can help modulate neurotransmitter release and pain, and help with mood, motor function, gastrointestinal function, cardiovascular function and more.

Side effects of marijuana usage tend to be rather mild and physical, and include psychoactive responses, or getting “high,” along with dry mouth, short term memory issues, and drowsiness.

More serious issues, though rare, include the risk of psychosis in people who may be susceptible to conditions like schizophrenia. The differences in safety profiles between medical marijuana and opioids, however, are rather vast.

“Marijuana has a vastly different safety profile. In fact, to date, there has not been a single documented death exclusively due to its use,” Carlson said.

Carlson said that when it comes to finding a dosing regimen for a new patient, past experience with marijuana, current medication usage, and numerous other factors are taken into account. The “low and slow” regiment works at finding a perfect point where pain is alleviated, without an excessive dose. Fortunately, marijuana’s therapeutic index — the area between a dosage that alleviates pain and causes overdose reactions — is rather accommodating, Carlson said.

“Marijuana has a huge therapeutic index. That gives us a lot of opportunity to titrate doses based on patients’ responses, without having an adverse reaction that could be fatal,” he said.

While marijuana remains a Schedule 1 drug on the federal level, people like Guadagnino and Carlson are looking forward to a fruitful future with the drug.

Coming to the end of the lecture, Carlson brought up the Oath of the Pharmacist, which he had to recite at his graduation.

Sections on keeping up to date with developments in the world of pharmaceuticals and embracing and advocating for changes in pharmacy that improves patient care struck a chord with him when it came to medical marijuana and the myriad ways it can alleviate pain, either directly, or through the treatment of reliance upon opioids.

“If this hasn’t been studied to the degree that it needs to be accepted as medicine, at least the voices of our patients will speak loudly enough to advocate for change that needs to happen in order for us to respect it as a medicine. That’s why we’re here,” he said.