Cannabis for Opioid Use Disorder: What Do Experts and Patients Say?

    Cannabis works as a treatment for opioid use disorder, according to many patients and some limited research. But experts suggest its medical use should be as an adjunct, rather than a sole treatment—and not as a replacement for MAT.

    In January 2019 when New York Gov. Andrew Cuomo announced that opioid use disorder (OUD) would be a covered condition for medical marijuana, he caught his own health department off guard. Many medical experts agree that marijuana does not treat opioid use disorder by itself (though that doesn’t mean it can’t be helpful).

    In neighboring New Jersey, Gov. Phil Murphy had added OUD to his state’s list of approved indications the previous month—but specified that they could be only an adjunct to other medications.

    In her much–publicized study on cannabidiol (not THC), published in May, Yasmin Hurd, PhD, found that abstinent heroin-addicted patients who took pharmaceutical cannabidiol (Epidiolex) experienced fewer cravings in the short term than patients taking placebo. While her subjects were experiencing cravings, they were no longer experiencing withdrawal.

    The lack of medical evidence that cannabis treats people with OUD who are actively using—as opposed to observed data showing cannabis users using opioids less—means that even ardent pro-cannabis physicians don’t recommend cannabis alone for this condition.

    Peter Grinspoon, MD, an addiction medicine physician at Massachusetts General Hospital, who formerly had OUD and strongly advocates medical marijuana use, doesn’t recommend cannabis for OUD except as an adjunctto buprenorphine, for example. Cannabis “hasn’t been proven to prevent overdoses,” he told Filter. But he agreed that patients with OUD often find that cannabis helps.

    The lack of research into cannabis for OUD may seem surprising in light of a crisis of opioid-involved deaths, but is exacerbated by marjuana’s federal Schedule I status and DEA obstruction.

    As might be expected, United States health authorities are not sanguine about marijuana, medical or otherwise. It’s federally illegal. Elinore F. McCance-Katz, MD, PhD, assistant secretary for mental health and substance use for the Department of Health and Human Services, told Alcoholism & Drug Abuse Weekly this year: “There is zero evidence that marijuana is safe or effective in the treatment of opioid use disorder.”

    The lack of research into cannabis for OUD may seem surprising in light of a crisis of opioid-involved deaths, but is exacerbated by marjuana’s federal Schedule I status and DEA obstruction.

    There is evidence, however, that medical cannabis reduces chronic pain, chemotherapy-induced nausea and vomiting, fibromyalgia and chronic pain, MS spasticity and sleep problems, and short-term sleep outcomes of chronic sleep apnea. The same report also found limited effectiveness for treating weight-loss associated with HIV/AIDS, symptoms of Tourettes, anxiety and PTSD.

    In New York, recommending of medical marijuana cards for OUD will be limited to facilities licensed by the Office of Alcoholism and Substance Abuse Services (OASAS) of the state Department of Health (DOH). And whatever the Governor says, OASAS-certified providers will be unlikely to recommend it for this purpose.

    In implying that patients might leave methadone treatment and go to dispensaries to get medical marijuana instead, the New York governor was committing the error of the politician acting as doctor. Opioid treatment programs (OTPs, or methadone clinics) in the state were outraged. Patients leave treatment to get marijuana? They would go right into withdrawal, relapse, and marijuana wouldn’t do a thing to help them.

    That doesn’t mean that methadone providers are all anti-cannabis. In fact, OTPs have long known that patients whose methadone dose is not high enough (doses are always low early in treatment) or who are craving could use marijuana, and this would help them avoid other substances, like benzodiazepines and alcohol, which can be dangerous if mixed with methadone. This is why many clinics don’t test patients for THC (though sadly, many others do).

    Allegra Schorr, president of the Coalition of Medication-Assisted Treatment Providers and Advocates in New York, says OUD should not be a qualifying condition for medical marijuana. She told Filter that she is relieved that patients in private practices with buprenorphinewho are not licensed by OASASwill not be able to recommend medical marijuana for OUD. But she is still concerned that patients will come into OTPs and say they don’t want methadone or buprenorphine, they want marijuana. That is likely, in her view, to lead to relapse, overdose and death.

    But many people who have had OUD testify to marijuana’s benefits in their lives, and Filter spoke with several. Most requested that their last names not be used.

     

    A Woman Who Used Cannabis to Help With Heroin Withdrawal

    Caitlin works at a drug rehab in Illinois. She didn’t use medical marijuana when she was coping with OUD because it wasn’t permitted at the time—she was 19 then and is 35 now. “Addiction runs strong in my family,” she said. And it was her father who recommended that she try marijuana when her opioid use got out of control.

    “I started with pharmaceutical pills, and it progressed very fastI then did heroin for about a year,” she said. She mainly snorted it. “Fortunately, something inside of me said I have to stop this,” she said. “My dad is a recovered alcoholic and he suggested that I use pot when I was struggling or having cravings. As far as emotional cravings, cannabis helped immensely.” 

    “Marijuana helped soothe me. I don’t know why, but it did.”

    Catilin had found that she was able to functionand work—while using heroin, but when she tried to quit, she found withdrawal was emotionally painful. Smoking marijuana helped. While experiencing addiction and withdrawal, “emotions are all over the place,” she said. “When I felt like that, [marijuana] helped soothe me. I don’t know why, but it did.”

    It’s also helpful to have a plan, she said. “Some people can stop using, but for other people, especially if they have been using substances as a means of coping in the first place, cannabis provides extra support.”

    As for buprenorphine or methadone, Caitlin believes she would not have been a good candidate. “Those would have been huge triggers for me.”

    But if someone is currently using heroin and goes to a doctor asking for a medical marijuana card to help them cut back or cope, she said that the doctor should give it. “It would be negligent for a doctor not to help,” she said. “People want help, they want attention, they want things from their doctor; now that cannabis is legalized, that can be one of the things.”

    Caitlin noted that the marijuana helped with her anxiety and “never interfered with my life.” She would smoke in the morning, not every day, but held down all of her jobs. “It wasn’t like I was coming in to work disoriented.” 

     

    Doctors Who Prescribe Buprenorphine

    Frederick E. Kahn, M.D., a psychiatrist who practices with Forest Recovery in New Jersey (he is also married to Schorr), prescribes marijuana for pain in buprenorphine patients. First, though, they must get a card elsewhere. And he has his doubts about cannabis alone for OUD.

    “I don’t think it does anything for the opioid withdrawal,” he said. “It won’t prevent relapse.” But it is approved as an adjunct to opioid withdrawal treatment in New Jersey.

    It may alleviate the anxiety associated with withdrawal, Kahn noted, and “there is some evidence that it can decrease some cravings. But if someone is going to have difficulty with opioids, they will still have difficulty if they’re smoking pot.” He also asserted that cannabis won’t help patients who are undermedicated with buprenorphine or methadone.

    As for a patient on street opioids, “No doctor would write a prescription for someone who is continuing to use heroin but wants medical marijuana,” said Kahn. “The danger is overdose. You’re not treating the opioid addiction.”

    This approach is controversial to those who say that cannabis may not be the whole answer but can nevertheless help. Kahn doesn’t work with harm reduction: “Either they come in and are being treated” or they don’t get the card.

    “My wife has noticed I’m not as irritable, my stress level has dropped, my sleep improved.”

    Thomas Walters, MD, prescribes buprenorphine in Livonia, New York. His patients get their medical marijuana cards from other doctors, not from him. But he has seen how much it helps them. He has seen this in his friends, as well.

    “I have friends who have had chronic pain problems, who got overmedicated with opioids and got pretty disabled from those high doses,” he told Filter. “They are now using less opioids, or no opioids, and are using cannabis.” One friend told him he had been testing marijauna gummies for chronic pain, and they “take the edge off,” reported Walters. “He said, ‘My wife has noticed I’m not as irritable, my stress level has dropped, my sleep improved.‘”

    One problem is that medical marijuana is off limits unless you have money. Most of Walter’s patients are on Medicaid, so they’re not used to having to pay for medicine, he said. It’s cheaper for them to get marijuana on the illicit market.

    Still, he does see that it workshe’s just not happy with the system. “My impression is in New York State it’s pretty much a joke,” he said. “There’s lip service paid to appropriate medical diagnosing, but the reality is the patient is paying cash to get permission to get the card so they can go to the dispensary to get the product.” Typically, the qualifying diagnosis is pain. 

     

    A Buprenorphine Patient

    One of Walters’ patients is Jessica, a 36-year-old mom of two who vapes cannabis. “It’s a lifesaver,” she said. “Dr. Walters allows me to keep the buprenorphine, and I have the prescription for the medical marijuana to help me got off the opioids. If I didn’t have it, I couldn’t stay away.” 

    She uses the cannabis for back pain, she said. “I used to use opioids for back pain, heavilyI overdid it and that’s why I’m in the situation I’m in.” The cannabis also helps her anxiety, and helps her to sleep at night, she added.

    She got her marijuana card through a doctor online, and has her cannabis delivered. “If I did not have my vape, I would get anxious,” she said. She has experienced sleeplessness and anxiety ever since she stopped using opioids other than bupe.

    When Jessica told Walters that she had a medical marijuana card and was going to use it in addition to the buprenorphine he was prescribing, “He didn’t have much to say, but I am one of his patients that does go through the program the right way,” she said. “I’m being straight-up honest.”

    “I went to Columbia care, and it was $125 for a seven-day supply,” she continued. Because of the cost, “I make it last me two months.” And ultimately, she knows it is the buprenorphine that is principally helping her. “I go to Dr. Walters for the buprenorphine, not the cannabis, and he is what’s helping me stay off drugs.”

     

    Pain and Laughter

    Kathie Kane-Willis, PhD, a drug policy researcher based in Chicago, once had OUD and was treated with methadone. Recently she was diagnosed with breast cancer with some terrible complications. All along, marijuana helped her.

    “There wasn’t medical marijuana when I was on methadone,” she told Filter. “But it did help me with the craving part, not only for opioids, but for any drug. It helped with any kind of relapsing.” This was particularly true, she said, when she started smoking marijuana more frequently.

    When she went for breast cancer surgery, she told her doctors that she didn’t want to take opioids. Instead, “I brought my edibles to the hospital.”

    She wanted to avoid opioids not because she was afraid of relapsing, but because of side effects like constipation. But the hospital didn’t make it easy for her. “After the mastectomy I said, ‘I don’t need opioids, I’m going to use edibles. They said, ‘You will go home with opioids.’” While at the hospital, her dispensary website was blocked.

    She was hospitalized many times, and sometimes, the pain was so bad—such as when wounds were being packedthat she needed Dilaudid. “It’s always a balance,” she said. She still has chronic pain from the radiation and the mastectomy, and edibles “make such a difference.”

    Because Kane-Willis has worked in drug research for so long, she was adamant about insisting on medical marijuana. She did research, and her oncologist provided the recommendation (in Illinois, patients must have a relationship with the doctor concerned, unlike the web-based situation in New York).

    Kane-Willis pointed out that marijuana can make it easier to laugh. “We need more laughter in our lives,” she said.

    Not everybody feels so positive about cannabis. Carlyn from Canada, for example, takes Tramadol for pain, and has a prescription for medical marijuana to keep the opioid level down (Tramadol can be toxic if the dose is even a little too high). She doesn’t like cannabis, she told Filter, because it makes her feel “numb,” and doesn’t help her to sleep.

    She said that many people eligible for OUD diagnoses may use marijuana, “but they’re not using it to manage craving so much as to feel better.” In fact, many people who use marijuana recreationally may really be using it medically, she pointed out. “The line between medical and recreational is very blurry.”


     

    Photo by Sharon McCutcheon on Unsplash.

     

    • Alison Knopf

      Alison has written about substance use for more than 30 years. She has also written for many years about medical coding. A freelance writer, she is also the editor of Alcoholism & Drug Abuse Weekly, and managing editor of Child & Adolescent Psychopharmacology Update and Child & Adolescent Behavior Letter—all published by WILEY. She also writes for Addiction Treatment Forum.

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