Study: Marijuana Use Associated With Decreased Symptoms Of Opiate Withdrawal In Methadone Maintenance Treatment SubjectsJuly 16, 2013
Cannabis consumption is associated with mitigated symptoms of opiate withdrawal in subjects undergoing methadone maintenance treatment, according to the findings of a new study published online in The American Journal on Addictions.
Investigators at the Farber Institute for Neurosciences at Thomas Jefferson University in Philadelphia assessed the use of cannabis in 91 opiate-dependent subjects undergoing methadone maintenance treatment. Researchers found that subjects seeking methadone treatment who acknowledged a history of cannabis use reported “significantly less daily expenditure on acquisition of opiates.”
Authors additionally reported that subjects’ use of cannabis during treatment was associated with less severe symptoms of withdrawal on the clinical opiate withdrawal scale (COWS), an index designed to serve as an objective measure of opiate withdrawal. “[I]ncreased cannabis use was found to be associated with lower severity of [opiate] withdrawal in a subset of the sample with available chart data,” authors wrote. “These results suggested a potential role for cannabis in the reduction of withdrawal severity during methadone induction.”
They concluded, “The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid–opioid system interactions.”
A 2009 study published in the same journal previously reported that moderate cannabis use and improved retention in naltrexone treatment among opiate-dependent subjects.
Full text of the study, “Impact of cannabis use during stabilization on methadone maintenance treatment,” appears online in The American Journal on Addictions.
Investigators at the University of California, Davis Medical Center conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in 39 subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Subjects inhaled cannabis of either moderate THC (3.53 percent), low dose THC (1.29 percent), or zero THC (placebo). Subjects continued to take all other concurrent medications as per their normal routine during the 3- to 4-week study period. Spontaneous pain relief, the primary outcome variable, was assessed by asking participants to indicate the intensity of their current pain on a 100-mm visual analog scale (VAS) between 0 (no pain) and 100 (worst possible pain).
Researchers reported: “Both the low and medium doses proved to be salutary analgesics for the heterogeneous collection of neuropathic pain conditions studied. Both active study medications provided statistically significant 30% reductions in pain intensity when compared to placebo.”
They concluded: “Both the 1.29% and 3.53% vaporized THC study medications produced equal antinociception at every time point. … [T]he use of low doses could potentially be prescribed by physicians interested in helping patients use cannabis effectively while minimizing cognitive and psychological side effects. Viewed with this in mind, the present study adds to a growing body of literature supporting the use of cannabis for the treatment of neuropathic pain. It provides additional evidence of the efficacy of vaporized cannabis as well as establishes low-dose cannabis (1.29%) as having a favorable risk-benefit ratio.”
Previous clinical trials have indicated that inhaled cannabis can safety and effectively relieve various types of pain, particularly neuropathy — a hard-to-treat nerve condition often associated with cancer, HIV, spinal cord injury, diabetes, multiple sclerosis, and other conditions. These include the following double-blind, placebo-controlled (FDA gold-standard) studies:
Ware et al. 2010. Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ 182: 694-701.
Wilsey et al. 2008. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. Journal of Pain 9: 506-521.
Ellis et al. 2008. Smoked medicinal cannabis for neuropathic pain in HIV: a randomized, crossover clinical trial. Neuropsychopharmacology 34: 672-80.
Abrams et al. 2007. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 68: 515-521.
Wallace et al. 2007. Dose-dependent Effects of Smoked Cannabis on Capsaicin-induced Pain and Hyperalgesia in Healthy Volunteers Anesthesiology 107: 785-796.
Separate clinical trial data also reports that inhaled “cannabis augments the analgesic effect of opioids” and therefore “may allow for opioid treatment at lower doses with fewer side effects.”
Since 1999, US sales of opiate drugs have tripled in number and in 2010, a record-setting 254 million prescriptions for opioids were filled in the United States — enough to medicate every American adult around the clock for a month. (In particular, the manufacturing of the drug Oxycodone has increased from 8.3 tons in 1997 to 105 tons in 2011, an increase of 1,200 percent.) Overdose deaths from the use of prescription painkillers are also now at record levels, totaling some 15,000 annually — more than triple the total a decade ago.
Full text of the study, “Low-dose vaporized cannabis significantly improves neuropathic pain,” appears in The Journal of Pain.
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Physicians who prescribe opioid drugs to patients with neuropathy (nerve pain) ought to consider recommending cannabis as an alternative therapy, according to a peer-reviewed paper published online this week in the Harm Reduction Journal.
“There is sufficient evidence of safety and efficacy for the use of (cannabis/cannabinoids) in the treatment of nerve pain relative to opioids,” the commentary states. “In states where medicinal cannabis is legal, physicians who treat neuropathic pain with opioids should evaluate their patients for a trial of cannabis and prescribe it when appropriate prior to using opioids. … Prescribing cannabis in place of opioids for neuropathic pain may reduce the morbidity and mortality rates associated with prescription pain medications and may be an effective harm reduction strategy.”
The author notes that between the years 1999 and 2006, “approximately 65,000 people died from opioid analgesic overdose.” By contrast, he writes “[N]o one has ever died from an overdose of cannabis.”
In November, clinical investigators at the University of California, San Francisco reported that vaporized cannabis augments the analgesic effects of opiates in subjects prescribed morphine or oxycodone. Authors of the study surmised that cannabis-specific interventions “may allow for opioid treatment at lower doses with fewer [patient] side effects.”
Neuropathy affects between five percent and 10 percent of the US population. The condition is often unresponsive to conventional analgesic medications such as opiates and non-steroidal anti-inflammatory drugs.
Full text of the paper, “Prescribing cannabis for harm reduction” is available online here.
Neither story particularly breaks any new ground, though the author (who I spoke with extensively prior to the stories publication) does note that investigators are now assessing the use of cannabis for a wide range of disease conditions, including Alzheimer’s disease and the so-called ‘superbug’ MRSA (multi-drug resistant bacterial infections).
Quoted in the story is Columbia University researcher Margaret Haney. I’ve written about Haney’s clinical work with cannabis before. In particular, Haney was the lead author of a 2007 clinical trial concluding that inhaled cannabis increased daily caloric intake and body weight in HIV-positive patients in a manner that was far superior to the effects of oral THC (Marinol aka Dronabinol). The study further reported that subjects’ use of marijuana was well tolerated, and did not impair their cognitive performance.
Yet Haney’s comments in US News and World Report ring tepid at best.
“I am not anti-marijuana, I’m not pro-marijuana. I want to understand it.” Haney expresses frustration at what she considers wrongheaded efforts by states to legalize medical marijuana. There is too much, she says, that scientists do not know.
Haney’s refrain is a common one, and at first glance it appears to make sense. After all, who among us doesn’t want to better understand the interactions between the marijuana plant and the human body? Yet placed in proper context this sentiment appears to be little more than a red herring. Here’s why.
Marijuana is already the most studied plant on Earth, and is arguably one of the most investigated therapeutically active substances known to man. To date, there are now over 20,000 published studies or reviews in the scientific literature pertaining to marijuana and its active compounds. That total includes over 2,700 separate papers published on cannabis in 2009 and another 900 published just this year alone (according to a key word search on the search engine PubMed).
And what have we learned from these 20,000+ studies? Not surprisingly, quite a lot. For starters, we know that cannabis and its active constituents are uniquely safe and effective as therapeutic compounds. Unlike most prescription or over-the-counter medications, cannabinoids are virtually non-toxic to health cells or organs, and they are incapable of causing the user to experience a fatal overdose. Unlike opiates, cannabinoids do not depress the central nervous system, and as a result they possess a virtually unparalleled safety profile. In fact, a 2008 meta-analysis published in the Journal of the Canadian Medical Association (CMAJ) reported that cannabis-based drugs were associated with virtually no serious adverse side effects in over 30 years of investigative use.
We also know that the cannabis plant contains in excess of 60 active compounds that likely possess distinctive therapeutic properties. These include THC, THCV, CBD, THCA, CBC, and CBG, among others. In fact, a recent review by Raphael Mechoulam and colleagues identifies nearly 30 separate therapeutic effects — including anti-cancer properties, anti-diabetic properties, neuroprotection, and anti-stroke properties — in cannabinoids other than THC. Most recently, a review by researchers in Germany reported that since 2005 there have been 37 controlled studies assessing the safety and efficacy of cannabinoids, involved a total of 2,563 subjects. By contrast, most FDA-approved drugs go through far fewer trials involving far fewer subjects.
Finally, we know that Western civilization has been using cannabis as a therapeutic agent or recreational intoxicant for thousands of years with relatively few adverse consequences — either to the individual user or to society. In fact, no less than the World Health Organization commissioned a team of experts to compare the health and societal consequences of marijuana use compared to other drugs, including alcohol, nicotine, and opiates. After quantifying the harms associated with both drugs, the researchers concluded: “Overall, most of these risks (associated with marijuana) are small to moderate in size. In aggregate they are unlikely to produce public health problems comparable in scale to those currently produced by alcohol and tobacco. On existing patterns of use, cannabis poses a much less serious public health problem than is currently posed by alcohol and tobacco in Western societies.”
That, in a nutshell, is what we ‘know’ about cannabis. I’d say that it’s ample enough information to, at the very least, cease the practice arresting people who possess it. As for what else Dr. Haney and others of a similar mindset would still like to know — and how many additional studies would it take to provide them with that information — well, that’s anybody’s guess.