Since the late 1990s, more than half of states have legalized marijuana in some form. Now, some are viewing the drug as a solution for the opioid crisis plaguing North Carolina and the rest of the nation.
A growing body of research conducted in the states where marijuana is legal for medical use suggests that increasing access to marijuana lowers rates of opioid prescriptions and subsequent abuse. As North Carolina works to solve the opioid crisis, pain management experts and the recovery community alike are debating whether medical marijuana can be used as a solution.
The North Carolina chapter of the National Organization for the Reform of Marijuana Laws and other groups have been fighting for years for legislation that would legalize the drug, but they have faced opposition from state and national officials.
“There, I suspect, is no one treatment entity that will be good for everyone,” said Kay Sanford, a professor in the Gillings School of Global Public Health. “And by saying we won’t use this one, only this one is appropriate, we tie our hands in providing the best type of medical management, the best type of social intervention, the best kind of law enforcement."
Currently, the only cannabis products that are available for purchase in North Carolina are hemp-derived products that contain some of the same chemical components as marijuana but are less than 0.9 percent THC and contain no other psychoactive substance. These products have some pain management qualities, but do not alter the user’s mental state.
Since hemp sales were legalized in North Carolina, shops that sell hemp-derived products have been opening up all over the state.
Two studies focusing on the public health cost of opioid prescriptions found that the legalization of cannabis products, including those derived from hemp, reduced the number of opioid prescriptions.
In May 2018, researchers from Emory University found that in states that legalized medical marijuana after 2010, the rate of opioid prescriptions fell 5.88 percent for Medicaid enrollees.
A second study from the University of Georgia found that prescriptions of opioids for Medicare recipients fell by more than 3 million daily prescriptions when medical cannabis dispensaries opened in a state. The average state fills just over 23 million daily doses of opioids under Medicare.
More to be done
More than 115 people in the United States die from opioid-related overdoses every day, according to the National Institute on Drug Abuse. In 2017, the opioid crisis was declared to be a public health emergency.
But some members of the recovery community think there's still more research to be done before marijuana is embraced as a solution.
Alexander Smith, a UNC-Greensboro graduate involved with the Spartan Recovery program and Guilford Solution to the Opioid Problem, said while the studies clearly show there is a relationship, he is still unsure whether the legalization of medical marijuana is the direct cause of lower opioid use rates.
“If someone is not dying, then I am for it no matter what,” he said. “If we can bring down this death rate, especially with how slow the process is now with getting new access to treatment and creating new programs, then anything we can do I think is positive overall. As a person in recovery, I would support that if someone can prove a causal relationship more than just a correlation.”
Timothy Ives, professor in the Eshelman School of Pharmacy and director of the Chronic Pain Program, said one concern moving forward is the lack of regulation regarding the sale of hemp and the quality of the products customers are receiving.
“The cannabidiols are pretty safe in terms of the central nervous effect, but if you’re also on three or four prescription medications, then what do you do?” he said.
Sanford said it’s necessary to have providers that are better trained in pain management, and patients with the language to express when something is not working for them.
“If you’re asking whether someone should be prescribed medical marijuana in contrast to something else, that should be something that as practitioner and patient you explore and discuss,” Sanford said. “And if that’s a good fit, hopefully it’s available.”
An evidence-based approach
Dr. Paul Chelminski, a professor in the UNC School of Medicine, said the medical school has begun teaching residents to prescribe opioids with more caution.
“At the residency level for the past 15 years we’ve been in a culture changing mode where we recognize the public health risk of opioids early on, and we also recognize the limited effectiveness of opioids in treating chronic pain,” he said.
But prescribing marijuana instead of opioids may not be the solution, Chelminski said.
He said there are many safety concerns regarding the prescription and sale of medical marijuana. Because marijuana is a Schedule I controlled substance as classified by the U.S. Drug Enforcement Administration, it has not been rigorously tested in clinical trials.
Chelminski said another obstacle is that marijuana itself contains about 50 other substances, and it’s difficult to perform a trial that tests the chemicals and how they react in isolation.
“I look at marijuana the same way I look at a new antibiotic or a new form of chemotherapy,” he said. “I can’t possibly be in favor of it until we know if it works or if it causes harm.”
A path to recovery
Currently, some recovery programs utilize drugs such as methadone and buprenorphine to help minimize the symptoms of pain and withdrawal associated with recovery.
“(Some say) if you are using a medication, if you are using methadone, that’s simply substituting one drug for another,” Sanford said. “And that’s a very simplistic and inaccurate description. The drugs methadone or buprenorphine are designed to get rid of pain and, more importantly, control the cravings so one is no longer being driven.”
But marijuana has not been proven to be an addiction treatment that works like methadone and buprenorphine.
Joe Schrank is the founder of the San Francisco-based recovery group Remedy Recovery MAT, which uses marijuana as a recovery agent. He said many traditional treatment programs fail to offer a viable way out of addiction.
“Opiate addiction is really disruptive to development, emotions, spirituality, family life, on the using end and the recovery end,” Schrank said. “Cannabis offers a softer landing. It offers people time to settle in to this.”
Schrank said while he doesn’t view marijuana as the perfect solution to the nation’s drug problem, he thinks it should be an option for patients and providers.
“There are people who can manage chronic pain without opioids at all,” he said. “They can use cannabis medicinally. One of the ways to avoid the pitfalls of opioids is manage pain before you even take an opioid.”
Smith said that while his own recovery from opiate abuse is abstinence-based, he knows people that have been abstinent from opiates for years who still use marijuana and alcohol.
There are risks associated with using marijuana in any capacity, Smith said, but there is also a stigma associated with using the drug for medical purposes.
“A comparison would be how the broad perspective on syringe exchange programs and safe injection sites, as a method to decrease overdoses and disease transmission rates has changed,” Smith said. “The stigma for those ways of helping people has decreased because we’ve seen how helpful they can be to people.”
Similarly, the stigma for medical marijuana use may change.
“Over time, once something becomes properly regulated and administered, it can be effective,” Smith said. “There definitely needs to be more research, there definitely needs to be more thought, but it’s definitely promising.”
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