Science
The Journal Club: Opioids, chronic pain and titrating cannabinoids
Grow Pharma shares what to expect in the latest issue of the Journal Club.
Grow Pharma launched the Journal Club to help educate UK doctors on the latest medical cannabis research. Here, Luca Marelli, shares a taste of what to expect in the latest issue.
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For this edition of the journal club, the focus is on opioids. Opioid analgesic overdose mortality continues to rise globally, driven by increases in prescribing for chronic pain. Several recent observational studies have reported reductions in opioid intake with medical cannabis [1], [2], raising the question of whether cannabis could help combat the opioid epidemic.
A landmark 2014 investigation [3] found that state-level medical cannabis laws in the USA were associated with significantly lower state-level opioid overdose mortality rates. However, a subsequent study found this association to be spurious [4]. Hsu et al (2021) – the first study featured in this journal club – suggest that these inconsistent findings could be due to the focus up until now being on legalisation events rather than access to cannabis itself.
They argue that state legalisation does not always correlate with cannabis being widely available; for example, some states that legalised cannabis do not provide legal allowances for stores (‘dispensaries’) to sell cannabis. Additionally, even in states that have legalised sale of cannabis, there is often a significant time lag between legislation being passed and patients actually being able to access cannabis.
In their study, Hsu et al (2021) therefore examine the association between active cannabis dispensary operations (as a more direct measure of legal cannabis availability than state legalisation alone) and age-adjusted opioid related mortality rates at the USA county level over the period 2014-2018.
In total, 812 counties with medical and/or recreational cannabis dispensaries were included in the research. Overall, cannabis (medical and/or recreational) dispensary counts were associated with reduced opioid related mortality rates at the county level. A doubling of cannabis dispensaries was associated with a 17 per cent reduction in the age-adjusted mortality for all opioid types. This association was particularly strong for deaths associated with synthetic opioids (e.g fentanyl).
The second study included in this edition of the journal club is a practical recommendation by a panel of Canadian specialists on how to safely introduce and titrate cannabinoids, acting as a companion piece to the Bhaskar et al (2021) [5] consensus recommendation covered in the first edition of the journal club (published December 1st, 2021).
In addition, however, this recommendation also includes guidance on when and how to taper opioids in patients taking cannabis for chronic pain. The guideline suggests opioid tapering should be considered when either the cannabis dose has been optimised, the patient reports an improvement in function, or seeks less as-needed medication to control pain.
Importantly, it is emphasised that opioid tapering should not begin at cannabinoid initiation or at a pre-specified cannabinoid dose. When initiating tapering, a gradual opioid dose reduction of five to 10 per cent of the morphine equivalent dose (MED) every one to four weeks is recommended, with a goal of reducing it to < 90mg MED. The timeline for the frequency of dose reduction is broad to allow for patient tailoring.
If you are a doctor and would like to discuss either of the clinical papers featured in this edition of the journal club or the broader medical cannabis literature, please reach out on luca.marelli@growbiotech.com
References:
1 Piper.B et al. Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep (2017). J Psychopharmacol 31(5):569-575
2 Lucas.P, Boyd.S, Milloy.M et al. Cannabis significantly reduces the use of prescription opioids and improves quality of life in authorised patients: results of a large prospective study (2021). Pain Med 22(3):727-739
3 Bachhuber.M, Saloner.B, Cunningham.C et al. Medical cannabis laws and opioid analgesic overdose mortality in the US, 1999-2010. (2014). JAMA Internal Medicine 174(10):1668-1673
4 Shover CL, Davis CS, Gordon SC, et al. Association between medical cannabis laws and opioid overdose mortality has reversed over time (2019). Proc Natl Acad Sci USA 116:12624-6.
5 Bhaskar.A, Bell.A, Boivin.M et al. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process (2021). Journal of Cannabis Research 3:22
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