Opiates. Ohio. Oklahoma.
I’m not from Oklahoma, but I have spent half of my career there, and I can’t say enough good things. I loved it there! Oklahoma also has a very special relationship with marijuana.
Oklahoma’s marijuana industry is permissive for several reasons. The cost to develop a marijuana business is low compared to other states. The requirements for patients to obtain medical cards are easy to satisfy, and they’ve licensed a lot of dispensaries. If you’re from Oklahoma, you know that’s an understatement- You can’t walk a few blocks without seeing a dispensary!
In 2019, a state judge ordered the pharmaceutical manufacturer Johnson and Johnson $527 million in damages to the state and its citizens for underplaying the dangers of opiates. Around this same time, Oklahoma legalized marijuana for medical purposes and the industry exploded.
I’m from Ohio, a state that has been absolutely decimated by the opioid epidemic. Ohio ranks 1st or 2nd in most opiate-related indices including deaths per capita and overdoses. It’s medically legal, but the laws regarding physician certification are strict, and Ohio’s dispensary game is weak. Even the big cities seem to only have 3-4 dispensaries on the outskirts of town.
Ohio would benefit from what Oklahoma has: supportive legislation and a competitive market. Oklahoma’s industry has driven down medication prices for patients, and a permissive patient application process has improved access to marijuana.
As a state with a high burden of opiate-related illness, Ohio should pay attention: marijuana legalization and liberalization is clearly associated with a decrease in opiate prescribing. Marijuana products, including simple isolated CBD, also appear to have a meaningful positive effect on opiate abstinence.
Marijuana as a Mechanism for Improving Community Health
After I started practicing on my own I worked primarily in tiny little rural communities throughout Oklahoma. When you work in small towns, you hear a lot of sad stories- Everyone knows someone that has had issues with opiate addiction. Eventually I got to the point where I had a strict motto: “I do not treat chronic pain with narcotics in the ER.”
One of the most impressive qualities of marijuana is its well-documented ability to affect opiate prescription rates and opiate usage rates.
Last year (2019), two large scale studies were published in JAMA (which is doctor-speak for legit) that confirmed that legalization of marijuana reduces opiate prevalence.
The first research paper (1, Wen) showed that states with legalized marijuana had a documentable decrease in opiate prescriptions for Medicaid enrollees. States that legalized medical marijuana between 2011-2016 had a 5.88% decrease in opiate prescriptions written. States that went recreational after that had another 6.38% decrease in opiate prescriptions.
The second paper (2, Bradford) measured the total number of daily opiates dispensed to Medicare Part D patients. The analysis showed a roughly 10% decrease in the number of daily doses of opiates in states that instituted a medical cannabis law. That’s just by passing legislation! When dispensaries actually opened, another 16% decrease was appreciated.
It’s quite clear that marijuana legalization causes a decrease in opiate use- I feel that direct, deliberate action is the best way to take this from an observation to an actuality.
Dispensaries in states with a high opiate burden could act as pill drop offs- removing dangerous medications from the public, while educating pain patients on healthier ways to manage their pain.
Pills to Pot
Pain has consistently been identified as the most common reason medicinal patients pursue cannabis. Chronic pain is common, costly to treat, and challenging to manage.
For a variety of reasons, opiates have been for years the traditional treatment for chronic pain. Opiates are effective and extremely inexpensive in the United States. Thanks to years-long efforts of pharmaceutical giants like the recently-chastised Johnson & Johnson, opiate prescription is a normalized part of medical practice.
I’m confident that that’s going to change- the Oklahoma lawsuit is only one of several similar legal actions, and marijuana legalization is near-inevitable.
I think that all medications have their limitations and their down sides (marijuana included- this is your daily reminder that marijuana smoke is unhealthy for you).
However, marijuana has the notable benefit of not straight-up killing people after usage the same way opiates do. Case reports of marijuana-related fatalities in adults are almost nonexistent- most are related to vast overdoses of edible cannabis. At last report, there were under 10. Opiate-related deaths topped 69,000 in 2019 (3).
For patients that use opiates, cannabis has routinely been shown to be an adequate substitute. In the past several years, marijuana use has been correlated with an individual’s decrease in opiate use over and over again (4-7).
There’s a growing body of literature that shows that marijuana products, including CBD alone, are effective in assisting with opiate withdrawal symptoms. CBD has been shown to reduce heroin cravings (8). That’s incredible! Humble CBD taking on heroin and in this small study, actually winning.
Again, observations are good, but the next step for marijuana being promoted as a direct treatment is absolutely more controlled, high-quality research. There is no substitution, and marijuana can never be recommended wholeheartedly without more research.
I think the next step is to go after the details- how much marijuana replaces how much opiate? Are edible or smoked products more effective? Is CBD sufficient, or does THC play a role in reducing addiction as well?
Wen H, Hockenberry JM. Association of Medical and Adult-Use Marijuana Laws With Opioid Prescribing for Medicaid Enrollees. JAMA Internal Medicine. 2018 May; 178(5): 673–679.
Bradford AC et al. Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018;178(5):667-672.
Center for Disease Control STATCAST https://www.cdc.gov/nchs/pressroom/podcasts/20190911/20190911.htm. September 2019.
Lucas P et al. Medical cannabis patterns of use and substitution for opioids & other pharmaceutical drugs, alcohol, tobacco, and illicit substances; results from a cross-sectional survey of authorized patients. Harm Reduct J. 16(1):9.
Boehnke KF et al. Pills to pot: observational analyses of cannabis substitution among medical cannabis users with chronic pain. 2019 Jan; 20(7): 830-841
Boehnke KF et al. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain. 2016 Jun;17(6):739-44.
Baron EP et al. Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort. J Headache Pain. 2018 May 24;19(1):37
Hurd YL et al. Cannabidiol for the Reduction of Cue-Induced Craving and Anxiety in Drug-Abstinent Individuals With Heroin Use Disorder: A Double-Blind Randomized Placebo-Controlled Trial. American Journal of Psychiatriy published online 2019; May 21.