Chronic cannabis use does not affect the normalization of hypothalamic-pituitary-adrenal (HPA) axis induced by methadone in heroin addicts

Differential effect of cannabis use on opioid agonist treatment outcomes: Exploratory analyses from the OPTIMA study

INTRODUCTION

Conflictual evidence exists regarding the effects of cannabis use on the outcomes of opioid agonist therapy (OAT). In this exploratory analysis, we examined the effect of recent cannabis use on opioid use, craving, and withdrawal symptoms, in individuals participating in a trial comparing flexible buprenorphine/naloxone (BUP/NX) take-home dosing model to witnessed ingestion of methadone.

METHODS

We analyzed data from a multi-centric, pragmatic, 24-week, open label, randomized controlled trial in individuals with prescription-type opioid use disorder (n = 272), randomly assigned to BUP/NX (n = 138) or methadone (n = 134). The study measured last week cannabis and opioid use via timeline-follow back, recorded at baseline and every two weeks during the study. Craving symptoms were measured using the Brief Substance Craving Scale at baseline, and weeks 2, 6, 10, 14, 18 and 22. The study measured opioid withdrawal symptoms via Clinical Opiate Withdrawal Scale at treatment initiation and weeks 2, 4, and 6.

RESULTS

The mean maximum dose taken during the study was 17.3 mg/day (range = 0.5-32 mg/day) for BUP/NX group and 67.7 mg/day (range = 10-170 mg/day) in the methadone group. Repeated measures generalized linear mixed models demonstrated that cannabis use in the last week (mean of 2.3 days) was not significantly associated with last week opioid use (aβ ± standard error (SE) = -0.06 ± 0.04; p = 0.15), craving (aβ ± SE = -0.05 ± 0.08, p = 0.49), or withdrawal symptoms (aβ ± SE = 0.09 ± 0.1, p = 0.36). Bayes factor (BF) for each of the tested models supported the null hypothesis (BF < 0.3).

CONCLUSIONS

The current study did not demonstrate a statistically significant effect of cannabis use on outcomes of interest in the context of a pragmatic randomized-controlled trial. These findings replicated previous results reporting no effect of cannabis use on opioid-related outcomes.

The Cannabis-Dependent Relationship Between Methadone Treatment Dose and Illicit Opioid Use in a Community-Based Cohort of People Who Use Drugs

Background: Methadone maintenance treatment (MMT) is an effective treatment for opioid use disorder. However, subtherapeutic dosing may lead to continued opioid use by failing to suppress opioid withdrawal and craving. Preclinical and pilot experimental research suggests that cannabinoids may reduce opioid withdrawal and craving. We sought to test whether the association between low methadone dose and illicit opioid use differs according to concurrent cannabis use patterns. Methods: Data for this study were derived from two community-recruited cohorts of people (≥18 years old) who use illicit drugs in Vancouver, Canada. We used generalized estimating equations to estimate the adjusted association between lower daily MMT dose (<90 mg/day) and daily illicit opioid use, testing for interaction between dose and daily cannabis use. Results: Between December 2005 and December 2018, 1389 participants reported MMT enrolment and were included in the study. We observed a significant interaction (p<0.01) between daily cannabis and lower MMT dose on concurrent daily illicit opioid use: lower MMT doses increased the odds of daily illicit opioid use by 86% (adjusted odds ratio [AOR]=1.86, 95% confidence interval [CI]=1.61-2.16) during periods of no or low-frequency cannabis use and by 30% during periods of daily cannabis use (AOR=1.30, 95% CI=1.01-1.67). Discussion: This study provides preliminary observational evidence that cannabis may mitigate some of the negative effects of subtherapeutic MMT dosing, guiding future clinical investigations into the safety and efficacy of cannabis and cannabinoids as adjunct treatment for MMT.

Alleviation of opioid withdrawal by cannabis and delta-9-tetrahydrocannabinol: A systematic review of observational and experimental human studies

BACKGROUND

While six U.S. states have already officially authorized cannabinoids to substitute opioids and treat opioid use disorder, the therapeutic benefits of cannabinoids remain unclear, especially when weighted against their adverse effects.

METHODS

We conducted a systematic review of studies examining the association between opioid withdrawal and cannabis use or delta-9-tetrahydrocannabinol (THC) administration. We searched multiple databases from inception to July 30, 2022, and assessed study quality.

RESULTS

Eleven studies were identified, with a total of 5330 participants, of whom 64 % were male. Nine observational studies examined the association between cannabis use and opioid withdrawal. Two randomized, placebo-controlled clinical trials (RCTs) investigated the withdrawal-alleviating effects of dronabinol, a synthetic form of THC. Four observational studies found an association between cannabis use and the alleviation of opioid withdrawal; one reported exacerbation of opioid withdrawal symptoms; and four reported no association. RCTs reported that THC alleviated opioid withdrawal, albeit with dose-dependent increases in measures of abuse liability, dysphoria, and tachycardia. There was high heterogeneity in measurements of opioid withdrawal and the type and dose of opioid at baseline.

CONCLUSIONS

Although there is preliminary evidence that cannabis and its main psychoactive constituent, THC, may alleviate opioid withdrawal, these effects are likely to have a narrow therapeutic window. Further, the potential of cannabinoids to alleviate opioid withdrawal is determined by complex interactions between patient characteristics and pharmacological factors. Collectively, these findings have clinical, methodological, and mechanistic implications for treating opioid withdrawal during cannabinoid use, and for efforts to alleviate opioid withdrawal using non-opioid therapeutics.

The relationship between cannabis use and patient outcomes in medication-based treatment of opioid use disorder: A systematic review

Despite high rates of cannabis use during medication-based treatment of opioid use disorder (MOUD), uncertainty remains around how cannabis influences treatment outcomes. We sought to investigate the relationship between cannabis use during MOUD and a number of patient outcomes. We searched seven databases for original peer-reviewed studies documenting the relationship between cannabis use and at least one primary outcome (opioid use, treatment adherence, or treatment retention) among patients enrolled in methadone-, buprenorphine-, or naltrexone-based therapy for OUD. In total, 41 articles (including 23 methadone, 7 buprenorphine, 6 naltrexone, and 5 mixed modalities) were included in this review. For each primary outcome area, there was a small number of studies that produced findings suggestive of a supportive or detrimental role of concurrent cannabis use, but the majority of studies reported that cannabis use was not statistically significantly associated with the outcome. No studies of naltrexone treatment demonstrated significantly worse outcomes for cannabis users. We identified methodological shortcomings and future research priorities, including exploring the potential role of adjunct cannabis use for improving opioid craving and withdrawal during MOUD. While monitoring for cannabis use may help guide clinicians towards an improved treatment plan, cannabis use is unlikely to independently threaten treatment outcomes.

Stress indices in methadone maintenance treatment - Cross sectional and follow up study

To study the prevalence of perceived high stress among methadone maintenance treatment (MMT) patients, and whether stress can predict outcome, and whether stress may improve during treatment, we studied a sample of 107 MMT patients using Perceived Stress Scale (PSS) questionnaires. We studied if PSS scores on admission predict long-term retention, and we monitored stress indices (PSS, heart rate variability, saliva cortisol) on admission, 6 and 12 months later, to measure changes. Variables included demographic data, history of adverse events, and urine test. A sample of 79 (73.8%) males and 28 (26.2%) females whose age at opioid use onset was 22.1±7.2 years and age at study onset 50.5±10.8 years was studied for PSS. Both high and very-high PSS patients characterized (logistic regression) as abusing benzodiazepine, and with history of depressive symptoms. The very-high PSS group on admission (n=29) had shorter cumulative retention (1.8 years, 95%%CI 1.2-2.4) compared with 50 others (2.8 years, 95%%CI 2.3-3.3, p=0.03). Monitoring stress indices among 25 patients found that no-benzodiazepine and cocaine use on admission, opioid discontinuation after 6 months, and any substance discontinuation after a year were associated with stress reduction. Conclusion: stress level appears to normalize among MMT patients if no other substance is abused.

Cannabis use during methadone maintenance treatment for opioid use disorder: a systematic review and meta-analysis

BACKGROUND

Rates of cannabis use among patients receiving methadone maintenance therapy are high, and cannabis use may be associated with outcomes of methadone maintenance therapy. We examined the effect of cannabis use on opioid use in patients receiving methadone maintenance therapy to test the hypothesis that cannabis use is associated with a reduction in opioid use.

METHODS

In this systematic review, we searched MEDLINE/PubMed, Embase, PsycINFO, CINAHL and ProQuest Dissertations and Theses Global from inception to July 12, 2018. We summarized the effects of cannabis use on opioid use during methadone maintenance therapy and treatment retention. We conducted meta-analyses using a random effects model.

RESULTS

We included 23 studies in our review. We performed a meta-analysis of 6 studies, with a total number of participants of 3676, examining use of cannabis and opioids during methadone maintenance therapy. Owing to high heterogeneity, we described the studies qualitatively but provide the forest plots as supplemental material. The overall quality of evidence was very low, with a high risk of bias, owing to the nature of observational studies.

INTERPRETATION

We found no consensus among studies that cannabis use is associated with reduced opioid use or longer treatment retention when used during methadone maintenance therapy in patients with opioid use disorder. PROSPERO Registration: CRD42015029372.

Development and validation of the scale to assess satisfaction with medications for addiction treatment - Buprenorphine-naloxone for heroin addiction (SASMAT-BUNHER)

BACKGROUND

Until now, no specific tool has been available to measure heroin-dependent patient satisfaction with buprenorphine-naloxone as a medication. The purpose of the present study was to develop the Scale to Assess Satisfaction with Medications for Addiction Treatment-Buprenorphine-Naloxone for Heroin addiction (SASMAT-BUNHER) and to examine its validity and reliability.

METHODS

The SASMAT-BUNHER was developed from a pool of 44 self-administered items grouped into nine theoretical domains, as follows: Overall Satisfaction, Pharmacotherapy, Initiation, Anti-Addictive Effect on Heroin, Mental State, Physical State, Personal Functioning, Acceptability, and Anti-Addictive Effect on Secondary Substances. The Treatment Satisfaction Questionnaire for Medication 1.4 version (TSQM 1.4) was used for convergent validation. Participants were 316 heroin-dependent patients in maintenance treatment with buprenorphine-naloxone sublingual tablets at 16 different treatment centres.

RESULTS

Principal component analysis of the SASMAT-BUNHER revealed a 5-factor structure that accounted for 65.1% of total variance. Based on similarities between empirically-obtained factors and theoretical domains, Factors 1 through 5 were named 'Mental and Physical State' (10 items), 'Anti-Addictive Effect on Other Substances' (5 items), 'Anti-Addictive Effect on Heroin' (4 items), 'Personal Functioning' (3 items), and 'Acceptability' (4 items). All factors showed acceptable internal consistency (Cronbach's alpha coefficients: 0.744-0.925) and test-retest reliability (intraclass correlation coefficients: 0.704-0.895). Correlation between SASMAT-BUNHER and TSQM 1.4 total scores was moderate (Pearson r = 0.552). Moreover, SASMAT-BUNHER total scores of patients reporting absence of buprenorphine-naloxone side effects were higher than those of their counterparts.

CONCLUSION

These results support the validity and reliability of the SASMAT-BUNHER.

Impact of synthetic cannabinoids on the duration of opioid-related withdrawal and craving among patients of addiction clinics in Kazakhstan: A prospective case-control study

OBJECTIVE

The aim of the study was to prospectively assess whether regular use of synthetic cannabinoids (SCs) affects the duration of opioid-related withdrawal and craving symptoms in patients undergoing drug detoxification treatments.

METHODS

Patients (n = 193) with opioid use disorder, among which 47 patients are regularly using SCs, underwent integrated drug detoxification therapies. The Clinical Opiate Withdrawal Scale and a specific visual analogue scale were used to assess opioid withdrawal and craving symptoms over time.

RESULTS

Subjects using SCs had significantly longer duration of withdrawal and craving symptoms (p < .001). Higher intake of SCs in the last 30 days (p = .045), shorter time since the last intake of SCs (p = .033), longer duration of SCs use (p < .001), and higher dosage of SCs (p < .001) were associated with longer duration of symptoms.

DISCUSSION

This is the first study to assess the impact of SCs on the course of opioid withdrawal and craving symptoms. The results (a) suggest that patients with opioid use disorder in combination with regular use of SCs exhibit a significantly longer duration of opioid withdrawal and craving symptoms, (b) add to the accumulating evidence showing clinical and molecular cross talks between cannabinoids and opioids, and (c) underline novel harmful effects of SCs.

Impact of cannabis use during stabilization on methadone maintenance treatment

BACKGROUND AND OBJECTIVES

Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner.

METHODS

To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance.

RESULTS

Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

Cannabinoid and opioid interactions: implications for opiate dependence and withdrawal

Withdrawal from opiates, such as heroin or oral narcotics, is characterized by a host of aversive physical and emotional symptoms. High rates of relapse and limited treatment success rates for opiate addiction have prompted a search for new approaches. For many opiate addicts, achieving abstinence may be further complicated by poly-drug use and co-morbid mental disorders. Research over the past decade has shed light on the influence of endocannabinoids (ECs) on the opioid system. Evidence from both animal and clinical studies point toward an interaction between these two systems, and suggest that targeting the EC system may provide novel interventions for managing opiate dependence and withdrawal. This review will summarize the literature surrounding the molecular effects of cannabinoids and opioids on the locus coeruleus-norepinephrine system, a key circuit implicated in the negative sequelae of opiate addiction. A consideration of the trends and effects of marijuana use in those seeking treatment to abstain from opiates in the clinical setting will also be presented. In summary, the present review details how cannabinoid-opioid interactions may inform novel interventions in the management of opiate dependence and withdrawal.

Differential effect of opioid and cannabinoid receptor blockade on heroin-seeking reinstatement and cannabinoid substitution in heroin-abstinent rats

BACKGROUND AND PURPOSE

Opioids and cannabinoids interact in drug addiction and relapse. We investigated the effect of the opioid receptor antagonist naloxone and/or the cannabinoid CB(1) receptor antagonist rimonabant on cannabinoid-induced reinstatement of heroin seeking and on cannabinoid substitution in heroin-abstinent rats. EXPERIMENTAL APPROACH Rats were trained to self-administer heroin (30 µg·kg(-1) per infusion) under a fixed-ratio 1 reinforcement schedule. After extinction of self-administration (SA) behaviour, we confirmed the effect of naloxone (0.1-1 mg·kg(-1)) and rimonabant (0.3-3 mg·kg(-1)) on the reinstatement of heroin seeking induced by priming with the CB(1) receptor agonist WIN55,212-2 (WIN, 0.15-0.3 mg·kg(-1)). Then, in a parallel set of heroin-trained rats, we evaluated whether WIN (12.5 µg·kg(-1) per infusion) SA substituted for heroin SA after different periods of extinction. In groups of rats in which substitution occurred, we studied the effect of both antagonists on cannabinoid intake.

KEY RESULTS

Cannabinoid-induced reinstatement of heroin seeking was significantly attenuated by naloxone (1 mg·kg(-1)) and rimonabant (3 mg·kg(-1)) and fully blocked by co-administration of sub-threshold doses of the two antagonists. Moreover, contrary to immediate (1 day) or delayed (90 days) drug substitution, rats readily self-administered WIN when access was given after 7, 14 or 21 days of extinction from heroin, and showed a response rate that was positively correlated with the extinction period. In these animals, cannabinoid intake was increased by naloxone (1 mg·kg(-1)) and decreased by rimonabant (3 mg·kg(-1)).

CONCLUSIONS AND IMPLICATIONS

Our findings extend previous research on the crosstalk between cannabinoid and opioid receptors in relapse mechanisms, which suggests a differential role in heroin-seeking reinstatement and cannabinoid substitution in heroin-abstinent rats.

Methadone is substantially less effective than morphine in modifying locomotor and brain Fos responses to subsequent methadone challenge in rats

Heroin addicts can benefit from methadone substitution therapy. However, little is known about the significance of pre-exposure to opioids for psychoactive effects of methadone. We modeled some behavioral and neurobiological aspects of the opioid abuse-related phenomena in Sprague-Dawley rats, using morphine (10 mg/kg/day) or methadone (1 or 2 mg/kg/day) treatment (14 doses over a 16-day period) followed by 2-week withdrawal and methadone challenge; control rats were given 0.9% NaCl treatment and methadone challenge by the same schedule. Locomotor response to the challenge showed substantial enhancement only after the morphine treatment. Fos immunohistochemistry in selected brain regions including cortex, nucleus accumbens, striatum and some parts of the hippocampus, thalamus and amygdala also revealed marked differences between the effects of the tested treatments. Sensitization of Fos response was found in a few regions of the morphine-treated rats. The rats given the higher methadone dose treatment showed a fairly weak tendency for sensitization that reached significance only in somatosensory cortex layer IV. The rats given the lower methadone dose treatment showed a weak while widespread tendency for an opposite change, which reached significance in cingulate cortex layer II/III and resulted in significant differences in Fos response between these rats and the morphine-treated rats in most regions studied. These results indicate that lasting neuroplastic changes associated with the sensitization caused by (sub)chronic exposure to opioids are relatively mild for methadone as compared to those caused by morphine, and suggest that psychoactive effects of methadone can be notably enhanced by past opiate use.