Does Medical Cannabis Use Increase or Decrease the Use of Opioid Analgesics and Other Prescription Drugs?

“Flower Power”: Controlled Inhalation of THC-Predominant Cannabis Flos Improves Health-Related Quality of Life and Symptoms of Chronic Pain and Anxiety in Eligible UK Patients

In November 2018, the UK’s Home Office established a legal route for eligible patients to be prescribed cannabis-based products for medicinal use in humans (CBPMs) as unlicensed medicines. These include liquid cannabis extracts for oral administration (“oils”) and dried flowers for inhalation (“flos”). Smoking of CBPMs is expressly prohibited. To date, THC-predominant cannabis flowers remain the most prescribed CBPMs in project Twenty21 (T21), the first multi-center, prospective, observational UK cannabis patient registry. This observational, prospective data review analyzes patient-reported outcome measures (PROMS) collected by T21 associated with the inhalation of KHIRON 20/1, the most prescribed CBPM in the project. PROMS collected at baseline and at subsequent 3-month follow-up included health-related quality of life (HRQoL), general mood, and sleep. Condition-specific measures of illness severity were performed with the Brief Pain Inventory Short Form (BPI-SF) and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Participants (N = 344) were mostly males (77.6%, average age = 38.3) diagnosed mainly with chronic pain (50.9%) and anxiety-related disorders (25.3%). Inhalation of KHIRON 20/1 was associated with a marked increase in self-reported HRQoL, general mood, and sleep (N = 344; p < 0.001). Condition-specific assessments showed significant improvements in pain severity (T = 6.67; p < 0.001) and interference (T = 7.19; p < 0.001) in patients using KHIRON 20/1 for chronic pain (N = 174). Similar results were found for patients diagnosed with anxiety-related disorders (N = 107; T = 12.9; p < 0.001). Our results indicate that controlled inhalation of pharmaceutical grade, THC-predominant cannabis flos is associated with a significant improvement in patient-reported pain scores, mood, anxiety, sleep disturbances and overall HRQoL in a treatment-resistant clinical population.

"Flower Power": Controlled Inhalation of THC-Predominant Cannabis Flos Improves Health-Related Quality of Life and Symptoms of Chronic Pain and Anxiety in Eligible UK Patients

In November 2018, the UK’s Home Office established a legal route for eligible patients to be prescribed cannabis-based products for medicinal use in humans (CBPMs) as unlicensed medicines. These include liquid cannabis extracts for oral administration (“oils”) and dried flowers for inhalation (“flos”). Smoking of CBPMs is expressly prohibited. To date, THC-predominant cannabis flowers remain the most prescribed CBPMs in project Twenty21 (T21), the first multi-center, prospective, observational UK cannabis patient registry. This observational, prospective data review analyzes patient-reported outcome measures (PROMS) collected by T21 associated with the inhalation of KHIRON 20/1, the most prescribed CBPM in the project. PROMS collected at baseline and at subsequent 3-month follow-up included health-related quality of life (HRQoL), general mood, and sleep. Condition-specific measures of illness severity were performed with the Brief Pain Inventory Short Form (BPI-SF) and the Generalized Anxiety Disorder 7-Item Scale (GAD-7). Participants (N = 344) were mostly males (77.6%, average age = 38.3) diagnosed mainly with chronic pain (50.9%) and anxiety-related disorders (25.3%). Inhalation of KHIRON 20/1 was associated with a marked increase in self-reported HRQoL, general mood, and sleep (N = 344; p < 0.001). Condition-specific assessments showed significant improvements in pain severity (T = 6.67; p < 0.001) and interference (T = 7.19; p < 0.001) in patients using KHIRON 20/1 for chronic pain (N = 174). Similar results were found for patients diagnosed with anxiety-related disorders (N = 107; T = 12.9; p < 0.001). Our results indicate that controlled inhalation of pharmaceutical grade, THC-predominant cannabis flos is associated with a significant improvement in patient-reported pain scores, mood, anxiety, sleep disturbances and overall HRQoL in a treatment-resistant clinical population.

Opioid use in medical cannabis authorization adult patients from 2013 to 2018: Alberta, Canada

BACKGROUND

The opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada.

METHODS

All adult patients defined as chronic opioid users who were authorized medical cannabis by their health care provider in Alberta, Canada from 2013 to 2018 were propensity score matched to non-authorized chronic opioid using controls. A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users.

RESULTS

Average age was 52 years and 54% were female. Patients on low dose opioids (< 50 OME) had an increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME > 100), showed a significant decrease over 6 months (- 435.5, 95% CI: - 596.8 to - 274.2) compared to controls.

CONCLUSIONS

This short-term study found that medical cannabis authorization showed intermediate effects on opioid use, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME > 100); however, continued surveillance of patients utilizing both opioids and medical cannabis is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.

Is Cannabis being used as a substitute for non-medical opioids by adults with problem substance use in the United States? A within-person analysis

BACKGROUND AND AIMS

Ecological studies have suggested that Cannabis legalization might have led to a decrease in opioid overdose deaths. Such studies do not provide information about whether individuals are substituting Cannabis for opioids at different points in time. The current study assessed the magnitude of the daily association between Cannabis and opioid use in individual adults with and without pain who use non-medical opioids.

DESIGN

Prospective cohort study.

SETTING

The greater New York area and a suburban inpatient addiction program.

PARTICIPANTS

Adults with problem substance use who use non-medical opioids, recruited from May 2016-June 2019. The analytical sample included 13 271 days of observation among 211 participants (64% male, 41% white, 78% unmarried, 80% unemployed, mean age 43 years).

MEASUREMENTS

Participants completed interviewer- and self-administered computerized surveys, and then responded to an interactive voice response (IVR) system daily for the following 90 days. The main exposures, Cannabis use and pain, were defined as responding affirmatively to the IVR question: 'Did you use Cannabis yesterday?' and endorsing moderate or severe pain at baseline, respectively. The main outcome, non-medical or illicit opioid use during 90-day follow-up, was defined as responding affirmatively to IVR question: 'Did you use heroin yesterday?' or 'Did you use prescription opioids more than prescribed or without a prescription yesterday?'.

FINDINGS

The mean IVR completion rate was 70%. The unadjusted odds ratio (aOR) indicating same-day use of Cannabis and opioids was 2.00 [95% confidence interval (CI) = 1.54-2.59]. Controlling for demographic characteristics, recruitment method, opioid types at baseline and pain, the aOR was 1.86 (95% CI = 1.44-2.41). A test of interaction between pain and Cannabis use to determine if the association of Cannabis with opioid use differed between people with moderate-to-severe pain and less-than-moderate pain was inconclusive.

CONCLUSIONS

Among US adults with problem substance use who use non-medical opioids, the odds of opioid use appear to be approximately doubled on days when Cannabis is used. This relationship does not appear to differ between people with moderate or more severe pain versus less than moderate pain, suggesting that Cannabis is not being used as a substitute for illegal opioids.

The Void in Clinician Counseling of Cannabis Use

As more states legalize cannabis for medical use, people increasingly use cannabis to treat medical conditions. Well-documented harms of cannabis use include increased risk of fatal auto accidents, neurocognitive deficits, and increased risk of addiction. Observational data supports the use of cannabis for pain, nausea and vomiting related to chemotherapy, and multiple sclerosis spasticity symptoms. Given potential harms versus benefits of cannabis use, how should physicians counsel patients regarding their cannabis use? This paper briefly reviews the evidence supporting medical cannabis use for pain. We consider cannabis use as a harm reduction strategy for pain management. We encourage routine, longitudinal assessments of cannabis use among patients. We discuss the commercialization of cannabis for financial gain, contributing to potent and addictive cannabis. We highlight the concerning phenomena of cannabis dispensary workers as proxy clinicians. Finally, we present three strategies to reduce public harms associated with potent cannabis use including required testing and reporting of tetrahydrocannabinol/cannabidiol concentrations, rigorous study of high-potency cannabis available for purchase in dispensaries across the USA, and large-scale efforts to measure cannabis consumption in medical records so prospective, longitudinal studies can be conducted to correlate consumption measures with medical and psychiatric outcomes.

Marijuana Use and Its Associations With Pain, Opioid Dose, and HIV Viral Suppression Among Persons Living With HIV on Chronic Opioid Therapy

BACKGROUND

Medical marijuana is legal in 29 US states and the District of Columbia: both HIV and chronic pain are "approved conditions" for receipt. Chronic pain is common among people living with HIV (PLWH). We anticipate PLWH will question their providers about medical marijuana for chronic pain. We examined marijuana use and its associations with pain, opioid dose, and HIV viral suppression among PLWH receiving chronic opioid therapy.

METHODS

PLWH prescribed chronic opioid therapy were recruited into the Targeting Effective Analgesia in Clinics for HIV cohort. The main exposure variable was any past 12-month marijuana use. The primary outcomes were (1) opioid misuse (≥9 on the Current Opioid Misuse Measure) and (2) opioid dose (morphine equivalent daily dose). HIV viral load (VL) suppression (<200 copies/μL) and pain severity and interference using the Brief Pain Inventory were exploratory outcomes.

RESULTS

Participants (n = 166) were men (65%), Black (72%), and had an undetectable VL (89%). We found no significant association between current marijuana use and opioid misuse, opioid dose, or pain. Current marijuana use was associated with 3.03 times the odds of having a detectable VL (95% odds ratio: 1.11-8.31, P = 0.03) while controlling for depressive symptoms and other substance use.

DISCUSSION

We did not detect an association between marijuana use and opioid misuse behaviors, opioid dose, or pain. In an exploratory analysis, current marijuana use was associated with 3× greater odds of having a detectable VL. This study provides insights into potential consequences of marijuana use among PLWH with chronic pain.