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Should Physicians Recommend Replacing Opioids With Cannabis?

Educational Objective Review research of the effect of Replacing Opioids With Cannabis.
1 Credit CME

Recent state regulations (eg, in New York, Illinois) allow medical cannabis as a substitute for opioids for chronic pain and for addiction. Yet the evidence regarding safety, efficacy, and comparative effectiveness is at best equivocal for the former recommendation and strongly suggests the latter—substituting cannabis for opioid addiction treatments is potentially harmful. Neither recommendation meets the standards of rigor desirable for medical treatment decisions.

Recent systematic reviews1,2 identified low-strength evidence that plant-based cannabis preparations alleviate neuropathic pain and insufficient evidence for other types of pain. Studies tend to be of low methodological quality, involve small samples and short-follow-up periods, and do not address the most common causes of pain (eg, back pain). This description of evidence for efficacy of cannabis for chronic pain is similar to how efficacy studies of opioids for chronic pain have been described (except that the volume of evidence is greater for opioids with 96 trials identified in a recent systematic review3).

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Article Information

Corresponding Author: Richard Saitz, MD, MPH, Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Fourth Floor, Boston, MA 02118 (richard.saitz@jamanetwork.org).

Published Online: February 1, 2019. doi:10.1001/jama.2019.0077

Conflict of Interest Disclosures: Dr Saitz reports receipt of personal fees from the American Society of Addiction Medicine (ASAM [editor and a practice guideline reviewer]), BMJ (editor and meeting travel), American Medical Association (editor and meeting travel), National Council on Behavioral Healthcare (change guide development and travel), Kasier Permanente (grant consultant, technical expert, and guideline review), UpToDate/Wolters Kluwer (editor and travel), Massachusetts Medical Society (editor), Yale University (member, data and safety monitoring board), National Committee for Quality Assurance (expert consultant on alcohol screening), University of Oregon (consultant), Oregon Health Sciences University (guideline review), RAND (research consultant), Leed Management Consulting/Harvard Medical School (collaborative education in substance use disorder [supported by the National Institute on Drug Abuse {NIDA}]), Harvard Medical School (lectures), Partners (lecture), Beth Israel Deaconess Hospital (lecture), American Academy of Addiction Psychiatry (enduring educational material), medical malpractice expert witness, and Group Health Cooperative (research consulting) outside the submitted work; nonfinancial support from Alkermes (medication for clinical trial); travel to the International Network on Brief Interventions for Alcohol and Other Drugs (supported via funds from Systembolaget); travel supported by Karolinska Institutet for expert panel meeting; work and travel supported by ASAM with the Institute for Research and Training in the addictions guideline development; Charles University, Prague, Czech Republic (travel support for addiction science publishing workshop); Brandeis expert panel; president, International Society of Addiction Journal Editors; research consulting to ABT Corporation; investigator supported in part by grants to Boston University from NIDA, National Institute on Alcohol Abuse and Alcoholism, and Patient-Centered Outcomes Research Institute (via Public Health Management Corp), and Burroughs Wellcome Fund (and to Boston University from McClean Hospital from NIDA). No other disclosures were reported.

Disclaimer: Opinions expressed are the sole responsibility of the authors and do not necessarily reflect official Veterans Administration viewpoints.

References
1.
Nugent  SM, Morasco  BJ, O’Neil  ME,  et al.  The effects of cannabis among adults with chronic pain and an overview of general harms.  Ann Intern Med. 2017;167(5):319-331. doi:10.7326/M17-0155PubMedGoogle ScholarCrossref
2.
Campbell  G, Hall  W, Degenhardt  L, Dobbins  T, Farrell  M.  Cannabis use and non-cancer chronic pain—authors’ reply.  Lancet Public Health. 2018;3(10):e469. doi:10.1016/S2468-2667(18)30182-8PubMedGoogle ScholarCrossref
3.
Busse  JW, Wang  L, Kamaleldin  M,  et al.  Opioids for chronic noncancer pain.  JAMA. 2018;320(23):2448-2460. doi:10.1001/jama.2018.18472PubMedGoogle ScholarCrossref
4.
Caputi  TL, Humphreys  K.  Medical marijuana users are more likely to use prescription drugs medically and non-medically.  J Addict Med. 2018;12(4):295-299. doi:10.1097/ADM.0000000000000405PubMedGoogle ScholarCrossref
5.
Campbell  G, Hall  WD, Peacock  A,  et al.  Effect of cannabis use in people with chronic non-cancer pain prescribed opioids.  Lancet Public Health. 2018;3(7):e341-e350. doi:10.1016/S2468-2667(18)30110-5PubMedGoogle ScholarCrossref
6.
New York State Department of Health.  New York State Department of Health announces opioid replacement now a qualifying condition for medical marijuana. Press release, July 12, 2018. https://www.health.ny.gov/press/releases/2018/2018-07-12_opioid_replacement.htm. Accessed January 29, 2019.
7.
Nader  DA, Sanchez  ZM.  Effects of regular cannabis use on neurocognition, brain structure, and function.  Am J Drug Alcohol Abuse. 2018;44(1):4-18. doi:10.1080/00952990.2017.1306746PubMedGoogle ScholarCrossref
8.
Hasin  DS, Saha  TD, Kerridge  BT,  et al.  Prevalence of marijuana use disorders in the United States between 2001-2002 and 2012-2013.  JAMA Psychiatry. 2015;72(12):1235-1242. doi:10.1001/jamapsychiatry.2015.1858PubMedGoogle ScholarCrossref
9.
Bonn-Miller  MO, Loflin  MJE, Thomas  BF, Marcu  JP, Hyke  T, Vandrey  R.  Labeling accuracy of cannabidiol extracts sold online.  JAMA. 2017;318(17):1708-1709. doi:10.1001/jama.2017.11909PubMedGoogle ScholarCrossref
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