Special Topics in Pain: Opioids

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Opioids Out, Cannabis In: Negotiating the Unknowns in Patient Care for Chronic Pain.

Author(s): Choo, E K et al.
Journal: JAMA. 2016; 316(17):1763-1764. 9 references.
Reprint: Esther K. Choo, MD, MPH, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park RD. HRC 11D47, Portland, OR 97239. Email: chooe@ohsu.edu
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: The current (and justifiable) backlash against opioids has now spawned new champion-cannabis. The potential for disaster is present, especially in states where recreational cannabis is legal plus in states where medical marijuana is legal. Will the patient become co-therapist?  What would be proper intervals for switching back and forth between drugs? Has Pandora’s box been opened and by the “authorities” at that?

Class: Pharmacology: Opioids versus Cannabis

Clinicians are being asked by federal agencies and professional societies to control their prescribing of narcotic medications for pain. Federal guidelines emphasize tapering, discontinuing and limiting initiation of these drugs except in provision of end-of-life care. Unless the nation develops an increased tolerance to chronic pain, reduction in opioid prescribing leaves a vacuum that will be filled with other therapies. The mandated transition to limit use of opioids, paired with the current climate around liberalizing cannabis, may lead to patients' formal and informal substitution of cannabis for opioids.

Observational studies have found that state legalization of cannabis is associated with a decrease in opioid addiction and opioid-related overdose deaths, but this premise merits careful attention. The empirical data supporting the use of cannabis as an effective therapy for pain is far from robust. A 2015 systematic review describes cannabinoids as "moderately" effective for chronic neuropathic and cancer-related pain. The use of cannabinoids, however, in clinical practice is complicated by a limited number of clinical trials, which results in an uncertain evidence base for most diseases. It is also difficult to relate the standardized cannabinoid formulations most often used in such trials to actual clinical use with the wide array of available cannabis products and modes of delivery.

Given the gaps in research and corresponding absence of medical education supporting the therapeutic uses of cannabis, engaging in detailed conversations with patients about this substance is challenging. Physicians may be placed in the uncomfortable position of explaining to patients why they might advise against treatment that appears to be endorsed by governing body (e.g., health departments of states in which medicinal use has been legalized) rather than supported by sciences.

Some states are allowing the legal sale of cannabis for recreational use, coexisting with ongoing medial allowances in each jurisdiction. Clinicians practicing in these locations are placed in a curious position--no longer in a gatekeeper role--and many are uncertain of how and when to encourage or discourage cannabis use.

There are many unanswered questions--should cannabis be treated like alcohol, is cannabis an acceptable substitute for opioids, if so, what amounts and forms should it be initiated, to mention just a few. Even a standard screening question for drug use could miss cannabis entirely: "Do you use illegal drugs or prescribed drugs for nonmedical purposes?" For a cannabis user in a cannabis-legal state, the answer would be no, and clinicians may move on to other areas of health inquiry. With all these unanswered questions, clinicians may leave patients without the benefit of medical guidance regarding their cannabis and that can negatively affect patients' quality of care.

Cannabis exists in a parallel pharmacotherapy that physicians cannot dismiss when prescribing other medications with potential interactions or when evaluating a patient's physical or mental health symptoms. In states with recreational legalizations, physicians essentially cede agency over the type, frequency, and amount of cannabis their patients use to retail shop owners with commercial interests. The same can be said, to some degree for states with legalized medical use, where physicians may authorize their patients to receive cannabis but are not involved in dosing or administration.

Clinicians miss the opportunity to counsel patients about serious adverse effects: risks of cannabis use disorders and withdrawal; potential negative effects on fetal development in pregnancy, dangers of driving under the influence of cannabis, especially with alcohol; potential effects of cannabis on the developing body and brain; and safe storage of cannabis products to avoid unintentional overdoses by children or other household members.

Important Points:
The prescribing of opioid therapy for chronic noncancer pain advanced unchecked until opioid-related adverse events and other consequences reached epic proportions. To ensure the medical community does not repeat this mistake with cannabis, physicians should balance the need to keep pace with the swiftly evolving cultural, social, and legal climate surrounding cannabis use for pain with the imperative to guide practice with sound science.  

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