The Case for Cannabis

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Figure: The rate of drug overdose deaths involving methadone increased from 0.3 in 1999 to 1.8 in 2006, then declined to 1.0 in 2016. The rate in 2017 was the same as in 2016. Source: Drug overdose deaths in the United States, 1999-2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018; https://bit.ly/2TtCkq6.FigureWe are in the midst of an opioid crisis in which the only options for treatment are opioid-based. Let me take this a step further: Opioids are mu, kappa, and delta receptor agonists, and some treatment strategies are focused on opioid antagonists (or blockers). Some treatment strategies are actually partial agonists (buprenorphine [Subutex]) or full agonists (methadone). There are currently no strategies that employ any other receptors outside of the mu, kappa, and delta opioid receptors. That's the first issue. Once patients have transitioned to another opioid receptor agonist or antagonist and are thought to have been successfully treated, they are still at risk for opioid overdose and death. (See graph.) Is this truly a “successful” treatment? This is the second issue. Those who are able to maintain methadone rehabilitation are required to go to a methadone clinic weekly or monthly for continued “treatment.” Eventually, they can have problems with withdrawal from methadone or, worse, fall back into illegal opioid use. (Issue 3.) We have set the bar for treatment success for opioids so low that we think getting patients on buprenorphine, methadone, and the rest is a success. It is not, as demonstrated by the graph. What would an ideal treatment strategy for opioid dependence and addiction be? A medication that does not affect the opioid receptors mu, kappa, and lambda. A medication that independently does not have a risk for overdose and death. A medication that does not lead to opioid withdrawal or catapult patients back into opioid abuse in the long term. A medication from which patients can be easily weaned off and that does not create further dependence and abuse. Am I dreaming? Does a medication that fulfill all of these requirements exist? Yes, but it is not an isolated medication and requires titration to therapeutic levels. A combination of cannabinoids—CBD and THC—used together can allow us to treat patients with opioid dependence. CBD and THC combinations fulfill all the prerequisites set forth in the issues I outlined. Cannabinoids affect the CB1 and CB2 receptors. There have been no direct lethal overdoses from THC or CBD. Cannabis does not cause an opioid-like withdrawal. While there is documentation of Cannabis withdrawal, it is more akin to caffeine withdrawal. It does not require hospitalization or inpatient treatment. Patients can be easily weaned off Cannabis. The data for further dependence and abuse are unknown. One of my current patients is a 39-year-old man with a history of chronic pancreatitis since age 27 who was started on sublingual fentanyl and had been slowly increased to 400 mcg sublingual fentanyl hourly (#24 fentanyl per day). This is 1248 mg morphine equivalents per day, which puts a patient at an 8.9 times higher risk of overdose, according to MDCalc. The patient presented with a request to stop using all fentanyl. He had never been a drug addict, nor had he taken anything that was not prescribed. In fact, he was also receiving clonidine patches and abdominal blocks routinely for pain management. With the use of all oral and sublingual CBD and THC products, he was able to remove 83 percent of his fentanyl sublingual use within 14 days. The patient did experience some anxiety and pain due to withdrawals, but was able to tolerate it at home without any dehydration, inpatient treatment, or use of other opioids. He is currently in the process of removing the last portion of the fentanyl (currently day 14 of removal, sleeping seven to eight hours, and dealing with some anxiety), with the worst part of this removal being insomnia. The patient in general does not like nor respond well to THC, thus requiring large doses of CBD instead to assist with opioid removal. In between the fentanyl removal, he was able to stop all Cannabis products (about one month between removal periods). The patient was motivated to stop all Cannabis products at completion. Treatment for this patient has been successful so far with all the issues I noted earlier. Updates and other cases will be presented in next month's column, lest anyone think this is the only patient (or a unicorn) who has had such successful results. Medications are only as useful as the advisor. If we physicians are armed with knowledge about the uses, advantages, dangers, and pitfalls of a medication, we can use them to bring patients to better health.