Can Cannabis Replace Opioids?

February 21, 2023

Can Cannabis Replace Opioids? | leafy

In 1995, the president of the American Pain Society called for pain to be added as a fifth vital sign to be evaluated and managed by physicians—body temperature, heart rate, respiration, and blood pressure being the original four. Pain measurement subsequently became a widely accepted practice among clinicians. With 20% of adults suffering from chronic pain, prescription opioids soon doubled and Americans began using 80% of the world’s opioid supply.

President Trump formally declared the opioid crisis a “public health emergency” in October 2017. By then, the United States was approaching 50,000 total opioid overdose deaths, and nearly 60% of those were due to illicit synthetic opioids such as fentanyl or tramadol. The problem has continued to escalate. Last year there were more than 80,000 opioid overdose deaths, about 90% of which were due to highly potent synthetic forms. This crisis is not getting any better and new strategies are needed to solve the problem.

Will Legalizing Cannabis Reduce Opioid Use?

There are several reasons why legalizing cannabis appears to be a promising strategy to combat the ongoing opioid crisis. For one, early population reports found that states that legalized medicinal cannabis saw a decrease in opioid overdose deaths. However, these results no longer apply if the time frame of the analysis is extended to date; Any benefit that cannabis legalization has in reducing opioid overdose appears to be short-lived.

States that legalized recreational cannabis saw an initial 7.6% reduction in opioid-related emergency room visits compared to states that had not legalized cannabis, but this difference disappeared within 6 months. It remains possible that cannabis can serve as a substitute for common prescription opioids such as oxycodone, codeine or hydrocodone, but cannot overcome the severity of addiction to stronger illicit opioids such as fentanyl or heroin, which are increasingly abused.

Some studies indicate a notable reduction in prescription opioid use in patients who also use cannabis, but this benefit disappears in tightly controlled clinical trials. These clinical studies do not find consistent results on the concomitant use of cannabis with prescription opioids, although most patients say they prefer cannabis over opioids.

How cannabis enhances the effects of opioids

How could cannabis replace opioids?

There are currently 15 ongoing clinical trials investigating cannabis’ ability to reduce the need for opioids. These clinical studies are based on hard-to-ignore evidence from animal studies looking at the pain-relieving interactions between the endocannabinoid system, which is stimulated by cannabinoids like THC, and the opioid system.

Rodent pain experiments have consistently found that THC reduces the need for opioids. In seven different studies, THC reduced the effective dose of morphine by 3.5 times. This beneficial effect is supported by three important pieces of evidence:

Many cannabinoids, such as THC, stimulate CB1 receptors in the endocannabinoid system, which are found in the The same thing pain-processing brain areas as opioid receptors and can also contribute to pain relief.
CB1 receptors in the body to interact with opioid receptors to enhance their analgesic effects in rodent studies.
CB2 Receptors, another target of cannabinoids, can stimulate the release of endogenous opioids that activate pain-relieving opioid receptors.

So why are there contradictions between these ongoing clinical studies and the population studies mentioned above?

A direct reason is unclear. Some argue that a sense of control over pain management, such as that experienced when choosing to use cannabis, can promote better outcomes. This effect could explain why patients who could choose to include cannabis in certain trials, as opposed to randomized clinical trials, reduced their need for opioids.

What is the endocannabinoid system and what role does it play?

It’s also possible that these benefits result from the placebo effect, which allows people to increase their opioid levels without medication and dull pain just by believing they are receiving an active pain reliever.

What makes the results even more confusing is that the opioid-reducing effects of cannabis can disappear with prolonged use of high-potency THC products, which are becoming more common in legal markets. Rodent studies of THC’s opioid-reducing effects are often short-lived, typically lasting only a few days, while human use is often chronic—people use it for weeks or more. Repeated use of potent THC leads to tolerance, which often results from reduced numbers of CB1 receptors and overall weakened endocannabinoid signaling.

Developing a THC tolerance would therefore impede the ability of CB1 and opioid receptors to work together to relieve pain. This may explain why short-term rodent studies show opioid-reducing benefits of THC and how these effects are often lost in long-term human clinical trials.

In addition, this phenomenon could explain the initial decline in opioid overdoses when states legalize cannabis, but with the eventual onset of tolerance over several months, the opioid-reducing effects of cannabis in the population disappear.

Given all the current evidence, there is no clear consensus on whether cannabis can replace or reduce the need for opioids in pain management.

Are there any risks in using cannabis and opioids together?

In some cases, combining cannabis with opioids has been linked to worsening mental health, and this combination may be worse for those over 65 years of age. Other safety issues, such as opioid respiration suppression, were not aggravated by concomitant use of cannabis, which at least eased some concerns.

And in most cases, concomitant use of cannabis does not increase opioid use, dispelling the notion that cannabis is a gateway drug, a warning voiced by many anti-drug activists.

Can CBD Help Opioid Addiction?

Despite the lack of clinical evidence that cannabis can replace opioids, CBD is emerging as a potential strategy to help those trying to overcome an opioid use disorder.

Italy inadvertently legalized CBD-rich cannabis (essentially “hemp” by US legal standards) in 2017 and saw a decline in opioid use, suggesting that CBD-rich cannabis could replace opioids in the short term.

Several clinical studies have found that CBD reduces cues that trigger opioid cravings and dampens the increased stress response that accompanies cravings. Evidence from rodent studies shows that CBD reduces many of the negative changes in behavior, anxiety, and genetic expression that accompany opioid withdrawal and lead to relapse.

These studies have set the stage for further clinical trials (such as one to be held at the Tarzana Treatment Center in Los Angeles) to investigate the potential of CBD as an adjunctive therapy for opioid use disorders.

The Complete Guide to CBD (Cannabidiol)

The jury is still out. Most patients report preferring cannabis over opioids for pain relief and believe it to be an effective alternative. However, the range of consumption patterns, product options, cannabinoid and terpene levels, and reasons for the need for pain relievers make this a particularly challenging research question to study empirically.

Control over the type of cannabis products used along with optimized pain management formulations (with moderate THC potencies!) will lead to a clearer picture of cannabis’ potential to replace opioids.

Josh Kaplan

Josh Kaplan, PhD, is an Associate Professor of Behavioral Neuroscience at Western Washington University. He is a passionate science writer, educator and runs a laboratory researching the developmental and therapeutic effects of cannabis.

Check out Josh Kaplan’s articles

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