Can Cannabis Be Used to Treat Opioid Addiction?

By Pat Anson, PNN Editor

Canadian researchers – with funding from U.S. taxpayers – are proposing a novel treatment for opioid use disorder: Cannabis.

In a paper published in the journal Drug and Alcohol Dependence, researchers from the University of British Columbia (UBC) and the BC Centre on Substance Use (BCCSU) say cannabis could help people being treated for opioid addiction by reducing their risk of exposure to illicit fentanyl and other street drugs.

The finding is based on urine drug tests of 819 people being treated for opioid addiction in Vancouver, BC, the first major city in North America to experience an outbreak of fentanyl-related overdoses. Addiction treatment usually involves taking opioid agonist drugs (OATs) such as buprenorphine or methadone.

The researchers found that over half the participants (53%) tested positive for fentanyl, suggesting they were still using street drugs. Those who tested positive for THC -- the psychoactive compound in cannabis -- were about 10 percent less likely to have fentanyl in their urine.

"These new findings suggest that cannabis could have a stabilizing impact for many patients on treatment, while also reducing the risk of overdose," said lead author Eugenia Socías, MD, a clinician scientist at BCCSU. "With overdoses continuing to rise across the country, these findings highlight the urgent need for clinical research to evaluate the therapeutic potential of cannabinoids as adjunctive treatment to OAT to address the escalating opioid overdose epidemic."

Socias and her colleagues say cannabis may play an important role in keeping people in addiction treatment programs. Previous research at BCCSU found that drug users initiating OAT who used cannabis daily were about 21 percent more likely to be retained in treatment after six months than non-cannabis users. People who stay in treatment face much lower risks of dying from an overdose, acquiring HIV or suffering other harms of drug use.

‘Gateway Drug’

The research at UBC and BCCSU was funded, in part, by grants from the U.S. National Institute on Drug Abuse, which is part of the National Institutes of Health (NIH).

The NIH has taken a dim view of cannabis in the past, calling marijuana a “gateway drug” for some users, particularly adolescents. A 2015 study funded by NIH found that nearly a third of those who use marijuana develop some degree of marijuana use disorder.

“Whether smoking or otherwise consuming marijuana has therapeutic benefits that outweigh its health risks is still an open question that science has not resolved,” said Nora Volkow, MD, Director of the National Institute on Drug Abuse.

Public health officials in British Columbia have proposed some controversial solutions to the opioid crisis, including decriminalization of all illicit drugs. A treatment center in Vancouver currently provides diacetylmorphine -- prescription heroin – to drug users to keep them from using street heroin that is often laced with fentanyl, a synthethic opioid that is 50 to 100 times more potent than morphine.

The Canadian Institutes of Health Research recently approved funding for a pilot study in Vancouver to evaluate cannabis as an adjunct therapy to OAT.

"Scientists are only just beginning to understand the role cannabis might play in supporting people's well-being, particularly those who use other substances," said co-author M-J Milloy, PhD, the Canopy Growth professor of cannabis science at UBC. "This study will help us understand if and how cannabis might have a role in addressing the overdose crisis."

FTC Warns CBD Companies About False Health Claims

By Pat Anson, PNN Editor

The U.S. Federal Trade Commission is once again going after companies that make unsubstantiated claims about the health benefits of cannabidiol (CBD) products. The crackdown, called “Operation CBDeceit,” is part of the agency’s ongoing effort to protect consumers from misleading advertising.

The FTC announced that six sellers of CBD oils, topical creams, gummies, lozenges and other products have signed administrative settlements agreeing not to make any further deceptive claims that CBD can treat pain, migraines, arthritis, cancer, heart disease and other health conditions.

“These CBD sellers lacked the scientific proof to back up their extreme claims. In fact, they often didn’t have any proof at all. But that didn’t stop them from saying these benefits were clinically proven. In truth, CBD is not a magical cure-all and there is no competent and reliable scientific evidence for these kinds of over-the-top health claims,” said Andrew Smith, Director of the FTC Bureau of Consumer Protection.

The FTC complaint against Utah-based Bionatrol Health alleged the company claimed its CBD products treat pain better than prescription medications like OxyContin. The company also allegedly deceived customers who ordered one bottle of its CBD oil by changing the order to five bottles without their consent.

The proposed settlement requires Bionatrol to pay $20,000 to the FTC and to notify customers about the FTC order. Similar settlements were reached with the other five companies.

This isn’t the first time the FTC and other federal agencies have gone after sellers of CBD, kratom and other dietary settlements for making unsubstantiated health claims.

The enforcement actions are sporadic and usually only target small companies. Sometimes a warning letter is as far as it goes and the company makes only a minor change in its marketing claims.

FTC IMAGE

In March 2019, for example, the FTC and Food and Drug Administration sent a warning letter to Nutra Pure, telling the company its hemp and CBD oils were unapproved drugs under federal law and “may not be legally introduced or delivered for introduction into interstate commerce.”

Nearly two years later, the company is still selling hemp and CBD oils, and has a disclaimer on its CBDPure website stating that its products “are not intended to diagnose, prevent, treat, or cure any disease.”

But when this reporter posed as a customer in an online chat with “Catherine,” a CBDPure representative, we were assured that CBD can treat pain and other health conditions.  

Customer: “Hi I'm wondering if you can recommend a CBD product for arthritis pain.”

Catherine: “Our oils are 300, 600 or 1000 mg CBD in full spectrum hemp oil. People with a mild condition or just looking to improve health start with the 300mg or 600mg. People with more severe or chronic conditions typically purchase the 1000 mg CBDPure hemp oil or 750 mg CBDPure soft gel.” 

Customer: “Will they help with pain and other health conditions?” 

Catherine: “Yes. There are numerous studies showing CBD has the ability to provide therapeutic benefits in the treatment of various conditions, including chronic pain, arthritis, anxiety/depression, nausea, epilepsy, insomnia and sleep issues, fibromyalgia, glaucoma and many other ailments.” 

Customer: “That's interesting. I have a friend with fibromyalgia. Is there something that can help her?” 

Catherine: “Yes. Same deal. Ideally, you start off with a lower mg dose and increase the amount you take weekly until you find what works for your body chemistry.” 

Customer: “And it'll eventually make the pain go away once you find the right dose?” 

Catherine: “Yes. It really depends on how your body tolerates and adapts to these dietary supplements.”

FTC officials say false claims about the therapeutic benefits of CBD and other supplements create a “real potential for serious harm to consumers health and safety.” But in a briefing with reporters announcing the six settlements reached in Operation CBDeceit, they acknowledged their investigation did not find any evidence about customers being harmed by the companies’ products.

“We’re not here saying CBD products are dangerous or that CBD products can’t offer benefits. Just that if you’re going to tout health benefits of your products, those claims have to be truthful and they have to be substantiated by the science,” said Smith.

Daily Drop of CBD Oil Reduces Migraine Headaches

By Pat Anson, PNN Editor

A CBD oil formulated for migraine sufferers significantly reduces the number of migraine headaches, according to a survey conducted by Axon Relief, a Utah-based company that makes a line of therapeutic CBD products.

“Our goal was to put out a CBD oil that is specific for people with migraine and to get feedback from them. There is a lot of anecdotal evidence that it works, but we haven’t seen any clinical data really behind it. And so this is kind of a first effort of ours to get some directional data on how effective this is,” says Ben Rollins, founder of Axon Relief.

Axon’s CBD Oil is made from pure hemp seed oil and has about 30mg of CBD per dose, a stronger than average dosage of cannabidiol. It contains no extra flavors, colors or THC (tetrahydrocannabinol), the psychoactive ingredient in cannabis, and is tested by a third-party lab.

The company asked new users of its CBD oil to take the Headache Impact Test (Hit-6™) both before and after a 30-day trial period. The questionnaire asks participants about the frequency and severity of their migraines, and how it impacts their daily lives.

Of the 105 customers who participated in the survey, 86 percent said a daily dose of the CBD oil reduced the impact of their headaches. On average, they also had nearly four fewer headache days per month.

The number of participants with chronic migraine – daily headaches – fell from 15 at the start of the study to 10 after the trial period, a 33% decline.

AXON RELIEF IMAGE

“Since the '90s I've been on constant high doses of carbamazepine and gabapentin. The periodic pain breakthroughs were only controlled by hydrocodone,” one user said. “What a change CBD Oil has made: no more carbamazepine or hydrocodone, and only half the gabapentin -- and far better pain control.”

Another participant said the CBD oil “significantly helped with my chronic migraines. If taken at onset, I can rely on it to take the edge off relatively quickly."

Previous studies have found that inhaled and ingested cannabis help reduce migraine pain.  A recent study of nearly 10,000 people in the U.S. and Canada who used a migraine tracking app found that 82 percent who used cannabis believed it was an effective pain reliever.    

A 2017 study conducted in Israel found that combining THC and CBD in a 200mg oral dose reduced pain by 55 percent in a small group of migraine sufferers.

And a 2016 study at the University of Colorado found that inhaled and ingested cannabis significantly reduced the number of migraine headaches. Inhalation appeared to provide the fastest results, while edible cannabis took longer to provide pain relief.

Axon Relief will soon be introducing an extra strength version of its CBD oil, which will contain about 100mg of CBD per dose. The company is also releasing a new dietary supplement in capsule form that combines CBD with magnesium, CoQ10 and riboflavin – ingredients recommended by the Migraine Trust. 

Caution Recommended on Cannabis Use Before Surgery

By Roger Chriss, PNN Columnist

The U.S. House of Representatives voted last week for the first time to legalize marijuana at the federal level. While passage by the Senate appears unlikely, the historic House vote on the MORE Act shows how much public attitudes about marijuana have changed.

A recent Gallup poll found that 68 percent of the country now favors having legal access to marijuana. Last month voters in four states approved recreational cannabis measures, raising to 15 the number of states where cannabis is completely legal. Thirty-six states have approved it for medical use.

As cannabis use becomes more accepted and widespread, healthcare providers need to take cannabis into consideration when treating patients, especially those undergoing surgery.

The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) recently convened a panel of 17 experts to develop new guidelines on the care of cannabis-consuming surgery patients. The result is a set of recommendations that include cannabis weaning before surgery and close monitoring during surgery, particularly for heavy cannabis users.

Because of the potential for cannabis to interfere with anesthesia, the guidelines recommend that patients who use a cannabis product more than 2 or 3 times per day should be considered for tapering or cessation several days before surgery. That includes patients who use more than 1.5 grams per day of smoked cannabis, more than 300 mg per day of CBD oil, or more than 20 mg per day of THC oil. Cannabis users may also need additional medication for postoperative nausea and vomiting.

There is only limited research on how cannabis interacts with analgesics and other medications. But the few studies that have been done suggest caution is warranted.

A 2006 study done in Germany looked at patients after surgery. None of the patients was able to achieve sufficient pain relief at any dose of Cannador, a cannabis plant extract. Several experienced significant side effects, including sedation and nausea. And the study had to be halted because of a severe adverse event in one patient.

A recent study at the University of Michigan looked at cannabis use and surgical outcomes in 1,335 adults undergoing elective surgery. About half reported using cannabis medically, recreationally or both. The results are concerning.

"On the day of surgery, cannabis users reported worse pain, more centralized pain symptoms, greater functional impairment, higher fatigue, greater sleep disturbances and more symptoms of anxiety and depression versus non-cannabis users,” the researchers said.

Medication use, including opioids and benzodiazepines, was also higher in the cannabis group. The study authors concluded that "cannabis users have higher clinical pain, poorer scores on quality of life indicators, and higher opioid use before and after surgery."

Another recent study at the University of Colorado Hospital was smaller and more specific, looking at 118 patients who had surgery for a broken leg. About one-fourth of the patients reported prior cannabis use. Although cannabis use was not associated with a higher dose of the anesthetic propofol during surgery, it was associated with more post-operative pain. Cannabis users also required significantly more pain medication than the control group.

Lead study author Ian Holmen, MD, told Practical Pain Management that it was important for clinicians to ask patients about their cannabis use before any surgical procedures.

“A provider just needs to know if the patient uses cannabis or not. It doesn’t matter if it’s a daily situation, just so [providers] are aware that the post-operative and possibly interoperative period are going to appear different in a patient who’s using cannabis than one who is not,” Holmen said.

Further study is needed to better understand how cannabis use affects surgical outcomes and how the effects may change at various doses of cannabis products. But the concerns of the Perioperative Pain and Addiction Interdisciplinary Network appear well-founded. Guidelines for the perioperative management of cannabis use are a necessary and useful step forward as cannabis use becomes more common.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research. 

12 Holiday Gifts on Life With Chronic Pain

By Pat Anson, PNN Editor

If you live with chronic pain or illness and want to have a friend or family member get a better understanding of what you're going through -- here are 12 books and videos that would make great gifts over the holidays. Or you can always “gift” one to yourself.

Click on the cover to see price and ordering information. PNN receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon. As an Amazon Associate, we earn from qualifying purchases. 

Finding a New Normal: Living Your Best Life with Chronic Illness by Suzan Jackson

For nearly 20 years, Suzan Jackson has lived with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) — a condition she shares with two of her sons. In this book, Jackson shares what she and her family have learned about living well with chronic illness and finding a “new normal” through strong relationships, healthy emotions and finding joy in everyday life. The emphasis is on living life, not just enduring it.

War on Us by Colleen Cowles

Lawyer Colleen Cowles looks at how the war on drugs and myths about addiction have created a dysfunctional drug policy that prosecutes doctors for treating pain and stigmatizes patients for seeking relief. The U.S. has spent over a trillion dollars fighting the war and has little to show for it except some of the highest rates of addiction, overdose and incarceration anywhere in the developed world.

Ketamine Infusions: A Patient’s Guide by Berkley Jones

Berkley Jones looks at the increasing use of ketamine, a non-opioid analgesic, in treating chronic pain, depression, post-traumatic stress disorder and anxiety. This book is a useful guide if you are considering ketamine infusions and want to know how to select a provider, what to expect during infusions and possible side effects. Although primarily used to treat depression, some pain patients say ketamine is effective in treating neuropathy and CRPS.

Bitten: The Secret History of Lyme Disease and Biological Weapons by Kris Newby

Author Kris Newby began looking into the origins of Lyme disease after she was bitten by a tick and became seriously ill. Her research led her to a secret U.S. government program during the Cold War that used insects as biological weapons to spread disease. Newby believes the Lyme outbreak that began 50 years ago and has infected millions of Americans may have been the result of a military experiment gone wrong.

Vagina Problems: Endometriosis, Painful Sex and Other Taboo Topics by Lara Parker

A memoir by Lara Parker that explores — with unflinching honesty — her battle with endometriosis, a chronic vaginal condition that makes daily life difficult and sex painful. As a teenager, doctors initially dismissed Parker’s pain as “bad period cramps” and suggested her pain was psychological. She nearly checked herself into a mental institution before finally getting a proper diagnosis.

A Quick Guide to CBD by Dr. Julie Moltke

CBD won’t cure you of chronic pain, but Dr. Julie Moltke says cannabidiol can reduce pain, inflammation, anxiety and insomnia — and help make life more livable. This handbook is intended for beginners who want to learn how and when to take CBD, and are puzzled by all the hype surrounding vapes, oils, gummies and edibles on the market.

Pain Warriors by Tina Petrova

A documentary produced by patient advocate Tina Petrova that examines the poor treatment and medical neglect faced by millions of pain sufferers in North America. The film is dedicated to Sherri Little, a chronic pain patient who committed suicide after one last attempt to get effective treatment. Available on DVD or for streaming on Amazon Prime.

Together: The Healing Power of Human Connection by Dr. Vivek Murthy

This timely book by former U.S. Surgeon General Dr. Vivek Murthy looks at the importance of human connections and how loneliness affects our health and society at large. To combat loneliness, Murthy recommends spending at least 15 minutes each day connecting with people we care about and to give them our undivided attention.

Bottle of Lies: The Inside Story of the Generic Drug Boom by Katherine Eban

Wonder why that generic drug you take doesn’t seem to work? About 90% of pharmaceutical drugs are generic and most are manufactured overseas. While generics are promoted as cheaper alternatives to brand name drugs, journalist Katherine Eban found the generic drug industry rampant with greed, fraud and falsified manufacturing data — resulting in many patients consuming drugs that are ineffective or have dangerous side effects.

In Pain: A Bioethicist’s Personal Struggle with Opioids by Travis Rieder, PhD

Travis Rieder is a professor of bioethics at Johns Hopkins University who severely injured his foot in a motorcycle accident and became dependent on opioids while recovering from surgery. In this book, he shares his frustration with the healthcare system and how it often abandons patients to pain, addiction or both. Rieder serves on a CDC advisory panel that is helping the agency prepare an update of its controversial 2016 opioid guideline.

The Chronic Pain Management Sourcebook by David Drum

A comprehensive guide about chronic pain by medical journalist David Drum, who summarizes the many causes, types and treatments of pain. Drum also has tips on managing stress, anxiety, lack of sleep and depression. The book is easy to understand and would be a useful resource for family members, friends and caretakers who want to understand and help someone living with chronic pain.

A Little Book of Self Care: Trigger Points by Amanda Oswald

This well-illustrated book provides 40 simple, step-by-step exercises you can use to manage back pain, migraine and other painful conditions. Author Amanda Oswald explains how “trigger points” — small knots of muscles and connective tissue — can be relieved through self-massage and the “power of touch” without visiting a chiropractor or physical therapist.

These and other books and videos about living with chronic pain and illness can be found in PNN’s Suggested Reading section.

Study Shows Cannabis Oil Improves Fibromyalgia Symptoms

By Pat Anson, PNN Editor

A small placebo-controlled trial shows that daily doses of cannabis oil rich in THC (tetrahydrocannabinol) significantly improves pain, fatigue and quality of life in people with fibromyalgia.

The study findings, recently published in the journal Pain Medicine, involved 17 women with fibromyalgia living in Florianopolis, Brazil. Participants were given drops of cannabis oil or a placebo for eight weeks, starting with an initial dose of one drop a day orally and then titrating to an average of 3-4 drops a day.

The cannabis oil used in the study contained 1.22 mg of THC and 0.02 mg of CBD (cannabidiol) per drop. THC is the psychoactive ingredient in marijuana.

The women self-reported their symptoms on a questionnaire every 10 days. Few changes were noted in the placebo group, but the women receiving cannabis oil reported significant improvement on a wide range of symptoms, including pain, depression, anxiety and fatigue. They were also more likely to “feel good” and not miss work compared to the placebo group.

“To our knowledge, this is the first randomized controlled trial to demonstrate the benefit of cannabis oil -- a THC-rich whole plant extract -- on symptoms and on quality of life of people with fibromyalgia,” researchers said. “During the intervention, the impact of the intervention on quality of life in the cannabis group participants was evident, resulting in reports of well-being and more energy for activities of daily living. Pain attacks were also reduced, albeit subjectively, in frequency and intensity.”

The researchers concluded that cannabinoids can be a low-cost and well-tolerated therapy for fibromyalgia patients, and recommended that it be included as an herbal medicine option in Brazil’s public health system.

“The demonstration of safety and efficacy in this gold-standard model is significant. Millions of Americans suffer with FM (fibromyalgia) – a condition that tends to be poorly controlled by standard medicines. These clinical findings indicate that for many of these patients, plant-derived cannabis preparations may be a safe and effective alternative,” said Paul Armentano, Deputy Director of NORML, a pro-marijuana advocacy group.

A major weakness of the Brazilian study is its small size. Participants also continued to self-medicate with analgesics and anti-inflammatory medications during the study, which could have affected the findings.

A larger 2019 study in Israel also found that cannabis reduces pain and improves quality of life for fibromyalgia patients. The cannabis used in that study was ingested by tincture, oil or vaporizer.

Growing Number of Seniors Discovering Medical Benefits of Cannabis

By Pat Anson, PNN Editor

A new survey shows that medical marijuana is increasingly being used by California seniors to treat pain, insomnia, depression and other conditions associated with old age. Many began using cannabis for the first time as older adults.

Researchers at the University of California at San Diego surveyed 568 seniors at a geriatric clinic in southern California. All were at least 65 years of age, and most were older than 75.

Fifteen percent of the seniors said they have used cannabis products within the past three years, with the method of consumption evenly split between lotions (35%), tinctures (35%) and smoking (30%). Over three‐quarters reported cannabis “somewhat” or “extremely” helpful in managing their symptoms, with few adverse effects.

Although medical marijuana has been legal in California since 1996, sixty-one percent of respondents said they used cannabis for the first time as older adults. Recreational use in California was legalized in 2016.

“Most older adults in the sample initiated cannabis use after the age of 60 years and used it primarily for medical purposes to treat pain, sleep disturbance, anxiety, and/or depression. Cannabis use by older adults is likely to increase due to medical need, favorable legalization, and attitudes,” researchers reported in the Journal of the American Geriatric Society.

Over half of respondents (53%) reported using cannabis on a daily or weekly basis. The majority (78%) used cannabis for medical purposes only, with the most common conditions being pain/arthritis (73%), sleep disturbance (29%), anxiety (24%), and depression (17%).

“It is not surprising that a rising percentage of seniors consider cannabis to be a viable therapeutic option in their later years. Many seniors struggle with pain, anxiety, restless sleep, and other conditions for which cannabis products may help mitigate,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

“Moreover, many seniors are well aware of the litany of serious adverse side-effects associated with available prescription drugs, like opioids or sleep aids, and they perceive medical cannabis to be a practical and potentially safer alternative.”

Most respondents said their family and friends knew of their cannabis use, but less than half (41%) reported their healthcare provider was aware.

Previous studies have found that cannabis is growing in popularity among older adults, primarily due to changes in public attitudes.

Nationwide survey findings recently published in the Annals of Internal Medicine found that about 5% of adults aged 55 and older said they'd used marijuana or hashish in the previous month. Use was almost twice as high among men, with 6.7% reporting cannabis use compared to 3.5% of women.

Although interest in medical marijuana is growing, there is limited research in the U.S. on its effectiveness in treating pain and other symptoms, especially among seniors.

A large study in Israeli found medical marijuana can significantly reduce chronic pain in elderly patients without adverse effects. Many patients were also able stop or reduce their use of opioid medication.    

Nearly 60 percent who originally reported "bad" or "very bad" quality of life said their lives had improved to "good" or "very good." And over 70 percent reported moderate to significant improvement in their symptoms. About one in four Israeli adults use cannabis, one of the highest rates in the world.

Study Finds Cannabis Does Not Reduce Opioid Abuse

By Pat Anson, PNN Editor

It’s a common belief that cannabis may reduce the use of opioids and may even help solve the opioid crisis. But a new study by researchers at Columbia University Mailman School of Public Health found that people with substance abuse problems are just as likely to use heroin or to misuse prescription opioids on days when they consume cannabis.

The study, published in the journal Addiction, is believed to be one the first to test whether adults with substance abuse problems are substituting opioids with cannabis. Researchers followed 211 adults in the New York City area for 90 days, asking if they had used cannabis, heroin, or misused prescription opioids.

Participants were mostly male, unemployed, unmarried, and had a high prevalence of substance misuse and pain. “Misuse” of prescription opioids was defined as taking more pain medication than prescribed or without a prescription.

On average, participants reported they used cannabis on 15% of days without opioids, opioids were used on 15% of days without cannabis, and both cannabis and opioids were used on 7% of days. On days that participants used cannabis, the odds of using opioids nearly doubled. The findings were consistent whether participants were experiencing pain or not.

"Our results suggest that cannabis seldom serves as a substitute for non-medical opioids among opioid-using adults, even among those who report experiencing moderate or more severe pain," said Deborah Hasin, PhD, professor of epidemiology at Columbia Mailman School. "In other words, our study suggests that cannabis is not an effective way to limit non-medical opioid use."

Cannabis Users Need More Anesthesia

Another recent study found that cannabis may actually raise pain levels for patients recovering from surgery. In an analysis of 118 patients who had surgery for a broken leg at a Colorado hospital, researchers found that cannabis users needed more anesthesia during surgery than non-users. They were also more likely to have post-operative pain and use higher doses of opioid pain medication while hospitalized.

The findings, presented at the annual meeting of the American Society of Anesthesiologists, adds to the growing body of research suggesting that patients who use cannabis have higher anesthesia needs and more surgery-related pain.

"There is some evidence that cannabis may be beneficial for chronic and nerve pain. However, early research suggests that this is not the case for acute pain such as for surgery of a broken leg," said lead author Ian Holmen, MD, an anesthesiology resident at the University of Colorado Hospital in Aurora, where the study was conducted.

"We now understand patients who chronically use opioids prior to surgery often have exaggerated pain responses and need increased pain medication after surgery because they have an increased tolerance. We speculate that cannabis use may cause a similar effect, but we need more research to determine if this is the case."

Holmen and his colleagues found that cannabis users had higher pain scores while recovering from surgery and received 58% more opioids per day while hospitalized. They also needed about a third more anesthesia. The amount of anesthesia during surgery is typically based on observations of a patient’s involuntary body movements, increased heart rate, high blood pressure or increased rate of breathing, which are signs the patient may be experiencing more pain.

Researchers did not include in the study patients who suffered from chronic pain or those who had previously been prescribed opioids.

"This study shows that it is important for patients to tell their physician anesthesiologist if they have used cannabis products prior to surgery to ensure they receive the best anesthesia and pain control possible, including the use of non-opioid alternatives," said Holmen. "It also confirms that more research is needed to understand how cannabis impacts pain."

A 2019 study of patients who had colonoscopies found that regular marijuana users required three times the amount of a common sedative, propofol, as did nonusers.

Cannabis-Based Drugs Risky for Older Patients with COPD

By Pat Anson, PNN Editor

While many senior citizens are discovering the benefits of medical cannabis in relieving pain and other health problems, a large new study suggests caution is warranted for those with chronic obstructive pulmonary disease (COPD).

Researchers at St. Michael's Hospital in Toronto say older adults with COPD who take prescription drugs made with synthetic cannabinoids were 64% more likely to die. The odds are even worse for elderly patients with COPD who take high-dose cannabinoids for the first time. New users had a 178% higher risk of being hospitalized for COPD or pneumonia and a 231% increased risk of death.

"Cannabinoid drugs are being increasingly used by older adults with COPD, so it is important for patients and physicians to have a clear understanding of the side-effect profile of these drugs," says lead author Nicholas Vozoris, MD, a respiratory specialist at St. Michael's and assistant professor at the University of Toronto.

"Our study results do not mean that cannabinoid drugs should be never used among older adults with COPD. Rather, our findings should be incorporated by patients and physicians into prescribing decision-making. Our results also highlight the importance of favouring lower over higher cannabinoid doses, when these drugs actually do need to be used."

The study analyzed the health data of over 4,000 older adults diagnosed with COPD who took either nabilone or dronabinol, two medications made with synthetic cannabinoids that are used to treat nausea, vomiting and loss of appetite.

The findings, published in the journal Thorax, suggest that nabilone and dronabinol may cause sedation and suppress breathing in patients whose health is already compromised by COPD, a progressive lung disease that causes difficulty breathing and chronic coughing.

"Older adults with COPD represent a group that would likely be more susceptible to cannabinoid-related respiratory side-effects, since older adults less efficiently break down drugs and hence, drug effects can linger in the body for longer,” said Vozoris.

“Cannabinoids may not be any safer to use among older adults with COPD than opioids, which are also associated with a heightened risk of respiratory- related morbidity and mortality. While further research is needed to confirm the safety profile of cannabinoid drugs among older adults with COPD, our findings should be taken into consideration in prescribing decision making in this population.”

Cannabis and Menopause

While high doses of cannabinoids may not be appropriate for older patients with COPD, many middle-aged women are using cannabis to treat symptoms of menopause.

According to a small study being presented at the annual meeting of The North American Menopause Society, over one in four women have either used or are currently using cannabis to manage menopause symptoms.

The study involved 232 female military veterans (average age of 56) living in Northern California. Over half reported hot flashes and night sweats regularly. Twenty-seven percent said they had used marijuana to help battle menopause symptoms, while another 10% said they were interested in trying cannabis.

“While the therapeutic use of cannabis by veterans is not altogether uncommon, this study is among the first to highlight veterans’ use of marijuana for this particular condition. Given cannabis’ relatively high rate of use among the women in this cohort, scientists and others would be well-advised to further explore its safety, efficacy, and prevalence among women experiencing menopause,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

A 2018 survey of over 2,700 elderly patients in Israel found that medical marijuana significantly reduced their chronic pain without adverse effects. Nearly one in five patients stopped using opioid medication or reduced their dose.

Study Finds Cannabis Effective for 82% of Migraine Patients

By Pat Anson, PNN Editor

Nearly a third of migraine patients have tried medical marijuana or cannabinoids to relieve their pain and other symptoms, according to a large new study that found 82 percent of those who used cannabis found it effective in providing pain relief.

The study gathered data from nearly 10,000 migraine sufferers in the U.S. and Canada who use Migraine Buddy, a migraine tracking app made by Healint, a healthcare technology company based in Singapore. Participants ingested cannabis by a variety of different methods, such as smoking, vaping, tinctures, oils and edibles. No form of ingestion was signficantly more effective than another.

"Cannabis is becoming a prominent treatment option for chronic pain patients, especially for migraineurs," Healint CEO and co-founder Francois Cadiou said in a press release.

"With more and more states across the United States legalizing medical marijuana, migraine patients are becoming acquainted with cannabis as a natural remedy that can help alleviate migraines and even prevent them. Research about the benefits of cannabis use among migraine patients is slowly emerging, but more must be done to properly inform individuals about the use and dosage of medical marijuana to treat migraines."

The findings are similar to a 2019 study, published in The Journal of Pain, that found inhaled cannabis cut headache and migraine severity in half. The effectiveness of cannabis diminished over time, however, as migraine patients appeared to develop a tolerance for the drug and used larger doses for pain relief.

Another recent study, published in the Journal of Integrative Medicine, reported that 94 percent of migraine sufferers who inhaled cannabis experienced symptom relief within two hours.

A major weakness of all three studies is that there was no control group or use of a placebo, and the data was self-reported by patients on mobile software apps. The Migraine Buddy app allows users to report the duration, frequency and intensity of their migraines and medication use, as well as information about sleep, diet and weather-related triggers.

“Migraines have a debilitating impact on tens of millions of Americans and, in many cases, are poorly addressed by conventional therapies. Therefore, it is not surprising to see a significant percentage of migraine sufferers turning to cannabis as a therapeutic option. Those that do so are consistently reporting it to be safe and effective at reducing both migraine symptoms and migraine frequency,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

About a billion people worldwide suffer from headaches caused by migraines, which affect three times as many women as men. Over 37 million people in the United States live with migraines, according to the American Migraine Foundation.

Election May Determine Whether Marijuana Will Be Decriminalized

By Dr. Lynn Webster, PNN Columnist

“Times have changed. Marijuana should not be a crime,” Sen. Kamala Harris (D-CA) said last year when she and Rep. Jerry Nadler (D-NY) introduced the Marijuana Opportunity Reinvestment and Expungement Act (MORE Act). The current Democratic vice-presidential nominee called the legalization of marijuana an important step "toward racial and economic justice."

“We need to start regulating marijuana and expunge marijuana convictions from the records of millions of Americans so they can get on with their lives," said Harris.  

"Racially motivated enforcement of marijuana laws has disproportionally impacted communities of color. It’s past time to right this wrong nationwide and work to view marijuana use as an issue of personal choice and public health, not criminal behavior," added Nadler, who chairs the House Judiciary Committee.

Thirty-three states and the District of Columbia have legalized medical cannabis and several states allow its recreational use.  If it became law, the MORE Act would decriminalize marijuana at the federal level by removing it as a Schedule I controlled substance.

That wouldn't instantly remove all restrictions; states could still prohibit the sale of cannabis. But the MORE Act would give states more latitude to create laws to suit their needs, establish a trust fund to support programs for communities impacted by the war on drugs, and destroy or seal records of marijuana criminal convictions.

Game Changing Legislation

This week the House Judiciary Committee passed the MORE Act and later this month the full House is expected to approve the bill and send it to Senate. Chances are the bill will not pass the Senate, because Majority Leader Sen. Mitch McConnell (R-KY) opposes it -- while paradoxically supporting hemp farming.

However, if the MORE Act passes, it would be a game changer. It could open the floodgates for the development of products that contain tetrahydrocannabinol (THC), which is the psychoactive compound in marijuana.  Some research suggests THC alone, or THC and cannabidiol (CBD) combined, could be more effective than CBD alone for treating pain, anxiety, insomnia and other conditions. More research could discover life-changing new treatments.

Since THC has rewarding properties, such as inducing euphoria, any drug that includes THC would likely be a controlled substance. Nevertheless, decriminalizing marijuana would create enormous economic opportunities for growers and anyone in the business of finding solutions to medical problems for which marijuana or its derivatives may be useful.

It doesn’t seem likely that marijuana will be decriminalized at the federal level this year. Congress criminalized marijuana in 1937 and all attempts to reform the law at the federal level have ultimately failed. Our current Senate is unlikely to change the status quo.

But the upcoming election will likely determine whether the MORE Act has a chance to become law in the near future. Democratic presidential candidate Joe Biden supports legalization and decriminalization at the federal level, while President Trump is generally opposed to changing federal marijuana laws. The election will also determine which party controls the House and Senate.

It behooves every voter to become familiar with the candidates' positions regarding cannabis. Criminalizing marijuana has caused great harm. We, as voters, have the power to change that.  

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences. You can find him on Twitter: @LynnRWebsterMD.

DEA Proposes Cuts in Opioid Supply for Fifth Consecutive Year

By Pat Anson, PNN Editor

For the fifth year in a row, the U.S. Drug Enforcement Administration is proposing significant cuts in the supply of hydrocodone, oxycodone and several other opioid pain medications classified as Schedule II controlled substances.

The cuts are partly based on a prediction by the Food and Drug Administration that medical need for the drugs will decline by over a third in 2021.

In a notice published Tuesday in the Federal Register, the DEA proposes to reduce production quotas for hydrocodone by 9 percent and oxycodone by 13 percent in 2021. The supply of hydromorphone would be reduced by nearly 20% and fentanyl by 29% next year.  

The DEA first proposed cuts in the supply of opioids during the Obama administration and the trend has accelerated under President Trump. If approved, the 2021 production quotas would amount to a 53% reduction in the supply of both hydrocodone and oxycodone since 2017.

DEA consulted with the FDA, CDC and the Centers for Medicare & Medicaid Services (CMS) before making its recommendations. The key analysis came from the FDA, which provides DEA with annual estimates of medical usage for controlled substances like opioids.

“FDA's predicted levels of medical need for the United States was expected to decline on average 36.52 percent for calendar year 2021. These declines were expected to occur across a variety of schedule II opioids including fentanyl, hydrocodone, hydromorphone, codeine, and morphine,” the DEA said.

The FDA’s analysis, however, came before COVID-19 infections became widespread in the United States. That led to an increase in demand for injectable opioids used to treat seriously ill coronavirus patients on ventilators.

Faced with growing shortages of those drugs, the DEA issued an emergency order in April raising production quotas for injectable pain medications. Many of those drugs, such as injectable fentanyl and hydromorphone, are still listed on an FDA database of drug shortages.     

DEA said its production quotas for 2021 reflect an “anticipated increase in demand for opioids used to treat patients with COVID-19.”

“Despite this public health emergency, DEA remains focused on the challenges presented by opioid addiction and its effect on the health and wellbeing of the millions of Americans and their families who have become dependent upon or addicted to them. The potential for addiction and misuse exists in every community and remains a pressing health issue with significant social and economic implications,” the agency said.

As PNN has reported, prescription opioids play only a small role in the U.S. opioid epidemic. A new CDC report estimates that nearly 85% of drug overdoses in the first six months of 2019 involved illicit fentanyl, heroin and other street drugs. Prescription opioids were linked to about 20% of overdoses.

In addition to reducing the supply of opioids, the DEA is proposing a significant cut in the production quota for marijuana, which is still classified as a Schedule I controlled substance. To accommodate increased demand for marijuana research, the DEA raised the 2020 quota for marijuana to 3,200 kilograms. Those gains would be reversed in 2021, with production quotas for marijuana and marijuana extracts being reduced to 1,700 kilograms.

Public comments will be accepted on the DEA’s proposed production quotas until October 1, 2020. Comments can be made by clicking here.

Pilot Study Finds Cannabis Helpful in Treating Sickle Cell Pain

By Pat Anson, PNN Editor

Cannabis may be an effective way to reduce acute and chronic pain in patients with sickle cell disease, according to a small pilot study published in JAMA Network Open.

Sickle cell is a genetic disease that affects about 100,000 people in the U.S., mostly of African or Hispanic descent. Their red blood cells are rigid and sickle-shaped, which causes blockages in blood vessels, starves tissues and organs of oxygen, and causes periods of intense pain.

Researchers at UC Irvine and UC San Francisco enrolled 23 adult sickle cells patients in a placebo-controlled study to see if inhaled cannabis could be a safe adjunct to opioid medication in treating sickle cell pain. Most patients continued to use opioids during the course of the five-day trial. Participants inhaled either vaporized cannabis or a placebo three times a day. The cannabis had an equal ratio of CBD and THC – the psychoactive ingredient in cannabis.

As the five-day study period progressed, patients who inhaled cannabis reported that pain interfered less and less with their daily activities, such as walking and sleeping, and there was a significant drop in how much pain affected their mood. The decline in pain levels was not considered statistically significant, however.

Although the findings were mixed, researchers say their pilot study should pave the way to larger clinical studies of cannabis as a treatment for sickle cell pain.

"These trial results show that vaporized cannabis appears to be generally safe," said Kalpna Gupta, PhD, a professor of medicine at UCI Irvine's Center for the Study of Cannabis. "They also suggest that sickle cell patients may be able to mitigate their pain with cannabis—and that cannabis might help society address the public health crisis related to opioids. Of course, we still need larger studies with more participants to give us a better picture of how cannabis could benefit people with chronic pain."

Opioid medication has been the primary treatment for sickle cell pain. But with many physicians now reluctant to prescribe opioids due to fears of addiction, overdose and government prosecution, sickle cell patients have been left with fewer options.

“In the current climate of increased awareness of the ongoing opioid epidemic, it would have been encouraging if this study had demonstrated decreased use of chronic analgesics during the active cannabis vaporization phase,” researchers concluded. “Our study’s small sample size and short duration may have contributed to the inability to demonstrate decreased opioid use among participants receiving the active drug compared with the placebo.”

Of the 33 U.S. states that have legalized medical cannabis, only four have included sickle cell disease as a qualifying condition. That forces many sickle cell patients to obtain cannabis from unapproved sources.

"Pain causes many people to turn to cannabis and is, in fact, the top reason that people cite for seeking cannabis from dispensaries," Gupta said. "We don't know if all forms of cannabis products will have a similar effect on chronic pain. Vaporized cannabis, which we employed, may be safer than other forms because lower amounts reach the body's circulation. This trial opens the door for testing different forms of medical cannabis to treat chronic pain."

A recent small study in Israel found that very low “microdoses” of inhaled THC can significantly reduce chronic pain in patients with neuropathy, radiculopathy, phantom limb pain or Complex Regional Pain Syndrome (CRPS).

Study Finds Cannabis Effective for Treating Depression

By Pat Anson, PNN Editor

Consuming dried cannabis flowers significantly reduces symptoms of depression and works much faster than pharmaceutical antidepressants, according to a new study of over 1,800 cannabis consumers.

The study findings, published in the Yale Journal of Biology and Medicine, is the latest research derived from the Releaf App, a free mobile software program that collects self-reported, real-time information from people on their use of cannabis and its effect on chronic pain, depression and over two dozen other medical conditions.

This particular study excluded the use of cannabis edibles, lotions and oils, and focused solely on cannabis buds that were smoked or inhaled through a vaporizer.

Over 95% of participants in the study reported a decline in depression within hours of ingesting cannabis, with an average reduction in symptom intensity of nearly 4 points, based on a numerical zero to 10 depression scale.

Relief from depression did not vary by the strain of cannabis consumed, but flowers with high levels of tetrahydrocannabinol (THC) were the strongest predictors of symptom relief. THC is the main psychoactive ingredient in cannabis. Levels of cannabidiol (CBD) were generally unrelated to changes in depression.

“Almost all patients in our sample experienced symptom relief from using Cannabis to treat depression and with minimal evidence of serious side effects in the short run,” researchers reported.

“One of the most clinically relevant findings from this study was the widely experienced relief from depression within 2 hours or less. Because traditional antidepressants have times-to-effect in weeks, short-term Cannabis use might be a solution to these delays in treatment or could be used to treat acute episodes associated with suicidal behavior and other forms of violence.”

Prescription drugs used to treat depression include sedatives such as benzodiazepines and antidepressants such as selective serotonin-reuptake inhibitors and tricyclics, as well as anticonvulsant medicines. Most normally take several weeks or months to cause significant relief and have potential side effects such as sedation and suicidal thoughts. Benzodiazepines have become particularly difficult for many pain patients to obtain if they are also prescribed opioid medication.

Medical marijuana is legal in 33 U.S. states and Washington, DC, but depression is not generally recognized as an approved condition under state-regulated medical marijuana programs.

“With no end to the depression epidemic in site, and given the limitations and potential severe negative side effects of conventional antidepressant medications, there is a real need for people to be able to treat mood disturbances with natural, safe, and effective medications, and cannabis checks off all three boxes,” co-author Jacob Vigil, PhD, a University of New Mexico psychology professor, told Forbes.

An earlier study by Vigil using data from the Releaf App found that cannabis flowers rich in THC reduced pain levels an average of three points on a 0 to 10 pain score. Those who ingested cannabidiol (CBD) did not experience similar pain relief.

Another study derived from ReLeaf App data found that cannabis can provide relief from a wide range of symptoms associated with chronic pain, including insomnia, seizures, anxiety and fatigue.

A significant weakness of these studies is that they rely on cannabis users to subjectively self-report their symptoms outside of a clinical setting. There is also no control group or way to measure the quality or quantity of the cannabis they are ingesting.   

Study Finds Microdosing THC Reduces Pain Levels

By Pat Anson, PNN Editor

Very low doses of inhaled THC – the psychoactive ingredient in cannabis – can significantly reduce pain levels in chronic pain patients, according to a small study conducted in Israel.

The concept of “microdosing” cannabis isn’t new, but this was the first clinical study to demonstrate its effectiveness in temporarily relieving pain. The study was sponsored by Syqe Medical, an Israeli medical technology company that makes an inhaler designed to deliver microdoses of cannabis and other drugs.

The study involved 27 patients living with neuropathy, radiculopathy, phantom limb pain or Complex Regional Pain Syndrome (CRPS), who self-reported pain levels of at least 6 on a zero to 10 pain scale. Participants were randomly assigned to three groups that inhaled either a placebo or two different microdoses of THC.  

The most effective dose to relieve pain was just 500 micrograms of THC, inhaled 3-4 times per day. Participants reported a 2 to 3 point reduction in their pain levels for 150 minutes.  

A typical cannabis patient might consume 150,000 micrograms of THC per day – about 75 times more than the highest dose used in the study. Researchers say their findings, published in the European Journal of Pain, suggest that pain patients can benefit from dramatically lower doses.

"We can conclude from the study results that low doses of cannabis may provide desirable effects while avoiding cognitive debilitations, significantly contributing to daily functioning, quality of life, and safety of the patient,” said lead researcher Elon Eisenberg, PhD, Director of the Multidisciplinary Pain Relief Unit at Rambam Health Care Campus in northern Israel.

“The doses given in this study, being so low, mandate very high precision in the treatment modality. This precision is unique to the Syqe drug delivery technology, enabling cannabis dosing at pharmaceutical standards."

There were side effects from inhaling microdoses of THC. About 20% of patients reported feeling “high” or experienced dizziness, sleepiness, nausea, cough or dry mouth. But researchers said there was “no evidence of consistent impairment” in any of the participants.

The risk of impairment from THC is one reason researchers and cannabis companies have largely focused on the medical benefits of cannabidiol (CBD), a compound also found in marijuana. CBD is not psychoactive, while THC can make people impaired – at least in high doses.

"This study is the first to show that human sensitivity to THC is significantly greater than previously assumed, indicating that if we can treat patients with much higher precision, lower quantities of drug will be needed, resulting in fewer side effects and an overall more effective treatment,” said Perry Davidson, CEO of Syqe Medical.

“The Syqe drug delivery technology is also applicable to opioids and other compounds that, while potentially effective, are notoriously associated with dangerous side effects. The introduction of a tool to prescribe medications at such low doses with such high resolution may allow us to achieve treatment outcomes that previously were not possible."

In addition to cannabis, the company is also exploring the use of its inhaler to deliver other drugs for treating pain, sleep, anxiety and cancer. The Syqe inhaler is sold in Israel by Teva Pharmaceuticals. Approval is also being sought to begin sales in Europe, Canada and Australia. Syqe is planning to submit a medical device application to the Food and Drug Administration in the United States.