“You haven’t actually tried heroin before, have you?” asks a friend who works as an addiction therapist. Because if I had, he ventures, my questions regarding cannabis and opiates would probably look a lot different.

Heroin can feel extremely and overwhelmingly pleasurable—even in comparison to weed. And for a lot of pain patients who are dependent on opioids, understanding that gap the key.

“At times in my life when I’ve been successful in [abstaining from heroin], cannabis has been an integral part of maintaining that sobriety,” explains my other friend James, who uses both cannabis and heroin. In treatment for addiction, cannabis is commonly regarded as one of the worst things someone could use while trying to get sober. But James has noticed there are a lot of people who call themselves “sober” and still smoke tons of weed. The observation changed his perspective: “I can smoke weed and still do stuff I need to do; a couple hits of weed improves my mood tremendously.” Medical cannabis may help wean people off heroin—but it might not cut their habit completely.

Maybe the old stereotype that cannabis makes you “lazy” has advantages in this case: Cannabis-use reduces the motivation to use opiates. “I can get stoned [on cannabis] and become carefree. I might not care about doing my homework, but I also don’t care about getting dope. I’m just content to be high,” says James.

 

High Sobriety

It’s an idea that’s familiar to Joe Schrank, founder of the Los Angeles-based cannabis-inclusive treatment center High Sobriety. Schrank refers to cannabis as “the condom of the Drug War,” pointing out that it can be central in harm reduction when it comes to more lethal substances. Some research seems to suggests a correlation between cannabis use and a reduction in opioid intake or related overdose deaths.

CBD on its own may also be effective in reducing opioid use and overdose fatalities. According to research…the anti-inflammatory effects of CBD—unlike opioids—not only helps with pain, but can treat the underlying source of pain.

For starters, explains Dr. Julie Holland, psychiatrist and author of The Pot Book, cannabis could magnify pain relief for people already using opioids, thus allowing them to use a lower dose and experience fewer side effects. In a 2018 study published in the European Journal of Internal Medicine, researchers found that, for cancer patients in need of painkillers, cannabis could stop opioid dependency before it even starts. “Cannabis is helpful when it comes to reducing opioid consumption, to increase quality of life and to reduce pain, nausea, and vomiting,” lead researcher Lihi Bar-Lev Schleider says. Within six months of initial intake, cannabis patients who participated in the study were able to lower their dose of opioid painkillers.

 

Great Pains

CBD on its own may also be effective in reducing opioid use and overdose fatalities. According to research from Drs. Yasmin Hurd and Julia Arnsten at Mount Sinai Hospital in New York, the anti-inflammatory effects of CBD—unlike opioids—may not only help with pain, but may also treat the underlying source of pain. Their research also shows that CBD may help repair neural circuitry that has been disrupted by long-term substance abuse disorders. Holland points out that when the state of New York legalized medical cannabis, opioid addiction was listed as a qualifying condition for a patient to receive a cannabis recommendation; several states have since followed suit.

Further research indicates that states with medical cannabis laws are associated with about a 25 percent decline in opioid-related fatalities. But experts remain skeptical. Between 1999 and 2010, research published in JAMA Internal Medicine showed a reduction in painkiller overdose deaths, but once the analysis was extended through 2017, states with cannabis policies actually saw a 23 percent increase in deaths. Data from California and Colorado also point to an increase in opioid fatalities—despite these states’ medical cannabis policies. Increasing access to cannabis hasn’t statistically shown a decrease in opioid-related deaths.

“Sure it’s possible that for some individuals, using cannabis can decrease their opioid use, but we don’t have systematic evidence that that’s true on a broad scale,” says Chelsea Shover, postdoctoral research fellow at Stanford University and lead author of a study finding that medical cannabis actually correlated with an uptick in opioid overdose fatalities. “In general, people who have pain use more things to treat their pain.”

But Shover also says that could change.

“The answer, eventually, I think, will be different, depending on whether you’re talking about CBD or cannabis as a whole plant,” she explains. “You’ll probably find, in the long run, some scenarios where cannabis or some of its constituents appear to make things better or worse. Whether that’s causal is hard to figure out. The evidence we have now doesn’t suggest firmly one way or the other.”

In other words, some cannabis-use patterns are associated with more opioid use, whereas others are associated with a reduction. This is on a micro scale, but on the macro population-level scale, we’re still not seeing results.

 

Macro/Micro

“The question has to be asked, for those states that have medical cannabis, why are the rates [of opioid use] going up? Why are the numbers going up?” says Dr. Kenneth Finn, who owns Springs Rehabilitation in Colorado Springs and specializes in physical medicine and pain management. “The rate itself isn’t as important as what the data is showing. We don’t want our patients on opioids; we want to taper them.” Even when green states show a percentage reduction in opioid use, the graph still has an upward trajectory. “The concept is attractive, but in real life, it has not been applicable to states like California or Colorado or others,” says Finn. “The data just isn’t there.”

For one thing, research indicating that cannabis can help reduce opioid use may not reflect real life. The kind of cannabis people are consuming—either from unlicensed dispensaries in places like California—where a faulty legal program has had the unintended effect of a booming black market—is not of medical or research-grade quality. “Especially with dispensary cannabis, where potencies are across the board, what’s in the bottle might not be what’s on the label—it’s a public health and safety disaster and it has not impacted the opioid problem,” says Finn. “Look at the data from California and Colorado and show me where it’s helped. No one has been able to provide me an answer for that.”

There have been numerous studies both in animals and humans that document that there is a synergy of pain reduction when combining cannabinoids and opioids; tiny doses of THC or cannabis that ordinarily wouldn’t have any effect on pain by themselves will produce a measurable benefit increase in pain reduction when combined with opioids.

For context, the absence of sufficient data is, by many accounts, a direct result of there being significant restrictions on funding for studies that prove the health benefits of cannabis. So far, the state has been more inclined to fund studies which prove cannabis causes harm than studies that prove otherwise.

Indeed, the data we do have tells a paradoxical story.

“The problem with some of these statistics is that you can torture them to make them look like anything you want. When you’re looking at populations, it gets very murky because the cause and effect may not be evident at all,” says cannabis expert Dr. Ethan Russo, founder and CEO of CReDO Science. “When you’re looking at population statistics you may see trends that have nothing to do with other factors under consideration. Some years ago, there were use rates and death statistic trajectories in states that had medical cannabis access showing a slow down; the implication was that those were related. Epidemiologists will tell you that they may be independent of one another—it’s hard to prove that the two are related.”

 

Cannabis and Opiates

But what we do know, says Russo, is that for over 150 years, cannabis has been used by patients who are taking opioids chronically for pain, and anecdotally, it has always correlated with a reduction in opioid dosages.

“There have been numerous studies both in animals and humans that document that there is a synergy of pain reduction when combining cannabinoids and opioids; tiny doses of THC or cannabis that ordinarily wouldn’t have any effect on pain by themselves, will produce a measurable benefit increase in pain reduction when combined with opioids.”

And cannabis may not be great for acute pain. “If someone breaks their leg or has a tooth taken out, we won’t advise the use of cannabis,” Russo says. “Where it does help is with chronic pain, particularly neuropathic pain, where it has a big advantage over other agents. In fact, chronic opioids can exacerbate or produce neuropathic pain.”

Russo doesn’t recommend smoking cannabis as the best delivery method either, but instead recommends tinctures or other oral cannabis-based medicines. “On a micro level, I can say that virtually everyone I know in the business is of the opinion that there is a marked benefit in their patients [who] come in with chronic pain on opioids,” he says. “On a macro level, it’s more difficult [because] in this country it’s onerous to do clinical trials with anything related to cannabis.”

With other cannabis components beyond THC—including CBD and terpenes like the anti-inflammatory and analgesic caryophyllene—the plant offers a number of individual and combined factors that could lead to a reduction in pain, and could help dependent opioid users taper off. But for a definitive answer to the question can cannabis actually put a dent in the opioid crisis, more research is definitely required. Because, like so many things, it’s complicated.

By Madison Margolin

May 15, 2020

Madison Margolin is an LA/NY-based journalist on the cannabis beat. Her work has been featured in Rolling Stone, LA Weekly, Merry Jane, Herb, Playboy, and other places too.