(Part 2) Cannabinoids as a Substitute for Opioids: Basic Science and Clinical Evidence

Despite conflicting evidence, for many patients with chronic pain, the risk of using opioids may be greater than the benefits, especially over long periods of time. It is important that patients wishing to understand the potential benefits and risks of using cannabis in addition to opioids discuss this with their health care provider prior to use.

We recently discussed the use of opioids for chronic pain, and highlighted the potential use of cannabis as an option to reduce opioid use and side effects. In the second part of this series we look at more evidence supporting cannabis use.

Evidence suggests that combining cannabis with opioids in treatment for pain may lead to a reduction in the dose of opioids or replace opioids altogether (Reiman et al., 2017;  Lucus & Walsh, 2017; Nielsen et al., 2022; MacCallum et al., 2021). A 2017 study found that 97% of medical cannabis patients agreed that by consuming cannabis, they could decrease the amount of opiates consumed (Reiman et al. 2017). Another study found that there was a 64% reduction in opioid use among cannabis users, which also led to decreased opioid-related side effects (e.g., nausea) and improved quality of life (Manzanares et al., 2006; Boehnke et al. 2016; Giorgi et al., 2020). Other symptoms such as anxiety, insomnia, and depression commonly experienced with chronic pain also improved.

It is important to acknowledge that there is some conflicting evidence showing cannabis did not help reduce pain or opioid doses. This highlights a need for more research. Despite this conflicting evidence, for many patients with chronic pain, the risk of using opioids may be greater than the benefits, especially over long periods of time. In this case, cannabis may be a useful addition. It is important that patients wishing to understand the potential benefits and risks of using cannabis in addition to opioids discuss this with their health care provider prior to use.

Stay tuned for an overview of the key concepts surrounding cannabis as a substitute for opioids in the third-part of this blog series.

References:

Boehnke KF, Litinas E, Clauw DJ. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain. 2016;17(6):739–44.

Giorgi V, Bongiovanni S, Atzeni F, Marotto D, Salaffi F, Sarzi-Puttini P. Adding medical cannabis to stan- dard analgesic treatment for fibromyalgia: a prospective observational study. Clin Exp Rheumatol. 2020;38(123):S53–9.

Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: a survey of authorized medical cannabis patients. Int J Drug Policy. 2017;42:30–5.

Manzanares J, Julian MD, Carrascosa A. Role of the cannabinoid system in pain control and therapeutic implications for the management of acute and chronic pain episodes. Curr Neuropharmacol. 2006;4(3):239–57.

Narouze SN, MacCallum CA. eds. Cannabinoids and Pain. Springer; 2021 Chapter 27; Cannabinoids as a Substitute for Opioids: Basic Science and Clinical Evidence

Nielsen, Suzanne, et al. "Opioid-sparing effect of cannabinoids for analgesia: an updated systematic review and meta-analysis of preclinical and clinical studies." Neuropsychopharmacology 47.7 (2022): 1315-1330.

Reiman A, Welty M, Solomon P. Cannabis as a substitute for opioid-based pain medication: patient self-report. Cannabis Cannabinoid Res. 2017;2(1):160–6.

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‍Dr. Caroline MacCallum is a specialist in internal medicine with expertise in complex pain and cannabinoid medicine. In addition to serving as an advisor to EO Care, she is a clinical instructor in the Department of Medicine; Adjunct Professor in the Faculty of Pharmaceutical Sciences program; and associate member of the Dept. of Palliative Care at the University of British Columbia. An avid researcher, Dr. MacCallum is primary author of Primary Considerations for Medical Cannabis Administration and Dosing, and assistant for Cannabinoids and Pain.

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