Summary: As wider and wider acceptance of the medicinal cannabis happens, many have begun to notice a drop in prescription opioid abuse and dependency. In this article, we will look at various government studies chronicling opiate abuse, and the rise of medicinal cannabis use. A brief look into the Gateway Theory, perpetrated by prohibitionists, will dispel the myth.
If you are a child of the 90’s, you all remember D.A.R.E. and the anti-cannabis campaigns they ran. Since the time of its prohibition, cannabis has been touted as a gateway drug, leading to harder substances like heroin and crack. The argument was that if one consumed cannabis, they would have no problem jumping to drugs like cocaine, methamphetamine, or heroin, due to a tolerance developed from smoking and chasing a “high” that doesn’t exist. But does the evidence really back up the theory? While medicinal cannabis has been legalized in 23 states, for a variety of medical conditions including cancer, should states consider full legalization of cannabis, to support cannabis based opioid abuse programs? Recent studies and data suggest a correlation of opioid abuse and overdose, to cannabis legalization. Some states have even considered medicinal cannabis as treatment for opioid abuse (AP, 2016).
By comparison, cannabis is safer and less toxic than opiate based medicines due to the fact that opioid receptors on the brain stem are linked to respiratory depression, i.e. heroin overdose (Shook et al, 1990). 6/10 drug overdoses involve an opioid, be it prescriptions or heroin, killing 78 Americans daily (CDC, 2016). Spanning 2000 to 2014, nearly half a million people have died from drug overdose, and 2014 had the most fatal drug overdoses of any year on record (CDC, 2016). With a 14 fold increase in the United States and Canada of the medical use of prescription opiates, they have become the second most prevalent type of abused drug, next to cannabis, with 1.7% of population abusing prescription opioids, and 0.7% dependent on opiate pain relievers (van Amsterdam, 2015). Further analysis found 40% of non-medical use was motived by pain relief, while about half of non-medical users used for intent to get intoxicated, “high” or relax, but decline in use and abuse after 2011, possibly due to variety of restrictive regulations (van Amsterdam, 2015). In a study of opioid analgesics or pain relievers, performed by the CDC, found that from 1999-2008, overdose deaths involving the pain relievers had exceeded heroin and cocaine deaths combined. Based on reviewing fatal opioid pain relievers, nonmedical use, sales, and treatment admissions, they found opiate analgesics were responsible for almost three quarters of all prescription drug overdoses, and states with lower death rates had lower nonmedical sale and use (CDC, 2011). The overdose death rate in 2008 was nearly 4 times higher than in 1999, and the sales rate of opioid analgesics as rose correspondingly 1999 to 2010. Positive correlations presented in increased overdose death rate and the percentage of non-Hispanic whites living below the poverty line (CDC, 2011). A later study reviewed demographics and substance use trends of heroin users, from 2002-2013, and found that heroin use had increased across most demographics, with use paralleling heroin-related overdose death rate, and use occurring with other substances as well. Annual average rates of past-year heroin use increased 1 per 1000, from 1.6 per 1000 in 2002-2004, to 2.6 per 1000 in 2011-2013, as well as odds of past-year heroin abuse and dependence were highest among other past-year substance abuse or dependency from data years 2011-2013 (CDC, 2015). In the most recent review from the CDC, they have called the rising drug overdose involving opioids, prescription or synthetic, is of epidemic proportion, reporting that since 2000, drug overdose death rates have increased 137%, including a 200% increase in overdose death rate involving opioids. Here are some viable numbers to see the epidemic (CDC, 2016):
- 47,055 drug overdose deaths in 2014, rising 6.5% from 13.8 per 100,000 in 2013 to 14.7 per 100,000.
- Drug overdose rate more than doubled from 6.2 per 100,000 in 2000 to 14.7 per 100,000 in 2014.
- Overdose deaths involving opioids increased 14% from 7.9 per 100,000 in 2013, to 9.0 per 100,000 in 2014.
- Largest annual increase rate involved synthetic opioids, other than methadone, like fentanyl or tramadol, nearly doubling from 1.0 per 100,000 to 1.8 per 100,000 in 2014, while methadone overdose death rate stayed the same from 2013-2014.
- Heroin overdose death rates increased 26% from 2013-2014, and more than tripled since 2010 from 1.0 per 100,000, to 3.4 per 100,000 in 2014.
- Rate of drug overdose deaths involving opioid pain relievers like morphine, oxycodone, and hydrocodone, remain largest contributor to opioid overdose death rates, raising 9% from 3.5 per 100,00 in 2013-3.8 per 100,000 in 2014(CDC, 2016).
In a case study, researchers realized the lack of quality information on factors of opioid-induced respiratory depression, especially for those on opioid treatment for chronic pain management. By dividing cases into two distinct groups, 1980-1999, and 200-2012, where cases before 2000 were primarily cancer patients on morphine,
and cases after 2000 involved methadone and fentanyl. Some of the specific factors located of limited studies were elevated plasma levels caused from drug interactions on cytochrome in post 2000 cases, and elevated opioid plasma levels due to renal impairment and the loss of sensory inputs from portions of the body in pre 2000 cases (Dahan et al, 2013). The study of opioid-related respiratory depression, concluded in saying that there are many complex often interacting factors, calling for careful titration of opioid dosages, and continuous monitoring to prevent the disease. With death being a possible side effect of opioids, opioid abuse is fairly common among those below the poverty line.
In a question and answer session with Michael Klein, Director of the FDA Controlled Substance Staff, he defined prescription drug abuse as the use of prescription drugs, for euphoric effects, not intended when prescribed, or purchased recreationally. The major difference between misuse and abuse are the individual intentions and motivations of taking the drug, citing someone taking additional sleep medicine to intensify therapeutic effect, or individual giving opioid pain reliever to friend in pain as drug misuse. He also states that both misuse and abuse of prescription drugs can be harmful and life-threatening (FDA, 2010). Nearly 35 million Americans reported using prescription pain relievers, including opioid-containing drugs like hydrocodone, oxycodone, and fentanyl, at least once in their lifetime (FDA, 2010). Past-year use of 12th grades percentages form University of Michigan 2014 Monitoring the Future Study showed that 4.8% of seniors used Vicodin for nonmedical use, 3.3% used OxyContin for the same purpose (UM, 2014). NIDA states that while the general populace believes prescription and over-the-counter drugs are safer than illicit drugs, but in fact can be as addictive and dangerous. These drugs can put users at risk for other adverse health effects, including overdose, especially when taken in conjunction to other drugs or intoxicants (NIDA, 2015). While the relationship of opioid-induced respiratory depression and opioid overdose is clearly defined, long term effects can induce hypoxia, or a lower oxygen amount actually reaching the brain. Hypoxia can have short-term and long-term effects including psychological and neurological effects, coma, and permanent brain damage. Studies have shown deterioration of brain’s white matter due to heroin use, affecting decision-making, regulating behavior, and response to stressful situations (NIDA, 2015). Castlight Health performed a major analysis of opioid abuse trends in the American Workforce, and found that the cost of opioid abuse to the economy is $56 billion annual, with 16,000 overdose deaths from prescription opioids. Baby boomers were 4 times more likely to abuse opioids than Millennials, and 1 in every three opioid prescription is abused, costing employers double in health care costs, compared to non-abusers. The top four pain-related conditions for abuse are neck, back, abdominal, and joint pain, with opioid abusers having double the pain related conditions as non-abusers (Castlight, 2016). A 2011 National Survey on Drug Use, found that nonmedical prescription use of opiates was second most prevalent illicit drug used next to cannabis, an unregulated, and widely available substance (SAMHSA, 2012). Just to give background, since 2011, regulation of opioid pain reliever have become restrictive, and is still second most prevalent illicit drug, next to a substance, that is not tracked, or regulated, but rather prohibited from regulation in general. While state to state nonmedical use has a range of abuse record, with 7 of the top ten states being in Western regions of Arizona, Colorado, Idaho, and Washington to name a few (SAMSHA, 2013). The swathe, and depth of the issue spans the world, and as more and track the opium production, a total of 7,554 tons of opium is produced annually, with 32.4 million opioid users, and 16.5 million opiate users worldwide. To give a visual representation, global cultivation of opium is 310,891 ha, is the equivalent 440,000 professional sized soccer, or football, fields, or 768228.3915 acres of land (UNDOC, 2015). Polling data from NIDA from 2002 to 2012 found that those using prescription opioids for nonmedical purposes, were 19 times more likely to try heroin, than those that did not. Interviews with injection drug addicts from 2008 to 2009, found that 86% had used prescription opiates before trying heroin, accessing prescriptions from three main sources, family, friends, and personal prescriptions (Lankenau et al., 2012). But what if there was a solution to the chronic pain of everyday people, and opiate epidemic killing thousands every year? Well, the solution could be cannabis.
With chronic pain affecting 100 million people a year annually, something must be done to cure this symptom. Maybe opiate based pain management is not the solution that major pharmaceutical companies keep pushing. In a study performed on non-malignant pain treatment in ambulatory setting, found that opioid prescribing has nearly doubled in ten years, from 11.3% to 19.6%, while non-opioid pain relievers remained steady at 26-29% of visits. Researchers viewed 3 measurements for results, annual visits volume among adults with primary pain symptoms or diagnosis, receipt of any pain treatment, and receipt of prescription opioids or non-opioid prescriptions pharmacologic therapy in visits for new musculoskeletal pain. Their conclusion was steady prescription of non-opioid analgesics, did not keep up with increases in opioid prescriptions, and no proportional ambulatory pain patients receiving pharmacologic treatment. Clinical alternatives to opioids may be underutilized, or not currently accepted as treatment in some states (Daubresse et al, 2013). In a retrospective cross-sectional survey of patients with chronic pain, cannabis use was associated with 64% lower opioid use, better quality of life for patients, and fewer medication side effects, and fewer medication needed (Boehnke et al, 2016). Researchers also pointed out, there is little to no evidence that opioids are effective in long term chronic pain treatment. Researchers have studied the correlation of state passage of medicinal cannabis, and overall opioid mortality rate, noting that states with medicinal cannabis had a 24.8% lower mean annual opioid overdose mortality rate, than states without medicinal cannabis laws (Bachhuber et al, 2014). The study concluded that, in fact, medical cannabis laws are associated with lower state-level opioid overdose dependency, showing that in years after implementation, showed lower rates, generally dropping more and more over time (Bachhuber et al, 2014). Boehnke and his team went a step further, examining the use of medicinal cannabis for chronic pain, changed patterns of opioid use by individuals. While more research is necessary, preliminary findings suggest that many chronic pain patients are substituting opioids and other medications, with medicinal cannabis, finding a greater benefit/side effect profile for cannabis, compared to other classes of drugs (Boehnke et al, 2016). Some researchers are even calling for cannabis consideration in pain management, due to its variable content of more than 100 different cannabinoids, and cannabidiol may be anti-inflammatory, anxiolytic, and anti-seizure without euphoria (Savage et al, 2016). With Twenty-three states permitting medicinal cannabis, substitution of a less harmful substance may go a long way in curbing the opioid epidemic. An open-label study determined long-term effect of medical cannabis on pain and functional outcomes of subjects with treatment-resistant chronic pain, using a Treatment Outcomes in Pain Survey-Short form, to quantify pain records. The results of baseline testing was median 83.3 in pain symptom score, to 75.0 afterward, and pain severity median baseline of 7.50 to 6.25, and pain interference baseline score of 8.14, to 6.71. Those improvements coupled with improving social and emotional disability scores, lead to a follow up decrease of 44% in opioid consumption (Haroutounian et al, 2016). Some states, including Maine, and Massachusetts, are even contemplating using medicinal cannabis to treat opioid addiction (Drug-Free Kids, 2015). Just to put some more things into perspective, many states are hesitant to open legal avenues for cannabis regulation, due to DEA and federal scheduling. With cannabis “scheduled” or deemed medically equivalent to heroine, ecstasy, and peyote, while cocaine, methamphetamine, Vicodin are deemed safer and less prone to abuse, the federal government can crack down at any point (DEA, 2016). But on the same token, how could the same government own a patent on cannabis, more specifically cannabidiol, or CBD, as an antioxidant, as well as a host of other effects (HHS, 2003). With all of this taken into account, can our government really be left to determine our best needs? What if that government had been systematically lying to its governed, using fear mongering, and deceit to sway public opinion?
Gateway theory was widely purported to associate the use of cannabis with harder, more dangerous substances. Initially coined the stepping stone theory, the basic logic was that if an adolescent smoked cannabis, then he was more likely than not, to graduate to harder substances like heroin. This was after a brief claim that smoking marijuana induced homicidal tendencies, and the breakdown of a then segregated society. The major player and proponent of the War on Drugs, especially cannabis was Harry Anslinger, the first director of the Federal Bureau of Narcotics, later turned into the Drug Enforcement Agency. The stepping stone theory has been used repeatedly to tout the dangers of cannabis, a more critical analysis has shed new light on the “stepping stones.” Through international studies, one study concluded alcohol misuse was more likely in adolescents in rural areas, demonstrating a reverse gateway theory, where cannabis use precedes the use of legal substances (Barrense-Dias et al, 2016). Furthermore, a French study found that:
- 5% used tobacco alone
- 5% used Tobacco then Cannabis
- 1% used Cannabis then Tobacco
- 5% followed the gateway theory, of tobacco, cannabis, then other illicit drugs (Attaia et al, 2016)
At their conclusion, they question the gateway theory, and finding a common liability to substance used to be more in line. Polysubstance initiation is a better predictor of further use and substance use disorder, and likelihoods increased with number of substances previously used (Attaia et al, 2016). In a study published in 2015, researchers were looking to compare nicotine and opiate addicts to determine differences in personalities, and onset smoking age. Two groups were randomly selected, opiate and nicotine addicts, and given various surveys and questionnaires, finding opiate addicts had higher scores in “novelty seeking,” low cooperativeness, and lower onset smoking age (Amirabadi, 2015). While these may be an important personality traits in determining future use of drugs, including subsequent use of opiates, another study found alcohol to be the gateway drug. Among a sample of seniors in high school, alcohol was found to be the most common used substance, and majority of polysubstance using respondents started with alcohol before tobacco or cannabis (Barry et al, 2016). The younger an individual begins use of alcohol, the more prone to lifetime illicit substance use, and the higher frequency of use. The study concludes that screening for substance abuse, even at a young age, is important, as well as school prevention programs targeting alcohol, possibly as early as third grade (Barry et al, 2016). A study aiming to study the transition between tobacco, cannabis, and other illicit drugs, as well as explore the gateway theory, common liability theory, and route of administration model (Mayet, 2015). The results find that early use propensity was associated with gateway sequence, with alternative begins, as well as tobacco use associated with higher likelihood of later cannabis use. While some were found with follow gateway theory, others followed the common liability model, and route to administration model explains the associated use of tobacco to cannabis and vice versa. Findings suggest shared influences of individual, such as personality traits, and environmental characteristics, such as substance availability and peer influence (Mayet, 2016). As the cannabis as a stepping stone has been disproven, the rationale for prohibition dwindles. With the movement under way to legalize and regulate rather than prohibit and lock our fellow human behind bars for mere possession, many wonder how we educate the next generation, where the previous had failed.
On an anecdotal point, I recall Drug Abuse Resistance Education, or D.A.R.E., and having uniformed police officers, coming into my classroom as early as elementary school. They taught the class about the perils of modern peer pressure, substance use, gang activity, attempting to curb youth abuse of substances. I even recall the old gateway theory rhetoric, teaching me how bad cannabis is, and how it would ruin your life. But, in a turn of events, D.A.R.E. quietly removed cannabis from its gateway list, while leaving both tobacco and alcohol on the list (Brosious, 2016). While they did not announce that they were removing it from their list, did they shift their opinion or stance on the matter? An article in Forbes, discussing a former deputy sheriff supporting legalization, for regulation and safety of youth, stating, “I know from enforcing senseless marijuana laws that children only are being put in more danger when marijuana is kept illegal.”. But when D.A.R.E. heard of the conundrum, they responded saying they have not changed their stance of opposition to legalization (Sullum, 2016). With the ground crumbling beneath the feet of prohibition, how much longer can ground stand before it collapses as well? As the movement grows, so does the reach and power behind it. Is cannabis just the tip of the iceberg, as the American people challenge the establishment in new ways? To conclude this article, I want to leave you with a quote from John Ehrlichman, a Watergate co-conspirator, in an interview with Dan Baum of Harper Magazine:
The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying? We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did (Baum, 2016).
Share your experiences below, has cannabis helped someone you know battle with opioid dependency, or get off opioid pain relieves for pain management? Be sure to share this article with everyone you know to educate the masses on this miraculous plant. Knowledge is power, and we live in the information age.
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