The Journal of the Arkansas Medical Society Issue 1 Vol 115 - Page 4

COMMENTARY

Will Medical Marijuana Help Reverse the Opioid Crisis ?

Darrell Over , MD , MSc , FAAFP Associate Professor UAMS ( South Central ) Family Medicine Residency
Compared to states with no medical cannabis law , access to a medical cannabis dispensary was associated with a decrease in prescribing of 3.742 million daily opiod doses ( 14.4 %) annually in Medicare Part D populations .

For my colleagues who have been practicing medicine at least 20 years , the path leading to the current opioid crisis is familiar . With the conceptualization of pain as a “ fifth vital sign ” by the American Pain Society in 1996 and its endorsement by the Veteran ’ s Health Administration , pain management achieved cause célèbe status . In 1998 , the Federation of State Medical Boards assured physicians they would not receive excessive scrutiny for prescribing notable amounts of opioids , and in 2001 , the Drug Enforcement Agency announced it would follow a “ balanced policy ” in evaluating physician prescribing practices . These decisions — coupled with the pronouncement by the Joint Commission on the Accreditation of Healthcare Organizations that pain assessment and treatment of all patients in accredited health care settings was mandatory in order to receive federal health care dollars — created a “ perfect storm ” wherein physicians were encouraged to aggressively treat pain and indeed were warned that failure to do so could result in sanctions .

Moreover , physicians were reassured by two influential retrospective studies suggesting low risk for opioid addiction when these drugs were used for treatment of pain . In a 1980 one-paragraph letter published in the New England Journal of Medicine , Jane Porter and Herschel Jick described narcotic use in nearly 12,000 hospital patients and reported that only four of these patients had become addicted – only one case was considered severe . A 1986 report in the journal Pain by Russell Portenoy and Kathleen Foley described 38 patients treated with opioids for chronic non-malignant pain over a number of years and reported “ no toxicity … and management became a problem in only two patients , both with a history of prior drug abuse .” Both of these studies were cited hundreds of times in the peer-reviewed and non-peer-reviewed literature to support the assertion that chronic opioid therapy for pain had low risk of addiction . This view guided the training of young physicians and other health care providers .
An unfortunate consequence of increased opioid prescribing was an acceleration of opioidrelated mortality . In 2016 , there were > 63,600 drug overdose deaths in the U . S . and the age-adjusted rate of overdose deaths ( 19.8 per 100,000 ) was 21 % higher than the rate in 2015 ( 16.3 ). The rates of drug overdose deaths were highest for persons aged 25-34 years ( 34.6 per 100,000 ); 35-44 years ( 35 per 100,000 ); and 45-54 years ( 34.5 per 100,000 ). 1 Interestingly , a public policy option that may have the unintended ( but fortuitous ) consequence of mitigating against the devastating effects of the opioid crisis is the legalization of medical cannabis .
Two recently published clinical trials from Israel ( where medical cannabis is legal ) have reported intriguing findings . One trial assessed the safety and efficacy of cannabis in 2736 patients ( mean age 74.5 + 7.5 years ) with pain ( 66.6 %) or cancer ( 60.8 %). At six months , about 94 % reported a decrease of pain score from 8 to 4 ( 10 point scale ) and 18 % reported either reduction or cessation of opioid use . 2 Another study reported the safety and efficacy of medical cannabis in 1211 patients ( mean age 59 + 16 years ) with differing cancers . At six months , about 96 % reported an improvement in their condition , with 36 % reporting cessation of opioid use and almost 10 % having decreased their dose . 3
Two recent studies evaluated the association between medical cannabis laws and opioid prescribing patterns in Medicare Part D populations 4 and Medicaid enrollees . 5 Compared to states with no medical cannabis law , access to a medical cannabis dispensary was associated with a decrease in
4 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY VOLUME 115
COMMENTARY Will Medical Marijuana Help Reverse the Opioid Crisis? F or my colleagues who have been practicing medicine at least 20 years, the path leading to the current opioid crisis is familiar. With the conceptualization of pain as Darrell Over, MD, MSc, FAAFP Associate Professor UAMS (South Central) Family Medicine Residency Compared to states with no medical cannabis law, access to a medical cannabis dispensary was associated with a decrease in prescribing of 3.742 million daily opiod doses (14.4%) annually in Medicare Part D populations. a “fifth vital sign” by the American Pain Society in 1996 and its endorsement by the Veteran’s Health Administration, pain management achieved cause célèbe status. In 1998, the Federation of State Medical Boards assured physicians they would not receive excessive scrutiny for prescribing notable amounts of opioids, and in 2001, the Drug Enforcement Agency announced it would follow a “balanced policy” in evaluating physician prescribing practices. These decisions — coupled with the pronouncement by the Joint Commission on the Accreditation of Healthcare Organizations that pain assessment and treatment of all patients in accredited health care settings was mandatory in order to receive federal health care dollars — created a “perfect storm” wherein physicians were encouraged to aggressively treat pain and indeed were warned that failure to do so could result in sanctions. Moreover, physicians were reassured by two influential retrospective studies suggesting low risk for opioid addiction when these drugs were used for treatment of pain. In a 1980 one-paragraph letter published in the New England Journal of Medicine, Jane Porter and Herschel Jick described narcotic use in nearly 12,000 hospital patients and reported that only four of these patients had become addicted – only one case was considered severe. A 1986 report in the journal Pain by Russell Portenoy and Kathleen Foley described 38 patients treated with opioids for chronic non-malignant pain over a number of years and reported “no toxicity … and management became a problem in only two patients, both with a history of prior drug abuse.” Both of these studies 4 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY were cited hundreds of times in the peer-reviewed and non-peer-reviewed literature to support the assertion that chronic opioid therapy for pain had low risk of addiction. This view guided the training of young physicians and other health care providers. An unfortunate consequence of incre 6V@B&W67&&rv266VW&FbBЧ&VFVB'FƗG#bFW&RvW&Rc2cG'VpfW&F6RFVF2FRR2BFRvRFW7FV@&FRbfW&F6RFVF2W"v0#RvW"FFR&FR#Rb2FR&FW0bG'VrfW&F6RFVF2vW&RvW7Bf"W'60vVB#R3BV'23BbW"3RC@V'23RW"BCRSBV'23BPW"FW&W7FvǒV&Ɩ2Ɩ7FFBfRFRVFVFVB'WBf'GVFW266WVV6Rb֗FvFrv7BFRFWf7FFpVffV7G2bFRB7&622FRVvƗF`VF66&2Gv&V6VFǒV&Ɨ6VB6Ɩ6G&2g&Ф7&VvW&RVF66&22Vv’fP&W'FVBG&wVrfFw2RG&76W76V@FR6fWGBVff67b6&2#s3`FVG2VvRsBRrRV'2vFࢃcbbR"66W"cRB6F2&W@BR&W'FVBFV7&V6Rb66&Rg&УFBB66RBR&W'FVBVFW &VGV7F"6W76FbBW6R"FW 7GVG&W'FVBFR6fWGBVff67bVF66&2#FVG2VvRS`V'2vFFffW&r66W'2B6F2&W@bR&W'FVB&fVVBFV"6FFvF3bR&W'Fr6W76FbBW6R@7BRfrFV7&V6VBFV"F6R0Gv&V6VB7GVFW2WfVFVBFR766F&WGvVVVF66&2w2B@&W67&&rGFW&2VF6&R'BBVF2@BVF6BV&VW2R6&VBF7FFW2vFVF66&2r66W72FVF66&0F7V6'v2766FVBvFFV7&V6RdTRP