Although studies are far from conclusive, there are promising signs that cannabis has a major role to play in treating multiple problems associated with opioid use.
For example, recent studies point to cannabis as beneficially controlling nausea and insomnia in people undergoing opioid withdrawal. Cannabis also has been shown to address the underlying symptoms of pain that often lead to opioid use in the first place. And some research has even suggested that cannabis use could effectively treat Opioid Use Disorder (OUD) (addiction) itself.
Many healthcare professionals are increasingly considering cannabis as part of a therapeutic approach to treating multiple adverse opioid issues. Even state governments have stepped forward in approving medical marijuana for opiate abuse. Though research is still limited, initial findings are encouraging in suggesting that cannabis can help alleviate opioid withdrawal symptoms such as nausea while also addressing underlying pain and insomnia. Healthcare officials caution, though, that more research, particularly randomized control trials, are needed.
The Endocannabinoid System
#To better understand how cannabis may have a positive effect on helping opioid users, it’s important to consider the human body’s endocannabinoid system (ECS) and its complex interplay with the chemical elements of both opioids and cannabis.
The ECS regulates a wide array of biological functions, most importantly through modulating homeostasis. It was only recently discovered to exist in all vertebrates.
It is made up of three main entities: endogenous cannabinoids (aka endocannabinoids, meaning cannabinoids produced within the body), the receptors that cannabinoids bind to (referred to as CB1 and CB2), and enzymes that help synthesize and degrade endocannabinoids. CB1 receptors are mostly present in the central nervous system, while most CB2 receptors are in the immune system.
Cannabinoids produced outside the body, such as phytocannabinoids (cannabinoids produced by plants), are also able to interact with the human body’s endocannabinoid system. Phytocannabinoids are derived from several kinds of plants but are particularly prominent in cannabis sativa (marijuana). There are more than 140 known phytocannabinoids in cannabis, but those that are in the strongest concentrations are tetrahydrocannabinol (THC) and cannabidiol (CBD).
It’s important to note that the endocannabinoid system is just one type of neurotransmitter system in the human body. Another is the opioidergic system, which is regulated by opioids, and researchers are only now beginning to better understand how the two systems work to modulate conditions such as pain and anxiety and how their functioning can both raise or lower the risk of drug abuse.
Opioid Addiction & Cannabis
Overall cannabis research efforts has lagged in the US because of cannabis’s historic classification as a dangerous Schedule I drug, precluding it from significant research. With increased acceptance of legalized and medical marijuana across the US, research now is beginning to grow, including research into whether and how cannabis can be used to combat opioid abuse. As it stands now, there are numerous observational studies, as well as some preclinical and clinical surveys, that give a glimpse of the possible benefit cannabis offers.
For instance, a 2018 National Institutes of Health report looked at the complex interplay of the endocannabinoid and opioidergic systems and found evidence to suggest that cannabis holds great potential to prevent opioid misuse (through its use as an analgesic alternative), alleviate opioid withdrawal symptoms, and decrease the likelihood of relapse. The study examined how CB1 receptors and mu opioid receptors (MORs) typically are distributed in the same areas of the brain and how this biological overlap points to the interaction between the two systems, especially in regard to emotional reward responses and other physiological actions that could affect opioid withdrawal.
An earlier study conducted by the University of Michigan in 2016 found that medical cannabis use is associated with decreased opiate use. Using an online questionnaire, researchers conducted a cross-sectional retrospective survey of 244 medical cannabis patients with chronic pain between 2013 and 2015. They concluded that cannabis can be a key asset in addressing opioid withdrawal symptoms.
A 2018 study published by Howard University Hospital reviewed how cannabis might positively affect OUD outcomes. That study found that one key benefit of using cannabis is that CBD actively controls nausea, one of the more prominent adverse effects of opioid withdrawal. The researchers cautioned, though, that cannabis still posed a risk of introducing disorientation and lethargy for some users.
A 2019 study also looked at how CBD might be used in addressing opioid abuse issues. The exploratory double-blind randomized placebo-controlled trial, published in The American Journal of Psychiatry, found cannabidiol (CBD) can reduce cue-induced craving and anxiety, two critical aspects of addiction that often contribute to relapse and continued drug use. It’s important to note that CBD was investigated in people with heroin use disorder, but researchers say they are confident the same data can be extrapolated for addiction to other types of opiates as well.
In addition, a 2018 Canadian study published in the journal Addiction looked at how cannabis use might affect the odds of an individual sticking with an anti-opioid treatment program. The study found that one of the main factors increasing the chances that people would stay enrolled and engaged in treatment efforts in Vancouver was participants’ daily marijuana use.
Though an ever-increasing number of studies are exploring the use of cannabis for opioid abuse, at least one study, conducted in 2015, found no evidence for a reduction of opioid-withdrawal symptoms by cannabis smoking during a methadone dose taper.
Cannabis is believed to be safe drug treatment for a variety of issues, and there have been no reported fatalities in its long history of use. The majority of reported side effects are mild to moderate and include fatigue, drowsiness, diarrhea, vomiting, decreased appetite, and fever. The short-term side effects of THC can include memory, motor and judgment impairment. Long-term possible side effects can include cognitive impairment, a small risk of addiction, and an increased risk of developing a psychotic disorder.
In the United States, the legal status of medical cannabis for treatment of any health condition differs by state. Three states (Idaho, Nebraska, and South Dakota) do not allow the use of any form of medical cannabis. Only four states — Colorado, Illinois, New York and Pennsylvania — specifically cite opioid-related topics as targets of therapeutic cannabis efforts.
Additionally, the District of Columbia and 33 states (Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Washington, West Virginia, Utah, and Vermont) allow the use of medical cannabis for a variety of chronic-pain treatments, which can affect opioid use in those states. In general, adult-use states have lower levels of opioid abuse.
Globally, the legal status of cannabis use for OUD differs by nation, too. In the Netherlands or Germany, for example, doctors are allowed to prescribe medical cannabis for practically any conditions if standard treatments aren’t effective. Yet, in Israel, the global leader in cannabis research, cannabis is not a legal treatment option for addressing opioid abuse and addiction.
Opioids are a class of drugs that affect the brain and nervous system in order to relieve pain and can also give a feeling of euphoria. Opioids include legally prescribed painkillers such as oxycodone, codeine, morphine, and fentanyl, as well as illegal drugs like heroin and opium. Opiate addiction, also known as opiate use disorder, is a chronic, long-term disorder due to addiction to opioids or opiates.
Opiate use disorder has become an epidemic in the United States over the past two decades along with many other countries. Overdose has become one of the leading causes of deaths for young people as a result of so many people addicted. When doctors began prescribing opiates to patients in an effort to provide pain relief, more and more people developed a dependency on opioids. Illicit use of opiates became more common as people could not get enough prescription medications and began using heroin and stronger forms such as fentanyl as substitutes. Today, tens of thousands of deaths in the United States each year are directly related to opiate overuse.
About 8-12% of people prescribed opioids develop opiate use disorder. It’s estimated that over 2 million Americans and 15 million people worldwide are affected by opioid use disorder. The number of people dependent on or at risk of addiction to opioids in Europe is around 1.3 million people.
It’s very easy to become dependent on opioids because the brain’s nerve receptors adapt to the effects of the drug, so that over time the same dose no longer provokes the same physical response. As a result, patients end up needing to take higher and higher doses to get the same effect, setting the stage for addiction. After a period of time, the brain is dependent on receiving the opiates and when stopping or even taking less, the body experiences symptoms of withdrawal. It can take as little as two weeks to become dependent on opioids.
It’s important to note that opioid dependence is not the same thing as opioid addiction. If you’re dependent on opioids, it means that you need them to ease your pain. That doesn’t necessarily mean that you have a compulsive need to keep using them. When you’re dependent on opioids, you still feel withdrawal symptoms when you stop using them, but you might not be addicted.
Opiate addiction and dependence can come about through illegal substances like heroin, but you could also become dependent on opiates while following your physician’s advice, without any connection to a drug lifestyle.
If you’re experiencing opiate use disorder, you’ll find that you can’t stop taking them, even when you try to cut down or stop. People addicted to opioids don’t strictly follow their doctor’s advice about dosage and frequency, and might even take more than they intend.
It can be difficult to tell the difference between dependence on opiates, and addiction to opiates. You’ll know that you’ve become addicted if you compulsively obsess about getting the drug, even if you’re still taking it according to your doctor’s advice.
Using someone else’s opioid drugs, obsessing about getting hold of more opioids, and giving up on other activities in order to get more of the drugs are also symptoms of opioid addiction.
As addiction continues and people crave for more opiates, they may turn to illegal opiates such as heroin to get their fix. Illegal forms of opiates like heroin might be mixed with other substances which can lead to more addiction or overdose.
Whether you’re addicted to opioids or are dependent on them, you’ll still feel the same withdrawal symptoms when you stop taking them. Opiate withdrawal symptoms include:
- Hot and cold flashes
- Nausea, vomiting, and diarrhea
- Cravings for more of the drug
- Anxiety and irritability
- Fast, irregular heartbeat
- Insomnia and disturbed sleep
- Shaky limbs and tremors
- Headaches, and aching muscles and joints
The severity of your symptoms depends on a few factors, like your general state of health, how long you’ve been using opioids for, and whether you’re quitting “cold turkey.” Symptoms of withdrawal can appear within 12 hours of your last dose, and last from a few days to two weeks.
It’s very difficult to stop taking opioids safely on your own. Most people need help and support from a doctor and/or a trained team. The good news is that withdrawal management programs can successfully treat opiate use disorder and help you recover from your addiction to or dependence on opiates.
There are two stages to treating opiate use disorder:
- Detoxification while the drug leaves your bloodstream
- Preventing a relapse once you have recovered from the withdrawal symptoms
The main focus of detoxification is managing the withdrawal symptoms while the brain readjusts to normal function without the help of opiates. It isn’t easy and it is often a difficult hurdle for sufferers to overcome.
There are a few different ways to treat opiate withdrawal symptoms. A good opiate withdrawal management program will use a combination of most or all of them. Opiate withdrawal management programs can be run on an in-patient basis or while you continue to live your normal life at home, depending on how long you’ve been addicted to opiates, how much you regularly take and how frequently you take it, and the severity of your withdrawal symptoms.
- Methadone is a long-acting opiate medication often given as an alternative for those addicted to heroin and other opiates. You can only get each dose at a special clinic, and the dose lasts for 24-36 hours. It has only a few side effects, so people can continue taking it indefinitely. Generally, about 25% of people eventually stop needing it, 25% continue to take it, and 50% have periods of taking it and periods when they don’t need it.
- Buprenorphine is an opioid replacement that doesn’t cause an opioid “high.” It’s usually combined with naloxone (Suboxone), which neutralizes the impact of other opiates. Like methadone, it’s safe to keep taking buprenorphine and naloxone for years, even for a lifetime.
Once you’ve recovered from the withdrawal symptoms and detoxified from opioid drugs, you’ll often be prescribed Naltrexone. This takes away the high that you feel from opioids to prevent you from relapsing. You have to be off opioids for at least 7-10 days before you start taking it.
Counseling and behavioral therapies
Many people who are recovering from opiate use disorder find that counseling and/or behavioral therapies make a big difference to their success. A trained counselor can help you to change your attitude towards opioids and encourage you to complete your detoxification program. Motivation enhancement therapy helps you feel motivated to stay off opioids, and contingency management therapy sets up positive incentives to stick with the detox program.
Many people benefit from group counseling, like the 12-step program used by Narcotics Anonymous. It can help you to feel that you’re not the only one grappling with this challenge.
Cognitive-behavioral therapy (CBT) helps you to spot negative thought patterns that can lead you back to opiate dependency, and replace them with healthier ways of thinking. CBT can help you to manage stress and discomfort that might otherwise lead you to take opioids again.
It’s important to note that alternative treatments like nutritional supplements, herbal remedies, and other therapies should not be used to replace a full withdrawal management program using methadone and other replacement drugs. But they can go a long way to helping you deal with the withdrawal symptoms and manage your pain once you stop taking opioids. Some popular options include:
- Acupuncture- Acupuncture can encourage the brain to release dopamine, which reduces pain and helps you relax. It lowers the discomfort of your withdrawal symptoms and enables you to bear them more easily.
- Herbal and nutritional supplements- A number of herbal supplements have been found to help with different aspects of withdrawal symptoms. For example, St. John’s Wort can help reduce tremors and shaking and ginseng is also popular. Many people with opioid use disorder are low in potassium, calcium, magnesium, and B vitamins.
- Exercise- Opioids can leave your body weak and vulnerable to infection. Regular, careful exercise boosts your mood, helping you overcome the emotional lows of withdrawal, distracts you from your cravings, and strengthens your immune system again. It also increases endorphins in your body which also help fight pain.
- Hydration- The most serious withdrawal symptoms are vomiting and diarrhea, both of which can leave you dehydrated, so it’s important to drink plenty of water or other fluids, while avoiding caffeine which can make you dehydrate faster.
- Diet- Opioids can be disastrous for your digestive system, causing severe constipation, so it’s important to eat carefully to build it back up. Regular light, healthy meals that are high in leafy green vegetables and fiber are recommended.
If left untreated, opiate use disorder can become very serious. Because people dependent on or addicted to opiates keep taking higher and higher doses, they can eventually take a dose that is high enough to weaken their breathing and cause death. In 2017 alone, 47,600 people died from an overdose of opioids in the United States alone.
A significant percentage of people who misuse prescribed opiates then turn to illegal opiates like heroin, which carry far greater health risks like catching HIV or hepatitis through infected needles. There’s also a much greater risk of overdosing on heroin, because it has a stronger and faster high. Also, when opiates are bought illegally, it is unknown what exactly is inside, further increasing potential complications and the risk of overdose.
Suddenly stopping taking opiates has its own dangers. Unless you go through a well supervised withdrawal management program and detoxification process, your withdrawal symptoms can be so severe that it leads to suicide. There are no official numbers, but it’s estimated that thousands of Americans commit suicide due to the depression, pain, and confusion of severe withdrawal symptoms from opioids.