In a Bad Way: Pain, Opioids, and Cannabis

Part One

Every summer, I’m invited to speak to a support group for people who live with chronic pain. The group members suffer from various ailments that hurt and are hard to treat – rheumatoid arthritis, fibromyalgia, low back pain.  Some are cancer survivors.  So I’m a bit off -field as a neurology nurse but I talk about how the brain responds to perpetual stress and lack of proper sleep, two subjects with which they are well acquainted.

People who suffer with intractable pain will tell you of all the visits they make to try to get help – visits to pain specialists, to acupuncturists, to chiropractors, to therapists, to the vitamin aisle at Whole Foods.  Oh, and to the pharmacy.  Most will tell you that the narcotic pain drugs that come from a pharmacy – the kind that are ordered on a special triplicate prescription form – are strictly last-resort measures.  So much so, that sometimes they will choose the pain over the drug.  One middle-aged man with chronic head and neck pain told me, “I just live hour to hour.  The pain has moved in and become a part of me.”

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“Pain is what the patient tells you it is” was a mantra I learned back in nursing school. It’s a complicated monster involving both subjective and objective experience. If your knee hurts, it’s not just your knee that bothers you.  It’s your brain relentlessly ruminating over your knee pain and how it might affect you now and how you envision your future self – say, cruising around Walmart in a motorized scooter.

Pain is big and costly.  Approximately, 100 million U.S. adults are encumbered by chronic pain, prompting more than 50 percent of all annual physician visits.  The financial burden of pain-related issues is in excess of $600 billion in annual healthcare costs and lost productivity.

Despite all the hand-wringing and political posturing about the aberrant use of opioids in this country, back here in Dogpatch they still seem to be regarded by many as the best pharmacotherapy for pain relief.  And for the short term, they can work well.  At least we thought we did.  “Get your patient off the pain ceiling” I was advised during my early years as a hospital nurse on an acute surgical floor.  This meant that we administer whatever it takes to get the terrible pain under control, opening the door for the real healing to begin.

But we know now that opioids are lousy for chronic pain.  That’s because over time such drugs make a person both hate and need that next hit and will empty their bank account to get it.  The prevailing theory behind such behavior is called “Opponent Process Theory” and there’s a long, scientific explanation that accompanies it.  The short version is that every drug you take will elicit both positive (such as euphoria) and negative effects (such as headache or nausea) in your body.  The first time you take the drug the positive effects are overwhelming and you feel absolutely terrific.  But as you take the drug more and more, the negative effects start to override the positive effects.  It’s not that you are building a tolerance but you need more of the drug to revisit that first dose experience.  Your body’s neurobiology is confused since the presence of the drug has become the new normal.   The irony is that at this point, drug users can actually become more sensitive to painful stimuli, a condition known as opioid- induced hyperalgesia.

Ouch.

Interestingly, as more states introduce medical and recreational cannabis policies, the learning curve is ramping up about the relationship between cannabis and opioids.   More rigorous studies have begun to appear providing evidence for the correlation of medical cannabis with decreased opioid usage and mortality.  For example, a recent examination of Medicare claims data also showed that the use of prescription pain medications, including opioids, was significantly reduced in states following the implementation of medical cannabis laws.   Another study demonstrated that the percentage of drivers testing positive for opioids after traffic fatalities was significantly reduced in states with medical cannabis laws compared to states without such laws. A University of Michigan March 2016 study published in the Journal of Pain found that cannabis decreased side effects from other medications, improved quality of life and reduced use of opioids by 64 percent.

When you look at studies collectively and a pattern seems to emerge – in this case, that medical cannabis is inversely correlated with opioid usage and mortality – you still need to dig deeper and ask why such a relationship exists.  Did the patients with chronic pain initiate their treatment with cannabis, thus lowering the need for opiates?  Or were opioid drugs used initially followed by a transition to cannabis?  These types of sundry particulars are what I’m most curious about.  The bottom line is finding out what works best for most people – and that’s an answer that will only come with more widespread usage and practice one patient at a time.

As I cruise Pub Med for scientific abstracts on this subject, more practitioners – who live and work in areas of legalized use – are chiming in with their own conundrums.  Here are a few I came across: Should cannabis be treated like alcohol, with established safe/dangerous thresholds?   If so, what is the threshold? If cannabis is an acceptable substitute for opioids, how should it be initiated, and graduated as opioids are tapered down?   When does treatment of pain begin to look like sanctioned cannabis use disorder?

It strikes me that we are now straddling the chasm between the old glory days of opioids and the burgeoning science of medical cannabis, at least in the realm of pain management.  Indeed, cannabis is now being considered in the same way that opioids were decades ago – a drug class of pain-relief enveloped by a huge social movement.   What a long, strange trip we have ahead of us.

Next time (stay tuned) – Part Two:  Different types of pain and how cannabis works to relieve it