Cannabis is deeply misunderstood. It has been hailed as a potential hero in the fight against all ailments, including cancer and the opioid epidemic. It has also been called the devil’s lettuce, with claims that its use will lead to laziness, madness and even murder. In part, this polarization in beliefs can be explained by the complexity of cannabis. It is not helpful or accurate to think about cannabis as a single substance, but rather as a mixture of over 500 chemicals with varying combinations of dosages.
Given that cannabis is essentially a chemical soup that until recently had mostly been prepared in the black marketplace, it has been difficult to draw conclusions from research about its effects. This is particularly true in the area of addiction and mental health, where many factors contribute to the muddy the picture of whether cannabis can be helpful or harmful.
In recent years, it has been suggested that cannabis could be the white knight of the opioid epidemic. Indeed, recent state regulations in the United States (e.g., Illinois, New York) have explicitly approved medical cannabis as a treatment for opioid addiction. Critics of these policy decisions have argued that there is not yet enough evidence to support and promote cannabis as an effective treatment. They are correct. There have been no randomized controlled trials evaluating cannabis specifically for the treatment of opioid addiction.
Further, as recently argued in the Journal of the American Medical Association (JAMA), substituting cannabis for evidence-based opioid addiction treatments could be harmful because discontinuing already-established treatments, such as methadone and buprenorphine, could be life-threatening. At this time, from a medical standards perspective, offering cannabis as a treatment for opioid addiction is not consistent with the practice of evidence-based medicine.
On the other hand, emerging evidence suggests that cannabis might actually be helpful in the treatment of opioid addiction. If the goal of treatment is to reduce the harm that a person experiences, then it makes intuitive sense to offer cannabis in the hope that opioid use will decrease. Cannabis is less harmful than illicit opioids to both the individual and society at large. While there is an approximate one in 10 chance that offering cannabis could result in the development of a cannabis addiction, it might well be worth this risk.
But the potential benefit of cannabis extends even beyond a harm reduction strategy. In a recent review in Cannabis and Cannabinoid Research, preliminary evidence is presented that shows cannabis might be able to help with the treatment of opioid addiction symptoms per se, such as withdrawal and cravings. The reason that cannabis can be helpful in this way is that biologically, the human cannabis and opioid systems interact very closely. This is exciting because it means that there is much promise for the development and use of cannabis-based medicines in the treatment of opioid addiction.
The tentativeness of this topic is also burdened by an elephant in the room: can cannabis help people who experience simultaneous opioid addiction and chronic pain. While less than 8 percent of chronic pain patients become addicted to opioids, people who experience opioid addiction have higher rates of chronic pain compared to the general population. Unfortunately, despite public perception, the effectiveness of cannabis for chronic pain is actually weak and research in this area is riddled with limitations.
This implies that many people who experience both opioid addiction and chronic pain might not be saved by cannabis and instead will need to utilize other established treatments for chronic pain management. While this news is deflating, the complexity of both the cannabis plant and chronic pain conditions themselves leave much room for research to explore, and therefore, the case is by no means closed.
Will cannabis be the cure to the opioid crisis? Likely not. The most obvious reason is that the opioid crisis is a multilayered and multi-causal problem that demands an equally multipronged solution. Opioid addiction develops as the result of many interacting biological, psychological and social factors, and therefore, effective treatment approaches are needed at each level of analysis. This means an approach that incorporates evidence-based psychological and pharmacological treatments, coupled with a system that allows people to easily access these treatments wherever they are in their motivation to change, whether it be at family physician offices, emergency departments, chronic pain centers, safe injection sites or outpatient and residential addiction treatment programs.
Also, despite the hype, it is absurd to believe that cannabis can be a panacea for all aspects of the human condition. In my opinion, it is unhealthy to think otherwise. There is, however, good reason to believe that future research will support a helpful role for cannabis in the treatment of opioid addiction.
But we are not there yet. This kind of research, especially randomized controlled trials, is sorely lacking and urgently needed. This research should be aggressively pursued so that we can say with better certainty whether cannabis belongs in the evidence-based toolkit in the fight against opioid addiction.