Study: Reduced opioid dosages during long-term medical cannabis use for chronic pain

reference

Nguyen T, Li Y, Greene D, Stancliff S, Quackenbush N. Changes in prescribed opioid dosages in patients receiving medical cannabis for chronic pain, New York State, 2017–2019.JAMA Network Open. 2023;6(1):e2254573.

Study objective

Comparing duration of medical cannabis use (MC) with changes in opioid dosage

Key to take away

Taking medical cannabis for at least a month can significantly reduce long-term opioid therapy (LOT) doses compared to patients with MC use duration of less than a month.

design

Retrospective Observational Study of a New York State Prescription Monitoring Program Cohort (2017–2019)

Participant

Of the 8,165 chronic pain patients who underwent LOT in this study, 4,041 took medical cannabis for at least a month, and 4,124 took medical cannabis for a month or less.

The researchers used two groups to compare:

The researchers used two groups to compare:

1. Diejenigen, die MC länger als 30 Tage eingenommen haben. Diese Gruppe bestand zu 41,2 % aus Männern (58,8 % Frauen) und hatte ein Durchschnittsalter von 57 (IQR: 47–65) Jahren
2. Diejenigen, die MC 30 Tage oder weniger eingenommen haben. Diese Gruppe bestand zu 42,5 % aus Männern (57,5 % aus Frauen) und hatte ein Durchschnittsalter von 54 (IQR: 44–62) Jahren.

These groups were divided into three dosage ranges for comparison in this study. The dosages were:

1. weniger als 50 Morphin-Milligramm-Äquivalente (MME),
2. 50 MME bis weniger als 90 MME und
3. 90 MME oder mehr.

Of those who took less than 50 MME, 2,009 used cannabis for more than a month and 2,002 for a month or less. Of those who used between 50 and less than 90 MME, 701 used cannabis for more than a month and 2002 used it for a month or less. Of those who took at least 90 MME, 1,331 used cannabis for more than a month and 1,365 for a month or less.

Individuals under 18 years of age, terminally ill patients, individuals with opioid use disorder, individuals taking more than 480 MME, and individuals with large gaps in MC use were excluded from this study.

intervention

The researchers compared those who took MC for more than a month with those who took it for a month or less.

Evaluated study parameters

The dosage of opioids used (per MME) relative to the time of initiation of MC use.

Primary outcome

Researchers assessed opioid dose reductions in all patients, comparing those who used medical cannabis for a month or less with those who used it for more than a month.

Key findings

In this retrospective review, longer-term (>30 days) use of MC was associated with lower dosage of MME. Looking at the data by stratifying MME dosages, those taking less than 50 MME of long-term opioid therapy (LOT) experienced an average opioid dose reduction of 48% after more than 1 month of MC use, compared to 4% for those taking MC for 1 month or less, resulting in an overall net MME reduction difference of −14.53 (CI: -17.45, -11.61) over 8 months between the two groups. The trend toward reduction in daily MME dose was significantly improved in patients with more than 1 month of MC use, which was -0.27 (CI: -0.43, -0.11) compared to those with 1 month or less of MC use, which was -0.20 (CI: -0.31, -0.09;P<0.05).

Those who took more than 50 and less than 90 MME LOT had an average reduction in opioid dose of 47% after more than one month of MC use compared to 9% for those who took MC for one month or less, resulting in an average reduction in opioid dose of 47%. Overall difference MME net reduction of -29.49 (CI: –35.94, –23.04) over 8 months between the two groups. The trend toward reduction in daily MME dose did not improve significantly in patients with more than 1 month of MC use, which was -0.13 (CI: -0.51, 0.25) compared to those with 1 month or less of MC use, which was -0.05 (CI: -0.31, 0.21).

Those who took at least 90 MME LOT experienced an average 51% reduction in opioid dose after more than one month of MC use compared to 14% for those who took MC for one month or less, resulting in an overall net MME reduction of −69.81 (CI: −87.09, −52.53) over 8 months between the two groups. The trend for daily MME dose reduction did not improve significantly in patients with more than 1 month of MC use, which was -0.25 (CI: -0.81, 0.32) compared to those with 1 month or less of MC use, which was 0.26 (CI). : –0.13, 0.66).

transparency

This study did not contain any conflict of interest disclosures.

Implications and limitations for practice

At least 20% of Americans suffer from chronic pain, which has been shown to significantly impact disability rates, quality of life, medical costs, daily functioning, and social activities.¹Cannabis has been used for pain around the world for thousands of years, with records from China dating back to 2900 BC. BC²The criminalization of recreational cannabis, which has colonial racist roots,³has been a barrier to learning more about its use in clinical settings.⁴As more places in North America legalize medical and recreational cannabis, more adults of all ages are exploring its use.^2.5

When 1,661 American adults living in states that have legalized medical cannabis were asked if they had used it, 31% said they had.⁶Of those who used medical cannabis, almost 95% reported also using pharmacological interventions.⁶More than half of those people who used medical cannabis to treat their chronic pain said it helped reduce their use of pain management medications, such as prescription opioids, non-opioids, and over-the-counter medications, while nearly 39% said it reduced their use of physical therapy.⁶

Opioids have a number of potential risks and side effects, including opioid use disorder, fatigue, dizziness, dulled emotions, impaired memory,⁷and risk of kidney and liver dysfunction,^8.9This leads many people to look for alternatives to treat chronic pain.

In a population study involving about 650 patients with chronic pain, about half reported that conventional treatment was ineffective.¹⁰This encourages people who treat and/or suffer from chronic pain to analyze current research on medical cannabis to provide multiple options for those seeking pharmaceutical alternatives.

Although some claim that cannabis is a harmless plant, it is not without its side effects.¹¹Common side effects of cannabis include cannabis use disorder, fatigue, mental confusion, dizziness and, rarely, cannabis hyperemesis syndrome.¹¹The problem with many clinical and observational studies is that the concentrations of cannabinoids such as delta-9-tetrahydrocannabinol (THC), with its more psychotropic effects, as well as its non-psychotropic counterpart cannabidiol (CBD), are not controlled or analyzed. which can lead to significant clinical differences.¹¹Higher doses of CBD and lower doses of THC can significantly reduce many of the side effects that are largely due to THC.^11,12 Another important factor to consider when considering cannabis for the treatment of chronic pain in a clinical setting is the route of administration.^11,12Oral consumption of cannabis, such as edibles, tinctures, and oils, is a safer option in terms of reducing adverse respiratory effects compared to inhalation, such as smoking or vaping.^11,12

This study supports a number of others that have shown that cannabis use can reduce opioid consumption in patients with chronic pain, but further randomized, placebo-controlled trials are needed.^{2.11, 13,14}Most naturopathic doctors cannot prescribe medical cannabis to their patients, but may recommend that they visit professional medical cannabis clinics in the meantime. Cost, medical history, risk of addiction, and potential age-related limitations are some considerations that should be communicated in informed consent discussions so that patients can make the best possible individual decisions regarding medical cannabis and opioid use.