The Role of Cannabis in Medicine: Canceling Chronic Pain & Combating the Opioid Crisis

Dr. Turck:
Even though a handful of cannabis-derived or related compounds are now approved by the FDA, federal laws still pose several practical barriers to conducting high-quality research in the form of randomized controlled trials that examine the potential roles of medical cannabis. However, despite the regulatory red tape, physicians and researchers, like the one we'll be hearing from today, continue to vocalize medical cannabis’s health benefits, including how it might even help us combat our country's opioid epidemic.

Welcome to Clinician’s Roundtable on ReachMD. I'm your host Dr. Charles Turck, and with me today is Dr. Dustin Sulak, an integrative medicine physician with a special focus on osteopathy, mind-body medicine, and medical cannabis. Dr. Sulak, welcome to the program.

Dr. Sulak:
Thank you, Dr. Turck. So glad to be here with you.

Dr. Turck:
Beginning with the big picture, Dr. Sulak, how can medical cannabis help with our nation's opioid addiction crisis?

Dr. Sulak:
So the opioid addiction crisis is a much bigger problem than just addiction. And I think we all realize that overprescribing has been a major contributing factor. And now that we have different laws and regulations and also different guidelines from professional societies, that's helping decrease overprescribing. But I think what's also really important is to have another option for treatment for patients with chronic pain. Now we've seen that cannabis is a usable option for chronic pain. Nothing works for everyone, but certainly a risk-benefit comparison between chronic use of cannabinoids or medical cannabis versus opioids in patients with chronic pain, it seems like cannabis is a much better option.

There's also Medicare, Medicaid, and private insurance data that associates a decrease in prescribing of opioids with state and the medical and adult use cannabis laws. And of course, that isn't necessarily causal, but it's suggestive that there might be something going on where when access to cannabis increases, people are using or prescribing less opioids for chronic pain.

Now, if you look at the data on opioid use disorder, that's a lot less clear than patients with chronic pain. But there is some emerging evidence that suggests the presence of cannabis in people's lives and in a population of individuals can provide some harm reduction. A recent study looking at methadone maintenance users in Rhode Island and Washington State found that there were 71% less non-fatal overdoses among the cannabis users versus the non-users. Another example is that people on opioid agonist therapy in Vancouver had less exposure to fentanyl if they were using cannabis. And in general, the data suggests that in people that are engaged in medication-assisted therapy, the cannabis users use a lower dose of the opioid agonist but have similar outcomes. And that's likely because cannabinoids can potentiate the effects of opioids.

Dr. Turck:
Well speaking of chronic pain, you recently published findings from a survey on patients suffering from chronic pain who were using a combination of prescribed opioid medication and medical cannabis. Would you share your observations from that survey?

Dr. Sulak:
Sure. So this was a survey from three practice sites in New England that I was involved with. We had 525 respondents who have chronic pain that were using opioids for at least three months prior to the survey. And I do want to mention that we have a very high selection bias in our practice. Essentially, people come to cannabis clinicians like myself because they are highly motivated to get off of drugs. That's probably the number one request that we see when people present for an initial visit. And then there's also possibly some respondent bias in this population. But of those 525 individuals, 40% were able to stop using opioids entirely after adding medical cannabis, and another 45% reduced their dosage, 87% reported improvements in their quality of life, and 80% reported improvement in function. And this is very consistent with other observational data. There's a number of studies looking at patients that have chronic pain, and it's usually in the 30, 40% that people are able to completely discontinue opioids. And I invite the listeners to think is there any other tool that could potentially achieve those goals even in a biased population; it’s just a really powerful tool.

Dr. Turck:
In a separate published paper, you also looked at patients tapering off opioids with the aid of medical cannabis. Would you explain your study setup and give us an overview the titration algorithm that came out of the study's findings?

Dr. Sulak:
Sure. So this was a modified Delphi process, which is basically in the absence of gold standard data that can provide clinical guidelines. What this group of cannabis clinicians decided to do was come together to make recommendations based on their expertise and their experience on the frontlines of the clinic. And so this was a paper that basically just kind of made it simple for clinicians that don't have a lot of experience with cannabis to recommend or guide patients that are wanting to add cannabis to their opioid treatment and how to titrate cannabis and taper the opioids.

And so basically we start with the oral route of delivery. Cannabis has many different routes of delivery, and to initiate with a CBD-dominant product, which could contain some THC, but it would just be more on the CBD side with the starting dose between 5 and 20 milligrams of total cannabinoids and to titrate up. And then if that titration seems like it's not working, and we didn't give a specific dose, but just my clinical experience would be after around 50 milligrams that starts to get expensive for the patient, then we would start adding in more THC at a level of a half to 3 milligrams per day, and increasing by 1 to 2 milligrams every one to two weeks. And so I hope that that at least orients the listener to milligram ranges of these compounds, CBD somewhere between 5 and 15 milligrams per day, might start to help with pain, but it works really well for some people, but it's not a very powerful agent. And it does get expensive at the higher doses. THC is often effective I would say in a daily dose between, like 2 and 20 milligrams can work really well for people with chronic pain that are looking to substitute opioids. And then for breakthrough pain, the inhalation route of cannabis is really superior because it's just got such a rapid onset, and it's easily titratable.

And so that's what we basically described in the paper. And our guidelines for tapering opioids are pretty much the same as what most people would do in their clinical practice.

Dr. Turck:
For those just tuning in, you're listening to Clinician’s Roundtable on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Dustin Sulak about his research on medical cannabis, including how it may help us combat the opioid epidemic.

Now, Dr. Sulak, it's clear from our discussion that you've done quite a bit of research on its health benefits, but are there other potential therapeutic avenues in which you see medical cannabis having a potential role and where you hope it'll be studied further?

Dr. Sulak:
I think that right now, we generally approach cannabis as a symptom reliever, and I think it's very good at that. And also I think that there's a lot more to it. For example, the mechanism of action of cannabis, mostly of THC, but also to some extent CBD, is the modulation of our endogenous cannabinoid system, our endocannabinoid system, which is a homeostatic regulatory system that affects every organ and every tissue in the body. And so that the therapeutic potential not just to relieve symptoms, but actually to modify the underlying pathophysiology of a wide variety of both physical and mental health conditions is just profound. And so I'm hoping to see more of that.

Also, I think we've just seen the tip of the iceberg of one of the really powerful attributes of cannabis is as an adjunct to nonpharmacological therapies, like psychotherapy, somatic-based psychotherapy, exposure therapy for people with PTSD. Cannabis has been shown to improve neuroplasticity and to enhance, for example, the consolidation of fear extinction after exposure therapy. So I think that a lot of people that are kind of plateaued in their progress with some of these traditional nonpharmacologic mental health approaches can really enhance their benefits with combination with cannabis or simply by using cannabis afterwards. Also, I've had a number of patients do well with combining cannabis with physical therapy, manual therapies like osteopathic manipulation, and exercise therapy. So I think as an adjunct, there's a huge amount of potential that hasn't been explored.

Dr. Turck:
You were the senior author recently on a survey of cannabis clinicians. What did that study find?

Dr. Sulak:
So in general, that study found that people like myself who are actively practicing with cannabis and who consider themselves cannabis clinicians didn't learn about this in medical school and didn't even learn about the endocannabinoid system in medical school, which is kind of a crime because it is such a cornerstone of our capacity to respond to injury and to maintain health. It's just a very primary regulatory system in the body. So it’s still not being taught, at least, as far as I know. And according to the survey, no one really learned about it in their traditional education. People were learning about it at conferences and by going to the primary literature.

The other thing that I found interesting in that survey is that 81% of us were receiving referrals from mainstream medical providers. And I encourage the mainstream medical providers listening to this show to locate the local cannabis expert. And if you have a complex case, I encourage you to identify candidates for cannabis treatment or for patients that are asking and you don't really know the answers find out who you can refer them to.

My other suggestion is, selfishly, I'll promote my new book called Handbook of Cannabis for Clinicians, Principles, and Practice, which is a really accessible guide for both people that are cannabis experts, but also those that know little about it and want help identifying good candidates for treatment.

Dr. Turck:
We're almost out of time for today. But before we wrap up, Dr. Sulak, what would you like to share with our listeners who might be hesitant to prescribe medical cannabis to their patients? Are there any key points you'd like them to know?

Dr. Sulak:
Yes so first of all, we'll just focus a little on the wording here, because cannabis is still a schedule one drug, and we absolutely can't prescribe it, so it's more of a recommendation. Sometimes we certify people depending on what state we're in, and they're able to take our certification. The first thing that's like a very common trend in the field right now is for a doctor to sign off on somebody's certificate, and then that patient to go to the dispensary, and basically interact with a clerk that has no clinical training. And it's that person who's providing the recommendations on which products to use and how much to use. I would love for our profession to kind of take more ownership of that process by either providing patients with a reputable education resources or making specific recommendations themselves or referring to an expert. Cannabis can be a bit complex.  There's many different types of cannabis and many different delivery methods. There's an incredibly broad, safe, and effective dosing range. And within that range, there's nonlinear dose response effects, meaning that sometimes increasing the dose can diminish the benefits. So it can be a bit complex. But, overcoming that learning curve provides a valuable skillset that doesn't just apply to cannabis. It also applies to other integrative treatments and other herbal medicines. And it can be highly rewarding and allow for clinicians to establish a really beautiful rapport with their patients who are often having this experience, “Wow, this is the first clinician that ever listened to me about cannabis and didn't just frown on it.” Because a lot of people are carrying around this conflict and this guilt, they’ve tried cannabis, they know it helps them but there's the stigma around it's still, and they're just not sure how to manage that conflict. And I think a clinical encounter can be extremely helpful for resolving that guilt.

I do want to say though, it doesn't have to be rocket science. And Marinol, which is a schedule three  synthetic THC available in 2.5, 5, and 10 milligrams is also a very versatile tool that can be used easily off label. For example,  if a patient was using say 10 milligrams of oxycodone three times a day, and they were interested in seeing if THC could potentiate that, and you're not in a medical cannabis jurisdiction, or maybe you just don't want to deal with the herbal aspect of this and want to keep it pharmaceutical. Very few people have adverse reactions to 2.5 milligrams of Marinol. That's an easy place to start. That's a dose that can certainly potentiate opioids, help promote sleep. If it's not effective, going up to 5 is another option. So it can be very straightforward.

Dr. Turck:
Well, there's clearly much more to explore when it comes to the research and application of medical cannabis. But as we're at the end of today's program, I want to thank my guest, Dr. Dustin Sulak for joining me. Dr. Sulak, it was great having you on the program.

Dr. Sulak:
Thank you so much, Dr. Turck.

Dr. Turck:
I'm Dr. Charles Turck. To access this and other episodes in our series, visit ReachMD.com/CliniciansRoundtable where you can Be Part of the Knowledge. Thanks for listening.