By Dale Gieringer
NAS Beckman Center, Irvine CA, Feb 9 2018. UCI’s forum “Cannabis and the Opioid Crisis: A Multidisciplinary Review” featured a dozen academic experts trying to figure out whether cannabis can be shown to have a favorable effect on the opioid crisis. The event was hosted by UC Irvine’s Cannabis Research Center and moderated by Prof. Joe Dunn and Robert Solomon of the Law School. Notably absent was any physician or patient with practical experience in treating pain with medical cannabis (except for Donald Abrams, who has conducted clinical trials, but not issued recommendations).
I brought along a couple of handouts which I managed to distribute to a few attendees —one listing published studies on cannabis and opioids, the other documenting complaints California NORML has received from pain patients denied treatment or prescriptions for controlled substances on account of using medical marijuana.
Most of the experts agreed that cannabis probably does help reduce opiate use, but that “more research is needed” to figure out whether this is truly the case.
Dr. Daniele Piomelli of UCI led off with an artfully presented overview of opiates and cannabinoids from ancient Greece and China to the present day. Searching PubMed, he found a total of 2,555 papers on cannabis and pain going back to 1972. A meta-analysis of animal data showed the effective dose of morphine is 3.6x lower when combined with cannabis and 9.5x lower for codeine!
Piomelli went on to declare that there were “no human studies.” His concerns: How does cannabis affect opioid dependence? Cannabis withdrawal (a defining feature of Cannabis Use Disorder) “is no laughing matter,” he said. Also, “Cannabis can cause toxicity, but we have little or no evidence of fatalities.”
Dr. Susan Weiss from the National Institutes of Health spoke on the “Evolving Opioid Crisis.” She explained how it began with Rx opioid users, based on favorable reports in the 1980s of extremely low addiction rates among patients treated in hospitals. More recently, there has been a trend to greater use of illegal fentanyl and heroin. Seventy percent of addicts start on RX opioids, 30% on heroin. Weiss lamented the lack of research $$$ for NIDA to develop new therapies, including new, targeted, safer opioids; new non-opioid pharmaceuticals; and non-drug therapies like meditation. She acknowledged that cannabis could be beneficial, but noted the counter-argument: cannabis use increases the risk of opioid misuse. She said that current evidence was from the “30,000 foot level” (ignoring from her ivory tower the many patient and doctor surveys documented in our handout). She lamented the many research barriers caused by the Schedule I status of MJ.
UCSF’s Dr. Donald Abrams summarized his studies on cannabis and pain conducted with funding from the Center for Medical Cannabis Research (CMCR). One of them incidentally showed a 10% reduction in pain when cannabis was added to opioids. A meta-analysis showed more efficacy with smoked cannabis than those with nabiximols (Sativex). Abrams also mentioned the HelloMD study showing 97% of patients agreeing cannabis could reduce opioid use. This was the ONLY patient survey mentioned by any participants in the forum throughout the day.
Dr. Ziva Cooper from Columbia University warned about Cannabis Use Disorder, asserting that 19.5% of all cannabis users become dependent at some point, of whom 25% have severe symptoms. Potency has risen, which could have some harm reduction benefits to the lungs, but dab extracts have now reached the extreme high of 93% THC.
UCSD Professor Igor Grant (the founding director of CMCR) spoke briefly, saying that we have a legalization “experiment” underway, patients are using cannabis, and we need to know more. He said use in pregnancy was a significant concern. Piomelli and Weiss strongly agreed. Abrams noted that the only adverse effect seems to be somewhat lower birthweight.
The floor was opened to questions, giving me the chance to discuss the handouts I’d brought along:
“Let me put in a word for the patients. California NORML has heard from countless users who say they’ve been able to reduce or eliminate their opiate use by medical cannabis. Here is this list of scientific studies we’ve compiled, with numerous patient and doctor surveys involving thousands of patients who confirm this. Sure, we could use research on which patients are helped most, how big the effect is, etc., but it’s a scientific fact that many patients find cannabis helpful in reducing opiate use. Can we agree?”
The panelists demurred. “We’ll be discussing that more this afternoon,” the moderator promised.I hoped that discussion would give me the opportunity to bring up my second handout , about pain clinics discriminating against MMJ patients, but as it turned out the proceedings veered in a different direction, and I never had the opportunity to publicly explain the problem to the academics 30,000 feet on high. Later I did have a private discussion about it with Rosalie Pacula of the RAND Corporation and she was shocked to learn it was happening.
The afternoon discussion opened on a decidedly different note with a presentation by UCSF Prof. Stanton Glantz, “Avoiding a new tobacco crisis.” His theme was that “Tobacco, marijuana and e-cigs are tied up with each other”posing an “upcoming disaster of marijuana legalization” from commercial exploitation. He hastened to add that he had no use for the war on drugs, and didn’t think marijuana should be illegal, but rather regulated along strict public health lines like tobacco, so as to be legal but socially unacceptable. He warned of the lobbying influence of Marijuana, Inc. and was outraged that the industry had representatives on the state’s Board of Cannabis Control advisory board.
Glantz said the carcinogenicity of marijuana smoke is clear from the fact that it’s on California’s Prop 65 list. He took credit for putting it there himself. “It’s hard to get on the list” he claimed with a straight face. He’s especially concerned about cardiac effects of cannabis, which he thinks are due to the smoke, not cannabinoids. He criticized California for poor label warnings, inadequate potency limits, the too-generous eight-ounce allotment for medical sales, and especially for allowing licensed indoor use and special events, in defiance of all of California’s rules against tobacco. Cannabis packages should have gruesome pictures like Australia’s packaging for cigarettes. He predicted that legalization will bring an upsurge in cancer, heart and lung disease.
Graham Boyd of New Approaches spoke about his legalization work. He played a major role in crafting Prop 64. New Approaches is supported by 15 major funders, none of whom have any stake in the cannabis industry. He boasted about having insisted on writing research funding into Prop 64 —in particular $10 million for implementation studies, some of which seems destined to go to UCI and the new UCLA center. (Glantz groused that this wasn’t nearly enough for the large-scale epidemiological studies he’d like to see.) Polling data from the legalization campaigns found that the cannabis-opioid issue didn’t have much appeal to voters in California, but did poll well in Maine and Massachusetts. He showed a powerful TV campaign ad for the Maine initiative in which a worker thanked MJ for ridding himself of opiate addiction. He worried about the current direction of federal policy, warning that California could be in the crosshairs of AG Sessions.
Dr. Marcus Bachhuber of the Albert Enistein College of Medicine discussed data showing that states with medical marijuana laws have fewer opioid deaths. He emphasized that states with medical marijuana laws had a higher than average rate of opiate use to begin with, but experienced a decline in deaths relative to what might otherwise be expected. Likewise, studies show lower Medicare and Medicaid expenditures for MMJ states. Apparent paradox: cannabis use is associated with higher risk of opioid use BUT medical cannabis associated with lower opioid use. Possible explanation: people with the worst disease are the heaviest users.
Rosalie Pacula of RAND discussed her latest research on opioid deaths and access to cannabis. Her analysis shows that access to dispensaries is the significant factor in reducing opiate abuse, not whether a law protecting patients is on the books. Data pre-2013 showed signiicant reductions in opioid use in states with dispensaries. However subsequent analysis showed a weaker effect post-2013. One possible factor: the opioid epidemic has changed; earlier it was driven by RX opioids, but more recently by illicit heroin and fentanyl. It’s too early to judge long-term effects of legalization. Driving studies are inconsistent. An article in the American Journal of Public Health showed no increase in traffic fatalities in CO and WA, but an insurance industry study showed a 2.7% increase in collision claims. Overall message: be cautious about evaluating policy, both sides abuse data to support claims still unproven.
Dr. Keith Humphreys of Stanford said he’d like to think that cannabis can alleviate the opiate crisis, but is skeptical of the data. There is evidence of a “modest” benefit of cannabis in treating chronic pain, he acknowledged, but massive use would be needed to significantly affect the statistics. Local trends don’t necessarily affect the overall average, due to what’s called the statistical aggregation fallacy. Bottom line: “We just don’t know if cannabis will cure the opiate epidemic.” Randomized prospective trials are needed.
(By the time such trials are completed the epidemic may have run its course. While panelists repeatedly stressed that more research was needed to inform policy decisions, they failed to cite an instance in which policy had ever been determined by research. It isn’t science, but politics that saddled us with the Marihuana Tax Act and Controlled Substances Act for most of the past century.)
Prof. Mireille Jacobsen, a former DPA staffer turned business economist at UCI, led the question session. I used the opportunity to take on Stan Glantz, whom I’d not met before, in a good humored manner, disputing his parallel between MJ and tobacco. I said cannabis has a long history of advocacy by consumers like us, who value its use for various purposes and consider it a matter of personal freedom. In contrast, tobacco consumers are mostly sorry they use it in the first place and leave advocacy to the industry. We are more like social use devotees of alcoholic beverages like beer and wine. Cal NORML has actively supported measures to prevent monopolization by large-scale corporate interests. Show us the evidence that marijuana causes lung cancer in humans —the best studies from Dr. Tashkin and others have found none. Furthermore, our vaporizer research shows that whatever toxins may still be present in MJ smoke can be 97-100% eliminated by vaporization.
“Marijuana smoke is on the Prop 65 list,” answered Glantz, as if that settled the matter. Humphreys observed that people smoke far lower quantities of MJ than tobacco. Piomelli agreed with me on pharmacological grounds about not lumping cannabis with nicotine, noting how much more difficult it is to get animals to self-administer cannabis. (He also remarked in a knowing manner “LSD is a very pleasurable compound, but it doesn’t cause out-of-control activity.”) “We shouldn’t expect things to go wrong with marijuana,” he said, “They can go right this time.” Glantz concluded by saying there was “a very good case” that marijuana could be mitigating the opium epidemic. He also mentioned that he’d been dis-invited from a CADCA conference after informing them he supported legalization.
About 60 people attended the forum, less than half the capacity of the room, although event registrations had been advertised as full up. Other attendees included field staffers from Sen. Harris and Feinstein’s offices, a Green State reporter, Nick Morrow of LEAP, Bill Britt and Kandice Hawes of OC NORML, and a couple of narcs from LAPD hovering silently in the back.Dale Gieringer