Just two days after Christmas, the Lt. Governor signed SB 0274, a bill to limit opioid based pain prescriptions for people in “acute pain”.

Governor Rick Snyder and Michigan Attorney Bill Schuette also are working to reduce opioid addiction, abuse and overdoses.

President Obama at the National Prescription Drug Abuse and Heroin Summit made similar comments on opioids.

It’s important to recognize that today we are seeing more people killed because of opioid overdose than traffic accidents.

http://legislature.mi.gov/doc.aspx?2017-SB-0274

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Sec. 7333b. (1) Beginning July 1, 2018, if a prescriber is treating a patient for acute pain, the prescriber shall not prescribe the patient more than a 7-day supply of an opioid within a 7-day period.

(2) As used in this section, “acute pain” means pain that is the normal, predicted physiological response to a noxious chemical or a thermal or mechanical stimulus and is typically associated with invasive procedures, trauma, and disease and usually lasts for a limited amount of time.

 

http://www.detroitnews.com/story/news/politics/2017/12/27/calley-signs-opioid-bills/108948644/ 

Lansing — Lt. Gov. Brian Calley signed a 10-bill package Wednesday aimed at reducing Michigan’s rapidly growing opioid addiction by requiring doctors and the state to better track and control the flow of opioid-based prescription drugs.

Calley signed six bills that will collectively require doctors to use a new online prescription tracking state database, set up a legitimate doctor-patient relationship and limit the number of pills dispensed in a given seven-day period. It comes as the number of heroin and prescription opioid overdose deaths in Michigan has doubled during the past five years.

Health and addiction experts have long urged the medical industry to adopt new prescription opioid standards. Many heroin addicts start out using legal painkillers first, and even people who take such drugs as directed by a doctor can still wind up addicted.

Calley and other public officials have called for legislation to stop “pill mills,” or unscrupulous doctors who authorize too many prescription painkillers and end up feeding addiction.

 

“It’s now claiming more lives than car accidents each year,” Calley said at a Wednesday press conference.

In 2015, 1,275 people died from heroin and opioid-related overdoses — 884 were caused by prescription opioids and another 391 from heroin, according to the most recent data from the state Department of Health and Human Services.

By comparison, 963 people died in car accidents in 2015, according to the Michigan State Police.

The 2015 heroin and prescription opioid overdose deaths represented a nearly 100 percent increase over the 639 deaths in 2010 — 195 from heroin overdoses and another 444 from prescription opioid overdoses.

 

“This will make a huge difference. It’s about earlier detection and prevention,” Calley said about the legislation.

“We’ve done a lot of great work to try and save lives after a person becomes addicted,” said the lieutenant governor, who chairs Gov. Rick Snyder’s task force on opioids. “What we’re doing now is the work to prevent the addiction from happening in the first place and to detect it earlier in the process and get ahead of this epidemic.”

In overall Michigan drug poisonings, 1,981 people died in 2015, according to the state, a 12 percent rise from the 1,745 fatalities from the year before.

What legislation does

One of the bills Calley signed Wednesday was by Sen. Tanya Schuitmaker, R-Lawton, and requires that doctors review a patient’s history on a new online database called MAPS before prescribing opioids. The measure was recommended by Snyder’s task force.

Calley said Schuitmaker’s bill is “very central to making progress in the fight against the addiction epidemic that has swept across this state and across the nation.”

He also praised a bill from state Rep. Andy Schor, D-Lansing, for expanding treatment options for Medicaid recipients in need of opioid addiction help. Lawmakers need to keep working to expand treatment, “but it seems like there’s never enough,” Calley said.

“At the end of the day, the most important aspect for whether a person recovers, the first thing is wanting to get better. And there’s so much more awareness today; there’s so much more acceptance among people to seek treatment than what we saw a few years ago. That makes me hopeful that we can turn this around.”

A related bill from Sen. Dale Zorn, R-Ida, requires the state to record opioid prescriptions in MAPS in an effort to keep tabs on doctors who prescribe too much. It’s also meant to help doctors know when patients are hopping from office to office to get too many pills.

According to the report, every state except Missouri has a prescription drug tracking system for pills. MAPS came online in 2002 but experienced a major upgrade in April that lawmakers and health professionals hailed as a cornerstone of the state’s opioid epidemic battle.

The legislation Calley signed Wednesday also would stop a prescriber other than veterinarians from distributing opioids without first looking into a patient’s prescription history on MAPS.

Other bills would require a “bona fide” patient-doctor relationship before a doctor could prescribe opioids and limit the supply of opioids.

Legislation signed last year by Snyder allotted $2.5 million for a new cloud-based database and did not require doctors to check the system before prescribing addictive painkillers to patients.

Although some in the industry say the system could help fight the state’s opioid-abuse epidemic, the Michigan State Medical Society has voiced strong concerns that requiring use of the new system would be time consuming and add more work for doctors.

As of Tuesday, 24,639 licensed doctors and pharmacists have voluntarily signed up to use the state’s drug tracking database and more than 4,000 nurses or office managers on behalf of licensed medical professionals, according to the Department of Licensing and Regulatory Affairs.

Blue Cross Blue Shield of Michigan CEO Daniel Loepp in a Wednesday statement called the package “a strong step forward that strengthens Michigan’s efforts to reduce addiction and abuse.”

According to Poison Control, adults aged 45–54 had the highest rate of drug overdose deaths in 2015.

http://www.poison.org/poison-statistics-national 

Key findings

Data from the National Vital Statistics System, Mortality

• The age-adjusted rate of drug overdose deaths in the United States in 2015 (16.3 per 100,000) was more than 2.5 times the rate in 1999 (6.1).
• Drug overdose death rates increased for all age groups, with the greatest percentage increase among adults aged 55–64 (from 4.2 per 100,000 in 1999 to 21.8 in 2015). In 2015, adults aged 45–54 had the highest rate (30.0).
• In 2015, the age-adjusted rate of drug overdose deaths among non-Hispanic white persons (21.1 per 100,000) was nearly 3.5 times the rate in 1999 (6.2).
• The four states with the highest age-adjusted drug overdose death rates in 2015 were West Virginia (41.5), New Hampshire (34.3), Kentucky (29.9), and Ohio (29.9).
• In 2015, the percentage of drug overdose deaths involving heroin (25%) was triple the percentage in 2010 (8%).

Deaths from drug overdose have been identified as a significant public health burden in the United States in recent years (1–4). This report uses data from the National Vital Statistics System (NVSS) to highlight recent trends in drug overdose deaths, describing demographic and geographic patterns as well as the types of drugs involved.

https://www.cdc.gov/nchs/products/databriefs/db273.htm 

With the current nationwide epidemic of opioid abuse, dependence, and fatalities, clinicians are being asked by federal agencies and professional societies to control their prescribing of narcotic medications for pain. Federal guidelines emphasize tapering, discontinuing, and limiting initiation of these drugs except in provision of end-of-life care. Reducing reliance on opioids, however, is a massive task. According to one estimate, more than 650 000 opioid prescriptions are dispensed each day in the United States. Unless the nation develops an increased tolerance to chronic pain, reduction in opioid prescribing leaves a vacuum that will be filled with other therapies.

Enter cannabis. As of August 2016, the District of Columbia and 25 states have legalized cannabis for medical use. Recreational use of cannabis has been legalized in 4 of these states and Washington, DC, and like initiatives are pending in other states. The mandated transition to limit use of opioids, paired with the current climate around liberalizing cannabis, may lead to patients’ formal and informal substitution of cannabis for opioids. Observational studies have found that state legalization of cannabis is associated with a decrease in opioid addiction and opioid-related overdose deaths

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5332546/ 

The Institute of Medicine in a 1999 report, the same report that the people of Michigan described when creating the MMMA, declared that cannabinoids from the marijuana plant, could be useful for patients “who have developed tolerance to opioids”.

All of the currently available analgesic (pain-relieving) drugs have limited efficacy for some types of pain. Some are limited by dose-related side effects and some by the development of tolerance or dependence. A cannabinoid, or other analgesic, could potentially be useful under any of the following circumstances:

• There is a medical condition for which it is more effective than any currently available medication.
• It has a broad clinical spectrum of efficacy and a unique side effect profile.
• It has synergistic interactions with other analgesics.
• It exhibits “side effects” that are considered useful in some clinical situations.
• Its efficacy is enhanced in patients who have developed tolerance to opioids.

President Trump’s ONDCP task force on the opioid prescriptions crisis has recommended calling for a national emergency.

The first and most urgent recommendation of this Commission is direct and completely within your control. Declare a national emergency under either the Public Health Service Act or the Stafford Act. With approximately 142 Americans dying every day, America is enduring a death toll equal to September 11th every three weeks.

Due to the interim report, President Donald J. Trump has instructed his Administration to use all appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic. 8-10-2017

In Medical Marijuana states, overdoses on opioid prescription painkillers are reduced by 25%.

Conclusions and Relevance Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates.”

Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented.

The CDC has declared opioid prescription overdoses an epidemic.

Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid. Since 1999, the number of overdose deaths involving opioids (including prescription opioids and heroin) quadrupled. From 2000 to 2015 more than half a million people died from drug overdoses. Americans die every day from an opioid overdose.

https://www.cdc.gov/drugoverdose/epidemic/index.html 

President Trump has a plan to limit opioid prescriptions.

Reduce the amount of Schedule II opioids (drugs like oxycodone, methadone and fentanyl) that can be made and sold in the U.S.

President Obama and President Trump have instructed the FDA and DEA to limit opioid based prescription painkillers.

http://jamanetwork.com/journals/jama/fullarticle/2503508 

April 19, 2016 CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016
Deborah Dowell, MD, MPH. Tamara M. Haegerich, PhD. Roger Chou, MD.
JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464

Fewer Canadian veterans have sought prescription opioids and tranquillizers in recent years, while at the same time prescriptions for medical marijuana have skyrocketed.

It is not clear whether the two are related, but the trend echoes what researchers have found in U.S. states with medical-cannabis laws.

New data provided to The Globe and Mail by Veterans Affairs Canada show that over the past four years, the number of veterans prescribed benzodiazepines – with brands such as Xanax, Ativan and Valium – had decreased nearly 30 per cent. Opioid prescriptions also shrank almost 17 per cent during that same period.

https://beta.theglobeandmail.com/news/national/among-veterans-opioid-prescription-requests-down-in-step-with-rise-in-medical-pot/article30285591/ 

Of course medical marijuana can be used as a painkiller in the states with working medical marijuana laws. What about the people who don’t know about medical marijuana?

Unfortunately, the limits, burdens and tightening of the rules for doctors and pharmacists to prescribe and dispense pain medication have caused patients’ quality of life to drop. Due to these new rules, patients have been dropped by physicians, denied prescriptions at pharmacies and have been forced to turn to heroin just to attain pain relief. Thousands of people have signed this petition to have some of these rules rescinded so they can get their medications back, to no avail.

The reports detailing denials of pain medications were posted to the change.org petition. The reports are heartbreaking. These patients need a replacement therapy after they have been denied prescription opioid analgesics by their physicians and pharmacists.

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David Jasko Hackensack, NJ Apr 27, 2017
“Tired of being treated as a “drug seeker,” when pain medications are requested. Since I have been in chronic pain, 9 of 10 doctors have refused pain medication, leaving me unable to walk 90% of the time.“

Sharron Rishling Las Vegas, NV Apr 27, 2017
“My daughter had had this terrible pain disease CRPS (Chronic Reflex Pain Syndrome) which is disabilitating. She is totally disabled and they are not letting her have her pain medication.“

nathan luse Wyoming, MI May 14, 2017
“I have chronic lower back pain, and chronic pain in my feet, pain meds got taken away, and there is no surgery to fix me. shots have zero effect, had a specialist notarized this. only thing that works and gets me out of bed is medication. Been cut-off since december.”

Susan Pare Otisville, MI Feb 1, 2017
“I have been in severe, chronic pain of one form or another since I was two years old. I will be 64+ later this year. There has been almost no time in that period where I have been free of pain. I recall having to beg my doctor to prescribe more than 15 days of Vicodin at a time and that had to last me SIX MONTHS. Granted this was 20 years ago, but suddenly it is like living that time all over again. Surely there must be a happy medium between me and the neighborhood dealer.”

Ariel G Baraga, MI Jan 28, 2017
Signing this because I deal with pain everyday that doctors do not help because they think I’m a drug seeking addict.

Deborah Palomarios Onaway, MI Jan 2, 2017
I have severe pain. I have had 4 back surgeries. The last two I was only given 10 days of pain meds then no more. Its barbaric!

Scott Behler Ann Arbor, MI Dec 18, 2016
Dealing with chronic pain for the last 19 years. I am a restaurant manager by career, and often am walking, standing, for 12 hours a day. Had the ability to manage my pain, and be successful in my position until about a year ago, when my doctor of many years cut me way back, and every time I see him now, directs me to see a different orthopedic or pain management clinic, who continually suggest additional surgeries (I’ve already had 7 of them, one more painful and longer recovery time than the next), or more injections ( I’ve had multiple spinal, steroid, cortisone, synvisk, etc., that have worked for very short periods). I understand the issues with recreational usage problems, but let the people who are in legitimate pain and need them to survive get them! Sad when some of us chronic pain patients start thinking about finding street drugs such as heroin just to be able to live a somewhat “normal” life. I’ve also heard of chronic pain patients that just give up and commit suicide. This is something that my faith would forever restrict me from doing, but I can understand giving up on life because what kind of life is it when you are continually suffering?

 

https://www.change.org/p/congress-ease-the-dea-s-grip-on-doctors-allowing-chronic-pain-patients-to-get-the-medications-we-need

Marijuana can prevent the intensity and amount of migraines. Marijuana is also useful as an adjunct therapy to opioid prescriptions because it allows the patient to use fewer opioids to achieve the same pain relief.

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Relationship Between Marijuana and Opioids

Cannabis access is associated with reduced rates of opioid use and abuse, opioid-related hospitalizations, opioid-related traffic fatalities, opioid-related drug treatment admissions, and opioid-related overdose deaths

• "We used an interrupted time-series design (2000-2015) to compare changes in level and slope of monthly opioid-related deaths before and after Colorado stores began selling recreational cannabis. ... Colorado's legalization of recreational cannabis sales and use resulted in a 0.7 deaths per month reduction in opioid-related deaths. This reduction represents a reversal of the upward trend in opioid-related deaths in Colorado."

  Recreational cannabis legalization and opioid-related deaths in Colorado, 2000-2015, American Journal of Public Health, 2017

• University of New Mexico investigators assessed opioid prescription use patterns over a 21-month period in 37 pain patients enrolled in the state's medicinal cannabis program compared to 29 non-enrolled patients. Compared to non-users, medical cannabis enrollees "were more likely either to reduce daily opioid prescription dosages between the beginning and end of the sample period (83.8 percent versus 44.8 percent) or to cease filling opioid prescriptions altogether (40.5 percent versus 3.4 percent)." Enrollees were also more likely to report an improved quality of life. "The clinically and statistically significant evidence of an association between MCP enrollment and opioid prescription cessation and reductions and improved quality of life warrants further investigations on cannabis as a potential alternative to prescription opioids for treating chronic pain."

  Association between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study, PLOS One, 2017

• "This paper uses a unique marijuana dispensary dataset to exploit within- and across-state variation in dispensary openings to estimate the effect increased access to marijuana has on narcotic-related admissions to treatment facilities and drug-induced mortalities. [It] finds that core-based statistical areas (CBSAs) with dispensary openings experience a 20 percentage point relative decrease in painkiller treatment admissions over the first two years of dispensary operations ... [and] provides suggestive evidence that dispensary operations negatively affect drug-induced mortality rates."

  The effects of marijuana dispensaries on adverse opioid outcomes. SSRN Working Paper, 2017

• "Medical marijuana policies were significantly associated with reduced opioid pain reliever-related hospitalizations but had no associations with marijuana-related hospitalizations. ... Medical marijuana legalization was associated with 23% (p=0.008) and 13% (p=0.025) reductions in hospitalizations related to opioid dependence or abuse and OPR overdose, respectively; lagged effects were observed after policy implementation."

  Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever, Drug and Alcohol Dependence, 2017

• "[The] review of the current literature suggests states that implement medical cannabis policies could reduce prescription opioid medication associated mortality, improve pain management, and significantly reduce health care costs."

  The use of cannabis in response to the opioid crisis: A review of the literature, Nursing Outlook, 2017

• Among patients with a musculoskeletal injury who acknowledged having used cannabis to assist in recuperating from injury over the past six months, 90 percent said that it was effective at reducing their pain. Eighty-one percent said that the use of cannabis reduced their intake of opioids. "n the subset of patients who used marijuana during their recovery, a majority indicated that it helped alleviate symptoms of pain and reduced their level of opioid intake."

  Perceptions of the use of medical marijuana in the treatment of pain following musculoskeletal trauma, Journal of Orthopaedic Trauma, 2017

• "State-specific estimates indicated a reduction in opioid positivity for most states after implementation of an operational MML. ... Operational MMLs are associated with reductions in opioid positivity among 21- to 40-year-old fatally injured drivers and may reduce opioid use and overdose."

  State medical marijuana laws and the prevalence of opioids detected among fatally injured drivers, American Journal of Public Health, 2016

• "The current study assessed the impact of 3 months of medical marijuana treatment on executive function, exploring whether MMJ patients would experience improvement in cognitive functioning, perhaps related to primary symptom alleviation. ... Results suggest that in general, MMJ patients experienced some improvement on measures of executive functioning. ... Patients also indicated moderate improvements in clinical state, including reduced sleep disturbance, decreased symptoms of depression, attenuated impulsivity, and positive changes in some aspects of quality of life. Additionally, patients reported a notable decrease in their use of conventional pharmaceutical agents from baseline, with opiate use declining more than 42%."

  A pilot study assessing the impact of medical marijuana on executive function, Frontiers in Pharmacology, 2016

• "Among study participants, medical cannabis use was associated with a 64% decrease in opioid use (n = 118), decreased number and side effects of medications, and an improved quality of life (45%). This study suggests that many CP (chronic pain) patients are essentially substituting medical cannabis for opioids and other medications for CP treatment, and finding the benefit and side effect profile of cannabis to be greater than these other classes of medications."

  Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain, Journal of Pain, 2016

• "The treatment of chronic pain with medicinal cannabis in this open-label, prospective cohort resulted in improved pain and functional outcomes, and a significant reduction in opioid use. ... Opioid consumption at follow-up decreased by 44%."

  The Effect of Medicinal Cannabis on Pain and Quality-of-Life Outcomes in Chronic Pain: A Prospective Open-label Study, The Clinical Journal of Pain, 2016

• "Using both standard differences-in-differences models as well as synthetic control models, we find that states permitting medical marijuana dispensaries experience a relative decrease in both opioid addictions and opioid overdose deaths compared to states that do not."

  Do Medical Marijuana Laws Reduce Addictions and Deaths Related to Pain Killers?, NBER Working Paper No. 21345, 2015

• "Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time."

  Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010, JAMA Internal Medicine, 2014

Cannabis access is associated with reductions in overall prescription drug spending

• "We conducted a pragmatic historical cohort study to measure the effect of enrollment in a state-authorized United States' Medical Cannabis Program (MCP) on scheduled II-V drug prescription patterns. ... Our pragmatic preliminary study found that enrollment in the NM MCP was associated with significant reductions in scheduled II-V prescription drug activity and associated use of conventional pharmacies and prescribing providers. ... 34% of the MCP patients cease to exhibit any evidence of scheduled drug consumption and an additional 36% reduce the number of prescriptions filled for scheduled drugs by the last 6 months of our sample period. ... In conclusion, a shift from prescriptions for other scheduled drugs to cannabis may result in less frequent interactions with our conventional healthcare system, and potentially improved patient health."

  Effects of legal access to cannabis on Schedule II-V prescriptions, Journal of Post-Acute and Long-Term Care Medicine, 2017

• "Using the variations across state MMLs between 1996 and 2014 of Medical Expenditure Panel Survey (MEPS) this paper estimates the effects of MMLs on prescription drug utilization, with a focus on opioids. I find that MMLs lead to a $2.47 decrease in per person prescribed opioid spending among young adults (ages 18-39) over a year. Most of this decrease results from the intensive margin of use and MML states that allow home cultivation experience even larger decreases."

  The effects of medical marijuana laws on prescribed opioids and other prescription drugs, SSRN Working Paper, 2017

• "Using quarterly data on all fee-for-service Medicaid prescriptions in the period 2007-14, we tested the association between those laws and the average number of prescriptions filled by Medicaid beneficiaries. We found that the use of prescription drugs in fee-for-service Medicaid was lower in states with medical marijuana laws than in states without such laws in five of the nine broad clinical areas we studied. If all states had had a medical marijuana law in 2014, we estimated that total savings for fee-for-service Medicaid could have been $1.01 billion."

  Medical Marijuana Laws May Be Associated With A Decline In The Number Of Prescriptions For Medicaid Enrollees, Health Affairs, 2017

• "Using data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, we found that the use of prescription drugs for which marijuana could serve as a clinical alternative fell significantly, once a medical marijuana law was implemented. National overall reductions in Medicare program and enrollee spending when states implemented medical marijuana laws were estimated to be $165.2 million per year in 2013."

  Medical Marijuana Laws Reduce Prescription Medication Use In Medicare Part D, Health Affairs, 2016

Patients often use cannabis as a substitute for other controlled substances, including prescription medications, alcohol, and tobacco

• "[O]ur results indicate that MC (medical cannabis) may be used intentionally to taper off prescription medications. These findings align with previous research that has reported substitution or alternative use of cannabis for prescription pain medications dues to concerns regarding addiction and better side-effect and symptom management, as well as complementary use to help manage side-effects of prescription medication."

  Preferences for medical marijuana over prescription medications among persons living with chronic conditions, The Journal of Alternative and Complementary Care, 2017

• Among patients with a musculoskeletal injury who acknowledged having used cannabis to assist in recuperating from injury over the past six months, 90 percent said that it was effective at reducing their pain. Eighty-one percent said that the use of cannabis reduced their intake of opioids. "n the subset of patients who used marijuana during their recovery, a majority indicated that it helped alleviate symptoms of pain and reduced their level of opioid intake."

  Perceptions of the use of medical marijuana in the treatment of pain following musculoskeletal trauma, Journal of Orthopaedic Trauma, 2017

• "[F]indings on cannabis substitution effect and the biological mechanisms behind it strongly suggest that cannabis could play a role in reducing the public health impacts of prescription and non-prescription opioids. ... The growing body of research supporting the medical use of cannabis as an adjunct or substitute for opioids creates an evidence-based rationale for governments, health care providers, and academic researchers to consider the implementation and assessment of cannabis-based interventions in the opioid crisis."

  Rationale for cannabis-based interventions in the opioid overdose crisis, Harm Reduction Journal, 2017

• An estimated two out of three medical marijuana patients substitute cannabis in place of opioids, according 2017 survey data compiled by Aclara Research, a Chicago-based consulting firm. Specifically, 67 percent of respondents reported that they ceased their use of opioids after initiating cannabis therapy. Twenty-nine percent of respondents said that they reduced their use of opioids.

  Aclara Research, Cannabis, Prescription Drugs, and Opioid Usage: Study Highlights, 2017

• "The largest survey on cannabidiol or CBD usage to date found that women were more likely than men to use CBD and once they started using it, were likely to drop their traditional medicine. ... Forty-two percent of the CBD users said they had stopped using traditional medications like Tylenol pain relievers or prescription drugs like Vicodin and had switched to using cannabis instead."

  Survey: Nearly half of people who use cannabidiol products stop taking traditional medicine, Forbes.com, 2017

• "Ninety-seven percent of the sample 'strongly agreed/agreed' that they are able to decrease the amount of opioids they consume when they also use cannabis. ... In addition, 80% of patients reported that cannabis by itself was more effective than their opioids. ... Supporting the results of previous research, this study can conclude that medical cannabis patients report successfully using cannabis along with or as a substitute for opioid-based pain medication."

  Cannabis as a substitute for opioid-based pain medication: patient self-report, Cannabis and Cannabinoid Research, 2017

• "Among respondents that regularly used opioids, over three-quarters (76.7%) indicated that they reduced their use since they started medical cannabis. This was significantly ( p < 0.0001) greater than the patients that reduced their use of antidepressants (37.6%) or alcohol (42.0%). Approximately two-thirds of patients decreased their use of anti-anxiety (71.8%), migraine (66.7%), and sleep (65.2%) medications following medical cannabis."

  Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep, Journal of Psychopharmacology, 2017

• "Findings include high self-reported use of cannabis as a substitute for prescription drugs (63%), particularly pharmaceutical opioids (30%), benzodiazepines (16%), and antidepressants (12%). Patients also reported substituting cannabis for alcohol (25%), cigarettes/tobacco (12%), and illicit drugs (3%)."

  Medical cannabis access, use, and substitution for prescription opioids and other substances: A survey of authorized medical cannabis patients, International Journal of Drug Policy, 2017

• "These patient-reported outcomes support prior research that individuals are using cannabis as a substitute for prescription drugs, particularly, narcotics/opioids, and independent of whether they identify themselves as medical or non-medical users. This is especially true if they suffer from pain, anxiety and depression."

  Cannabis as a substitute for prescription drugs - a cross-sectional study, Journal of Pain Research, 2017

• "Substituting cannabis for one or more of alcohol, illicit drugs or prescription drugs was reported by 87% of respondents, with 80.3% reporting substitution for prescription drugs, 51.7% for alcohol, and 32.6% for illicit substances. ... The finding that cannabis was substituted for all three classes of substances suggests that the medical use of cannabis may play a harm reduction role in the context of use of these substances, and may have implications for abstinence-based substance use treatment approaches."

  Substituting cannabis for prescription drugs, alcohol and other substances among medical cannabis patients: The impact of contextual factors, Drug and Alcohol Review, 2015

• "Participants were 367 patients recruited from four medical cannabis dispensaries located throughout Arizona. ... Patients reported using medical cannabis to treat a variety of conditions. ... [P]atients reported using other medications less frequently when using cannabis. This is consistent with findings from other studies."

  Medical cannabis in Arizona: Patient characteristics, perceptions, and impressions of medical cannabis legalization. Journal of Psychoactive Drugs, 2015

Chronic pain patients are less likely to abuse medicinal cannabis as compared to opioids

• "Generally, rates of problematic use of MC (medicinal cannabis) among MC users seem lower than rates of problematic use of opioids among those prescribed opioids,"

  Problematic use of prescription opioids and medicinal cannabis among patients suffering from chronic pain, Pain Medicine, 2016

Chronic pain patients are less likely to become depressed using medical cannabis

• "Prevalence of depression among patients in the OP (opioids), MM (medical marijuana) and OPMM groups was 57.1%, 22.3% and 51.4%, respectively and rates of anxiety were 48.4%, 21.5% and 38.7%, respectively. ... Levels of depression and anxiety are higher among chronic pain patients receiving prescription opioids compared to those receiving MM. Findings should be taken into consideration when deciding on the most appropriate treatment modality for chronic pain, particularly among those at risk for depression and anxiety."

  Depression and anxiety among chronic pain patients receiving prescription opioids and medical marijuana, Journal of Affective Disorders, 2017

Physician Guide to Cannabis-Assisted Opioid Reduction
Prepared by Adrianne Wilson-Poe, Ph.D.
Distributed by Congressman Earl Blumenauer

Quote

Cannabis reduces opioid overdose mortality.

• In states with medicinal cannabis laws, opioid overdoses drop by an average of 25%. This effect gets bigger the longer the law has been in place. For instance, there is a 33% drop in mortality in California, where compassionate use has been in place since 1996 (1).
• This finding was replicated by Columbia’s school of public health, using a completely different analysis strategy (2).

Cannabis reduces opioid consumption.

• Cannabis is opioid-sparing in chronic pain patients. When patients are given access to cannabis, they drop their opioid use by roughly 50%. This finding has been replicated several times from Ann Arbor to Jerusalem (3, 4).
• This opioid sparing effect is accompanied by an enhancement of cognitive function once patients begin cannabis therapy: this effect is most likely due to the fact that patients reduce their opioid use (5).
• Cannabis use is associated with a reduction in not only opioid consumption, but also many other drugs including benzodiazepines, which also have a high incidence of fatal overdose. In states with medicinal cannabis laws, the number of prescriptions for analgesic and anxiolytic drugs (among others) are substantially reduced (6). Medicare and Medicaid prescription costs are substantially lower in states with cannabis laws (7).

Cannabis can prevent dose escalation and the development of opioid tolerance.

• Cannabinoids and opioids have acute analgesic synergy. When opioids and cannabinoids are coadministered, they produce greater than additive analgesia (8). This suggests that analgesic dose of opioids is substantially lower for patients using cannabis therapy.
• In chronic pain patients on opioid therapy, cannabis does not affect pharmacokinetics of opioids, yet it still enhances analgesia. This finding further supports a synergistic mechanism of action (9).
• Pre-clinical models indicate that cannabinoids attenuate the development of opioid tolerance (10, 11).

Cannabis, alone or in combination with opioids, could be a viable first-line analgesic.

• The CDC has updated its recommendations in the spring of 2016, stating that most cases of chronicpain should be treated with non-opioids (12).
• The National Academies of Science and Medicine recently conducted an exhaustive review of 10,000+ human studies published since 1999, definitively concluding that cannabis itself (not a specific cannabinoid or cannabis-derived molecule) is safe and effective for the treatment of chronic pain (13).
• When 3,000 chronic pain patients were surveyed, they overwhelmingly preferred cannabis as an opioid alternative (14).

1. 97% "strongly agreed/agreed" that they could decrease their opioid use when using cannabis
2. 92% "strongly agreed/agreed" that they prefer cannabis to treat their medical condition
3. 81% "strongly agreed/ agreed that cannabis by itself was more effective than taking opioids

Cannabis may be a viable tool in medication-assisted relapse prevention

• • CBD is non-intoxicating, and is the 2nd most abundant cannabinoid found in cannabis. CBD alleviates the anxiety that leads to drug craving. In human pilot studies, CBD administration is sufficient to prevent heroin craving for at least 7 days (15).
• • Cannabis users are more likely to adhere to naltrexone maintenance for opioid dependence (16).

Bibliography and References Cited
1. Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose
mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668-73. doi:
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