With the rise in awareness of the extent and implications of opioid misuse, alternative treatments are now more commonly considered for chronic pain control. Here, Dr Mark Ware explores the option of medical cannabis.
Chronic pain is a major public health issue, affecting nearly 28 million adults in the UK – nearly half of the entire population. Managing chronic pain is increasingly recognised as a significant challenge for healthcare systems and providers; patients report feeling frustrated and lost in their journey to find a source or reason for their pain and for adequate support and treatment. In my research into chronic pain and interacting with many of these patients, I know that chronic pain can be very difficult to diagnose, measure and treat. When nothing else seems to work, patients may even be prescribed strong painkillers such as opioids in an attempt to relieve their pain.
In the UK, opioid-related deaths saw a sharp rise in 2014 and since then have increased to record levels. The University of Bath recently commissioned research assessing the dangers of opioid abuse and concluded that the misuse of opioids had become even higher in lockdown across England and Wales as patients are being prescribed higher volumes of these drugs at once. Similar experiences are being reported elsewhere. This, combined with the added stress and anxiety of lockdown restrictions, has meant even more patients with chronic pain appear to be turning in desperation to opioids for relief.
So, what other options are there?
With the rise in awareness of the extent and implications of opioid misuse, the tide is turning, and alternative treatments are now more commonly reviewed and considered for chronic pain control. The National Institute for Health and Care Excellence (NICE) recently recognised the need for alternative treatment options, publishing guidance against the use of opioids for those with chronic pain.
One of these options may be medical cannabis. We know that the cannabis plant has been used as a painkiller for many years, and components of the plant such as CBD and Tetrahydrocannabinol (THC) interact with specific receptors in a unique way to not only control pain but to make the pain and related symptoms less unpleasant. Unlike opioids, however, pain relief with THC is triggered through engagement of the endocannabinoid system (ECS) which plays an important role in, not only pain, but other biological functions like sleep and memory. Research has shown that while THC works on the part of the nervous system that modulates nerve pain in particular, CBD works as an anti-inflammatory and reduces opioid cravings. This suggests that medicinal cannabis products which contain one or more of these compounds could not only be used as an alternative to opioids, but may also help those battling opioid addiction.
Up until now there has been little progress in the treatment of opioid dependency, with patients most likely to be advised to reduce their dose or substitute with other painkillers. However, there remains a risk of adverse health effects, including tolerance, long-term dependency, cognitive issues and drug interactions. This highlights the need for a consistent, safe and effective treatment for opioid addiction, and medicinal cannabis could be one option, given what we know about its safety profile.
As with any treatment, further research will need to be carried out, however early observational research in Canada has shown that cannabis may have a stabilising impact for people with opioid use disorders. There is emerging real-world evidence that patients on medical cannabis are reducing their opioid doses and improving quality of life. While this needs to be confirmed in large, controlled trials, the opioid crisis will not wait, and there is a need to act now. We know that there is no simple solution to this complex disease but increasing clinician and patient education around medical cannabis as a potential treatment option is key. Spectrum Therapeutics have created local and international education programmes to standardise the dissemination of cannabis education to physicians. These courses are critical to help healthcare professionals (HCPs) gain comfort and increased understanding of the potential risks and benefits of medical cannabis as an option for their patients especially as the essentials of medical cannabis – such as the physiology of the endocannabinoid system – have not traditionally been taught in medical schools.
Alongside these education programmes we also recently supported a consensus paper written by 22 clinicians and experts which provides practical recommendations for clinicians who wish to use medical cannabis in an attempt to reduce opioid use in patients. The paper includes guidance on when and how to safely initiate and titrate cannabinoids in the presence of opioids, as well as how to safely taper opioids when being treated with cannabinoids. There is also counsel on how to monitor patients and evaluate outcomes, so we hope this will be a useful tool for clinicians who have patients interested in exploring cannabis as an option to opioids.
As many of us are witnessing, the opioid crisis is not going away and may be closer to home than we think. With any addiction disorder, sufferers may feel like there is no way out, especially when they are highly stigmatized and treatment options have been exhausted. Given the potential for harm reduction, it is vital that patients have a legal route to explore and access standardised medicinal cannabis products under the supervision of their clinicians.
 Fayaz A., Croft P., Langford R.M., et al. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open 6:e010364 (2016).
 NIHR. How has the COVID-19 pandemic affected people in rural areas who take opiate substitutes? Available from: http://www.hprubse.nihr.ac.uk/research/covid-19-research/how-has-the-covid-19-pandemic-affected-people-in-rural-areas-who-take-opiate-substitutes/. Last accessed: August 2021.
 Hurd Y.L., Yoon M., Manini A.F. et al. Early Phase in the Development of Cannabidiol as a Treatment for Addiction: Opioid Relapse Takes Initial Center Stage. Neurotherapeutics 12, 807–815 (2015).
 Thompson G.R., Rosenkrantz H., Schaeppi U.H., et al. Comparison of acute oral toxicity of cannabinoids in rats, dogs and monkeys. Toxicology and Applied Pharmacology 25;3, 363-372 (1973).
 British Columbia Centre on Substance Abuse. Cannabis could reduce fentanyl use, reduce overdose risk: study. Available from: https://www.bccsu.ca/blog/news-release/cannabis-could-reduce-fentanyl-use-reduce-overdose-risk-study/. Last accessed: August 2021.