by Alison Knopf
Politicians like the idea of cannabis as a way to cure society’s opioid ills. It’s popular (almost everyone in health care, including many opioid treatment programs [OTPs], supports marijuana legalization). Whatever is popular with the people usually is popular with politicians.
Take a year ago when New York Gov. Andrew Cuomo said that opioid use disorder (OUD) would be a covered condition for medical marijuana. Across the state, OTPs were horrified that their patients would try to replace methadone or buprenorphine with marijuana. They–and all medical experts–knew that the result of switching from methadone or buprenorphine to cannabis would be immediate withdrawal symptoms and relapse.
The state’s Office of Addiction Services and Supports (OASAS) was caught off guard by its own governor, and quickly issued a clarification that only its licensed programs could recommend medical marijuana for OUD. That solved the problem, because OASAS-licensed treatment programs had no intention of doing so.
Calling cannabis an “adjunct” to OUD treatment, as New Jersey did, is different. Still, the issue is largely moot for most OUD patients. Insurance doesn’t pay for medical marijuana for OUD, and the products are expensive.
Don’t be misled by misinterpreted mainstream news. There is the study by Yasmin Hurd, PhD, who found that patients taking cannabidiol (CBD)–not THC–had fewer cravings in the short term than patients taking placebo. Dr. Hurd used Epidiolex–an FDA-approved CBD product indicated for rare forms of childhood epilepsy–and her subjects were all abstinent from heroin. Abstinent. They had already been through withdrawal.
Ban on SAMHSA Funds for Cannabis
The top “politician” in the substance use disorder world, however, is having none of the cannabis-for-OUD promotions. She is getting impatient.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has heard about reports from the field about programs wanting to use federal funds for medical marijuana. Elinore F. McCance-Katz, MD, PhD, assistant secretary for mental health and substance use for the Department of Health and Human Services, has embedded language in all contracts banning grantees from:
- Using grant funds to purchase, prescribe, or provide cannabis or treatment using cannabis, and
- allowing patients to use cannabis “for the purposes of treating substance use or mental disorders.”
It shouldn’t be surprising that a federal agency would ban the use of its funds for a drug that is still, on a federal level, illegal. But to many grantees–new to the grant system and flush with all the SOR (State Opioid Response) money from SAMHSA–it was an affront.
Does this put state health agencies on a collision course with state marijuana laws? In many cases, yes. But the bottom line is that there are always conditions when you get a grant. If you want the SAMHSA money, you comply–no medical marijuana for OUD. If you don’t comply, you have to give the money back.
Most OTPs don’t get SAMHSA SAPT (Substance Abuse Prevention and Treatment) block grant or SOR money. But many other programs using buprenorphine and naltrexone do.
It’s not just a matter of money. Dr. McCance-Katz doesn’t want patients to be treated with something that has no evidence supporting its use. Not with her agency’s money–and preferably, not with anybody’s.
What the Studies Are Showing
In fact, studies show that it doesn’t work. Do patients like it? That’s another story. In fact, many patients do have other problems that marijuana can help them with: anxiety and insomnia, for example. It’s just not the same as OUD.
A recent study has found that replacing opioids with cannabis, in methadone patients, just doesn’t work (McBrien et al.). It doesn’t reduce other drug use in methadone patients, and it doesn’t increase their retention in treatment. That doesn’t mean that cannabis can’t help with anxiety or other problems. It just does nothing to treat withdrawal. And it certainly is not a substitute for methadone or buprenorphine.
Yes, a 2014 study found a correlation between marijuana legalization and a reduction in opioid overdoses, state by state. But correlation doesn’t mean causation. And that study had many limitations, clearly stated by the authors, but not included in the widespread news coverage it got (Bachuber et al.). In a study published this summer, researchers found no link between legalization and overdose reduction, and in fact, found that the course had reversed since 2010, with states that have legalized marijuana showing an increase in opioid overdoses (Shover et al.).
Whether OTPs test for cannabis is another question. It’s better for patients if they don’t–because states that require it, usually also require punitive action, like reducing take-homes (see https://atforum.com/2019/02/cannabis-otps-what-next/). Both SAMHSA and the Joint Commission require THC testing only upon admission.
Finally, the American Association for the Treatment of Opioid Dependence (AATOD) is not ignoring the role of cannabis. At a workshop at the AATOD conference held in October, Christine Roussel, PharmD, and Gail Groves Scott, MPH, gave a presentation on facts and myths about the therapeutic use of cannabis. Dr. Roussel is director of pharmacy at Doylestown Hospital in Philadelphia, where she is adjunct professor at University of the Sciences, and Ms. Scott is an opioid policy researcher at the University of the Sciences. We were not at their session, but according to the excellent slides, there is a lot of research that still needs to be done in terms of OUD. And cannabis is not a harmless substance. Risks include falls, anxiety, and memory problems (short term, acute use) and cannabis use disorder (long-term use).
“Uncontrolled psychosis” doesn’t sound like a good side effect for anyone, certainly not for someone with any substance use disorder. And methadone and buprenorphine do not list psychosis as an adverse effect.
Hurd YL, Spriggs S, Alishayev J, et al. Cannabidiol for the reduction of cue-induced craving and anxiety in drug-abstinent individuals with heroin use disorder: A double-blind randomized placebo-controlled trial [Epub ahead of print May 21 2019]. Am J Psychiatry. 2019;176(11):911-922. doi:10.1176/appi.ajp.2019.18101191.
McBrien H, Luo C, Sanger N, et al. Cannabis use during methadone maintenance treatment for opioid use disorder: A systematic review and meta-analysis. CMAJ Open. 2019;7(4):E665-E673. doi:10.9778/cmajo.20190026.
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):1668-1673. doi:10.1001/jamainternmed.2014.4005.
Shover CL, Davis CS, Gordon SC, Humphreys K. Association between medical cannabis laws and opioid overdose mortality has reversed over time [Epub ahead of print June 10 2019]. Proc Natl Acad Sci U S A. 2019;116(26):12624-12626. doi:10.1073/pnas.1903434116.