23 June 2015

Treating Opioid Addiction/s with Cannabis

Most of today's illegal drugs originally had medicinal uses. Opiates are effective short-term pain killers but are not always effective for chronic pain and there are side effects and risks with long-term use of opioid pain relievers. Heroin, a very pure form of opiate, was developed by the Bayer company to treat wounded soldiers and send them back into battle as heroes (hence the name 'hero-in'). It was used medicinally in many countries for many years. Ecstasy (MDMA) was first synthesised in 1912 and later used in psychotherapy. Cocaine was advocated by Sigmund Freud as a cure for heroin addiction.

Research has shown that cannabis, while criminalised at the federal level in the US and illegal across Australia, can be effective as a substitute for treating opioid addicts and preventing overdoses. In the early 1900's in Australia, cannabis was not consumed on a large scale, although it was readily available for sale as cigarettes called 'Cigares de Joy' (until the 1920's). From the mid-19th century to the 1930's, American physicians prescribed cannabis for a plethora of indications and cannabis tinctures could be bought over the counter to treat a range of ailments. Before the 1960's, when the notion of 'recreational' drug use became a cultural phenomenon, most drug dependencies resulted from medicinal uses of drugs like heroin and morphine.

In 1970 US Congress classified cannabis as a Schedule I substance, illegal, and without medicinal value. In Australia, cannabis is currently a Schedule 9 'prohibited' substance. Simultaneous with prohibition, cannabis became the most widely used illicit recreational 'drug' in the US, a substance generally regarded as pleasurable and relaxing without the addictive dangers of opioids or stimulants. Meanwhile, cannabis never lost its cachet in alternative medicine circles, going mainstream in 1995 when California became the first state to legalise medicinal use, despite the federal ban. Little about cannabis is straightforward. Its main active ingredient, delta-9-Tetrahydrocannabinol (THC), was not isolated until 1964, and not until the 1990's were the far-reaching modulatory activities of the Endocannabinoid System (ECS) in the human body appreciated. This system's elucidation raises the possibility of many promising pharmaceutical applications.

Many, many studies support the therapeutic benefits of cannabinoids, (Google Scholar returns 20,400 results) including the psycho-active THC, to treat a wide range of conditions including nausea, weight loss, chronic pain, depression and a variety of mental health conditions and neurological diseases. The scientific debate over the harms and benefits of cannabis has impeded US federal lawmakers from moving forward on cannabis legislation reform. As a result, in 23 US states and Washington DC, medicinal cannabis has been legalised by popular vote. Australia is still waiting for a legitimate debate to begin, even though a recent AU$33.7m donation to Sydney University for cannabis research could be a starting point. 

Among drug treatment specialists, cannabis remains controversial. Although research has shown cannabis to be an alternative treatment for more serious drug addiction, addiction treatment specialists still view cannabis as highly addictive and dangerous. These views handicap policy reform, however, research shows cannabis could be a big part of the solution to the problem of opioid drug addiction in the US, Australia and worldwide. The World Health Organisation (WHO) estimates that worldwide, 69,000 people die from opioid overdose each year.

In an article in November 2014 an addict reported that telling people his story of recovery from addiction always proved controversial. However, it’s a story echoed by the experiences of countless others, usually airbrushed out of mainstream addiction narratives. He emerged from nearly 10 years of addiction to cocaine and heroin without sticking to a '12-Step' program and without becoming totally abstinent from all 'drugs' - in fact, using cannabis was a key part of his success. In the early days of recovery, using cannabis was a vital way to stave off his cravings for heroin, short-circuiting the urge and allowing quiet self-reflection instead. His fears would subside and he was able to regroup. Having used methadone for years, he found that using cannabis instead had an amazingly positive effect on him. His story seemed to resonate with many others. “Trying to maintain complete abstinence was like hanging onto the side of a cliff; it was just a matter of time until I got tired and let go”, commented one reader. The US National Epidemiological Survey on Alcohol and Related Conditions (NESARC) states that over 90% of people with substance use disorders overcome them without Alcoholics Anonymous (AA) or Narcotics Anonymous (NA, in both the US and Australia) or any formal treatment.

“There is a reason they call it ‘marijuana maintenance’ in AA”, said an addict who hadn’t used alcohol or other drugs in his 14 years in the program. “Many people get and stay off the hard 'shit' smoking 'pot'. In AA, where the goal is complete abstinence, that is a no-no … but as we all know, most junkie AA guys will, in candour, say, ‘You’re smoking weed? That’s not a drug!’ I mean, after every meeting I’ve ever been to, everybody rushes outside to light a cigarette and glug down a few cups of coffee. So it’s not surprising you’re getting some people looking at that and saying, ‘Hey, no fair. How come you can smoke tobacco and still be considered sober, but if I smoke marijuana it’s considered a relapse?’ After all, they’re both mood-altering substances but marijuana is the healthier of the two.”

“Certainly, I have clients who use it in this way,” says Dr Adi Jaffe when asked for his professional opinion on the pros and cons of using cannabis as a tool to wean off other drugs. Jaffe is a UCLA-trained addiction expert and a regular contributor to Psychology Today. He draws from his personal experiences with meth addiction when working with clients at his addiction treatment centre in Los Angeles. “When you think about it, this is classic harm reduction methodology, replacing a more harmful and dangerous drug with a lesser one to improve coping while reducing consequences. Harm reduction literature in general supports this idea as a positive step in recovery. If someone struggles with anxiety, they need something to help with it, whether that be neurofeedback, talk therapy or 'weed'”. Dr Jaffe notes, “My sense is that most typical 12-Step followers look at the practice unfavourably" and it’s certainly true that not everybody is happy with the idea of the erosion of cannabis’s forbidden status within the recovery community.

The once-taboo idea of using cannabis as a tool for people who want to stop using 'dangerous drugs' is catching on. In 2013, the Centre for Addictions Research of British Columbia, Canada published a study in the journal, Addiction Research & Theory, Cannabis as a substitute for alcohol and other drugs: A dispensary-based survey of substitution effect in Canadian medical cannabis patients. The results: Over 41% stated they used cannabis as a substitute for alcohol, 36.1% used cannabis as a substitute for illicit substances and 67.8% used cannabis as a substitute for prescription drugs. The three main reasons cited for cannabis-related substitution are 'less withdrawal' (67.7%), 'fewer side-effects' (60.4%) and 'better symptom management' suggesting that many patients may have already identified cannabis as an effective and potentially safer adjunct or alternative to their prescription drug regimen. 75.5% of respondents cited that they substituted cannabis for at least one other substance.

A study in the Journal of American Medicine reported that US states where medical 'marijuana' is legal had 25% fewer opioid overdoses. This tracks with other research indicating people use cannabis to stay off hard drugs. Could it be that instead of being a gateway to addiction, cannabis is a gateway to recovery? It’s a question that is likely to resonate as more states debate legalising cannabis in the midst of a crisis involving other drugs.

In Australia the National Opioid Pharmacotherapy Statistics Annual Data (NOPSAD) collection is a set of jurisdictional data that includes information about clients accessing pharmacotherapy for the treatment of opioid dependence among other things. Currently in Australia, opioid dependence may be treated by replacing the drug of dependence with one of the following longer-acting opioids:
  • methadone
  • buprenorphine
  • buprenorphine/naloxone.
These drugs are known as opioid pharmacotherapies. Over 48,000 Australians were on a course of pharmacotherapy treatment for their opioid dependence in June 2014.

Botanical cannabis (whole plant) attracts notoriety and controversy. Given the far-flung influence of endocannabinoids throughout the body, it is not surprising that botanical cannabis has traditionally been used to combat so many ills. In modern times, it has become an option of last resort for those for whom available pharmaceuticals have proven ineffective, including individuals with intractable nausea and vomiting, those dealing with cancer chemotherapy or anorexia in human immunodeficiency virus disease. This is the same substance, of course, that delights recreational users, blurring the boundary between health care and pleasure.

Cannabis is now legal for adult recreational use in Colorado, Washington state, Oregon, Alaska and Washington, DC. Like addiction, recovery is tightly bound by time and culture: If history had played out differently, with cannabis remaining legal and tobacco illegal (something that would almost certainly have saved millions of lives), cannabis might be seen as an acceptable part of recovery, while tobacco would clearly be a relapse. The same holds true for caffeine. High-dose caffeine, as anyone who has gotten jittery, talkative and paranoid from it can attest, is a serious stimulant and the fact that we don’t see it as a drug relates more to history than to science. Similarly, although cannabis can cause immediate impairment while tobacco does not, the serious long-term effects of tobacco use make it a good candidate for being named the single most powerfully addictive drug known.

Resources include;
Blurred Boundaries: The Therapeutics and Politics of Medical Marijuana
Cannabis The Exit Drug
Marijuana Use and Opiate Addiction
Can Medical-marijuana-curb-the-heroin-epidemic
Hot Topics-Drugs History

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