We need to rethink our cannabis strategy during the overdose crisis
Treatment for opioid use disorder must take evolving cannabis policies into account to give people the best chance at recovery.
Chris Rousakis/Bloomberg Creative Photos/Getty Images
The United States is facing a devastating overdose epidemic, driven initially by painkillers and then by heroin and the synthetic opioid fentanyl. According to data from the Centers for Disease Control and Prevention, there were more than 81,000 opioid-related overdose deaths last year alone. Millions of American adults experience opioid use disorder. Yet, as of 2021, four in five of these people are not receiving treatment. This paradox highlights the urgent need to expand access to medications to aid in recovery.
One of the major barriers to treatment is the restriction of cannabis use for potential patients. Currently, many opioid use disorder treatment programs require abstinence from cannabis before being eligible for treatment. This approach highlights a major failure in addiction medicine. Misguided attitudes toward cannabis have often led to individuals being excluded from treatment. We have failed to thoroughly explore the therapeutic effects of cannabinoids and have excluded people from opioid treatment programs based on their use. This short-sighted policy means that thousands of individuals may not be able to access treatment and that we have overlooked the possibility that some components of cannabis may have therapeutic effects. To address the opioid crisis, it is essential to reevaluate attitudes toward cannabis to ensure a more comprehensive and effective treatment approach, as well as rigorously assess the risks and benefits in a balanced manner.
As the opioid crisis worsened over the past decade, attitudes toward cannabis have also changed dramatically in the United States. Cannabis is the fourth most widely used psychoactive substance in the world, behind alcohol, caffeine, and tobacco. Cannabis contains more than 550 components, the best known of which are delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Currently, 38 states and Washington DC have legalized medical cannabis, and an increasing number of states are allowing its non-medical use as well. Some states have designated opioid use disorder as a qualifying condition for medical cannabis, but there is still a lack of quality data supporting this indication. Recently, the Biden administration recommended reclassifying cannabis at the federal level as a drug with low abuse potential, a move that effectively legalizes the medical use of cannabis nationwide. This potential reclassification also represents a shift in federal policy. However, these evolving policies clash with traditional approaches to the treatment of opioid use disorder.
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In the United States, methadone, a life-saving medication for opioid use disorder, is distributed through federally regulated opioid treatment programs. These specialized clinics provide daily medication along with counseling and other support. However, many programs implement strict abstinence policies, preventing people who test positive for cannabis or its constituent cannabinoids from receiving treatment. This prohibition is based on the assumption that cannabis use impedes recovery. As cannabis legalization expands and people’s attitudes change, traditional abstinence-based policies are increasingly at odds with the growing acceptance of cannabis use. The rise of “California sobers,” those who choose a lifestyle that continues to involve cannabis use while abstaining from alcohol and other drugs, further highlights this disconnect.
Abstinence policies were born out of the idea that cannabis use might undermine treatment for opioid use disorder, but emerging evidence, including the results of a systematic review and meta-analysis we conducted in January, calls this assumption into question. Our review found that aggregate data from studies that followed individuals for 4 to 15 months showed no significant association between cannabis use and relapse to non-medical opioid use among people receiving treatment. These findings call for a reconsideration of the role of cannabis and specific cannabinoids in recovery and a reevaluation of how policies related to cannabis use affect access to and retention in treatment.
Several mechanistic findings suggest that cannabis and its components may have potential benefits in the treatment of opioid use disorder. For example, some studies have shown that THC may help reduce the need for opioids in pain management, and CBD may help reduce drug-seeking behavior and cravings triggered by environmental cues. However, more research is needed to clarify these findings. There is still a long way to go before cannabis components can be considered approved treatments for opioid use disorder.
To gain approval of a drug from the U.S. Food and Drug Administration, it must undergo a rigorous evaluation process based on randomized, double-blind, placebo-controlled clinical trials, the gold standard of evidence. In these trials, participants are randomly assigned to groups, some of whom receive the drug being tested and others receive a placebo. The agency typically requires two well-designed trials with at least 200 people before considering approving a new drug. To date, only relatively small studies have specifically tested the efficacy and safety of cannabinoids in treating opioid use disorder. Until these data are replicated in larger experimental studies, it is important to approach the idea of using cannabinoids to treat opioid use disorder with caution and rely on proven FDA-approved treatments for this condition.
Recovery from opioid use disorder is a complex journey. While complete abstinence may be ideal for some, it is not realistic for many in the early stages of the recovery process. Harm reduction strategies that prioritize reducing the dangers of drug use offer a more compassionate and practical approach. Policies that immediately remove people from treatment because they occasionally use cannabis do not consider the nuanced challenges of recovery. Moreover, they may unintentionally lead people back to dangerous non-pharmaceutical opioids such as fentanyl and its derivatives.
Our research suggests the need for policy change. Current evidence calls into question the legitimacy of zero-tolerance policies that deny treatment for opioid use disorder based on cannabis use, even though maintaining access to life-saving medication is paramount to recovery. To be clear, we are not endorsing the use of cannabis in opioid use disorder recovery. Rather, we believe a thoughtful, individualized assessment of cannabis’ role relative to treatment goals is necessary.
Healthcare professionals should monitor drug use while also having honest conversations with patients about how cannabis affects recovery, including its effects on pain, opioid withdrawal, and cravings for other drug use for non-medical purposes. The complex relationship between cannabis and recovery from opioid use disorder needs to be elucidated. Future research should explore the safety and efficacy of cannabis and its components in managing symptoms of opioid use disorder, as well as the impact of cannabis-derived products and different consumption patterns on treatment outcomes. This research, combined with thoughtful clinical discussion, can produce more personalized and effective treatments.
As the opioid crisis drags on, we must rethink our approach to ensure life-saving treatment reaches everyone who needs it. We must adopt evidence-based policies that prioritize access to approved medicines, as well as carefully consider the potential role of cannabinoids to help treat opioid use disorder. Our top priority must be to close persistent treatment gaps. By combining compassion with scientific evidence, we can work toward a more effective, comprehensive approach to the opioid crisis and provide better support to those struggling on their path to recovery.
This is an opinion and analysis article and the views of the author are not necessarily those of Scientific American.
