As the majority of states in the U.S. have passed some form of Medical Cannabis Program (or Medical Marijuana, “MMJ”), the number of patients seeking recommendation for MMJ use has increased dramatically in recent years. Despite this increase across the nation, the specific impact of MMJ on patients who are also prescribed opioids for chronic pain and any resulting effects on abuse had not previously been examined. This treatment “… combination is now believed to provide synergistic antinociceptive effects, decreasing the lowest effective … opioid dose.” (Cooper, et al) In a controlled study using an experimental model of pain and its effects on abuse, pain patients frequently report greater pain relief when Cannabis is used with their opioids and that they do not have a higher incidence of abuse. This effect is attributed to MMJ enhancing the anti-pain effects of opioids. Cooper’s findings illustrate that Cannabis enhances the pain-relieving effects of even low-dose opioids, suggesting a reduced patient opioid need for pain control without an increase in abuse. These findings support future research into the use of opioid-cannabinoid combinations for pain and also support my own anecdotal evidence as a Pain-Management Physician.
Furthermore, as the bill previously referred to as Oklahoma Senate Bill 1446, now a law, was implemented with enforcement on 1 Nov 2018 the pain management sector of Oklahoma healthcare has been thrown into upheaval by politicians and bureaucrats that have never cared for a single patient. This law has resulted in numerous patients having diminished access to continual pain relief for a multitude of devastating illnesses that could potentially affect anyone, or in the worst cases being illegally abandoned by their healthcare providers. On top of the short- sighted tenets of this law, it also prohibits patients from having well-known comorbid conditions being treated effectively in a simultaneous fashion, namely anxiety/insomnia and pain as it is now illegal in the state of Oklahoma to prescribe the two classes of medications called opioids and benzodiazepines (eg. Xanax or Valium et al.) to the same patient. This is true even if two separate prescribers and experts in these diseases write the prescriptions independently. It also comes at a time, when research into even the worst-case scenario; that of a patient with “Opiate Use Disorder” (formerly Opiate Addiction) supports the safety and efficacy of very potent opioids with the lowest effective dose of benzodiazepine medication (Martin et al. 2018). This is knowledge that we have never possessed before and has been published in an extremely prestigious Medical Journal in only the last two months.
It is unfortunate that once again, our legitimately wonderful state has highlighted our uninformed State Legislators, and their voluntary choice to lead the nation in a “worst” category. In this case, that category is one of the worst patient-centric laws ever penned and it is tantamount to the corollary of asking a patient if they want their high blood pressure or their asthma treated. I believe most voters understand that both of the aforementioned conditions NEED to be treated and that the importance of the high blood pressure and asthma analogy is no more important than the pain and anxiety/insomnia reality. Thankfully, the citizens of Oklahoma have prevailed where our legislators have failed. They approved an incredibly effective Medical Cannabis Law that provides for the alleviation of both of these ailments at a time when the OK State Government seems to have become the most pronounced and prolific anti-patient governing body that I personally can imagine. The next time we all visit the polls, it is my personal wish that we hold these individuals accountable for their personal agendas and once again declare that we will no longer let non-healthcare providers hurt patients and make physicians their own weapons of that pain. Besides, any physician practicing without a license would be held accountable for the exact same infraction our Legislators have committed. It’s ironic that at least the physician in this example would at very least have the requisite education to make an informed decision regarding these matters, while we allow elected officials with no medical education whatsoever to commit this exact offensive, erroneous, and unlawful action.
Cooper ZD, Bedi G, Ramesh D, Balter R, Comer SD, Haney M. “Impact of co-administration of oxycodone and smoked cannabis on analgesia and abuse liability.” Journal of Neuropsychopharmacology. 2018. http://www.cannabis-med.org/studies/ww_en_db_study_show.php?s_id=672
Martin SA, Chiodo LM, Bosse JD, Wilson A “The Next Stage of Buprenorphine Care for Opioid Use Disorder.” Annals of Internal Medicine. Doi:10.7326/M18-1652. 23 Oct 2018
Jeremy Boucher, M.D., PCEO