Marijuana vs. Opioids

Doctors Test the Promise of Marijuana for Pain

Doctors are achieving solid outcomes in transitioning opioid patients to medical marijuana, but lack of research and regulation on dosage still poses challenges for comp.
By: | August 7, 2015 • 4 min read

Marijuana helps many chronic pain patients reduce or eliminate their opioid pain medication consumption, said a doctor who makes opioid reduction a condition for certifying his patients participation in New Mexico’s medical cannabis program.

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Eligibility for the state’s medical marijuana program requires a doctor’s confirmation that a patient suffers from an ailment among 20 qualifying conditions, including chronic pain.

Dr. Carlos Esparza said he provides the certification only for established patients, not just anyone who walks through the door, because he doesn’t want his practice to become known as a place where people can easily obtain the marijuana program certification.

The goal, he said, is weaning patients off prescription opioid pharmaceuticals, which raise more safety concerns than marijuana.

“That is essentially the goal,” he said. “If they are going to go on the medical marijuana program we tell them that we are going to reduce their [narcotic pain] medications at least by half. And of course if they do really well, the goal is to hopefully wean them off them completely.”

“If I prescribe opioids, I have to be careful because that patient could overuse it, abuse it, and kill themselves. [With] marijuana they can get too high, they can get stoned, but it won’t kill them.” — Dr. Carlos Esparza

Nationally, 44 people die daily from prescription opioid overdoses. Many more become addicted to the medications, according to the Centers for Disease Control and Prevention. Workers’ compensation claimants consuming large opioid doses, often in dangerous combinations with other drugs like antidepressants, remain a concern for claims payers.

Meanwhile, 23 states now have medical marijuana programs with legislation pending in others.

Discussing marijuana use with chronic pain patients consuming large opioid doses makes pharmaceutical sense because existing evidence shows that cannabinoids contained in marijuana reduce pain while evidence that marijuana use leads to other addictions is not strong, said Kathryn Mueller, an M.D. and professor in the University of Colorado’s schools of medicine and public health.

“Personally I think it is appropriate,” Mueller said. “We have a huge problem with opioids and if we can maintain someone on marijuana that is not having a lot of cognitive impairment from it, they are going to be better off.”

Mueller is also medical director for the Colorado Division of Workers’ Compensation. She is highly respected for developing treatment guidelines for injured workers. Mueller is also past president of the American College of Occupational And Environmental Medicine, but the views expressed for this article are her own and do not represent those of the organizations she associates with.

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Evidence of cannabinoids’ effectiveness includes known success in treating neuropathic pain with clinically-tested prescription pharmaceutical cannabinoids, Mueller explained. Sativex is one such drug. It is approved for use in Canada and European countries, but not currently in the United States.

While attempting to reduce opioid consumption and address chronic pain with cannabis is not a bad idea, doing so remains a challenge because doctors do not know the amount of cannabinoids and other ingredients patients receive when purchasing marijuana, Mueller said.

With a lack of research establishing how much marijuana consumption is necessary for treating specific medical problems, it’s up to patients to determine the appropriate quantity for their condition, said Esparza, a physical medicine and rehabilitation specialist.

Under New Mexico’s medical cannabis program, launched in 2007, dispensaries selling marijuana must be licensed.

It’s also up to patients visiting dispensaries to determine whether they purchase marijuana that has more pain-reducing cannabinoids than tetrahydrocannabinol or THC, the mind-altering psychoactive ingredient that makes people high.

“But even that helps with certain patients as far as (treating problems with) sleep and anxiety,” Esparza said.

Lack of research and regulations establishing appropriate consumption amounts means, however, that one patient may purchase 10 times more marijuana than another. Then it’s unknown if the buyer of larger amounts does so because of medical necessity, just for the high, or to sell the drug, Esparza said.

Therefore, Esparza doesn’t believe workers’ comp insurers should be responsible for paying for marijuana.

New Mexico’s Court of Appeals disagrees, however. Since May 2014, the court has ruled in three cases that workers’ comp insurers and employers must reimburse claimants’ for their medical marijuana purchases.

In the most recent case decided in June, Dr. Esparza certified the claimant to participate in New Mexico’s medical cannabis program. The case involved a lower back injury with a patient consuming numerous drugs for chronic pain, including oxycodone, Soma, Norflex, gabapentin, Lyrica, Percocet, fentanyl, and Zantac.

Court records show Esparza certified that the injured worker suffered from debilitating, painful peripheral neuropathy and that the “benefits of medical marijuana outweigh the risk of hyper doses of narcotic medications.”

Prescribing opioids presents a safety hazard absent with marijuana use, Esparza said in an interview. Opioid toxicity levels can kill while that is not so much the case with marijuana, which also has much lower addiction risk, he explained.

“If I prescribe opioids, I have to be careful because that patient could overuse it, abuse it, and kill themselves,” he said. “[With] marijuana they can get too high, they can get stoned, but it won’t kill them.”

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With approximately 50 to 100 of his patients participating in the medical cannabis program over the past five years, Esparza said many of them are functioning better than when they consumed more opioids.

While some patients want marijuana more for recreational use, “certainly there have been those that we have reduced or actually got them completely off their narcotic medications,” he said. “In fact, a lot of them have felt it was more effective because they didn’t have the same side effects that they did from the opioid medications.”

Roberto Ceniceros is senior editor at Risk & Insurance® and chair of the National Workers' Compensation and Disability Conference® & Expo. He can be reached at [email protected] Read more of his columns and features.

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The R&I Editorial Team can be reached at [email protected]