Cannabis > Opioids?

The title of an article published in the Santa Fe New Mexican on November 4 certainly piqued my interest - "Advisory panel backs medical cannabis as tool in opioid war." While not binding or official until the Health Secretary decides how to proceed, the advisory board to the New Mexico Medical Cannabis Program voted 5-1 to add "opiate use disorder" to the list of qualifying conditions. Let that sink in for a little bit.

The proposal drew support from health professionals, addiction specialists and lawmakers. Medical Advisory Board Chairman Dr. Mitch Simson cast the only vote against adding opioid addiction to the cannabis program, saying he was concerned about substituting one addiction for another. 

So there you have it, the argument distilled into two simple sentences. Can cannabis help resolve our opioid epidemic? Or are we just trading one problem for another?

I heard this argument when lobbying for HB 195 earlier this year in Santa Fe that would have removed the case precedent requirement for Work Comp to reimburse injured workers for medical cannabis. On both "sides". Opponents of the bill made the argument that opioids are dangerous (I've been preaching that since 2003) and that cannabis could help resolve the epidemic. Proponents of the bill were mostly focused on the financial and legal repercussions but there certainly were concerns about sanctioning marijuana use by reimbursement.

I was quoted in a WorkCompCentral article today (subscription required) as follows:

Is it (cannabis) a solution for the opioid issue? That may be in the eye of the beholder. If it supplants opioids in the treatment regimen, you could make the argument that it is. If it doesn't, you could say it's adding more fuel to the fire. 

Given that there are six states I know of where Work Comp has reimbursed for medical cannabis use (New Mexico, Maine, Minnesota, Connecticut, Massachusetts, New Jersey) ... and that recent decisions on reimbursement have often been based on medical efficacy and not concerns about Federal illegality (and in some cases were voluntary, not mandated) ... and that last Tuesday eight of nine states with ballot initiatives about marijuana received voter approval ... you can see how we've gotten to this point.

I usually ask three questions when I'm presenting on this subject. Granted, my audiences typically are Work Comp focused and payer-centric, but at times they have been broader in scope. The questions are:

1. How many of you think that cannabis is part of the solution to our opioid epidemic? Typically 10-15% will raise their hands.
2. How many of you think that cannabis is absolutely not part of the solution to our opioid epidemic? Typically 10-15% will raise their hands.
3. How many of you haven't decided yet and are open to either possibility? The remainder (70-80%) raise their hands.

I've seen this bell curve repeated so many times that I think it's truly reflective of where we are as a country.

New Mexico has been #1 (!) on a variety of fronts. They were the first to have reimbursement mandated. They were the first to establish a fee schedule for reimbursement ($12.02 per dry gram). And now they may be the first to explicitly allow cannabis to be used to facilitate and make permanent weaning from opioids and other dangerous prescription drugs. Obviously, the Medical Cannabis Program is not exclusive to Work Comp, but it's naive to think that it will not have an effect.

I don't have any insight into whether Health Secretary-designate Lynn Gallagher will accept the advisory council's recommendation. But given the politics I saw play out earlier this year in Santa Fe it would not surprise me if she did. And since her bio lists being "committed to working to prevent and treat substance abuse," it's easy to see how this message might resonate with her.

I found this interesting quote attributed to Anita Briscoe, an advanced practice registered nurse in Albuquerque who apparently was used by the advisory council as a subject matter expert:

... about 25 percent of her patients struggling with opioid use disorder have told her that cannabis soothes their cravings, relieves their pain and helps them stay off opiates. Three of her colleagues who certify patients for medical marijuana cards estimated that together, they’ve seen about 400 patients successfully kick opioid addictions with the help of cannabis. 

Statistics? Yes. Anecdote? Yes. Scientific? No. Accurate? For the 400 people mentioned above, a reasonable person would probably say yes. Since dealing with chronic pain and overcoming addiction are highly individualized, science is somewhat less important than the anecdote of what works for that person at that time (NOTE: Choices should always be guided by evidence based medicine).

So is the proposal yet another milestone in our national discussion on the benefits (or lack thereof) from cannabis? I don't know. But I'm confident this will further fuel the conversation on it's merits (or lack thereof). And make managing a safe workplace even more complicated. If you thought this was an issue that is going away ...

About the Author

Mark Pew, Senior Vice President of PRIUM, has been focused since 2003 on the intersection of chronic pain and appropriate treatment. That ranges from the clinical and financial costs of opioids and benzos, to the corresponding epidemic of heroin use, to the evolution in medical cannabis. Educating is his job and passion. Contact Mark at mpew@prium.net, on LinkedIn at markpew, or on Twitter @RxProfessor.

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