While medicinal cannabis has been used in the treatment of mental health concerns such as anxiety and irritability, it has also had causal effect on numerous psychosocial complications. These include symptoms such as panic attacks, social anxiety, prolonged adolescence with cognitive decline, schizophrenia, paranoia, psychosis, and induced suicidality. All of these have been demonstrated with prolonged cannabis use.5,10 Some evidence of cognitive impairments have been expressed even in acute phases of consumption; including prolonged reaction times, memory and cognitive delays, which can persist for several days following last use.5
Despite the commonly held belief that cannabis does not cause a physiologic dependence in patients who use regularly, research has suggested compelling evidence to the contrary.5,10 Classic withdrawl symptoms, coined marijuana abstinence syndrome, have been reported and may include depression with and without anxiety, irritability, anorexia with weight loss, parasomnia, tremors, and even myalgia.5,10 The extent of symptoms and intolerance are challenging to predict and are often correlated with the patient’s quantity and frequency of use.10 Yet, this is generally more widely tolerated by prior users and is often only reported in approximately 50% of regular, frequent users, making the generalizability of certain risk negligible.10
Abuse and Overdose Potential
A systematic review of the literature revealed rising opioid dependence concerns among patients with chronic pain as early as 1992, with nearly 20% of patients with evidence of substance abuse disorder.11 A similar study revealed the prevalence of opioid use disorder to be as high as nearly 33% in at-risk populations.11 A 10-year prospective study of the US population revealed the substance abuse rate had more than doubled with an estimated 43% to 45% of chronic pain patients demonstrating behavior and physiologic evidence consistent with dependence.11
In 2015, out of the 20.5 million Americans above the age of 12 who had a substance abuse problem, 2 million abused prescription pain medications and 591,000 abused heroin.22 In the same year, the leading cause of accidental death in the United States was drug overdose.22 Of the 52,404 drug overdose deaths, 33,091 were from opioid use (20,101, opioid pain medication; 12,990, heroin).22
Contrasting these assertions of rising threats of opioid abuse were similar studies that revealed the absence of similar disease findings exhibited in patients being treated with cannabis who did not demonstrate similar signs of abuse or dependency, including irritability, parasomnia, and anxiety.16
Between 1997 and 2007, there have been no overdose related deaths attributed exclusively to cannabis use. 23 Though cause and effect cannot be safely assumed, it is interesting to note that in the states that have adopted legislation to legalize medical cannabis use starting in or prior to 2010 (Alaska, California, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington), there was a significantly lower (24.8%) mortality rate due to opioid overdose, as compared to states that have more restrictive laws.24
Since the institution of state medical cannabis laws, researchers have studied the effect that these laws have had on morbidity, hospital admissions, and length of stay related to treatment with cannabis vs. opioids.24 Between 1997 and 2014, medical cannabis has been associated with a 23% reduction in hospitalizations due to opioid dependence or abuse and a 13% reduction in opioid overdose.24
The United States is in the middle of a rising pandemic of opioid abuse and dependency. Medical use of cannabis may be emerging as a potential adjunct or alternative to reduce the morbidity and mortality related to opioid use. Now available in most states as a prescription alternative, with modest evidence, cannabis has been found to provide analgesia in chronic pain. Though more studies are needed to confirm the effectiveness of medical cannabis and provide reliable outcome measures, safety profile of extended use, and patient candidacy, the existing evidence is promising enough to begin a dialogue of a potential future paradigm shift in contemporary pain management.
Christopher M. Howell, DSc, MSc, MPAS, PA-C, MBA, is a program director and associate clinical professor at Miami University, in Oxford, Ohio. He works in family, emergency, and addiction medicine in Ohio and Indiana.
David Malesko, PA-C, currently practices in psychiatric medicine in Dayton, Ohio. At the time that the article was initially written, he was a student in Kettering College’s PA program in Dayton, Ohio.
Authors Disclosure: The authors neither favor nor disapprove of cannabis and similar alternative treatment strategies for both acute and chronic pain for all patients plagued with disease; as any treatment requires considering the “whole patient”. We aim only to review the evidence and risks associated with medical cannabis, as it is known to the community at this time. It is up to the practitioner to consider his or her role in current and future dialogues with colleagues industry as well as eligible patients, in determining the appropriateness of medical cannabis use.
- Miranda A, Taca A. Neuromodulation with percutaneous electrical nerve field stimulation is associated with reduction in signs and symptoms of opioid withdrawal: a multisite, retrospective assessment. Am J Drug Alcohol Abuse. 2018;44(1):56-63.
- Pade PA, Cardon KE, Hoffman RM, Geppert CM. Prescription opioid abuse, chronic pain, and primary care: a Co-occurring Disorders Clinic in the chronic disease model. J Subst Abuse Treat. 2012;43(4):446-450.
- Cone EJ, Buchhalter AR, Lindhardt K, Elhauge T, Dayno JM. The ALERRT® instrument: a quantitative measure of the effort required to compromise prescription opioid abuse-deterrent tablets. Am J Drug Alcohol Abuse. 2017;43(3):291-298.
- Wollman SC, Alhassoon OM, Hall MG, et al. Gray matter abnormalities in opioid-dependent patients: A neuroimaging meta-analysis. Am J Drug Alcohol Abuse. 2017;43(5):505-517.
- Fitzcharles MA, Häuser W. Cannabinoids in the management of musculoskeletal or rheumatic diseases. Curr Rheum Rep.2016;18(12):76.
- Wallace A. Where is weed legal? Map of U.S. marijuana laws by state. The Cannabist. Updated January 25, 2018. Accessed October 15, 2019. https://www.thecannabist.co/2016/10/14/legal-marijuana-laws-by-state-map-united-states/62772/.
- Okafor CN, Cook RL, Chen X, et al. Prevalence and correlates of marijuana use among HIV-seropositive and seronegative men in the Multicenter AIDS Cohort Study (MACS), 1984-2013. Am J Drug Alcohol Abuse. 2017;43(5):556-566.
- Draz EI, Oreby MM, Elsheikh EA, Khedr LA, Atlam SA. Marijuana use in acute coronary syndromes. Am J Drug Alcohol Abuse. 2017;43(5):576-582.
- Green KM, Doherty EE, Ensminger ME Long-term consequences of adolescent cannabis use: examining intermediary processes. Am J Drug Alcohol Abuse. 2017;43(5):567-575.
- Lamarine RJ. Marijuana: modern medical chimaera. J Drug Educ. 2012;42(1):1-11.
- Rosenblum A, Marsch LA, Joseph H, Portenoy RK. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmocol. 2008;16(5):405-416.
- Kim PS, Fishman MA. Cannabis for pain and headaches: primer. Curr Pain Headache Rep. 2017;21(4):19.
- Piper BJ, DeKeuster RM, Beals ML, et al. Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep. . J Psychopharmacol. 2017;21(5):569-575.
- Lucas P, Walsh Z. Medical cannabis access, use, and substitution for prescription opioids and other substances: a survey of authorized medical cannabis patients. Int J Drug Policy. 2017;42:30-35.
- Jensen B, Chen J, Furnish T, Wallace M. Medical marijuana and chronic pain: a review of basic science and clinical evidence. Curr Pain Headache Rep. 2015;19(10):50.
- California Society of Addiction Medicine. The adverse effects of marijuana (for healthcare professionals). Accessed November 19, 2020. https://csam-asam.org/page/AdvEffectsOfMarijHCP?&hhsearchterms=%22adverse+and+effects+and+marijuana+and+healthcare+and+p%22524-x.
- Grant I, Atkinson JH, Gouaux B, Wilsey B. Medical marijuana: clearing away the smoke. Open Neurol J. 2012;6:18-25.
- Earleywine M, Barnwell SS. Decreased respiratory symptoms in cannabis users who vaporize. Harm Reduct J. 2007;4:11.
- Schuchat A. THC products may be a factor in outbreak of vaping-related lung injuries. Healio, September 27,2019. Accessed November 19, 2020. https://www.healio.com/news/pulmonology/20190927/thc-products-may-be-factor-in-outbreak-of-vapingrelated-lung-injuries-cdc.
- Perrin CG, Pickens CM, Boehmer TK, et al. Characteristics of a multistate outbreak of lung injury associated with e-cigarette use, or vaping-united states, 2019. MMWR Morb Mortal Wkly Rep. 2019;68(39):860-864.
- Miech RA, Patrick ME, O’Malley PM, et al. Trends in reported marijuana vaping among US adolescents, 2017-2019. JAMA. 2020;323(5):475-476.
- ASAM (American Society of Addiction Medicine). Opioid Addiction 2016 Facts & Figures. ASAM website. Accessed October 15, 2019. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.
- Deaths from Marijuana vs. 17 FDA-Approved Drugs. ProCon.org website. Updated July 8, 2009. Accessed November 19, 2020. https://medicalmarijuana.procon.org/view.resource.php?resourceID=000145#drugdeathchart.
- Shi Y. Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever. Drug Alcohol Depend. 2017;173:144-145.