A Question of Evidence: There isn’t a lot of research on whether cannabis can help treat opiate addiction. But people are flocking to it because they say it helps – yet doctors remain divided on whether that patient experience should count for anything. Which side is right?

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The Pennsylvania Psychiatric Society tried to get opioid use disorder (OUD) removed from the list of conditions that can be treated with medical cannabis. Specifically, Pa. allows it to be used as “adjunctive [additional] therapy … in combination with primary therapeutic interventions,” i.e. methadone and buprenorphine, to help treat the symptoms of opioid withdrawal such as pain, anxiety, insomnia, and gastrointestinal problems. The Society’s vice president, Kavita Fischer, MD, appeared at a panel discussion earlier this month (below) and defended their position on the grounds that there simply isn’t any evidence to support the claim that medical cannabis offers any additional benefits for OUD patients, challenging her fellow panelists to produce any.

Peter Grinspoon, MD, an internist at the Mass. Gen. Hospital and a lecturer at the Harvard Medical School took exception to Fischer’s position on the lack of evidence, putting it this way:

How can you ignore the tens of millions of people that are actually using it for chronic pain with good benefit. Why would they be making it up? For example, people with fibromyalgia, half of them use cannabis; multiple sclerosis, half of them use cannabis; people with breast cancer, 2/3 of them are using it. Why would they make this up? How can you not consider this evidence? I don’t get that – [what you’re saying is] let’s not listen to patients!

Grinspoon went on to say that medical cannabis is clearly having a huge impact on the opiate crisis. Because as a doctor he can offer cannabis instead of opiates to treat chronic pain. He can use it to lessen their dosage of opiates because opiates and cannabis work well together, synergistically. And that matters, he says, because a lot of the problems you get into with opiates – addiction – is dose related. And, he stressed, as anybody who is withdrawing from opiates or trying to get off them will confirm, cannabis is “extremely effective” (his emphasis) for the symptoms of opiate withdrawal: “there is nothing, no medicine, that’s as effective for opiate withdrawal,” Grinspoon says.

The final panelist, Shalawn James, a member of the Pennsylvania Medical Marijuana Advisory Board, agreed with Grinspoon, also arguing that patient experience has to count for something:

Medical marijuana is not something people have to take. It is an option. And people are flocking to that option. So that has to mean something. People aren’t making up that they’re having pain, and now they’re saying they’re not having pain. People aren’t making up the fact that they weren’t able to go to work before and now they’re able to go to work. …

We also know that people are sufferg, people are begging for alternatives, and the reality … is that people are dying in the streets from opioids. I can’t tell you of one case where someone has said, I OD’d on medical marijuana.

Fischer’s response was that this is all anecdotal evidence, “the lowest form of evidence that exists, unfortunately.” She wants randomized controlled trials.

Which didn’t sit well with Grinspoon who pointed out that there are different types of evidence. For example, real world evidence, where you actually listen to what patients have to say. Which, in Grinspoon’s experience, is this: “Thousands of patients have said cannabis has saved my life from opiates.”  

The law defines evidence as anything that tends to prove or disprove a material fact. The material fact in question is whether medical cannabis helps treat opioid addiction. What Peter Grinspoon and Shawlan James are saying is that the “Thousands of patients” who’ve said medical cannabis has saved them from opiates, coupled with the “tens of millions of people that are actually using it for chronic pain,” tends to prove that medical cannabis is a helpful therapeutic – so Pa. is right to allow it to be used to treat OUD. Kavita Fischer believes that what patients say and do proves no such thing – so Pa. ought to strike OUD from the list of conditions eligible for medical cannabis treatment.

Which side is right?

(The early research sides with Grinspoon & James.)

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