Canada is in the midst of an opioid addiction crisis, in part created from the good intentions of our modern-day healthcare system. Approximately 20 per cent of Canadians experience chronic pain, and healthcare providers are tasked with providing pharmacological and non-pharmacological interventions to manage this disease.
Chronic pain is estimated to cost the economy $6 billion dollars per year in direct healthcare costs and up to $37 billion dollars per year in job productivity costs related to job loss and sick days. Unfortunately, the options for management of chronic pain are limited and healthcare providers are often defaulted to prescribing opioids for long-term use. This has inevitably lead to higher rates of addiction to opioids and the crisis we are in today.
More recently there have been a number of efforts to decrease harm to opioid users including needle exchange programs and more access to naltrexone as a life-saving measure to reverse the effects of overdose, all with the goal to prevent unnecessary deaths. However, we still need to identify alternative preventative measures in order for healthcare providers to reduce prescribing opioids for long-term use. One of the potential alternatives for pain management is medical cannabis. While there has largely been a lack of definitive research done on the issue, there has been a lot of anecdotal evidence and research showing its efficacy in managing pain.
Medical cannabis has a long-standing reputation of being a useful tool in the management of chronic pain. Physicians and researchers across the country are beginning to draw conclusions that dried cannabis use can help reduce pain intensity. However, there is a lack of clinical research looking specifically at the effectiveness of medical cannabis as a substitute for opioids in chronic pain. As one physician puts it, “Many of the patients that seek treatment through the [addictions medicine] program use Cannabis on their own for a variety of reasons including aiding with the tapering process, it is worth investigating this anecdote from a research perspective now.”
Many Canadians are turning to medical cannabis for their pain management. Physician survey results from 2016 indicate that chronic pain comprised 79 per cent of prescriptions for medical cannabis in Canada. Many patients report being able to significantly reduce or discontinue their opioid usage using cannabis to manage their pain symptoms. However, medical cannabis is far from being a first-line pharmacological option as it has no Drug Identification Number, which precludes it from insurance coverage and forces patients to pay out of pocket. This also holds true for many non-pharmacological treatment options for pain, forcing patients to use opioids as a viable treatment option.
Table 1 Costs of opioids versus cannabis:
|Drug name||Cost (CAN)
|Dosage||Route||Average use per/day||Cost /day|
|Oxycodone||$60.14/120 tabs||5 mg||PO||15 mg||1.50|
|Tramadol||$110.62/120 tabs||50 mg||PO||150 mg||2.76|
|Fentanyl||$35.77/5 patches||25mcg/hr||Transdermal||25 mcg Q 72 hrs||7.15|
|Hydromorphone||$17.52/30 tabs||2 mg||PO||24 mg||7.00|
|Methadone||—||10 mg/mL||PO||30 mg||7.00|
|Morphine||$64.20/120 tabs||15 mg||PO||45 mg||1.60|
|Cannabis||$8.00/Gram||—||Dry bud||0.7 gram/day||5.60|
|Cannabis||$100/50 mL||—||Oil||2 mL/day||4.00|
Although, using prescription drugs such as opioids is less expensive in comparison to medical cannabis for direct medication costs, there are other things to consider from a harm reduction paradigm. The side effect profile for medical cannabis is better than that of opioids, especially as it relates to overdose and death. Unlike opioids, which caused an estimated 2,458 overdose deaths in Canada in 2016, cannabis has had no reported overdoses. This difference in these numbers may be linked directly to a biological explanation. Particularly, the regions of the brain in which opioids may act (respiratory centres of the brainstem), can cause fatal respiratory depression when overstimulated. Cannabinoids, the main active ingredient in medical cannabis, do not appear to have the same effect on respiration. Additionally, route of administration of medical cannabis does not carry the same high risks of infectious diseases related to needle sharing, as seen in those who abuse and misuse opioid drugs.
Table 2 Side effects of Opioids versus Cannabis
|Impaired short-term memory|
|Feelings of panic|
As medical cannabis has been shown to be a strong contender for the management of chronic pain, it is important to assess whether medical cannabis can be a potential option as a substitution for opioids, given its safety profile and emerging evidence of its efficacy. The National Institutes of Health in the United States has taken the initiative to fund a five-year $3.8 million dollar grant studying whether medical cannabis reduces opioid use among adults with chronic pain. If Canada is going to take its opioid crisis seriously, it should follow suit to examine and study cannabis in a similar long-term study.
Authors: Chirag Dave, director of clinical affairs at TerrAscend; Jason Moreau, scientific advisor at Canadian Institute for Medical Advancement; and Sabrina Ramkellawan, president/co-founder at Canadian Institute for Medical Advancement