Ask the Expert: Treating Drug Addiction

Q: What evidence is there that cannabis can benefit my patients addicted to illicitly sourced and prescription opioids, and what specific recommendations can I make to patients to help them minimize and/or completely stop use of these dangerous and addictive substances?

A: Addiction is defined as a chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. It’s primarily considered a brain disorder because it involves functional changes to brain circuits associated with reward, stress, and self-control—changes that may last a long time after a person has stopped taking drugs.1 Addiction is similar to other diseases, such as lung disease; both disrupt the normal, healthy functioning of an organ in the body, have serious harmful effects, and, in many cases, may be preventable and treatable. If left untreated, they can last a lifetime and may even lead to death.  

According to the Centers for Disease Control and Prevention (CDC) and the National Center for Health Services, illicit drug use by persons aged 12 years and older was 11.2% during a study month in 2017, while nonmedical use of a psychotherapeutic was 2.2%.2 In 2018, the age-adjusted rate of drug overdose deaths in the United States was 4.6% lower than the that in 2017; however, the rate of drug overdose deaths involving synthetic opioids increased from 9% in 2017 to 9.9% in 2018.3 Specifically, drug overdose deaths involving any opioid, prescription opioids, other synthetic opioids, and heroin rose from 18,515 deaths in 2007 to 47,600 deaths in 2017 before slightly declining to 46,802 in 2018. More than 68% of deaths occurred among males.4

Traditional Treatment for Drug Addiction
Treatment for drug addiction is complex because addiction is a chronic disease. Effective treatment must address all patients’ needs, and not only their drug use/abuse. Many believe the simple cure is stopping the drug, but all too often, stopping an addictive drug is extremely difficult for most patients. When patients are able to stop taking the drug, continued therapy (drug and behavioral) is often necessary to prevent a relapse. No single treatment is right for everyone. Drug addiction treatment includes behavioral counseling, medications, and medical devices to treat withdrawal symptoms. Treatment may also include ongoing evaluation by a mental health professional and long-term follow-up to prevent relapse. Follow-up care may include community- or family-based recovery support systems.

The first step in this long process is detoxification. Various drugs and devices can be used to help reduce withdrawal symptoms. In 2017, the FDA granted a new indication to an electronic stimulation device called the NSS-2 Bridge for helping to reduce opioid withdrawal symptoms.5 This device is placed behind the ear and sends electrical pulses to stimulate certain cranial nerves. In 2018, the FDA approved lofexidine, a non-opioid medicine designed to reduce opioid withdrawal symptoms. Reestablishing normal brain function and decreasing cravings are the hallmarks of medication therapy. Methadone, buprenorphine, and naltrexone are common medications used for opioid addiction. Although the focus of this article is on the use of cannabis for opioid addiction, it’s common for patients to abuse more than one addictive substance. In addition, co-occurring conditions of depression or anxiety often may contribute to addiction.

Other treatment options include behavioral therapy that’s intended to help patients modify their attitudes and behaviors related to drug use, increase healthy life skills, and persist with other forms of treatment, such as drug therapy. There are many outpatient behavioral treatment options such as cognitive behavioral therapy that help patients recognize, avoid, and cope with the situations in which they’re most likely to use abusive drugs. Other outpatient options include multidimensional family therapy, motivational interviewing, and motivational incentives. Inpatient or residential treatment options encompass the use of licensed residential treatment facilities offering 24-hour structured and intensive care programs.

Drug abuse changes the function of the brain, and many things can trigger drug cravings within the brain. Treatment options are intended to help the patient learn how to recognize, avoid, and cope with the triggers they are likely to be exposed to during and after treatment.6

There exists the possibility of addiction with cannabis. However, when cannabis addiction is compared with addiction to other substances, a significant difference in dependence and withdrawal has been observed. According to the CDC, 1 in 10 Americans who use cannabis will become addicted. This number increases to 1 in 6 if cannabis use begins before age 18. Regular users of cannabis may experience addiction and withdrawal symptoms that include difficulty sleeping, mood swings, sleep disturbances, diminished appetite, irritability, loss of focus, cravings for cannabis, sweating including cold sweats, chills, depression, and stomach problems. These symptoms typically range from mild to moderate, aren’t likely to be severe, and can vary from person to person. The longer cannabis is used, the greater likelihood of experiencing withdrawal symptoms. In contrast, cannabis withdrawal symptoms may not be as severe as the withdrawal symptoms from other substances.

Opioids, cocaine, alcohol, and heroin can produce severe and dangerous withdrawal symptoms and even death. Cannabinoid receptors are not densely packed in the medulla (within the brain stem), which controls breathing and the cardiovascular system. Conversely, receptors for opioids and other narcotics are abundant in this region of the brain. This is why a heroin or opioid overdose can be fatal; prescription and nonprescription narcotics can shut down the respiratory control center. In contrast, no fatal cannabis overdoses have ever been documented in humans.7

Cannabis in the Treatment of Addiction
The legal cannabis industry is still in its infancy in Illinois, but Daniel Hostetler, executive director at Above and Beyond, a behavioral outpatient addiction treatment center on Chicago’s west side, has seen a growing number of patients who’ve gotten relief from their addictions with the use of recreational cannabis. They’ve told him that their compulsive, chronic, physiological, and psychological need to abuse alcohol or other addictive substances in compulsive, self-harmful ways has been mitigated, even to the point of being neutralized for some, by the calming effects of cannabis—a substance that can itself be abused.

Not only does cannabis appear to diminish the common withdrawal symptoms—anxiety, irritability, tremors, and nausea—but it often allows individuals to make it all the way through withdrawal to their goal of abstinence with the guided use of cannabis.8

Cannabis for Opioid Addiction and Withdrawal
Incorporating cannabis into a patient’s treatment regimen for opioid addiction often produces promising results, including pain relief and reduction or complete elimination of opioid use. According to the hands-on experience and research done by Dustin Sulak, DO, it’s common to see a significant decrease in pain and reduction and/or elimination of opioids of up to ~40% in most patients. In addition, improvement in quality of life as defined by improved day-to-day functioning is possible in up to 80% to 90% of patients that properly incorporate cannabis into their treatment.9

Cannabis may also enhance the pain relief effects of opioids. The therapeutic window (effective vs lethal dose) for opioids widens (ie, smaller doses of opioids are needed for relief) when cannabis is taken simultaneously.

Cannabis may relieve the symptoms of opioid withdrawal as well. It’s generally safer than other medication treatment options such as methadone and suboxone. There’s no risk of a fatal overdose with cannabis, and it carries much lower risk of dependence. In fact, studies have shown that cannabis users tend to be more successful at adhering to other forms of opioid addiction treatment.9,10

Cannabis Use Guidelines and Recommendations
There are various approaches to helping patients use cannabis for drug addiction therapy. One method is recommending a low dose of cannabis with every dose of opioids. The starting and maintenance dose range is dependent on several factors—the patient’s age, current and past use of cannabis, comfort level of using cannabis, severity of condition, and comorbidities. The dose of THC should receive careful attention due to its intoxicating effects. Compared with THC, CBD hasn’t traditionally caused intoxication and therefore can be dosed more liberally. But it’s always best to recommend the lowest effective dose of both THC and CBD to help the patient avoid building tolerance to each of these medicinally beneficial components of the cannabis plant.

The route of administration is also important. For longer-acting effects, oral delivery via a tincture or oil taken sublingually or an edible or capsule swallowed and absorbed into the intestine is optimal. Inhaled cannabis should only be used to reduce cravings and for breakthrough symptoms such as severe pain, panic attacks, and withdrawal symptoms. During the COVID-19 pandemic, inhaling cannabis through combustion or vaporization isn’t recommended unless absolutely necessary.

According to Sulak, cannabis can be taken three to four times a day or with every dose of an opioid drug. It’s suggested that a ratio of CBD:THC be in the 1:1 range to first test and understand how well the patient tolerates and benefits from medical cannabis. If a patient is hypersensitive to the effects of THC, recommend a ratio of 4:1 CBD to THC. The suggested starting dose can be 1 mg of CBD to 1 mg of THC. This dose will likely be too low to have a noticeable effect for many patients, but some do report benefits. After the starting dose, increase the THC dose by 1 to 2 mg three to four times a day, and continue to increase the CBD and THC doses to equal degrees. Most patients achieve good results at 2 to 15 mg of THC and CBD per dose. Once the pain-reducing effects of opioids last longer or the patients take fewer opioids overall, they’ve reached the effective or optimal dose. The optimal dose has been exceeded if there are fewer beneficial effects or there’s an increase in unwanted side effects. Many patients can decrease their opioid dosage by 50% to 70% in the first two weeks of achieving an optimal dose of cannabis.

There may be situations in which a patient doesn’t derive benefit from this conservative dosing protocol. For those individuals, after 30 days, start increasing the dose to 20 mg of THC three times a day and gradually increase to 100 to 500 mg THC per dose over one to four weeks. It’s very important to use gradual titration to prevent unpleasant side effects of cannabis overconsumption, such as extreme anxiety or panic attacks; psychotic reactions (eg, losing touch with reality, paranoia, hallucinations, delusions, or a loss of personal identity); decreased judgment, perception, and coordination; a fast heart rate; chest pain; uncontrollable shaking or seizures; pale skin color; unresponsiveness; and sudden high blood pressure with headache.

The CDC offers a pocket guide for tapering opioids, which can assist health care professionals with opioid tapering and/or discontinuing.11

— Joseph Friedman, RPh, MBA, is a pharmacist with a master’s degree in business administration and a member of the CRx Advisory Board.

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