Cannabinoids for the Treatment of Opioid Use Disorder
1 For 1–3 However, a subsequent study that The authors noted that although the 1 As such, using population-level studies 6 5 Indeed, there are other population-level studies 4 A recent meta-analysis of 23 studies of patients in There have been no prospective clinical trials of canna- The evidence cited for the potential benefits of cannabis example, Bachhuber andenacted colleagues medical marijuana foundenced laws that fewer from fatal opioid states 1999 overdoses comparednot to that to states 2010 enact that experi- did such laws. as justification toevidence-based place treatments cannabis fortheir in OUD families the will the false sameproducts give impression are patients category that indeed and as cannabis effective treatments and for related OUD. methadone maintenance treatment compared outcomes (reten- tion and nonprescribed opioid use)did among not those who use did cannabis. and medications for OUD (MOUD). bis or cannabinoids forcompare the such treatment compounds of to OUD,norphine. existing nor The MOUD potential trials for such that harm asuse from bupre- both of acute and cannabinoids chronic has been well-described, yet is often overall quality ofbiased the due evidence to wasresults the low suggested that observational and cannabis nature quite usecomes overall. of A did possibly sub-group analysis not most of studies affect conducted studies,US in patient the showed out- the an inverse relationshiptreatment retention, between whereas the cannabis association was use in the and direction opposite for studies in Israel. Unfortunately, it remains difficult to know how to interpretlargely these defined findings. The cannabis includedtoxicology studies testing use results. In through evaluating the impacton patient of OUD cannabis self-report outcomes, however, or additionalmation pharmacologic would infor- be needed. Given the complexityplant of and the cannabis its constituents, researchers wouldonly need the to dosage know used, not butextract), also constituents (% the tetrahydrocannabinol form and cannabidiol of cannabis[CBD]), (flower route vs of administration (oral vs smoked),use frequency of (daily vs intermittent), andvs indication for medical). use (recreational Inexisting addition, clinic studies policies that would explicitlypermit need or to implicitly the prohibit account use or for of cannabis for patients being treated with examined the same datafurther out used to 2017 by found that Bachhubermarijuana the association and between laws medical colleagues anddirection. opioid overdoses actually reversed in to treat OUD generallyshowing come an inverse from association population-level between research enactmentmarijuana of laws medical and opioid-related adverse outcomes. that indicate cannabis usedeveloping is an OUD. associated with a higher risk of OMMENTARY C JAM-D-20-00267 Where is the Evidence? Joji Suzuki, MD and Roger D. Weiss, MD Volume 00, Number 00, Month/Month 2020 2020;xx: xxx–xxx) cannabinoids, cannabis, opioid use disorder 2020 American Society of Addiction Medicine ß Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction of this article is prohibited. Copyright © 2020 American Society of Addiction Medicine. Unauthorized reproduction peutic benefits of cannabis and cannabinoids in the here is a growing public interest in the potential thera- M-D-20-00267; Total nos of Pages: 2; Drug and Alcohol Abuse, McLean Hospital, Belmont, MA (RDW). K23DA042326 (JS), 2UG1DA015831 (RDW)]. Therapeutics, Astellas Pharmaceuticals, and Analgesic Solutions. Fenwood Rd, Boston, MA 02115. E-mail: [email protected] MA (JS); Harvard Medical School, Boston, MA (JS, RDW); Division of A Cannabinoids for the Treatment of Opioid Use Disorder: J Addict Med weak evidence andeschew evidence-based and could potentially life-saving encouragein treatments favor those of the with hoped-for OUD benefits of to cannabis. treatment of opioidgrown use to disorder suchadded an (OUD). or extent The proposed thatstate’s interest medical to some marijuana has add program, states givingcannabis OUD have an may impression as now that be an either aoptions indication suitable for alternative for OUD. to their existing However, treatment these initiatives are based on J Addict Med Received for publication JuneThis 26, work 2020; was accepted June supported 27, by 2020. NationalRoger Institutes D. of Weiss Health served as [grant a numbers consultantSend to correspondence Takeda to Joji Pharmaceuticals, Suzuki, Cerevel MD, Brigham and Women’s Hospital, 60 Copyright From the Department of Psychiatry, Brigham and Women’s Hospital, Boston, T from portraying cannabis and cannabinoidsments as evidence-based for treat- OUD. Key Words: ( cations for OUD,comes interventions are that especially needed. further Theof improve potential cannabis and therapeutic clinical cannabinoids applications in out- thefurther treatment study, of but OUD it are should worthy beexpect of conducted of with all the pharmaceutical same products. rigorto that Until show we we their have more efficacy, research policy makers and clinicians should refrain as an indication forever, their these initiatives state’s are medical based on marijuana weaknot program. evidence which support How- at the present listing do of cannabisOUD. or Nevertheless, cannabinoids as studying a the treatmentof potential for carefully therapeutic chosen applications components of cannabisspecific or aspects cannabinoids of to treat OUDhigh is rates not of without treatment scientific discontinuation merit. among Given the those taking medi- With the growing public interest inof the cannabis potential and therapeutic cannabinoids benefits in the(OUD), treatment some of states opioid have use now disorder either added or proposed to add OUD ISSN: 1932-0620/16/0000-0001 DOI: 10.1097/ADM.0000000000000711 DM/J A CE: ; Downloaded from http://journals.lww.com/journaladdictionmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/17/2020 Downloaded from http://journals.lww.com/journaladdictionmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/17/2020 CE: ; ADM/JAM-D-20-00267; Total nos of Pages: 2; JAM-D-20-00267
Suzuki and Weiss J Addict Med Volume 00, Number 00, Month/Month 2020
ignored or minimized in the current climate of permitting also be studied to facilitate difficult buprenorphine induc- greater access to cannabis.7,8 As clinicians and researchers, tions.15 Additionally, CB1 agonists could be studied as adjuncts we need to follow the science; there are no data at present to to ease opioid withdrawal for patients attempting to taper off support the listing by some states of cannabis or cannabinoids MOUD or patients with chronic pain who are tapering off of as a treatment for OUD, and we therefore strongly agree with opioid analgesics. It is also possible that adjunctive CBD may those who have argued against recommending cannabis or aid in preventing relapse to opioid use by attenuating the cannabinoids as a substitute to existing MOUD options.9 response to environmental cues and stressors among individu- Nevertheless, studying the potential therapeutic applica- als already taking MOUD. Given the high rates of treatment tions of carefully chosen components of cannabis or cannabinoids discontinuation of MOUD, pharmacologic treatments that help to treat specific aspects of OUD are not without scientific merit. patients to initiate MOUD, remain in treatment for longer Although only a few controlled studies utilizing pharmaceutical durations, and prevent relapse are especially needed. cannabinoids in humans with OUD have been conducted, results In the context of the growing opioid crisis, research to of these trials have been informative. Two placebo-controlled improve treatment outcomes among those already taking randomized clinical trials of the synthetic tetrahydrocannabinol MOUD is critically needed. The potential therapeutic appli- dronabinol have shown modest reduction in opioid withdrawal cations of cannabis and cannabinoids in the treatment of OUD symptoms compared to placebo among individuals with is worthy of further study, but it should be conducted with the OUD.10,11 In the study by Lofwall and colleagues, after abrupt same rigor that we expect of all pharmaceutical products. cessation of an opioid, dronabinol 20 mg and 30 mg provided Until we have more research to show their efficacy, policy modest suppression of opioid withdrawal compared to placebo, makers and clinicians should refrain from portraying cannabis although it was accompanied by adverse effects including tachy- and cannabinoids as evidence-based treatments for OUD. cardia and subjective highs. Bisaga and colleagues compared dronabinol 30 mg to placebo in individuals with OUD undergoing REFERENCES a rapid buprenorphine detoxification; those receiving dronabinol 1. 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