Legalization of Marijuana: A Valid Alternative For Chronic Pain Management

Recreational marijuana is not legal in New York State, although it is legal in 11 states and Washington, DC. At the time of writing (11/21/2019), there are two bills underway to legalize marijuana on the federal and state levels. New York Congressman Jerry Nadler is proposing to remove marijuana from the federal list of controlled substances, thus decriminalizing it on the national level. This bill would still allow states to have the ability to regulate marijuana independently. In New York State, the Marijuana Regulation and Taxation Act failed to pass this year. Still, the executive and legislative branches are working on concerns regarding the legal process, managing state revenue from sales, and regulations on public safety.

While the goal of the legalization of marijuana may be driven by prospective state revenue from sales, expunge prior convictions for marijuana offenses, and appealing to the shift in public opinion on a Schedule 1 controlled substance --- the most surprising champions of legalization are the medical and law enforcement communities.

Medical Marijuana is gaining support in combating the opioid epidemic in the United States. While there is no solid evidence in medical literature that cannabis can help solve the epidemic, recent research has shown that states that have medical cannabis laws have lowered their opioid overdose rates by almost 25% compared to states without medical cannabis laws (Bachhuber, 2014). The challenge physicians face in chronic pain management is two-fold; responsibly meeting a patient's demand for relief through compassionate care while also monitoring potential prescription abuse.

President Trump declared a public health emergency in October of 2017 to address the opioid epidemic. According to the Centers for Disease Control and Prevention (CDC), more than 140 Americans die every day from an opioid overdose. On the federal level, the president directed agency and department heads to use appropriate emergency authority to combat this statistic. Dr. Jose David is a Clinical Professor at Albany Medical College and Family Physician in the Capital Region. Dr. David speaks to New York State legislatures, physicians, community leaders, and patients as a proponent of medical marijuana as a tool for chronic pain management. "Medical Marijuana is a term that was coined as a phrase that includes a physician prescription of cannabis as a legal product purchased through a state regulate dispensary (David, 2019)." Companies are registered, products are licensed, physicians are certified, and patients are evaluated to obtain a medical card.

The statistics point to that prescription opioids are a gateway drug to heroin as four in five new heroin users started out misusing prescription painkillers (Jones, 2013). Dr. David explained the typical progression from medication to illegal drug addiction due to dependency on pain medication that develops after an unfortunate accident, advancing to an addiction to stronger, more dangerous drugs. "What do you do in a rural town or remote area when there are no pain specialists to give you the right treatment? You resort to buying illicit oxycodone or morphine. When this becomes too expensive, you resort to heroin. And when you resort to heroin, to make the drug more powerful, you add fentanyl to it (David, 2019)."  Fentanyl is a synthetic opioid that is fifty times more potent than heroin and one hundred times more potent than morphine. The facts, sadly, support his example: 94% of respondents in a 2014 survey of people in treatment for opioid addiction said they chose to use heroin because prescription opioids were “far more expensive and harder to obtain" (Cicero, 2014). 

The government is scrambling to address the opioid epidemic through mandatory prescriber education, opioid prescription guidelines, eliminating "pill mills" (physicians who are operating as unscrupulous pain management specialists), prescription drug monitoring programs, increased access to naloxone, and availability of opioid use disorder treatment. Dr. David points to cannabis as a non-opiate medication for chronic pain patients. Twenty-nine states, including New York State, have legalized medical marijuana. The challenge, Dr. David admits, is changing generations of negative sentiment and prohibition of cannabis to see the positive administration of cannabis in where traditional pain therapies fail. "This was the original intent for approving medical marijuana for compassionate care (David, 2019)." In New York State, medical marijuana is approved for conditions related to cancer, HIV/AIDS, ALS, Parkinson's Disease, MS, spinal cord damage, and epilepsy. 

Ironically, legalizing marijuana on the state and federal level offer the best opportunity to expand medical use, while also meeting society benefits and increased state revenue. Legalization will allow for needed clinical research on cannabis applications. Trials and studies would allow for FDA approval, which would allow insurance drug coverage. Currently, Dr. David acknowledges that physicians play a pivotal role in the state's program. "We, as medical providers, should continue to educate our patients and the community. We should be well-versed and serve as a useful resource for alternative therapies available for our patients, including medical marijuana or CBD, especially if the benefits outweigh the risks (David, 2019)."

Sources:

Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010. JAMA Intern Med. 2014;174(10):1668–1673. Retrieved from: https://doi.org/10.1001/jamainternmed.2014.4005

Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. "The changing face of heroin use in the United States: a retrospective analysis of the past 50 years." JAMA Psychiatry. 2014;71(7):821-826. 

David, Jose M. "Pain Management and Medical Marijuana." Presentation. Oct 30, 2017. Retrieved from: https://www.health.ny.gov/commissioner/grand_rounds/pain_management_and_medical_marijuana/docs/david_presentation.pdf

David, Jose M. "Medical Marijuana." HeartTalk presented by Capital Cardiology Associates. Nov 24, 2019. Retrieved from: https://www.iheart.com/podcast/960-heart-talk-on-wgy-29451492/

Jones CM. Heroin. "Use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers - the United States, 2002-2004 and 2008-2010." Drug Alcohol Depend. 2013 Sep 1;132(1-2):95-100. Retrieved at: 10.1016/j.drugalcdep.2013.01.007. Epub 2013 Feb 12.