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BERNVILLE, Pa. — The back pain started when Luke Shultz was a teenager, and it got worse. When he was in his late 30s, he said, it led him to leave his job as a park ranger with the U.S. Army Corps of Engineers. Around the same time, since it hurt too much to sit for very long, he stopped driving. The family set up a cot in the back of a minivan so he could lie down while someone else drove.

“That really makes it tough,” said Shultz, now 59. “You’re stuck at home and you can’t even go to the grocery store.”

Over the years, the Berks County resident tried different treatments: back braces, surgery, physical therapy, and prescribed opioids and other medication. Eventually, he turned to cannabis and became an advocate for its benefits.

In 2018, as a member of Pennsylvania’s newly formed Medical Marijuana Advisory Board, he helped push the state Department of Health to expand the list of serious medical conditions that makes someone eligible for cannabis to include opioid use disorder.

He and some other members of the panel saw the expansion as one more way for Pennsylvania — which has one of the highest drug overdose death rates in the country — to respond to the opioid epidemic.

“Cannabis can offer pain relief and has been reported by patients to ease the symptoms and process of opioid withdrawal,” the advisory board said in an April 2018 report. “It has been used by patients as an ‘exit drug’ to get off of heroin and other opiates.”

State officials accepted the recommendation, and at the time, Gov. Tom Wolf’s administration said Pennsylvania was the first state to take such action.

More than three years later, Pennsylvania remains an outlier in its approach. The Department of Health allows doctors to approve cannabis as a supplement to conventional opioid use disorder therapies, such as buprenorphine and methadone, which are approved by the federal government and studies have found to be highly effective.

But there’s a potentially riskier scenario: Physicians can also approve cannabis if those conventional therapies are “contraindicated,” a medical term generally meaning they could be risky, or “ineffective.” Treating patients that way raises concerns even among some medical professionals who see cannabis as relatively safe.

How many of the state’s roughly 550,000 registered cannabis patients use marijuana for opioid use disorder is not publicly known. The Health Department would not provide that information to Spotlight PA, despite the state previously making similar statistics public in early 2020.

In a presentation made at a Medical Marijuana Advisory Board meeting, one of the slides said 3% of patients listed opioid use disorder as their primary medical condition, making it the sixth most popular choice.

One of the main reasons former state Health Secretary Rachel Levine approved opioid use disorder as a qualifying condition was so eight medical schools could study cannabis’ impact on it. The program, which the department said is the first of its kind, is supposed to fill critical information gaps.

But that kind of rigorous research can often stretch for many years, and the state’s research program hit some early challenges, including a lawsuit filed by a group of medical marijuana companies. The department denied Spotlight PA’s public records request seeking information on ongoing studies, and none of the eight medical schools provided findings related to opioid use disorder from their research programs.

The policy has met fierce resistance from some medical groups, who warn that the state’s endorsement of cannabis could lead patients to pass over proven medications.

The American Society of Addiction Medicine tells health care professionals not to recommend cannabis for the treatment of opioid use disorder and urges those professionals to use “great caution” when recommending it for any reason to someone who has a substance use disorder.

In a 2019 petition urging the state to reverse its decision, the Pennsylvania Psychiatric Society’s then-president, Dr. M. Ahmad Hameed, wrote that patients should “not be given sham treatments or those which might worsen their addiction.” Group leaders echoed those concerns again in April 2021, writing that the state already has “many effective treatments which may be ignored based on the commonwealth’s endorsement of a regimen unsupported by science.”

The Wolf administration has stood by its decision to add opioid use disorder to the list of qualifying conditions.

“Every individual is different and should work with their doctor to create and implement a treatment plan that meets their needs,” Health Department spokesperson Maggi Barton said in an email.

Complicating the situation is the ongoing conflict between the state and federal governments. While Pennsylvania endorses cannabis for treating opioid use disorder, the federal government has discouraged it.

In at least one case, as Spotlight PA reported in June, failure by the state to clarify federal rules had serious consequences: A Bucks County man was wrongly denied addiction treatment funding because of his medical marijuana card and soon after died of an overdose.

In the absence of the kind of proof that exists for federally approved medications, there are patients who say their lives have been transformed by cannabis.

Shultz is now certified to use marijuana for both pain and opioid use disorder. He’s been able to drastically reduce the number of opioids he takes to about one Percocet tablet daily, he said. With the pain he has now, Shultz can drive about 20 minutes on a good day.

“I don’t have the science to back it up. I typically go by anecdotal evidence — myself included — that basically for real people it’s had real, positive effects,” Shultz said. “Hopefully, at some point, the science will show that.”

Chris Braddock, a 37-year-old house painter from Washington County, said he struggled with opioid addiction for several years, going through periods of using traditional treatment options. But he said he couldn’t break a cycle of relapsing until he received approval for cannabis almost three years ago.

“I see how it works on me and people I know. I mean, that’s all the scientific evidence I need,” Braddock said. “I’m content. I’m happy. My life is good.”

Dr. Peter Grinspoon — an instructor at Harvard Medical School and a board member of Doctors for Cannabis Regulation, a group that supports cannabis legalization for adults — said he’s heard a lot of anecdotal evidence like Braddock’s. But he said anecdotal evidence has its limits.

If a patient has a headache and wants to try marijuana, Grinspoon said, the worst-case scenario is the cannabis doesn’t work and their migraine sticks around.

“Then we try something else,” said Grinspoon, who has talked publicly about his own experience with opioid addiction and recovery.

But the risk of failure is higher when treating a potentially deadly condition. If a patient were to rely solely on cannabis to treat opioid use disorder, there’s a big fear: They could relapse, overdose on opioids, and die.

The research vacuum

Views on the benefits and potential risks of cannabis use vary among medical professionals. Grinspoon’s position is nuanced.

He believes the drug can have a significant, positive role in responding to the opioid crisis, as patients can use cannabis for chronic pain instead of opioids or to lower the doses of opioids they use. And he supports using cannabis in addition to other treatments, including for treating withdrawal symptoms.

But Grinspoon said he would not recommend patients use cannabis as their primary treatment for opioid use disorder. There’s research showing significantly lower overdose death rates for people who use buprenorphine and methadone, two approved medication-assisted treatments, compared to people who don’t.

“We just don’t have that data yet for cannabis,” Grinspoon said.

Shalawn James, a prominent mental health advocate, is one of the state’s advisory board members who supported adding opioid use disorder. James said a chronic illness led her son to use prescribed opioids, and she was alarmed to see his tolerance increase.

She saw the addition of opioid use disorder as a qualifying condition as one more way to give patients options.

Still, she said it wasn’t an easy vote.

“I think with all of the votes, we want to see the research,” James said, but “a lot of the research that could happen doesn’t happen because of the federal restraints.”

The U.S. Drug Enforcement Administration classifies cannabis as a Schedule I drug — a category that includes heroin, ecstasy, and LSD. The designation means the agency considers cannabis to have no currently accepted medical use and a high potential for abuse.

“It’s a catch-22,” said Shultz, the advisory board member from Berks County. “There’s not enough research to show the value of medical marijuana, but yet it’s almost impossible to do the research properly.”

He said the research he found primarily dealt with cannabis being used for pain control as a substitute for prescribed medicine, but he said the studies didn’t directly support using marijuana to suppress a person’s addiction to opioids. He advocated for the addition anyway.

The health secretary conducted her own review, and the department provided a list of studies and articles in response to Spotlight PA’s public records request for resources that informed the agency’s decision.

The department’s press office declined to say how the materials supported or informed the decision. Some of the articles directly acknowledged the complexity of the issue.

In a 2017 article, neuroscientist Yasmin Hurd wrote that one of the compounds of cannabis, THC, “is not a suitable treatment option, given that it can even enhance opioid reward self-administration and induce other psychopathologies,” but there was a strong scientific basis for considering another compound, CBD.

Since then, Hurd’s research has continued to find CBD has potential medical benefits but, she said in 2020, the only way to get definitive information on its full safety and efficacy is through large, clinical trials.

Hurd, director of the Addiction Institute of Mount Sinai in New York, told Spotlight PA there is not adequate data to support the position that cannabis is effective for treating opioid use disorder, even when used alongside other medications. She hopes researchers can find alternative medications to help with opioid use disorder, but she’s cautious.

“We all would love for this to be true, but that has not been proven,” Hurd said.

At Thomas Jefferson University in Philadelphia, Dr. Brooke Worster said researchers don’t know enough about cannabis to recommend it as a replacement for the conventional treatments that exist for substance use disorder. She’s leading efforts to learn more as part of Pennsylvania’s research program.

The university has nearly completed a study that followed about 215 Pennsylvanians over the course of a year, assessing the type of cannabis they were using and its impact on quality of life and various symptoms.

Her team is now recruiting people who use opioids for chronic pain or have opioid use disorder for another study. Researchers will collect daily data on people’s pain levels, cravings, cannabis use, and opioid use after being exposed to three different cannabis formulations.

Worster said she understands objections to placing opioid use disorder on the list of qualifying conditions in Pennsylvania, but many people with addiction were already using marijuana — regardless of whether policymakers acknowledged it.

Medical professionals can choose to study the good and the bad, “or we can continue not to — and sort of pretend it’s not happening or not acknowledge that it’s happening,” Worster said. “And then it’ll just keep happening. Right? Because cannabis isn’t going away.”

‘This has saved my life’

Since Pennsylvania added opioid use disorder to its list of qualifying conditions, officials in New York, New Jersey, and New Mexico have taken similar steps.

Some states, including Maryland, give health-care practitioners greater discretion to decide when cannabis is OK for patients, including for addiction treatment. Still, the Maryland Medical Cannabis Commission in 2019 warned against adding opioid use disorder to its list, saying that doing so without substantial clinical research “presents significant public health and safety concerns.”

In Pennsylvania, more than 1,300 physicians were authorized to certify patients for cannabis as of 2020, the Department of Health said in a report. Currently, a few dozen are described as addiction specialists in a public list maintained by the agency

Spotlight PA spoke to seven doctors, including four in Pennsylvania, who said they approve cannabis for patients with opioid addiction. Their experiences and views varied, but several emphasized that cannabis is just one part of someone’s treatment, along with counseling and social support programs.

Some made distinctions between treating opioid use disorder itself and treating related problems, like anxiety or insomnia. They acknowledged the limited research but argued for the importance of doctors using their own clinical judgment.

In Blair County, Dr. Lawrence Levinson runs a small clinic specializing in opioid use disorder. He treats patients with Suboxone — a combination of the opioid medication buprenorphine and overdose-reversing drug naloxone — and he also certifies people to use cannabis.

The vast majority of his patients became addicted to opioids because of underlying pain, Levinson said. He said he’s “extremely hesitant” to certify patients for cannabis who became addicted to opioids through recreational use.

Over the last few years, he’s come to see more benefits to cannabis. “I hear continuously, ‘This has saved my life,’” Levinson said.

Dr. James Latronica in Allegheny County, listed in the state’s medical marijuana directory as an addiction specialist, told Spotlight PA he would not recommend cannabis to treat an opioid use disorder for any reason. He sees some potential benefits, but worries about the lack of control he would have over his patients’ marijuana use.

Patients, like 36-year-old Michael Silver from Chester County, are figuring out their own approaches. Silver said his opioid addiction started when he got his wisdom teeth removed as a teenager.

“That was the first time I had ever taken an opioid,” Silver said. “And I just immediately fell in love.”

Pain pills led to heroin and fentanyl. He overdosed in late 2017, was revived, and went to rehab. He was prescribed Suboxone, and it worked for a while. But he relapsed near the end of 2018 and went back to rehab in the spring of 2019.

Silver had trouble sleeping after leaving rehab and smoked cannabis for relief. When he went to a doctor for Vivitrol, another federally approved treatment option, the cannabis showed up during a drug test. Silver’s doctor told him if cannabis was helping, he could keep taking it.

Silver has been certified for cannabis for opioid use disorder since then. He uses it as needed —when he’s feeling anxious or having trouble sleeping — along with a monthly Vivitrol injection.

“For me,” he said, “the combination of the two has just been a godsend.”

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