The opioid crisis in the United States is a national health emergency that should galvanize the nation and its leaders to allocate abundant resources to fund scientifically rigorous research into the nature of substance use disorders, their physiological and medical consequences, and their psychosocial origins.
As the leadership of the nation's only comprehensive academic resource for research, education, and practice regarding medicinal cannabinoids, we read with great interest Lenny Bernstein's Nov. 1 article "White House opioid commission calls for wide-ranging changes to antidrug policies" and wish to comment on the fundamental misunderstandings attributed in the article to the White House Opioid Commission and its chairman, Gov. Christie.
The Commission — which of great concern to us does not list even one physician as a member — declined to endorse the use of medical cannabis for pain. Gov. Christie stated that there is "a lack of sophisticated outcome data on dose, potency, and abuse potential for marijuana."
We fully agree that more research is needed in this area and we are establishing a scientifically sound and feasible series of protocols to provide the data Gov. Christie seeks. Meanwhile, there is already a living laboratory that could potentially provide observational data, as nearly all of the 29 states (plus Washington D.C.) that have adopted medical cannabis laws include chronic pain as an indication for the substance's supervised use.
Anecdotal evidence and several peer-reviewed studies, including some funded by the National Institute on Drug Abuse (NIDA) whose authority Gov. Christie cites, provide evidence that cannabis and cannabinoids can effectively reduce chronic pain and potentially treat some acute pain syndromes. In the face of the opioid epidemic, identifying effective pain-management solutions that extend beyond opioid analgesics should be a clear public-health priority. This message is consistent with that reported on NIDA's public website, which states that "though none of these studies are definitive, they cumulatively suggest that medical marijuana products may have a role in reducing the use of opioids needed to control pain."
Blurring the line between recreational use, substance use disorders, and medicinal applications of cannabis, Gov. Christie also stated that cannabis users were two-and-a-half times more likely to suffer from opioid abuse than nonusers.
The implication is that cannabis is a "gateway drug" to opioid-use disorder, meaning cannabis use directly causes problematic opioid use. In fact, the progression of drug use, especially among adolescents, is not this well-characterized or straightforward. Most users of illicit drugs begin experimenting with tobacco, alcohol, and cannabis because generally they are more available and culturally acceptable than others. Some of these users then progress to opioids (including heroin), cocaine, and other illegal substances. In this regard, it is incorrect to isolate cannabis as the sole gateway substance.
More importantly, the fact that cannabis use may be correlated with future drug use does not prove that it causes that use; the studies necessary to make this claim have not been done. Efforts to dispel this myth date back as far as 1999, when the Institute of Medicine stated "there is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs."
Our Center has no advocacy mission regarding cannabis other than advocating for better science and better education. The controlled trials that are necessary to determine whether combining cannabinoids with opioids can reduce the amount of opioids necessary to manage pain have not yet been completed. We call on the Opioid Commission to financially support the type of well-designed, large studies that will be needed to explore this biologically plausible approach to the opioid crisis.
Substance-use disorders and its causes are complex. Pain management is often challenging for physicians and their patients because of the delicate balance that often exists between effectively managing pain while reducing the risk for developing problems with opioids. The recent shift in societal acceptance of medicinal cannabis indicates the public is interested in alternative pain-management products, and there is much yet to be learned about the use of medicinal cannabinoids (whether derived from cannabis or hemp) in the management of both acute and chronic pain.
We argue that Gov. Christie's comments related to cannabis were misguided and can result in the unintended consequence of suppressing this important area of research. We believe rigorous basic science and clinical studies are necessary to determine best practices and that a national commitment to serious academic research regarding medicinal cannabis can help us solve the opioid epidemic.
From The Lambert Center for the Study of Medicinal Cannabis and Hemp at Thomas Jefferson University.
Charles V. Pollack, Jr., MA, MD, Director; Philadelphia, PA
Donald I. Abrams, MD, Steering Committee Member; San Francisco, CA
Richard Dart, MD, PhD, Steering Committee Member; Denver, CO
Mahmoud ElSohly, PhD, Steering Committee Member; Oxford, MS
Marcel Bonn-Miller, PhD, Steering Committee Member; Devon, PA
David Casarett, MD, MA, Steering Committee Member, Durham, NC
Larry I. Good, MD, Steering Committee Member; New York, NY
Manuel Guzman, PhD, Steering Committee Member; Madrid, Spain
Lumir Hanus, PhD, Steering Committee Member, Jerusalem, Israel
Kevin Hill, MD, Steering Committee Member; Boston, MA
Marilyn Huestis, PhD, Steering Committee Member; Annapolis, MD
Zoe Selzer-McKinley, ESII Director, Lambert Center; Philadelphia, PA
Susan Sisley, MD, Steering Committee Member; Pueblo, CO
Nancy Skinner, RN-BC, CCM, ACM-RN, CMCN, Steering Committee Member; Whitwell, TN
Lindy L. Snider, Chair, ESII Board of Advisors, Lambert Center; Philadelphia, PA
Judith Spahr, MPH, MLS, MEd, Administrative Director; Philadelphia, PA
Ryan Vandrey, PhD, Steering Committee Member; Baltimore, MD
Eugene Viscusi, MD, Steering Committee Member; Philadelphia, PA
Mark A. Ware, MBBS, MSc, Steering Committee Member; Montreal, PQ