As bad as getting off opioids the first time was, nothing prepared Briana Kline for trying to come back from relapse. She was in deep, past the Percocets and other pills. This time it was heroin, even a close brush with fentanyl. But the medicine that so helped slay her cravings before didn't seem to be cutting it.
"The Suboxone didn't make me feel the way it usually does," said Kline, 26, of Lancaster County. "I was struggling a lot with cravings. I'd go a couple of days, be OK. Then I'd go use again."
So her family doctor suggested she give something else a try in addition to opioid-based medication, which is well-proven to offer more lasting recovery than abstinence alone.
"That's when he started talking about medical marijuana," said Kline, a pizza-delivery driver with two young children. "I was like, 'Definitely. Let's give it a shot.' "
In an opioid epidemic that is killing tens of thousands of Americans a year, people like Kline and her doctor Michael Peck are unlikely pioneers in a drug-treatment experiment. Though there's no clear scientific evidence that it will work, supporters say medical marijuana could some day change the way we deal with opioid addiction.
About two months ago, Pennsylvania became the first state to approve medical marijuana as a treatment for opioid use disorder. Doctors with the required credentials can offer medical marijuana to patients when treatments such as abstinence therapy or medication-assisted treatment have failed, or in conjunction with those methods.
The state has tapped eight universities to conduct medical-marijuana research, and hopes opioid use disorder will be among the topics for exploration, said a state Health Department spokeswoman.
Why approve a medical use that is not proven? Because of marijuana's highly restrictive federal drug classification, research into its medical value has been limited. Observational studies suggest that there are fewer opioid-related deaths in states that allow medical marijuana and that fewer opioids are prescribed when medical marijuana is available for pain relief. But whether medical marijuana actually causes those effects hasn't been proven in gold-standard medical studies.
Evidence is even weaker for cannabis to treat opioid addiction. There is anecdotal information about people using marijuana to wean themselves from opioids, ease the misery of withdrawal, or limit their opioid use. Some people report that marijuana relieves aches and anxiety, possibly contributing to opioid abstinence.
Skeptics say much of this is Wild West pharmacology – no real guidelines, let alone standardized dosing, and no real scientific backing.
"We're really in unchartered waters here," acknowledges Peck, who had been prescribing Suboxone, a mixture of the opioid buprenorphine, and the opioid antagonist naloxone, for years before deciding to add cannabis to his therapeutic tools.
"You have critics saying, 'You don't have any data,' " the York County physician said. "No, you don't. But does that mean you don't try?"
No easy answers
Caron Treatment Center, a nationally regarded drug and alcohol rehabilitation program based in Pennsylvania, has urged state Health Secretary Rachel Levine to remove opioid use disorder from the list of conditions that qualify for medical marijuana.
"We should be focusing on proven addiction treatment methods that we know work and have been studied extensively," said Caron medical director Joseph Garbely, "not bringing in another substance that has known and documented addictive qualities and little to no research on its use and efficacy as a medical treatment."
Three medications are federally approved to treat opioid use disorder. Naltrexone blocks the effect of opioids and eases cravings. The two others are opioid-based and have been more thoroughly studied: methadone and buprenorphine, a main component of Suboxone. Without medication-assisted treatment (MAT), the relapse rate 30 days after detox is as high as 90 percent, compared with 50 percent after six months for those who take their medicine and also participate in behavioral therapy, often including 12-step support.
Yet there remains a stigma against treating drug addiction with drugs on the part of some patients, family, and even health-care providers. Less than 30 percent of even those with private insurance who could benefit from MAT get it.
"The problem is not that there's ineffective treatment," said Chinazo Cunningham, an addiction researcher and professor at the Albert Einstein College of Medicine and an internist at the Montefiore Medical Center in the Bronx. "The problem is people are not getting the effective treatment."
Kent Vrana, pharmacology chair at Pennsylvania State University's College of Medicine, said there is no evidence of any danger in combining marijuana and an opioid-based medication. But he doubts that marijuana alone would help much during the intense, early stage of opioid withdrawal.
"There may be a therapeutic benefit in the later stages," he said, "especially when combined with MAT."
Seeking better treatments
But since even the best-chance treatment offers daunting odds, scientists such as Yasmin Hurd, director of the Addiction Institute at Mount Sinai in New York City, are looking for other possibilities.
"Unless a disease is completely cured, I think we should never stop trying to find better and more optimal treatments for people in need. I don't care what disease it is," said Hurd, who is also a professor of psychiatry and neuroscience at Mount Sinai's Icahn School of Medicine. "I don't think we'd say for cancer, 'Oh, we have enough medications out there, so there is no need to keep finding new treatments.' "
Hurd's research centers on cannabidiol, or CBD, a non-intoxicating compound of the marijuana plant, as a potential tool against drug relapse.
Hurd's theory — and she is the first to say it is still a theory — is that opioid-based treatments don't allow the brain to recover from the impact of opioids. She is continuing research on the potential of CBD, a non-addictive component of marijuana, to relieve cravings and anxiety, while allowing the brain to heal from opioid exposure.
But Hurd, like other researchers, said her progress has been slowed by federal restrictions on marijuana. She applauds Pennsylvania's plan to encourage more investigation, and would like to see the same commitment on the federal level.
"Without that, you're still going to have people fighting unnecessarily when we have people dying," Hurd said.
‘A lot more balanced’
In the Pennsylvania heartland, Kline and Peck are making up the rules as they go. For them, that means sticking with a proven course of treatment and trying to make it better.
With Peck's input and guidance, Kline, who still takes Suboxone, has tried various cannabis formulations. The first felt like nothing. The next was all THC, the marijuana component that produces a high. Too strong. For now, she and her doctor have settled on a mix – mostly CBD, with some THC. She vapes it four times a day. It doesn't make her feel high, she says, just better.
"It puts you in a place that's a lot more balanced," said Kline. "It's a lot easier to get through the day and not think about things that you shouldn't."
Kline was about 14 when she started on opioid pills. At 16, a date introduced her to heroin; it was the drug she fell for, not the guy. Other drugs followed. She hopes her trial-and-error experiences with medical marijuana will one day help others.
She said her efforts already have helped her life and that of her two children, Kylie, 4, and Paisley, 11 months. Kylie stopped getting up in the night to look for her mother, or worry about what she's doing behind the bathroom door. Kline herself feels less anxious, more present in the world, instead of trapped in the dark corners of her own head.
"Being able to have a normal day is my best day," Kline said. "Making breakfast and playing, going outside and being able to do the things I always loved to do, but I wasn't able to do for so long.
"A normal day is a good day," she said. "Exactly how it should be."