Marijuana & Opioids

If anyone thinks that the momentum in medical marijuana legalization is not tied to the opioid epidemic, they’ve not been paying attention.

I’ve been engaged in addressing the inappropriate over-prescribing of opioids since 2003. Next week will be the start of my fifth year studying, talking and writing about medical marijuana. So I have a unique perspective borne from years of observation. Early on in that process I believed there was a connection between opioids and marijuana because of conversations I had and stories I read. This was the argument I heard repeatedly from proponents …

Medical marijuana can be a substitute for prescription opioids and is the solution to the opioid epidemic

Elected representatives and non-elected bureaucrats around the country have taken those words seriously. And yesterday, January 23, New Jersey joined that crowd.

Gov. Phil Murphy on Wednesday announced a broad attack on opioid addiction in New Jersey by adding it to the list of illnesses that qualify residents for medical marijuana. “We are pleased to announce that, as of today, opioid use disorder is a condition for which physicians can recommend medical marijuana to patients,” State Health Commissioner Shereef Elnahal said.

To be fair, another part of their strategy to battle the opioid epidemic includes expanding Medicaid coverage for medication-assisted treatment (which is an incredibly important tactic). But that wasn’t the title of the article. This was – “Medical marijuana can now be used to treat opioid addiction in N.J.”

However, New Jersey isn’t the first state to go down this path. I have posted in the past that Illinois, Louisiana and Pennsylvania had as well. So this news from Trenton sparked a thought after dinner – had I missed initiatives in other states? It took me a couple of hours last night but it was worth the research because there are even more than I thought.

I started with for a consolidated list of qualifying conditions included in medical cannabis programs around the country. Because their list has not been updated since October 6, 2018 and there is constant change, I decided to visit each state’s website for the most updated list. So as of January 23 at 10pm ET, here are my findings:

  • District of Columbia: They have some interesting language – “A serious medical condition for which the use of medical marijuana is beneficial: (B) For which there is scientific evidence that the use of medical marijuana is likely to be significantly less addictive than the ordinary medical treatment for that condition.” They do list “scientific evidence” as a caveat but broach the subject of marijuana being “less addictive.” Depending upon who you believe, the scientific evidence is there – or it’s not. So something that sounds declarative may actually not be.
  • Illinois: As of 8/28/18 they have an Opioid Alternative Pilot Program (OAPP) included in their medical cannabis program. The name is self-explanatory.
  • Louisiana: During April 2018 deliberations “proponents of the bill said adding chronic pain to the list of conditions covered by the state’s medical marijuana law would actively address opioid addiction rates in the state.” HB 579 included the language “Intractable pain means a pain state in which the cause of the pain cannot be removed or otherwise treated with the consent of the patient and which, in the generally accepted course of medical practice, no relief or cure of the cause of the pain is possible, or none has been found after reasonable efforts. It is pain so chronic and severe as to otherwise warrant an opiate prescription.” It was signed into law by the Governor in June. At the very least this is an implied connection.
  • Maine: Very similar to Louisiana, LD 1539’s description of pain mentions narcotics – “A chronic or debilitating disease or medical condition or its treatment that produces intractable pain, which is pain that has not responded to ordinary medical or surgical measures for more than 6 months or which is pain that, in the medical provider’s opinion, is not managed effectively by prescription narcotics.” The bill was vetoed by the Governor on July 6 then his veto overridden on July 9. Interestingly, the above language did not survive into the final bill.
  • Massachusetts: Their list of qualifying conditions includes the vague language “and other conditions as determined in writing by a qualifying patient’s physician.” That obviously leaves great discretion to the treating physician.
  • Missouri: They specifically allow for a physician’s discretion and tie it not to addiction but dependence – “A chronic medical condition that is normally treated with a prescription medication that could lead to physical or psychological dependence, when a physician determines that medical use of marijuana could be effective in treating that condition and would serve as a safer alternative to the prescription medication.”
  • New Mexico: The Medical Cannabis Advisory Board has recommended twice that “opiate use disorder” be added to their list of qualifying conditions. In each instance the Health Secretary has denied the request. Obviously they’re not going to stop trying, and now may have even more of an argument if they use other states as an example (peer pressure is powerful). I can add Minnesota to this same category where opioid-use disorder was a requested addition to the list of qualifying conditions but declined by the state Health Commissioner in December 2018.
  • New York: They have an “Opioid Replacement Condition” (the name is self-explanatory) that has an interesting caveat – “The regulations do not require a patient to try opioids first. Any condition for which an opioid could be prescribed qualifies as a condition to receive medical marijuana.” Interestingly the regulations do not prohibit concurrent use of opioids and marijuana (most people agree that’s not a good idea – pick one or the other). And it does apply to Opioid-Use Disorder. So wrap your head around what they’re saying. Marijuana is not just a treatment after the fact but equal and in parallel with prescription opioids.
  • Oklahoma: They have no listed qualifying conditions so a recommendation is totally at the discretion of the treating physician who fills out a form with up to three ICD-10 codes to serve as their “recommendation” to treat the “patient medical conditions.” This is the very definition of open door.
  • Pennsylvania: Their regulations directly tie marijuana to opioid use disorder as one of the qualifying conditions – “Opioid use disorder for which conventional therapeutic interventions are contraindicated or ineffective, or for which adjunctive therapy is indicated in combination with primary therapeutic interventions.”
  • Virginia: A March 2018 law made qualifying much easier with the following strikeout and addition – “A practitioner in the course of his professional practice may issue a written certification for the use of cannabidiol oil or THC-A oil for treatment or to alleviate the symptoms of  any diagnosed condition or disease determined by the practitioner to benefit from such use.” That certainly opens the door for discretion.

By my count that yields four states with an explicit connection (IL, NJ, NY, PA) and six states that appear to leave an open door to a connection (DC, LA, MA, MO, OK, VA).

In addition, if you consider opioid-use disorder a “chronic or debilitating disease / medical condition” (there is consensus that addiction is a disease) then the following states could potentially include marijuana as a qualifying treatment:

  • Alaska, Arkansas, Arizona, Colorado, Delaware, Hawaii, Michigan, New Hampshire, North Dakota, Rhode Island, Vermont, Washington.

The caveat is the patient needs to exhibit one or more of the following symptoms: cachexia (wasting syndrome), severe pain, severe nausea, seizures, severe and persistent muscle spasms. Thinking through the side effects of opioid-use disorder there could be an argument these symptoms are possible.

So, there you have it. The connection of medical marijuana to opioids (prescription and illicit) is not just words. In many cases, it’s law. And chances are good that process is only beginning. Whether you think marijuana is medicine is immaterial at this point. That decision has already been made by public vote, law and regulation. For better or for worse, it’s here. And it’s here to stay.

So is the momentum for medical marijuana connected with the opioid epidemic? Absolutely.