Pubdate: Sun, 16 Jul 2017
Source: Detroit Free Press (MI)
Copyright: 2017 Detroit Free Press
Author: Daniel Clauw


Chronic pain is a tremendous public health problem. The Institute of
Medicine estimates chronic pain affects 100 million Americans at an
estimated annual cost of $600 billion. But the rampant use of opioids
to treat chronic pain stands out as the least-defensible and
most-harmful of our maltreatments. Many U.S. physicians remain
resistant to this, though I would argue other options should be considered.

More than 14,000 Americans died in 2014 from unintentional overdose of
prescription opioids, making this the leading cause of death among
younger individuals in many states, according to the Centers for
Disease Control and Prevention. Countless others continue to take
opioids not because they have meaningful pain and functional
improvement, but because they enjoy feeling numbed, or simply have not
been presented with more appropriate and helpful therapeutic options.

Unfortunately, it is far faster and easier to give a patient an opioid
than to work through the complex issues often present in chronic pain
patients. As physicians begin to realize the problems with prescribing
opioids for individuals with chronic pain, an increasingly common
route to opioid addiction and death is the initial prescription of
opioids for acute pain after a surgical or dental procedure or
emergency room visit.

At present, this is almost a uniquely U.S. problem. We constitute less
than 5% of the world's population, and we consume 80% of the world's
opioid supply. And at the same time, there has been a movement toward
legalizing or decriminalizing the use of cannabis for the treatment of
chronic pain and other conditions.

Medical marijuana advocates have used data and compelling patient
stories to show legitimate uses of cannabinoids, especially for
conditions such as chronic pain, epilepsy and post-traumatic stress
disorder, which are notoriously difficult to treat with our standard

Although the public has moved rapidly toward accepting cannabis
decriminalization or legalization, the medical community does not
generally share this enthusiasm for cannabinoids.

Most regulatory agencies, such as the Food and Drug Administration,
evaluate potential therapies based on benefit versus risk, at both the
level of the individual patient and the general public health. If one
compares the benefits of opioids with those of cannabinoids for
chronic pain, the least contentious assessment would be to call it a

Both classes of drugs are at best modestly effective and work well
only in a small subset of patients. Both work in a similar manner to
dissociate individuals from the sensory unpleasantness of pain rather
than to treat the root cause of pain. Opioids may be more effective in
pain related to peripheral inflammation or damage, and cannabinoids
more effective for neuropathic and centralized pain conditions such as

Although the benefits of these two classes of drugs might be
comparable, the risks are not. While an analysis of their benefit/risk
profiles seems to favor cannabinoids, U.S. physicians greatly favor
opioids. Much of this distorted perception can be traced back to the
1960s or earlier. Opioids were considered effective for chronic pain,
and thus opioids in use at that time were placed on the list of
compounds considered effective by the FDA.

These older opioids (and even newer opioids) now get a broad label
implying they work well for any type of chronic pain, even if they are
shown to be effective for only a single chronic pain condition. This
is in marked contrast to drugs that are not grandfathered in and must
undergo trials in each chronic pain condition in order to label that
they work in that condition.

Meanwhile, in part because there has been scant research on the
potential benefits of cannabinoids, many U.S. physicians are stuck
back in a "Reefer Madness" era of cannabinoid knowledge, in which
cannabis will inevitably lead to "death, debauchery or hopeless
insanity." We need to adjust our perceptions about these two classes
of drugs based on evidence.

There is no excuse for the common practice in U.S. pain clinics to
liberally prescribe opioids while doing drug screens and discharging
patients if they test positive for a cannabinoid. There is also no
excuse for pharmaceutical companies to continue to market opioids as
though they work broadly for chronic pain when we know there is no
evidence they have efficacy for common conditions such as

It also makes no sense that cannabis is still a Schedule I drug when
extracts or synthetic forms of cannabinoids are generally Schedule
III. Rescheduling cannabis would enable physicians who are interested
in trying to help their patients find an appropriate formulation and
dose of a cannabinoid to do so.

Ultimately, neither opioids nor cannabinoids should be used as first-,
second-or third-line therapies for pain, as there are almost always
many much more effective and safer drug and non-drug therapies. We can
and should do better for patients.

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Dr. Daniel Clauw is a professor of anesthesiology, psychiatry and
rheumatology at the University of Michigan.
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