Pubdate: Fri, 06 Jul 2018
Source: Philadelphia Daily News (PA)
Copyright: 2018 Philadelphia Newspapers Inc.
Author: Rita Giordano, Staff Writer


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.

Briana Kline vapes medical marijuana as part of her opioid treatment

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?"

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, which is not an opioid, 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."

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

"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."
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MAP posted-by: Matt