Colorado doctors can now recommend medical marijuana in place of opioids
Twenty-five years ago, when Dr. Brian Siegel began his career in medicine, he had a liberal policy when it came to prescribing opioids to his patients.
As he remembers, almost everyone did.
In 2012, doctors wrote a total of 255 million prescriptions for opioids, the most ever recorded, according to the Centers for Disease Control and Prevention.
Siegel followed the recommendations of fellow doctors and pharmaceutical companies. They had the same message: “If they need more, you give them more,” Siegel said.
Experts in Colorado, including Siegel, a pain management physician at UCHealth Pain Management Clinic in Steamboat Springs, now believe the frequent and free-wheeling approach to opioid prescriptions contributed to the state’s current opioid crisis. The impacts in Routt County have been among the worst in Colorado.
The rate of drug overdoses increased six-fold from 2014 to 2016, with more than 65% of those deaths attributed to the abuse of prescription opioids.
To combat the epidemic, state lawmakers have passed several pieces of legislation in recent years aimed at reducing opioid prescriptions.
The most recent among them was Senate Bill 19-013, which went into effect Aug. 2. It allows doctors to recommend medical marijuana in cases where they would otherwise prescribe opioids. New Jersey and Pennsylvania, where drug overdoses are the leading cause of accidental death, have similar laws.
Siegel and other health care professionals are skeptical about the bill. Marijuana is still a federally illegal substance, and it does not have the approval of the U.S. Food and Drug Administration. They argue more research needs to be done before replacing opioids with marijuana to treat pain, particularly for acute injuries.
Finding a solution to the opioid epidemic
Under current laws, doctors may authorize people to use medical-grade marijuana for a number of disabling and debilitating conditions, including cancer, seizures, severe pain and PTSD — or post-traumatic stress disorder.
The bill expands the qualification to allow a person to receive a state-issued medical marijuana card for “any condition for which a physician could prescribe an opioid,” according to the Colorado Department of Public Health and Environment.
It received bipartisan support from lawmakers who saw it as a way to reduce the number of patients who take opioids. They argue it can curb the number of people with an opioid use disorder, many of whom became addicted after a doctor temporarily prescribed them painkillers to treat pain.
“I believe in medical marijuana helping a lot of people,” Sen. Joann Ginal, a state Democrat and one of the sponsors of the bill, told KUNC. “I’ve seen it in helping people with PTSD, with autism and now using it for acute pain may be one of the ways that we can also help cut down on opioid addiction.”
In 2017, prescription opioids were involved in more than 35% of all overdose deaths — nearly 17,000, according to the CDC.
Siegel has seen that downward spiral among his own patients.
“A lot of the people who become addicted to opioids generally start out as a ski racer kid who has broken their leg,” he said as one example. “They lose their identity, are treated for an acute injury, start on opioids and progress to a chronic opioid-type of regimen.”
Lack of research on marijuana
Despite the toll painkillers have taken, Siegel does not believe medical marijuana is the panacea to pain relief, or even a better alternative.
“I don’t personally prescribe it,” he said. “There have been no good studies.”
Some supporters of using medical marijuana in place of opioids cite a 2014 study, published by the American Medical Association. Between 1999 and 2010, according to the study, states that legalized medical marijuana reported a 25% reduction in opioid overdose deaths.
A 2019 study, published in the National Academy of Sciences, challenged those findings. By expanding the timeframe to 2017, researchers found that states with medical marijuana reported almost a 23% increase in overdose deaths.
Of course, as the old statistics adage warns, “correlation does not imply causation.” Yet the potential, under-researched side effects of marijuana give a local addiction expert her own reservations about the bill.
Nancy Beste, executive director of Road to Recovery, a substance abuse treatment center in Steamboat, treats many people with opioid use disorders.
She and her colleagues gained statewide notoriety for her implementation of a medication-assisted treatment program, which has allowed many with substance use disorders to stay sober.
When it comes to treating people who already have an opioid addiction, as many of her patients do, she says medical marijuana could exacerbate the problem if a patient switches from painkillers to cannabis.
“I feel like people jump from one substance to another often when struggling with substance use disorder,” she said. “I want people to learn to be healthy and happy without any chemicals, if possible.”
Patients younger than 18 also may receive medical marijuana instead of opioids as long as they have the approval of two physicians, according to the bill. When consuming medical marijuana at their school, on the school bus or at a school-sponsored event, it must be in a form that cannot be smoked, according to the most recent bill text.
That worries Beste, who pointed to studies that show many people who began using marijuana in their adolescent years, particularly on a regular basis, developed psychosis later in life.
Again, correlation does not imply causation. But it does underscore the need, Beste argued, for more research.
A different approach to treating pain
When patients come in with certain types of pain, Siegel says a brief prescription of painkillers can be the best solution.
“Opioids are great for acute pain but not for chronic pain,” he said.
In other words, “If I break my leg and my bone is sticking out of my shin, I am going to demand some type of opioid,” Siegel said.
His aim, particularly during the past six years, has been to prevent that transition from acute pain to chronic pain. Siegel believes that chronic pain has a psychological component as much as, and perhaps more than, a physiological one.
“Some of these people are prewired to transform their anxiety and depression into a chronic pain syndrome,” Siegel said.
As he added, that often leads to a dependence on opioids, which treat a symptom instead of the underlying problem.
“An adverse childhood experience can be a predictor of someone developing chronic pain,” Siegel said as a common example. “I don’t think any drug is going to be great at preventing that, whether it’s THC or opioids or whatever else.”
That is why Siegel has focused on behavioral health as a way to treat chronic pain and any underlying, psychological trauma that may be causing the pain.
Before they begin treatments, his patients have an appointment with his office’s licensed behavioral health specialist, Amy Goodwin.
“We tend to be a culture that gets very anxious about pain,” Goodwin said, which can often lead people to find quick fixes rather than focusing on the long term.
Goodwin and Siegel help people find alternative ways to manage their pain, such as acupuncture, heat treatment and both cognitive and physical therapies.
The overall goal, according to Siegel, is to keep people off chronic opioids.
Beste and Siegel see some potential pain treatment benefits for marijuana, specifically in helping people sleep and eat. They have also seen promise in CBD, the nonpsychoactive cannabinoid, in treating inflammation and easing anxiety.
But when it comes to substituting marijuana for opioids, they believe lawmakers and health care professionals alike need to gain a better understanding of the plant and its effects, particularly when prescribing it over long periods or giving it to children and adolescents.
To fail to do so would be to repeat the same mistake that Siegel and his colleagues made decades ago, and have been working to correct ever since.