Opioid Epidemic:

Can Medical
Marijuana Help?
Terrence Shenfield MS, RRT-ACCS, RPFT,
NPS, AE-C
President of ATECAM LLC
Objectives
• Opioid crisis
• NJ State statistics
• How Opioids work
• The endocannabinoid system
• What is the role of cannabis in pain modulation?
• Studies supporting it use
I am sure
your not
surprised!
 Roughly 21 to 29 percent of patients prescribed opioids for
chronic pain misuse them
Between 8 and 12 percent develop an opioid use disorder

An estimated 4 to 6 percent who misuse prescription opioids

transition to heroin
About 80 percent of people who use heroin first misused
Some stats prescription opioids
Opioid overdoses increased 30 percent from July 2016
through September 2017 in 52 areas in 45 states
The Midwestern region saw opioid overdoses increase 70
percent from July 2016 through September 2017
Opioid overdoses in large cities increase by 54 percent in 16
states
 In the late 1990s, pharmaceutical companies reassured the
medical community that patients would not become addicted
to prescription opioid pain relievers
Healthcare providers began to prescribe them at greater rates

Led to widespread diversion and misuse of these medications

How did this

happen?
These medications are highly addictive

Opioid overdose rates began to increase

 Pain medications and illicit drugs

Can cause both physical and psychological

dependence

What is an Examples:
Opioid? • Prescription pain medications
• Natural opioids: Morphine, codeine
• Semi-synthetic opioids: Oxycodone, oxymorphone,
hydrocodone, hydromorphone
• Synthetic opioids: methadone, fentanyl, tramadol
• Illicit drugs
• Heroin
New Jersey State Specific
Statistics
• 128,000 people addicted to opioids or heroin in 2015

• 32,529 substance abuse treatment admissions

related to opioids in 2015
• 27,621 cases related to heroin abuse
• 4,908 cases related to abuse of other opioids

• Ocean, Essex, and Monmouth are the three counties

with the highest number of reported cases
 Approximately 3 out of 4 new heroin users report
having abused prescription opioids in the past

Easier access to heroin than prescription opioids

Opioids to • Heroin does not require a prescription

• Street price for heroin may be more affordable than
Herion prescription opioids

The concern with heroin

• Higher risk of overdosing

• Variable concentration with harmful impurities
• Transmission of diseases through injection & needle sharing
Why is cannabis
important for you
to know about?
• Evolving field
• Becoming mainstream
• Patients will be asking
• Legal reasons
EVOLVING INDUSTRY
SO WHAT IS
THE
PROBLEM?

• Cultural Paradigm
• Misunderstanding
• Lack of education
• Inaccurate representation
 • Intractable Skeletal Muscular Spasticity
• Multiple sclerosis
• Muscular Dystrophy
• Inflammatory Bowel Disease (Crohn’s)
• Intractable Epilepsy
• Glaucoma
• Terminal Cancer
• AIDS
• PTSD
• ALS
• Migraines
• Chronic pain due to musculoskeletal
disorders
• Opioid Disorder
•
NEW JERSEY QUALIFYING •
Visceral organ chronic pain
Fibromyalgia

CONDITIONS
 Raphael
Mechoulam
 • Crucial for homeostasis
• CB1 which is in the central nervous system
(brain and nerves of the spinal cord)
• CB2 which is in the peripheral nervous system
(nerves in your extremities), the digestive
What is the system, and specialized cells in the immune
system

Endocannabinoid • Regulate a lot of important functions

• Appetite

System? • Digestion
• Immune function
• Inflammation, including
neuroinflammation
• Mood
• Sleep
• Reproduction/fertility
• Motor control
• Temperature regulation
• Memory
• Pain
• Pleasure/reward
Endocannabinoids: Bind CB1 > CB 2
structure, related to prostaglandins

• Annandamide
(arachidonyl-ethanolamid)

• 2-Arachidonoyl - glycerol
(2-AG)
more abundant, less
potent

Nicoll & Alger, 2004

NATURES
PERFECT
SCIENCE
• Travel in reverse: Bind to
CB1 that is on Pre-
Synaptic cleft
• Dampen pattern of
electric activity
• Release the neuron from
inhibitory input and
disinhibit
What is the role of cannabis
in pain modulation?

• 2900BC Chinese doctors used

cannabis for a host of
disorders including rheumatic
pain

• 1000BC India – used for

analgesic and anti-
inflammatory conditions
Is Pain Subjective?
 Pain is a complex experience
that involves more than just
the site of the pain. It is all
encompassing of your body,
mind and spirit
Pain is different
for everyone
It is difficult to appreciate
another's person pain
The psychology of
pain
• Vicious cycle in which pain
causes disability and stress
which worsens the perception
of pain
• Emotional response to pain
• Role of attention to pain
• Role of anxiety to pain
• Role of memory to pain
THC act as a distractor of the pain mechanism

Level of pain more bearable

THC demonstrated more brain activity connecting their right amydala and a part of
the cortex known as the primary sensorimotor area

THC’s effectiveness in reducing the unpleasantness of pain varied greatly between

individuals

Role of cannabis in the management of

subjective pain
 Types of pain

Neuropathic pain is caused Centralized pain is the

by damage to sensory or result of amplification of
Nociceptive pain is caused
spinal nerves, which send peripheral signals due to
by damage to body tissue
inaccurate pain messages persistent central nervous
to higher centers system dysfunction
 Injured tissues produce endogenous cannabinoids that
modulate neural conduction pain signals via the CB1
receptor

The endocannabinoid Anandamide and 2-AG are produced in injured tissues

system and to suppress pain and inflammation

mechanisms of pain
Anandamide mobilizes in response to inflammation
reduction and nerve injury and modulates nociceptive signals by
activating local CB1 receptors and mitigating pain and
inflammation

CB2 receptors regulate neuroimmune interactions and

interfere with inflammatory hyperalgesia
 Anandamide and 2-AG are recruited during
tissue injury to provide a first response to
nociceptive signals.

Understanding the function of endogenous

How can medical cannabinoids helps explain the efficacy of
exogenous cannabinoids, such as those
cannabis help? found in the cannabis plant, in treating pain.

Hypothesized rationale for cannabinoid

administration is whole-body exposure to
exogenous cannabinoids to turn on pain
inhibition
Cochrane The potential benefits of cannabis-based
Review medicine (herbal cannabis, plant-derived
or synthetic THC, THC/CBD oromucosal
spray) in chronic neuropathic pain might
Cannabis be outweighed by their potential harms.
products for
adults with
The quality of evidence for pain relief
chronic outcomes reflects the exclusion of
neuropathic participants with a history of substance
pain abuse and other significant comorbidities
from the studies.
 Eva Martín-Sánchez, Toshiaki A.
Furukawa, Julian Taylor, Jose Luis
R. Martin; Systematic Review and
Meta-analysis of Cannabis
Treatment for Chronic Pain, Pain
Medicine, Volume 10, Issue 8, 1
November 2009, Pages 1353–
1368
From: Systematic Review and Meta-analysis of Cannabis Treatment for Chronic Pain
Pain Med. 2009;10(8):1353-1368. doi:10.1111/j.1526-4637.2009.00703.x
Pain Med | © American Academy of Pain Medicine
Case Study: A 46-year-old Caucasian female presented to the St. Paul’s Hospital Chronic
Pain Program in Vancouver, Canada
Management
of Post-
Parotidectomy Hypersensitivity to clothing affecting her right neck and shoulder girdle
radiating down to the inferomedial border of the scapula
Neuropathic
Pain with
Right facial palsy and numbness in the distributions of the right V2 and V3
Tetrahydrocan trigeminal nerve as well as sympathetic nervous system involvement.

nabinol:
cannabidiol Muscle spasms associated with sensory allodynia were relieved by
cyclobenzaprine (Flexeril), 30 mg at bedtime.
(Sativex) Gabapentin (Neurontin) at 900mg three times daily was partially beneficial
in reducing hyperesthesia.
Case Study:
Management of Sativex is used in this case study to treat a patient suffering from neuropathic pain.

Post-
Six weeks later, the patient returned to the clinic with pain symptoms alleviated
Parotidectomy and transient decrease in alertness as the only side effect experienced.
Neuropathic
Pain with Two years since the initiation of Sativex treatment for allodynia, the patient has not
experienced any relapse and is now working and fully functional.

Tetrahydrocann
This case study demonstrates a successful use of Sativex to treat post-parotidectomy
abinol: neuropathic pain.

cannabidiol Sativex is currently indicated in Canada to treat neuropathic pain only in multiple
(Sativex) sclerosis and cancer. This is the first case study to report successful treatment of post-
parotidectomy neuropathic pain with THC:CBD (Sativex) buccomucosal spray.
Boehnke, K. F., Litinas, E., &
Clauw, D. J. (2016). Medical
cannabis use is associated
with decreased opiate
medication use in a
retrospective cross-sectional
survey of patients with
chronic pain. The Journal of
Pain, 17(6), 739-744.
• Cannabis use was associated
with 64% lower opioid use in
patients with chronic pain.
• Cannabis use was associated
with better quality of life in
patients with chronic pain.
• Cannabis use was associated
with fewer medication side
effects and medications used
Cannabis and Opioid Interactions

Bachhuber, M. A., Saloner, B., Cunningham, C. O., & Barry, C. L.

(2014). Medical cannabis laws and opioid analgesic overdose
mortality in the United States, 1999-2010. JAMA internal
medicine, 174(10), 1668-1673..

Bradford, A. C., & Bradford, W. D. (2016). Medical marijuana laws

reduce prescription medication use in Medicare Part D. Health
Affairs, 35(7), 1230-1236..
References
• Johnson, T. (2019). The American Opioid Epidemic: Is Medical
Marijuana Really The Answer.
• Maher, D. P., Carr, D. B., Hill, K., McGeeney, B., Weed, V., Jackson,
W. C., ... & Kulich, R. J. (2019). Cannabis for the treatment of
chronic pain in the era of an opioid epidemic: a symposium-based
review of sociomedical science. Pain Medicine, 20(11), 2311-2323.
• Olfson, M., Wall, M. M., & Blanco, C. (2018). Medical marijuana and
the opioid epidemic: Response to Theriault and
Schlesinger. American Journal of Psychiatry, 175(3), 284-285.
• Yang PT, Ong-Lam M. Case Study: Management of Post-Parotidectomy
Neuropathic Pain with Tetrahydrocannabinol: cannabidiol (Sativex). UBCMJ.
2010 2(1):45-48.