2018/05/09 Council Agenda Packet

Reiman,et al.;Cannabis and Cannabinoid Research 2017,2.1 161 http://online.liebertpub.com/doi/10.1089/can.2017.0012 term efficacy. The management of chronic pain impacts of cannabis has made it difficult to conduct large-scale 11.2%of adults in the United States with about 3%to 4% clinical trials on its efficacy. Recent clinical and system- of these patients receiving long-term opioid therapy.4 atic reviews have acknowledged the promise that canna- This translates to 100 million Americans and incurs bis might hold as a standardized pain treatment, while costs of up to $635 billion dollars per year.5 Long-term recognizing the limitations that come from small sample opioid therapy is associated with a number of risks, in- sizes and lack on controlled studies.While these reviews eluding opioid use disorder, overdose, and death. In show moderate evidence for cannabis as a treatment for 2012 the National Institute of Drug Abuse estimated pain-related conditions, they also call for additional re- that there were ti 2.1 million people in the United States search in the form of standardized clinical trials.12'13 suffering from substance use disorders related to pre- Meanwhile, in parallel, medical cannabis patients are scription opioid pain relievers and another half million reporting the use of cannabis to treat their pain in lieu addicted to heroin.6 of or in conjunction with opioid-based pain medications. Used in combination with opioid pain medications, The act of substituting cannabis for opioids has also cannabis can lower opioid side effects, cravings, and been documented in several studies of medical cannabis withdrawal severity, as well as enhance the analgesic patients.Consistently,these studies saw substitution rates effects of opioids, thereby allowing for lower doses for prescription drugs over 50%, with less side effects and less risk of overdose.7'8 A previous study reported from cannabis being a top reason for substitution across that their subjects' pain "was significantly decreased studies.14-16 Given the efficacy data on how cannabis as- after the addition of vaporized cannabis"and suggested sists patients' management of pain,while also mitigating that cannabis treatment "may allow for opioid treat- the risks associated with long-term opioid therapy, the ment at lower doses with fewer [patient] side effects." present study uses data gathered directly from the im- The authors concluded that their results "demonstrate pressions of patients who have used cannabis. Patients that inhaled cannabis safely augments the analgesic ef- were provided an opportunity to comment on how can- fects of opioids."9 Research published last year found nabis compared with their use of opioid and nonopioid- that 80% of medical cannabis users reported substitut- based pain medication for the treatment of pain. ing cannabis for prescribed medications, particularly among patients with pain-related conditions.8 Materials and Methods In an 1889 seminal article published in The Lancet, This study utilized a cross-sectional survey to gather Dr. Edward A. Birch writes about his tremendous suc- data about the use of cannabis as a substitute for opioid cess in using cannabis to help patients who had become and nonopioid-based pain medication. This study was addicted to pain medications, including opioids. He approved by the IRB at the University of California, wrote, "I prescribed the cannabis simply with a view to Berkeley (Protocol No. 2016-08-9044). Drs. Welty and utilizing a well-known remedy for insomnia, but it did Reiman did not receive compensation from HelloMD much more than procure sleep. I think it will be found to complete the study. that there need be no fear of peremptorily withdrawing the deleterious drug, if hemp be employed." (p. 625).1° Instrument Birch's comments from 127 years ago predicted what The survey instrument (see Supplementary Appendix we know to be true today, despite some controversy SAI for a copy of the instrument) used for this study that continues to surround the topic of cannabis as med- was a modified version of the survey used in the Tilray icine. Numerous scholarly studies have demonstrated Observational Patient Survey (TOPS). The survey for the efficacy of cannabis for multiple conditions, includ- this study included questions about demographic charac- ing the management of pain,while concurrently reduc- teristics, conditions for which cannabis is used, and pre- ing the reliance on opioid medications and nonopioid ferred method of cannabis ingestion. Participants were medications.5 In a 2010 pain study conducted in Can- then asked about their use of cannabis as a substitute ada, Ware et al. found that "a single inhalation of for opioid and nonopioid-based pain medication to create 25 mg of 9.4% tetrahydrocannabinol herbal cannabis subsets of respondents who were engaging in substitution. three times daily for five days reduced the intensity of An affirmative answer led participants to the sections that pain, improved sleep, and was well tolerated."11 asked about their experiences using cannabis as a substi- While the use of cannabis to treat pain is becoming tute. Questions in this section asked about perceived effi- more accepted in the United States,the Schedule I status cacy of cannabis compared to their other medications,