Chronic prescription opiate pain pill abuse has been recognized by the CDC as a national epidemic.(5)
Deaths from opiate pain pills have quadrupled since the early 1990’s, when doctor’s prescribing practices fundamentally changed. Why did they change? The drug industry launched a campaign to convince doctors that patients with chronic pain syndromes were “under treated” and were suffering needlessly.
Oxycontin from Purdue
An illustrative example is the slow release opiate, Oxycontin, manufactured by Purdue. Although deemed a commercial success for Purdue, it was an unfortunate public health disaster.(6,7)
“When Purdue Pharma introduced OxyContin in 1996, it was aggressively marketed and highly promoted. Sales grew from $48 million in 1996 to almost $1.1 billion in 2000. The high availability of OxyContin correlated with increased abuse, diversion, and addiction, and by 2004 OxyContin had become a leading drug of abuse in the United States.” (7) Above image courtesy of NPR.org
While Purdue Pharma enjoyed the commercial success of its slow release opiate, Oxycontin, with increasingly huge profits, law enforcement took notice and filed criminal complaints. In May of 2007, Purdue and 3 executives plead guilty to criminal charges of misbranding and paid a 634 million dollar fine. Apparently they had falsely promoted the drug as “less addictive than other opiates.” (7)
As a result of these types of deceptive and false promotional campaigns by the drug industry, doctors liberalized the use of opiate pain pills to include patients with chronic non-cancer pain, such as chronic musculoskeletal pain (low back pain), for example.(5)
Opiates are a Poor Choice for Chronic Pain Management
From a medical perspective, the many adverse effects of opiates render it a poor choice for management of chronic pain. These unwanted effects include narcotics addiction, chronic suppression of the endocrine and immune system, development of drug tolerance which makes the drugs ineffective, opioid-induced hyperalgesia which magnifies the pain, and accidental death from overdose causing suppression of the respiratory centers in the brainstem.(7)(17)
A Safer Alternative to Opiates for Chronic Pain
In a 2011 report by Dr Carter, the authors state:” Opioids may produce significant morbidity. Cannabis is a safer alternative with broad applicability for palliative care.” (2)
There has never been a fatality from medical cannabis overdose. The reason for this is unlike opiates, which cause respiratory depression, medical cannabis does not. This is explained by autoradiographic studies showing sparse distribution of cannabinoid receptors in the brainstem at the location of the respiratory centers,
An Unexpected Benefit-Reduction In Mortality From Opiates
An unexpected benefit of medical marijuana legalization is reduction in deaths from opiate overdose.(3) In these states with medical cannabis, the opiate pain pills are replaced by safer and more effective medical cannabis preparations.(3)
Marcus Bachhuber MD at Johns Hopkins
A 2014 study from Dr Marcus Bachhuber at Johns Hopkins Bloomberg School of Public Health reported that states that have legalized medical cannabis to manage chronic pain have a 25 percent lower mortality rate from opioid drug overdose compared to other states without medical cannabis laws.(1-4) Above image courtesy of Marcus Bachhunber MD..
How to Run a Healthy Corporation- Ban the Competition
It is clear from the above discussion that medical cannabis is a more effective and safer alternative to prescription pain pills (opiates) for management of chronic pain, and neuropathic pain, and this is the largest indication for prescribing medical cannabis (where available). I propose that this has been known and understood by the drug industry for decades. Drug manufacturers are no different from any other corporation. They are most concerned with maintaining healthy profits, and will do whatever necessary to eliminate competition and increase market share. I propose to you the original 1930’s campaign to ban medical cannabis was motivated by this same economic competition and the need to maximize drug industry profits.
Anti-Legalization Campaigns Funded By Drug Industry
Another revelation is that this drug industry opposition continues today in a more deceptive form The drug industry hides behind front groups such as the Community Anti-Drug Coalition of America (CADCA), and the Partnership for Drug-Free Kids to oppose medical marijuana legalization initiatives. Some of the largest donors to these groups include Purdue Pharma, the manufacturer of OxyContin, and Abbott Laboratories, maker of the opioid Vicodin.(8-11) In spite of drug industry opposition to legalizing medical cannabis, the movement appears unstoppable, as the public has become aware of the overwhelming medical evidence.(12-15) Above left logo courtesy of Partnership for Drugs Free Kids.
Update Jan 2015: Chronic pain: Do opioid painkillers really help?
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Links and References
Bachhuber, Marcus A., et al. “Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010.” JAMA internal medicine 174.10 (2014): 1668-1673.Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them.Objective To determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality.
Design, Setting, and Participants A time-series analysis was conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included.
Exposures Presence of a law establishing a medical cannabis program in the state.
Main Outcomes and Measures Age-adjusted opioid analgesic overdose death rate per 100 000 population in each state. Regression models were developed including state and year fixed effects, the presence of 3 different policies regarding opioid analgesics, and the state-specific unemployment rate.
Results Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95% CI, −37.5% to −9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: year 1 (−19.9%; 95% CI, −30.6% to −7.7%; P = .002), year 2 (−25.2%; 95% CI, −40.6% to −5.9%; P = .01), year 3 (−23.6%; 95% CI, −41.1% to −1.0%; P = .04), year 4 (−20.2%; 95% CI, −33.6% to −4.0%; P = .02), year 5 (−33.7%; 95% CI, −50.9% to −10.4%; P = .008), and year 6 (−33.3%; 95% CI, −44.7% to −19.6%; P < .001). In secondary analyses, the findings remained similar.
Conclusions and Relevance :
Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose.
Am J Hosp Palliat Care. 2011 Aug;28(5):297-303. Cannabis in palliative medicine: improving care and reducing opioid-related morbidity. Carter GT1, Flanagan AM, Earleywine M, Abrams DI, Aggarwal SK, Grinspoon L. Hospice Services, Providence Medical Group, Olympia, WA 98531,
Unlike hospice, long-term drug safety is an important issue in palliative medicine. Opioids may produce significant morbidity. Cannabis is a safer alternative with broad applicability for palliative care. Yet the Drug Enforcement Agency (DEA) classifies cannabis as Schedule I (dangerous, without medical uses). Dronabinol, a Schedule III prescription drug, is 100% tetrahydrocannabinol (THC), the most psychoactive ingredient in cannabis. Cannabis contains 20% THC or less but has other therapeutic cannabinoids, all working together to produce therapeutic effects. As palliative medicine grows, so does the need to reclassify cannabis. This article provides an evidence-based overview and comparison of cannabis and opioids. Using this foundation, an argument is made for reclassifying cannabis in the context of improving palliative care and reducing opioid-related morbidity.
Interview with Bachhuber
Legalizing Medical Marijuana May Reduce Opioid Deaths By Bridget M. Kuehn on August 26, 2014In states like Colorado, where medical marijuana has been legal since 2000, the primary reason for a physician to recommend medical marijuana is pain.Dr Bachhuber: Our study provides evidence of a possible unexpected public health benefit of medical marijuana legalization.
By Jessica FirgerCBS NewsAugust 25, 2014, 6:19 PM
Medical marijuana laws reduce prescription painkiller deathsStates that have legalized the use of medical marijuana to manage chronic pain and other conditions have a 25 percent lower rate of deaths from opioid drug overdose than states where medical marijuana is illegal, according to a new study. These findings suggest laws that make cannabis available to manage chronic pain and other illnesses may be useful in the U.S. health care system’s uphill battle to reduce prescription painkiller abuse.
The researchers at Johns Hopkins Bloomberg School of Public Health and the Philadelphia Veterans Affairs Medical Center found rates of death from prescription painkiller overdoses climbed steadily from 1999 to 2010. But in states where medical marijuana use is legal, the rates of overdose were, on average, 25 percent lower. The study looked at data on death certificates from the Centers for Disease Control and Prevention.
Examining the Growing Problems of Prescription Drug and Heroin Abuse April 29, 2014 Witness: Daniel Sosin, MD, MPH, FACP
Testimony – Testimony before the House Energy and Commerce Subcommittee on Oversight and InvestigationsThe National Prescription Drug Overdose EpidemicDrug overdose death rates have climbed sharply and steadily over the past decade and are higher now than they have ever been.Increases in prescribing opioid pain relievers – drugs like oxycodone, hydrocodone, methadone and fentanyl – are driving the dramatic increase in overdose deaths over the last decade. Opioid pain reliever overdose deaths have quadrupled since 1999.2 CDC has declared the problem of prescription drug abuse a public health epidemic and addressing it remains a key priority for the Agency.The prescription drug overdose epidemic is driven by fundamental changes in the way healthcare providers prescribe opioid pain relievers. Beginning in the 1990s, providers started prescribing more opioid pain relievers in an effort to address what was, at that time, perceived to be a widespread problem of undertreated pain. As opioid pain reliever prescribing increased, overdose deaths increased simultaneously.3 Today, the supply of opioid pain relievers is larger than ever.4
OxyContin: Purdue Pharma’s painful medicine by Katherin Eban Fortune Magazine November 9, 2011
What the strange saga of Purdue and its $3 billion drug tells us about our national dependence on painkillers.
FORTUNE — We have become a nation of pill poppers. Pain tablets are the prime culprits — more specifically, opioids. You may have never heard the word “opioid,” which refers to a broad category of drugs derived from natural or synthetic forms of opium or morphine. You have, however, likely heard of many of the medications in the group, which includes everything from Percocet to Vicodin to Fentanyl. Their chemical composition is such that the U.S. is just a few carbon molecules from being a nation of heroin addicts.
Consider these statistics, all for 2010: 254 million prescriptions for opioids were filled in the U.S., according to Wall Street analysts
Cowen & Co. Enough painkillers were prescribed
to “medicate every American adult around the clock
for a month,” the federal Centers for Disease
Control reported on Nov. 1. It estimated that
“nonmedical use of prescription painkillers costs
health insurers up to $72.5 billion annually
in direct health care costs.” Opioids generated
$11 billion in revenues for pharmaceutical companies, says market research firm Frost & Sullivan.
Some 15,000 Americans died of opioid overdoses in 2008 — triple the number for 1999, according to the new CDC findings.
Purdue Pharma, maker of the No. 1 drug in the class: OxyContin, which generated $3.1 billion in revenue in 2010.
Its marketing was misleading enough that Purdue pleaded guilty in 2007 to a federal criminal count of misbranding the drug “with intent to defraud and mislead the public,” paid $635 million in penalties, and today remains on the corporate equivalent of probation.
Am J Public Health. 2009 Feb;99(2):221-7. doi: 10.2105/AJPH.2007.131714. Epub 2008 Sep 17.
The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Van Zee A. Stone Mountain Health Services, St Charles Clinic, St Charles, VA 24282, USA.
An in-depth analysis of the promotion and marketing of OxyContin illustrates some of the associated issues.
The Real Reason Pot Is Still Illegal. By Lee Fang July 21-28, 2014 The Nation. The Anti-Pot Lobby’s Big Bankroll
Opponents of marijuana-law reform insist that legalization is dangerous—but the biggest threat is to their own bottom line.
Community Anti-Drug Coalition of America (CADCA
The Nation obtained a confidential financial disclosure from the Partnership for Drug-Free Kids showing that the group’s largest donors include Purdue Pharma, the manufacturer of OxyContin, and Abbott Laboratories, maker of the opioid Vicodin.
Florida shelden Adelson Drug Free Florida Mel and Betty Sembler
Drug Free Florida. Mel and Betty Sembler, “Straight, Incorporated” Florida drug treatment centers
Washingtom Post Niraj Chokshi October 28 2014
Casino billionaire Sheldon Adelson is behind 85 percent of Florida’s anti-pot campaign
The single largest contributor on either side of the fight over Amendment 2, which grants patients with “debilitating diseases” access to medical marijuana, is billionaire casino mogul Sheldon Adelson, who, new campaign finance filings show, added $1 million to the $4 million he’s already spent in support of the campaign to defeat the measure. Adelson, the chairman and CEO of Las Vegas Sands and America’s 12th richest person, is responsible for 85 percent of the $5.8 million raised by Drug Free Florida, the organization leading the charge against the measure and headed by former Reagan drug czar Carlton Turner. For Adelson, that amount of spending is roughly equivalent to a person worth $1 million writing a $157 campaign contribution check.
The businesspeople who benefited from the defeat of Florida medical marijuana include heroin street dealers, pharmacists who provide heroin-like drugs such as OxyContin, police, prisons, prison guards, doctors, politicians, the drug treatment industry, the booze industry, and pharmaceutical companies.
Who spent money to defeat Amendment 2, and how did they reduce voter support so Amendment 2 failed?
Corrupt casino mega-billionaire and Republican funder Sheldon Adelson handed $3 million to an anti-cannabis organization called Drug Free Florida.
Mel Sembler is a long-time GOP insider who was a major fundraiser and donor (along with Sheldon Adelson) for Mitt Romney’s failed 2012 presidential campaign.
Drug Free Florida is also run by the Florida Sheriffs Association, a tobacco industry lobbyist, and former White House “drug czar” Carlton Turner.Adelson’s money comes from casinos that help people get addicted to gambling, alcohol, and prostitution.He also makes money from business involvement with addiction clinics.And he’s funding cannabis researchers who’re working on synthetic CBD pharmaceutical medicines.Adelson’s investment in addiction clinics explains his opposition to marijuana.He surely knows about recent research showing that in states with legal marijuana, people use less pharmaceutical and illegal opioids such as Vicodin, OxyContin, Percocet, and heroin, and consequently have less problem with addiction to those substances.
The Journal of the American Medical Association found that 13 states that allow citizens to use marijuana had way lower rates of opioid-related deaths than states without legal marijuana.
Three wealthy people donated 98.5% of funds to oppose FL marijuana initiative.
The Drug Free Florida Committee, spearheading the opposition to Amendment 2, recently pocketed a check for $2.5 million from Sheldon Adelson, chairman and chief executive of Las Vegas Sands Corp. The Carol Jenkins Barnett Family Trust, headed by the daughter of Publix Super Markets founder George Jenkins, gave $540,000. And Mel Sembler, local developer and former ambassador to Italy and Australia, donated $100,000.
CMAJ. Oct 5, 2010; 182(14): E694–E701.
Smoked cannabis for chronic neuropathic pain: a randomized controlled trial
Mark A. Ware, MBBS, Tongtong Wang, PhD, Stan Shapiro, PhD, Ann Robinson, RN, Thierry Ducruet, MSc, Thao Huynh, MD, Ann Gamsa, PhD, Gary J. Bennett, PhD, and Jean-Paul Collet, MD PhD
We used a randomized, double-blind, placebo-controlled, four-period crossover design.
We found that 25 mg herbal cannabis with 9.4% tetrahydrocannabinol, administered as a single smoked inhalation three times daily for five days, significantly reduced average pain intensity compared with a 0% tetrahydrocannabinol cannabis placebo in adult participants with chronic post-traumatic or postsurgical neuropathic pain.
We found significant improvements in measures of sleep quality and anxiety.
Our results support the claim that smoked cannabis reduces pain, improves mood and helps sleep.
J Pain. 2013 Feb;14(2):136-48. doi: 10.1016/j.jpain.2012.10.009. Epub 2012 Dec 11.
Low-dose vaporized cannabis significantly improves neuropathic pain. Wilsey B1, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe H.
1VA Northern California Health Care System, and Department of Physical Medicine and Rehabilitation, University of California, Davis Medical Center, Sacramento, California 95817, USA.
We conducted a double-blind, placebo-controlled, crossover study evaluating the analgesic efficacy of vaporized cannabis in subjects, the majority of whom were experiencing neuropathic pain despite traditional treatment. Thirty-nine patients with central and peripheral neuropathic pain underwent a standardized procedure for inhaling medium-dose (3.53%), low-dose (1.29%), or placebo cannabis with the primary outcome being visual analog scale pain intensity. Psychoactive side effects and neuropsychological performance were also evaluated. Mixed-effects regression models demonstrated an analgesic response to vaporized cannabis. There was no significant difference between the 2 active dose groups’ results (P > .7). The number needed to treat (NNT) to achieve 30% pain reduction was 3.2 for placebo versus low-dose, 2.9 for placebo versus medium-dose, and 25 for medium- versus low-dose. As these NNTs are comparable to those of traditional neuropathic pain medications, cannabis has analgesic efficacy with the low dose being as effective a pain reliever as the medium dose. Psychoactive effects were minimal and well tolerated, and neuropsychological effects were of limited duration and readily reversible within 1 to 2 hours. Vaporized cannabis, even at low doses, may present an effective option for patients with treatment-resistant neuropathic pain.
PERSPECTIVE:The analgesia obtained from a low dose of delta-9-tetrahydrocannabinol (1.29%) in patients, most of whom were experiencing neuropathic pain despite conventional treatments, is a clinically significant outcome. In general, the effect sizes on cognitive testing were consistent with this minimal dose. As a result, one might not anticipate a significant impact on daily functioning.
Rambam Maimonides Med J. 2013 Oct 29;4(4):e0022. doi: 10.5041/RMMJ.10129. eCollection 2013.
The endocannabinoid system, cannabinoids, and pain.
Fine PG1, Rosenfeld MJ.
Author information 1Professor of Anesthesiology, Pain Research and Management Centers, Department of Anesthesiology, School of Medicine, University of Utah, Salt Lake City, Utah, USA; and.
Abstract The endocannabinoid system is involved in a host of homeostatic and physiologic functions, including modulation of pain and inflammation. The specific roles of currently identified endocannabinoids that act as ligands at endogenous cannabinoid receptors within the central nervous system (primarily but not exclusively CB 1 receptors) and in the periphery (primarily but not exclusively CB 2 receptors) are only partially elucidated, but they do exert an influence on nociception. Exogenous plant-based cannabinoids (phytocannabinoids) and chemically related compounds, like the terpenes, commonly found in many foods, have been found to exert significant analgesic effects in various chronic pain conditions. Currently, the use of Δ9-tetrahydrocannabinol is limited by its psychoactive effects and predominant delivery route (smoking), as well as regulatory or legal constraints. However, other phytocannabinoids in combination, especially cannabidiol and β-caryophyllene, delivered by the oral route appear to be promising candidates for the treatment of chronic pain due to their high safety and low adverse effects profiles. This review will provide the reader with the foundational basic and clinical science linking the endocannabinoid system and the phytocannabinoids with their potentially therapeutic role in the management of chronic pain.
Cannabinoids have a very high therapeutic index. In fact, it is virtually unlimited insofar as fatalities have not been reported directly related to the toxicity of any cannabinoid, even with extremely high dosing. However, there are potentially severe cognitive, psychotomimetic, and substance abuse-related adverse effects associated with Δ9-tetrahydrocannabinol (THC) exposure that must be taken seriously, especially in young or cannabis-naïve patients
There is ample evidence that CB2 receptor activation reduces nociception in a variety of preclinical models, including those involving tactile and thermal allodynia, mechanical and thermal hyperalgesia, and writhing.39 With regard to their role in modulating neuropathic pain, the presence of CB2 receptors on microglia within the nervous system may explain the putative benefits of cannabinoids in reducing cytokine-mediated neuroinflammation.
CB2 cannabinoid receptor activation produces antinociception by stimulating peripheral release of endogenous opioids.
Ibrahim MM1, Porreca F, Lai J, Albrecht PJ, Rice FL, Khodorova A, Davar G, Makriyannis A, Vanderah TW, Mata HP, Malan TP Jr.
Author information 1Department of Anesthesiology, University of Arizona College of Medicine, Tucson, AZ 85724-5114, USA.
Abstract CB(2) cannabinoid receptor-selective agonists are promising candidates for the treatment of pain. CB(2) receptor activation inhibits acute, inflammatory, and neuropathic pain responses but does not cause central nervous system (CNS) effects, consistent with the lack of CB(2) receptors in the normal CNS. To date, there has been virtually no information regarding the mechanism of CB(2) receptor-mediated inhibition of pain responses. Here, we test the hypothesis that CB(2) receptor activation stimulates release from keratinocytes of the endogenous opioid beta-endorphin, which then acts at opioid receptors on primary afferent neurons to inhibit nociception. The antinociceptive effects of the CB(2) receptor-selective agonist AM1241 were prevented in rats when naloxone or antiserum to beta-endorphin was injected in the hindpaw where the noxious thermal stimulus was applied, suggesting that beta-endorphin is necessary for CB(2) receptor-mediated antinociception. Further, AM1241 did not inhibit nociception in mu-opioid receptor-deficient mice. Hindpaw injection of beta-endorphin was sufficient to produce antinociception. AM1241 stimulated beta-endorphin release from rat skin tissue and from cultured human keratinocytes. This stimulation was prevented by AM630, a CB(2) cannabinoid receptor-selective antagonist and was not observed in skin from CB(2) cannabinoid receptor-deficient mice. These data suggest that CB(2) receptor activation stimulates release from keratinocytes of beta-endorphin, which acts at local neuronal mu-opioid receptors to inhibit nociception. Supporting this possibility, CB(2) immunolabeling was detected on beta-endorphin-containing keratinocytes in stratum granulosum throughout the epidermis of the hindpaw. This mechanism allows for the local release of beta-endorphin, where CB(2) receptors are present, leading to anatomical specificity of opioid effects.
Baker, David, et al. “The therapeutic potential of cannabis.” The Lancet Neurology 2.5 (2003): 291-298.
17) Nat Rev Rheumatol. 2010 Apr;6(4):191-7. Adverse effects of chronic opioid therapy for chronic musculoskeletal pain.
Crofford LJ. Division of Rheumatology & Women’s Health, University of Kentucky, Room J-503, Kentucky Clinic, 740 S. Limestone Street, Lexington, KY
The use of opioids for the treatment of chronic pain has increased dramatically over the past decade. Whether these drugs provide considerable benefits in terms of pain reduction and improved function to balance the risks associated with their use, however, is unclear. Of particular importance to clinicians treating chronic musculoskeletal pain is opioid-induced hyperalgesia, the activation of pronociceptive pathways by exogenous opioids that results in central sensitization to pain. This phenomenon results in an increase in pain sensitivity and can potentially exacerbate pre-existing pain. Opioids also have powerful positive effects on the reward and reinforcing circuits of the brain that might lead to continued drug use, even if there is no abuse or misuse. The societal risk of increased opioid prescription is associated with increased nonmedical use, serious adverse events and death. Patients with chronic musculoskeletal pain should avoid the long-term use of opioids unless the benefits are determined to outweigh risks, in which case, the use of chronic opioids should be regularly re-evaluated.
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