Opioids or Cannabis? Rethinking Pain Management
The first time a doctor handed Shannon Hartmann a prescription for an opioid pain medication, she thought about her sister, who had battled a devastating heroin addiction throughout her teens and early 20s. Hartmann, 39, who lives in Worcester, Mass., remembers her sibling disappearing for months, the many attempts at rehab, the phone calls from hospitals, even a visit to a psychiatric clinic. In withdrawal and heavily medicated, her sister was unresponsive, drooling. “It was like the stuff you see in horror movies,” Hartmann said. “It was awful.”
For her part, Hartmann has suffered from chronic back pain since she was 13 and was eventually diagnosed with spinal arthritis. Hartmann’s parents initially took her to a chiropractor, who recommended daily stretching, ice packs and strengthening exercises. In high school, Hartmann played competitive basketball and volleyball, and the sports led to recurring back injuries that left her immobile. Her coaches pushed her to take medication and get back on the court, but she preferred her chiropractor’s approach. He told her, “ ‘When your body is in pain, it’s telling you something’s not working correctly, and you need to treat the problem, not the symptom,’ ” Hartmann recalled.
But after college, still suffering from debilitating back pain, Hartmann began to visit medical doctors for relief beyond what her chiropractor had advised. “Every single one of them wrote me a prescription for Percocet or Vicodin,” she said. By that time, Hartmann had a cousin who also had become addicted to opioids while recovering from injuries sustained in a car accident and eventually died of a cocaine overdose. Knowing that addiction ran in her family, Hartmann chose never to fill the prescriptions. Almost two decades later, Hartman has recovered from her sports injuries, but as the mother of two children, ages 6 and 9, Hartmann said she still has “pain every day of my life, but it’s pain that I can handle.”
She still ices her back and does stretching exercises daily, but on especially sore days, she turns to cannabis. Although debate continues about the effectiveness and risks of marijuana, it has become an increasingly popular alternative to opioids for chronic pain as states legalize its medical use. A 2017 report by the National Academies of Sciences, Engineering and Medicine found “conclusive or substantial evidence from randomized controlled trials that cannabis is effective for the treatment of chronic pain in adults.”
Smoking or consuming edible marijuana products helps relax her muscles, Hartmann said, and “takes the edge off” the pain while still allowing her to function normally. Hartmann and her husband grow marijuana plants legally for their own use as well as buy the substance from local dispensaries.
Hearing story after story from patients who became addicted to prescribed opioids led Dr. Jordan Klein to focus his pain management practice in Harrisburg, Pa., on reducing their use. Depending on the type of pain—musculoskeletal from physical injury; neuropathic, involving nerves; or related to diseases like cancer—Dr. Klein, a physical medicine and rehabilitation specialist, developed a treatment plan that includes painkillers like acetaminophen and ibuprofen. A recent study by the Minneapolis Veterans Affairs Health Care System found the two over-the-counter drugs to be equally effective and even superior to opioids for certain types of chronic pain. Dr. Klein also prescribes anti-seizure and anti-depressant drugs; Botox injections, which can relieve muscle spasms; modalities like transcutaneous electrical nerve stimulation (TENS), which blocks pain signals from reaching the brain; ultrasound therapy, which can reduce inflammation; and physical therapy.
Dr. Klein will prescribe opioids only when they are the most effective option. “If the patient has multiple rib fractures,” he said, “they need to be on narcotics, usually to control their pain and allow them to breathe. Anybody who has cancer, I never touch their opioids unless they want me to, since it’s been proven that opioids can help them.”
Many physicians, however, have simply reduced or eliminated opioid prescriptions for their patients without providing alternatives to prevent addiction and hopefully stem the rise in overdose deaths for which Pennsylvania has one of the worst rates in the country. While the American Medical Association and the Centers for Disease Control and Prevention have issued guidelines on opioid prescriptions aimed at reversing the crisis, they do not mention or recommend alternative treatments.
Dr. Klein discourages his patients from relying on benzodiazepines—often called “benzos” and usually taken for anxiety—like Ativan and Xanax, particularly if they are taking opioids. A 2018 study from the University of Pittsburgh School of Pharmacy found that taking benzos and opioids together can increase the risk of opioid-related overdose by up to five times.
As the United States grapples with the current opioid crisis, Dr. Klein says he is worried about a future benzodiazepine crisis, which may make opioid abuse even more deadly. Researchers from Harvard Medical School have found that prescriptions for benzos, which can also be addictive and carry their own overdose risks, are on the rise, more than doubling between 2003 and 2015.
As an alternative to opioids, Dr. Klein also has embraced the potential of medical marijuana for certain types of pain. While he stressed that cannabis is not a “magic bullet,” he has recommended it for many patients and said the results have been compelling. A 2014 study led by researchers at the Perelman School of Medicine at the University of Pennsylvania showed that states where medical cannabis has been legalized had significantly reduced rates of opioid-related death by an average of nearly 25 percent. Dr. Klein estimates that his own patients have reduced their opioid use between 50 and 75 percent after beginning treatment with cannabis.
While federal laws classifying cannabis as a Schedule I narcotic make research difficult in the United States, Israel has become a leader in exploring its potential. Dr. Elyad Davidson, an anesthesiologist and director of the pain relief unit at Hadassah Medical Center, said that while certain patients have found cannabis to be very effective, the experience is extremely variable. “We learn a lot from our patients, and it’s very valuable,” Dr. Davidson said, noting that the literature says that cannabis is more effective for neuropathic pain. “I would say that’s not always the case. But there’s no way that I can tell you who is going to be helped by it, and who is not.”
Dr. Davidson, who also heads the medical marijuana program at Hadassah Hospital, warned that cannabis should not be viewed as an “innocent medicine.” Although there is little risk of death from overdose, there are still many unanswered questions about the effects of long-term use.
One question he hopes to study is whether cannabis is effective in getting people off opioids, although Israel has not seen an epidemic on par with the United States. Opioid-related deaths in Israel have been assessed at about one-thirtieth of the number in the United States. In contrast, the CDC has measured a sharp rise in opioid-related deaths in America every year since 1999.
The question of saving lives urgently concerns Rabbi James Kahn, director of the Liberty Cannabis dispensary in Rockville, Md. A former educator at the University of Maryland Hillel and former director of chaplaincy at the Jewish Social Service Agency of Greater Washington, Kahn estimated that at least a quarter of his customers are seeking an alternative to opioids. He has taken a personal, even spiritual approach to alleviating pain, listening to patients tell their stories, choosing and adjusting products and treatments to find a minimal effective dose, and taking into account other aspects of a patient’s life, including sleep problems, anxiety and depression. “We’re striving to create dispensaries that reflect our values, which are very much Jewish values, especially the dignity inherent in each human being,” Kahn said.
Depending on state requirements, he explained, some dispensaries have a pharmacist onsite during store hours; others keep medical professionals on call. In Maryland, he said, “we are required to train all staff in the pharmacology of cannabis, adverse effects, signs of abuse, and to provide continuing education to ensure staff remain up-to-date on cannabis research and application.”
Living with chronic pain can be deeply damaging to the spirit, said Kahn, reducing our connection to others and taking us out of the present moment. He often meets people who believe pain has become part of who they are, which he calls the “oy vey syndrome,” and said it can be difficult to convince them that they deserve to live pain-free. “Suffering is not a mitzvah,” Kahn advised, quoting his father, Rabbi Jeffrey Kahn, who opened one of Washington, D.C.’s first dispensaries, Takoma Wellness Center, in 2013. Both companies, Kahn said, aim to challenge the stigma around cannabis and normalize, even “sanctify,” the experience.
Kahn recalled an incident at his father’s dispensary when an attempted robbery nearly prevented them from opening the store, until an elderly patient arrived in tears. “She had just gotten off of OxyContin, and she hadn’t slept in 48 hours,” Kahn said. “She was desperate. So we put duct tape over the bullet holes and opened the shop, and that lady, I’ll never forget her gratitude.”
Kahn believed that the stakes for this work could not be higher. “At this time in our history,” he said, “when the opioid epidemic is ravaging this country, we have to consider that cannabis is part of the solution. For people that believe in pikuach nefesh, in the value of a single life, how many could be saved by allowing people to try this medication? These are real lives at stake.”
Sarah Yahr Tucker is a writer based in Los Angeles. Her articles about health care and parenting have appeared in Vice, Good Housekeeping and Elle.