There's a situation that happens almost daily in Alisha Shoemaker's Oneida, Tennessee, medical clinic. A new patient walks in looking for a doctor. The friendly receptionist asks if he has a specific issue he needs addressed, or if he's simply in need of a primary care provider.
"I was in a work accident; I have back pain," he says.
The tenor in the waiting room changes.
"We don't do pain pills," says the receptionist, less friendly than before.
Of course, the practice gives out prescriptions for opioid painkillers like OxyContin, Vicodin, and Percocet. It has to, since sometimes patients need them. But Shoemaker and her partner, Gracie Burke, both nurse practitioners, are seeing patients like this man—who, based on their experience, may be shopping for a doc with an itchy prescription-writing hand—coming through their doors all too often.
"It's really bad. It's a crisis, especially in this area," Shoemaker says. Oneida is a former coal-mining town of about 3,700 near the Tennessee-Kentucky border, though the mines have been closed for decades. The average household income is less than $32,000, and almost 30 percent of all families with kids fall under the poverty line. According to the National Prescription Audit, there were between 96 and 143 prescriptions for opioid painkillers for every 100 Tennessee residents in 2012. Basically, almost everyone has one prescription to their name, though some people have more.
When Shoemaker does take on a patient with a painkiller dependency, she uses every tool at her disposal to try to get them off the pills completely—and that's the best-case scenario. If she can't do that, she'll at least try to ease them down to the smallest possible dose. Her protocol goes like this: "We start with non-controlled medicines, physical therapy; we use imaging to confirm what's really causing the problem, then we move to less controlled medicines," she explains. But there's one tool she wishes she could use: marijuana, either medical or recreational.
"I have some patients I would absolutely prescribe it for. When I was working in Atlanta, we had a cancer patient that we gave Marinol (a man-made, medical marijuana drug) to and you could see it working. You would see a big difference very quickly; it really improved their quality of life," she says. (The US Food and Drug Administration approved Marinol in 1985.)
But in Tennessee, marijuana is illegal in all applications. Earlier this year, a medical marijuana bill lasted only a few weeks before being withdrawn in late March. And legalizing the stuff outright? Forget about it.
Meanwhile, opioid manufacturers continue to pour money into state legislators' coffers. An investigation by the Associated Press and the Center for Public Integrity found that, over the past decade, drug companies threw $1.6 million at Tennessee elected officials, who repeatedly voted against limits on opioid prescriptions even as overdose deaths spiked in their hometowns.
Far from the marble floors and high ceilings of the Tennessee state house, back in the green hills of Appalachia, medical professionals and patients alike are asking the same question: Could marijuana be a life raft out of this sea of painkillers?
It's a life raft with a slow leak at best. Not only is research on both medical and recreational marijuana sparse, but the legalities are confusing, especially for medical professionals. Still, in a moment of dire need—more than 33,000 people died from opioid overdoses in 2015, with painkiller ODs outnumbering those from heroin—a leaky raft starts to look pretty appealing. Some people who get addicted to painkillers turn to heroin after they run out of doctors willing to write them scripts; heroin is cheaper than buying pain pills on the street. More and more doctors find that they're facing a tough choice: Join the band that's stoically playing on by handing out more prescriptions, or make like the rats and fling themselves overboard, hoping for a better outcome.
The hardest thing about comparing marijuana to prescription painkillers is the paucity of research, especially when it comes to recreational use. Because the Drug Enforcement Agency considers marijuana a schedule 1 drug, with no accepted medical uses, studying it with federal dollars is tricky. Getting funding from the National Institute on Drug Abuse for marijuana research is possible, but it's easier to score research grants if your hypothesis is one testing the negative impacts of the drug, says Karen Lounsbury, a pharmacology professor who teaches a medicinal marijuana course at the University of Vermont's Larner College of Medicine. Colorado is funding medical marijuana research with tax revenue from pot sales but most of the grants have gone to the University of Colorado.
If you do get funding for medical research, the only kind of weed you're allowed to use right now is a single strain grown at the University of Mississippi, says Kevin Gilliland, executive director of Innovation360, a Dallas, Texas-area drug and alcohol treatment facility, and a psychology instructor at Southern Methodist University. But there are a dizzying array of strains available in places where pot is legal (and in places where it isn't). So what's being studied and what's being consumed could be strikingly different. They certainly look, uh, different.
While US institutions are wringing their hands over the fact that they can't do much in the way of research on managing pain with marijuana, recreational users are marching the process forward without them. Sites like Leafly allow people to log their experiences with a specific strain. As more users have signed up, the database has grown, so people can now search which varieties helped others with migraines or fibromyalgia, or managing appetite during chemotherapy, and choose accordingly. Sure, crowdsourcing your medication needs probably isn't ideal, but at some point, a large collection of anecdotes does become (possibly flawed) data.
Consumer cannabis brands are also stepping in to fill the void. California-based Hmbldt sells metered-dose vape pens in four formulas, including one for pain relief, that deliver targeted blends of cannabinoids and THC while minimizing psychoactive effects. Businesses are working toward pot for pain whether the government is on board or not. Meanwhile, our Canadian neighbors just introduced legislation that would legalize weed nationwide.
The Trump administration seems intent on using the lack of positive research (along with some serious narc-style attitudes) to shape its policies. Hints of marijuana enforcement crackdowns have come from both Attorney General Jeff Sessions and Press Secretary Sean Spicer. But what the feds are going to do and what we probably should do are two completely different things (for more on that, see all of 2017). If you ask researchers, physicians, and drug abuse specialists whether legalizing weed could be our life raft, their responses are much more nuanced and thoughtful than those from the administration (surprise, surprise).
"I wouldn't say we should stop handing out opioids completely. There's still nothing better than opioids when it comes to managing pain. They work," Lounsbury says, though adding that people addicted to pain pills, probably "don't want to just jump into using marijuana, because you could trade one dependency for another."
No matter what your stoner friends say, marijuana can be addicting. "We used to say that there was no physical dependency on pot, that it was a psychological dependency only," Gilliland says. "But you can't say that anymore," he says, adding that there's now clear evidence that marijuana dependency is a real issue. It's called cannabis use disorder and it's in the Diagnostic and Statistic Manual of Mental Disorders, though a 2015 study found that two-thirds of people with CUD no longer met the criteria after three years.
Plus, cannabis is not totally innocuous. In the year after Colorado legalized weed, the rates of patients admitted to the ER with cannabis-related emergencies tripled, says Esther Choo, an emergency room physician in Oregon and an associate professor of emergency medicine at Oregon Health & Science University. She sees plenty of patients who have eaten a fistful of pot brownies, done something supremely stupid, and ended up in her ER.
That being said, "If it's between trading one vice for another [in this case, weed for opioids], yeah, I'd make that trade any day," Gilliland says. He points out that while using pot is very unlikely to kill you, opioids are far too lethal to have floating around in bathroom cabinets.
The problem is that opioids slow your pulse and breathing rate, says Choo, who wrote a November editorial in JAMA entitled "Opioids Out, Cannabis In." While you'll continue to breathe even when you black out from drinking too much, that's not always the case with opioids. "They have a really potent depressant respiratory effect and it's compounded when you're mixing them with other medications," she says. Gilliland adds, "The margin for error is so slim with opioids; it's why we see so many deaths."
While there's still a lot we don't know about marijuana's clinical value, research is starting to trickle in, with some of it is examining this exact issue. A 2014 study from JAMA Internal Medicine found that states with medical marijuana laws had opioid overdose death rates that were 24.8 percent lower than states without medical marijuana. And a 2017 study in the International Journal of Drug Policy found that, when medical marijuana was available in Canada, 63 percent of patients reported choosing it over prescription drugs, including 30 percent who subbed pot for opioids (the study, however, was funded by a marijuana company).
Both Choo and Lounsbury say this initial research is encouraging, and that it's spurring conversations within their professional communities. But medical marijuana isn't legal everywhere, so the question becomes whether recreational use (legal or not) would help people manage their pain and thereby curb the number of opioid prescriptions.
"I think one of the missing pieces here is more data about who is using it recreationally," says Marcus Bachhuber, an assistant professor of medicine at Albert Einstein College of Medicine and lead author of the 2014 JAMA study. "Some preliminary work we've done in Colorado suggests that many people in the recreational market report using marijuana for pain and sleep. If that is widespread and people are replacing opioids with marijuana then we could see a difference in overall prescribing. But it's all speculation at this point."
Currently, 28 states and Washington, DC have medical marijuana programs and eight of those states have legalized weed outright. For cannabis users who live in the 42 states without legal weed, or those in the 28 medical states who don't have a prescription card, it means they're buying weed from a dealer rather than at a licensed dispensary. If they need something for pain relief, they're relying on the dealer's knowledge. Still, the experts we spoke to were even cautious about dispensaries.
"Self-prescribing anything is always risky," Lounsbury says, adding that, because you don't have a medical professional walking you through the process of selecting the right drug for your condition, you may end up with the wrong kind of marijuana—or with something that interferes with other medicines you're taking. "People working in dispensaries are mostly trying to make a sale," she says. "And the people growing are trying to breed a product that grows well. They're botanists, they don't have a pharmacological-type background."
Gilliland adds that the marijuana that's available in most recreational shops these days is very different from what your parents grew back in the day. "In the 90s, most pot was 3 percent THC. There was recently a study that showed that in 2012 or 2013, average THC levels among popular strains were 12 percent. It's common to even find pot that has THC levels up to 25 percent," he says. In Colorado, some samples had 30 percent THC or more. So unlike a pure medical product with carefully managed THC and CBD levels, you may instead get a super high complete with unpleasant side effects, like paranoia.
But bud tenders working in dispensaries argue they're not clueless. Legally, recreational dispensary employees can't give any sort of medical advice to consumers. They're not even supposed to mention a product's potential benefits, even if research supports the claims. But a source we talked to, who works in a Washington state dispensary and asked to use the pseudonym Sarah to protect her identity, says it isn't quite the blind leading the soon-to-be-stoned.
She and her colleagues have all been trained on the different varieties and their benefits. Furthermore, thanks to anecdotal reports from past clients, she's started to form a mental database of what works in different situations. She takes her job seriously, too. "There are a million ways to consume THC and CBD now; it's our job to help people find the best way for them," Sarah says. "If someone comes in with their grandma and says, 'she's never tried pot,' well then, it's my responsibility to make sure she doesn't have a horrific first experience."
More and more, Sarah is seeing customers who hope to find something that will help them avoid painkillers. "Sometimes they'll say, 'they put me on pain pills after a surgery and they were awful. I want something else,'" she says. A few days ago, a cannabis supplier dropped off stickers reading "Fuck Opioids." They were a marketing piece for their newest product, billed as "capsules for people who take pills."
While none of the doctors or nurse practitioners we interviewed for this story are ready to sign off on "fuck opioids" pills, there is one common theme among all of them: We have to do something about this crisis, and preferably sooner rather than later. "There are 100 million Americans suffering from chronic pain of one type or another. And chronic pain is horrible. We need to be able to help them and we really need some alternatives for pain medicines," Gilliland says. So is letting Joe Pain Pill User into a legal pot shop a possible solution? "I'm not going to say that pot is without its side effects, but it really is a better bad choice." And if that's not an endorsement for abandoning the ship for a leaking life raft, we don't know what is.
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