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No Cannabis Before OUD Treatment Policy Challenged

New research challenges the policy of some opioid use disorder (OUD) treatment programs that require patients to abstain from cannabis before qualifying for treatment.

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Pooled data from 10 longitudinal studies showed cannabis use had no statistically significant effect on use of nonmedical opioids, defined as opioid use outside medical guidance, in patients receiving US Food and Drug Administration (FDA)–approved medications for OUD (MOUD).

"Cannabis use should not be a barrier to receiving life-saving medications for opioid use disorder," lead investigator Joao P. De Aquino, MD, from the Department of Psychiatry at the Yale University School of Medicine, in New Haven, Connecticut, told Medscape Medical News.

"Policies that mandate abstinence from cannabinoids as a requirement for MOUD should be reconsidered," De Aquino added.

The study was published online on January 16, 2024, in the American Journal of Drug and Alcohol Abuse.

Filling a Knowledge Gap

The rationale for the study was that the relationship between cannabis use and the risk for relapse to opioid use among people with OUD has been unclear, with data suggesting that cannabis use may either negatively or positively impact OUD outcomes.

"Clarifying how cannabis and opioids interact is crucial if we are to equip healthcare professionals to provide evidence-based addiction treatment, prevent overdose deaths, and save lives," first author Gabriel Costa, from the University of Ribeirão Preto in Brazil, said in a news release.

To address this knowledge gap, the study team conducted a systematic review and meta-analysis to quantify the potential effects of cannabis use on the risk of returning to nonmedical opioid use in patients currently receiving one of the three FDA-approved MOUD: Methadone, buprenorphine, or intramuscular, extended-release naltrexone.

The meta-analysis included a total of 8367 individuals with OUD (38% women), who were followed for an average of 9.7 months. Approximately, 76.3% of individuals received methadone, 21.3% buprenorphine, and 2.4% intramuscular, extended-release naltrexone.

Cannabis did not significantly affect the risk of using of nonmedical opioids (pooled odds ratio, 1.00; 95% CI, 0.97-1.04; P = .98).

The results were consistent in subgroup analyses focusing on individual pharmacotherapies for OUD.

"These findings neither confirm concerns about cannabis increasing nonmedical opioid use during MOUD nor do they endorse its efficacy in decreasing nonmedical opioid use with MOUD," the authors noted in their article.

"Our data suggests the need for individualized OUD treatment approaches which take into account each patient's circumstances," De Aquino told Medscape Medical News.

"Effective treatment should involve evaluating patients for cannabis use disorder, a condition of dependence on cannabis leading to substantial impairment or distress, affecting approximately 30% of persons who use cannabis regularly; providing comprehensive pain management; and addressing co-occurring mental health conditions such as depression and anxiety, which are frequently cited motivations for cannabis use," De Aquino noted.

Limitations of the meta-analysis included heterogeneity and how the included studies were conducted. This included differences in how cannabis and opioid use were measured and variations in baseline opioid use status. Furthermore, while the findings related to general patterns of cannabis use among people with OUD, they may not extend to individuals with OUD who have cannabis use disorder.

Individualized Approach Best

Commenting on this research for Medscape Medical News, Scott Hadland, MD, MPH, chief of adolescent and young adult medicine at Mass General for Children, Boston, Massachusetts, said, "Ideally, treatment should be patient-centered. When someone is receiving care for an opioid use disorder and is also using cannabis, we as clinicians should be working with the patient to determine whether they're interested in and able to cut back on their cannabis use at the same time as their opioid use."

"In many cases, patients choose not to make changes to their cannabis use. This might be because they have physical pain and cannabis might be helping to control it. There are lots of other reasons patients might choose to continue their cannabis use," Hadland said.

"Regardless, we always want to meet the patient where they are and support any positive changes they're seeking to make with their opioid use, even if they aren't able to make changes in their cannabis use," he told Medscape Medical News.

Hadland said a noteworthy finding in this study is that cannabis use doesn't necessarily help people discontinue opioids.

"Some have argued that cannabis might be a 'replacement' of sorts for opioids (since, for example, they can both address symptoms of physical pain), but these data suggest that cannabis may not necessarily help in this way," Hadland said.

Funding for the study was provided by grants from the National Institute on Drug Abuse and Doris Duke Charitable Foundation. De Aquino was supported in clinical trials by Jazz Pharmaceuticals, specifically through medication provisions, and was a compensated consultant for Boehringer Ingelheim. Costa and Hadland had no relevant disclosures.