Dr. Alex Bekker Weighs in on Cannabis for Recreational Use

On election day earlier this month, 67% of New Jersey voters cast a ballot to legalize cannabis for recreational use. In light of this new development, NJMS professor and clinical chair of the department of physiology and pharmacology, Dr. Alex Bekker shared the following research and expert insights on cannabis.

Chronic pain is one of the leading causes of disability worldwide. Although acute pain is usually successfully managed with local anesthetics, such as NSAIDs or opioids, chronic pain is often challenging to treat. With a 20 to 30% prevalence in the general adult population and an annual cost in the US alone exceeding 600 billion dollars, it has enormous negative societal impact.

Opioids are commonly used to treat chronic (neuropathic) pain. Opioid consumption, however, is associated with numerous adverse effects and poses a risk of addiction. Thus the need to find viable alternatives to opioids has become progressively urgent. Given its antinociceptive properties and safety profile, cannabis has received increasing attention as both a substitute for opioid-bases pain treatment as well as a therapeutic strategy for opioid dependency. 

Cannabis has been used for medicinal purposes for thousands of years. The scientific studies elucidating mechanisms of these effects, however, begun in the late 60s with the discovery of the endocannabinoid system by Raphael Mechoulam.

Numerous clinical studies suggest that cannabis can indeed reduce opioid requirement in chronic pain patients. Our laboratory is focusing on the study of neuronal mechanisms of opioid-cannabinoid systems interaction. Like opioid mu receptors, cannabinoid receptors (CB1) are highly expressed in areas of the central nervous system involved with nociceptive signaling, including periaqueductal gray, locus coeruleus, ventral tegmental area, prefrontal cortex, caudate putamen, and nucleus accumbens. Our findings suggest that CB1 receptors are located on presynaptic terminals in the lateral habenula (LHb)as well. LHb is an epithalamic structure that attracted substantial attention due in part to its role in modulating opioid withdrawal symptoms.

Chronic opioid exposure can cause a paradoxical emergence of heightened pain sensitivity to noxious stimuli, termed hyperalgesia, which may drive to progressively increased use of opioids to manage worsening pain symptoms. Our results suggest that pain during opioid withdrawal is associated with the increased activity of the LHb. Cannabis activates CB1 receptors in the LHb mitigate LHb excitation and reduce hyperalgesia, which, in turn, reduces craving and escalation of opioid seeking behavior in chronic pain patients (3). The proposed mechanism is one of several other interactions between endocannabinoid and opioidergic systems that contribute to the beneficial effects of cannabis in reducing opioid dependence.

Although there is a lack of clinical observation supporting the use of cannabis for treating opioid addiction, several epidemiological investigations in states with legal cannabis demonstrated the promising role of cannabis in the opioid crisis. The implementation of both medical and recreational cannabis laws significantly reduced a number of opioid overdoses, mortality of opioid positive automobile accidents, and opioid prescription rates.

These epidemiological impacts are not exclusive to opioids; states with legalized cannabis observed a significant decrease in Medicare and Medicaid spending on anxiolytics, antidepressants, anti-inflammatory, antiemetics, antispasmodics, and drugs for sleep disorders.

Some studies have suggested that cannabis might preferentially target the affective aspects of pain and that cannabinoids induce anti-anxiety effects. One of the beneficial mechanisms of cannabis use for pain disorders could be related to its ability to alter the reactive thoughts regarding negative feelings associated with pain. Thus, cannabinoid might positively affect a patient's awareness of pain and improve coping mechanisms. The dissociation of objectively measured pain outcomes (i.e., pain assessment scores) from the perception of pain might explain the minimal effects of cannabis reported by some authors. Thus, it is imperative to develop a tool that assess the comprehensive effects of the therapy, including the increased ability to sleep, focus, and function.    

Safety considerations related to the medical applications of cannabis is a concern among healthcare providers. A significant portion of our research is dedicated to evaluation of the safety profiles of cannabis. It is imperative to assess the safety of cannabis according to scientific facts rather that than popular beliefs and misconceptions. The review of literature and a number of meta-analysis suggests that the majority of cannabis users will not suffer lasting adverse consequences. According to the FDA Adverse Event Reporting System, 2,155,067 serious adverse effects, including 196,807 deaths have been directly related to the FDA approved drugs in 2018.

In contrast, there is no reported death associated with the use of cannabis. Overall, by comparison with other recreational drugs, cannabis could be rated to be a relatively safe drug.

To learn more or to view citations for this piece, contact Dr. Alex Bekker at bekkeray@njms.rutgers.edu