LETHAL SMOKE SCREEN: MARIJUANA, TOBACCO, CHRONIC PAIN, AND THE OPIOID CRISIS
By Clark Miller
Published September 13, 2018
Updated April 4, 2021
Medical model response to the national opioid crisis gets it backwards. Marijuana use, often disallowed by healthcare providers or programs for patients with chronic pain or using prescription opioids, is supported by research as providing benefit in managing chronic pain and reducing dependence on opioid medications. In contrast tobacco use, long ignored or enabled by medically-managed programs especially in substance use treatment settings, is established by research as contributing to development of chronic pain syndrome, as worsening perception of chronic pain, and as a “gateway drug” for return to problem alcohol and opioid use.
That research and its importance are not shaping and improving healthcare policy and use of public healthcare funds generally including in some areas most affected by problem opioid use.
The importance of research-driven effective responses to smoking as a public health problem and its direct and indirect effects is profound. Health care system and social costs of tobacco use eclipse those of opioids and illicit substances combined, and tobacco use is directly related to the opioid crisis – an epidemic generated largely by inappropriate use of addictive opioid medications for chronic pain. Tobacco use is established (below) as contributing to the causes of chronic pain conditions and to worsened perception of chronic pain.
Coastal rural Oregon, hard-hit by the opioid crisis,
is a confluence – of rivers and tides; new and old cultural forces; of progressive ideals and policies running against regressive and compromised institutions including a Managed Healthcare Insurance Industry that rejects evidence-based practice and clinical expertise, supports with public funds invalidated practices with no predicted benefit including coerced religious programming, and banned an invited, reviewed and approved professional presentation challenging effectiveness of those practices.
Those scientifically, ethically, and medically compromised practices by organizations controlling public healthcare funds and how they are used to address current crises, like Columbia Pacific Coordinated Care Organization (CPCCO) in Oregon, represent unacceptable risk: of threats to public health; of abuse of public healthcare funds; and of continuation of the epidemics.
Health care system and social costs of tobacco use eclipse those of opioids and illicit substances combined, and tobacco use is directly related to the opioid crisis . . . contributing to the causes of chronic pain conditions and to worsened perception of chronic pain.
What does the research say
about marijuana use, tobacco use, and chronic pain as related to the opioid crisis, and about how public healthcare funds should be effectively used for those problems?
[See numbered links to the primary research at bottom this post.]
There is no research pointing to increased risk of harm due to therapeutic use of Marijuana concurrently with opioid pain medication
Accumulating research(1) supports beneficial effects in reduced chronic pain perception with use of Marijuana
In therapeutic practice, correlational evidence suggests Marijuana use can reduce perceived need and use of opioid pain medications (2)
Concerns about lasting effects attributable to Marijuana use by youth is not supported by the most current evidence(3), moderating risk profile for Marijuana use.
In distinct contrast for tobacco use:
Extensive research supporting the role of tobacco use in etiology (cause) of chronic pain conditions including fibromyalgia, lower back pain, rheumatoid arthritis and in exacerbated perception of chronic pain(4)
and increasing risk of continued or return to problem use of substances including opioids (acting as a “gateway drug” for opioids)(5-7)
Recognition of the research-based links among tobacco use, chronic pain, and problem opioid use has led progressive, evidence-based programs to begin making tobacco cessation services a key component of addressing the opioid crisis(5,7)
In the context of an opioid crisis continuing to claim lives, how effectively are business-model controllers of public healthcare funds, like Columbia Pacific CCO, providing evidence-based services to vulnerable Americans trapped in the epidemic?
Here’s what it looks like in hard-hit rural coastal Oregon
I Columbia Pacific CCO has failed to support clinical practices that would support patient use of Marijuana to assist, as supported by research, in managing pain without opioids while tapering off prescribed opioids, instead recommending clinical policy that would abruptly end prescription of opioids if a urine drug test is positive for THC, leaving patients – who generally were provided the opioids in medical settings overseen by Columbia Pacific CCO – at risk of turning to illicit opioids – “on the street”. Clinic chronic pain and opioid prescription policies, as guided by the CCO, ignored the established role of tobacco in worsening chronic pain and risk of problem opioid use.
II Columbia Pacific CCO uses public healthcare funds to exclusively support Treatment as Usual (TAU) for substance use problems, TAU established by decades of research to predict no benefit or harm for problem substance use and to increase risk of tobacco use.
For example, TAU is wedded to and incorporates 12-Step programming -a set of religious prescriptions completely unrelated to treatment for substance use disorders – and encourages or requires participation in meetings of the religious subcultures (like Alcoholics Anonymous and Narcotics Anonymous) identified with 12-Step practices. At those meetings, addictive use of tobacco – arguably the most lethal and addictive substance among public health threats –is encouraged in a variety of ways. At meetings, tobacco use is:
– socially reinforced – used to connect socially, feel accepted
– ritualized – a reliable, structured part of the experience, a habit
– normalized – ignored as an “addiction”, accepted as something different
– sometimes rationalized – Don’t worry about smoking, focus on your alcohol use
– and rewarded – each time smokers are celebrated for being “clean and sober” while remaining dependent on tobacco
III Columbia Pacific CCO uses public healthcare funds to support New Age remedies with no support by research for effectiveness in treating a life-threatening substance use disorder -tobacco use. Creating the belief in smokers that the practices without evidence of effectiveness are treatment for their lethal compulsive behaviors – and billing Medicaid funds for the group sessions – causes harm and looks a lot like abuse of public funds.
IV Columbia Pacific disseminated clinical practice advice to healthcare programs for tobacco cessation practices, by employees presented by Columbia Pacific as “experts” in the required areas of interpretation of research, substance use problems, and evidence-based practices for substance use. But none of the “experts” had competence or expert background in those areas, neglected to review the current research, and disseminated inaccurate information – recommending use of nicotine replacement products to help stop smoking, when current research points to no benefit from that approach.
Each of these failures by a business-model managed care organization
to use public healthcare funds effectively for beneficial services deprived Oregonians of effective treatments for the highly addictive and lethal problem of tobacco use, thereby also contributing to risk of problem opioid use and perpetuation of the opioid crisis.
Consistently in these examples the business-model managed healthcare system, allowing insurance companies to use control of public healthcare dollars to drive and determine clinical practices is failing to support effective evidence-based practices for vulnerable Americans trapped in opioid and other substance use epidemics, failing egregiously in hard-hit rural Oregon.
The harmful and increasingly lethal consequences may be predictable based on consideration of the values, competencies, and orientations of professionals selected, employed by and functioning in managed care organizations. To meet job expectations in a business-model organization driven to reduce costs of healthcare requires values and competencies different from those necessary to provide healthcare services competently, directly and ethically. From all appearances, in the areas of behavioral health services, research analysis and synthesis, and substance use treatment, Columbia Pacific CCO, for example, is operating in a clinical and ethical vacuum, with predictable malfeasance and public harm.
Columbia Pacific isn’t acting alone as an institution entrusted with the health, lives and wellbeing of vulnerable Oregonians in need of effective healthcare or in the malfeasant provision of inaccurate health information predicting harm. Oregon’s medical, research, and teaching university, Oregon Health & Sciences University (OHSU) is entrusted to provide research-based clinical practice knowledge, guidance, and consultation and support for medical and behavioral healthcare in the state.
Through its online ECHO program, for example, OHSU provides consultation and training for medical and other professionals in areas of medical, psychiatric, and behavioral health practices, and specifically Medication-Assisted Treatment (MAT) aimed at moderating the opioid crisis and focused on use of the partial agonist Suboxone and other medications.
Unfortunately, the medical experts providing that guidance, training, and consultation in areas of behavioral health, substance use, chronic pain, and evidence based practice (EBP) treatment for those areas of practice, are outside scope of competence and unable to provide valid guidance. That scope of competence problem arises because problems in those areas are not medical conditions at all and are not usefully conceptualized or treated as medical conditions. The distorted attempt by the medical industry to force chronic pain into a medical model, for example, is essentially responsible for the opioid crisis and perpetuates a national substance use epidemic.
As observed directly in the ECHO series of presentations on MAT:
The trainers were unable to recognize, pull together and use the current research related to marijuana and tobacco use as related to chronic pain, resulting in dissemination of misinformation placing Oregonians at risk of harm.
Marijuana was treated as a prohibited or contraindicated substance in practices for tapering dependent patients off prescribed opioids, despite evidence of benefit from marijuana use in reducing use of opioids for pain.
Tobacco use was ignored and enabled – expert presenters endorsing invalidated treatment as usual (TAU) for substance use, including positive orientation of opioid/MAT patients to recovery models including the religious subcultures AA and NA, with no treatment benefit and where use of tobacco is normalized, socially ritualized, and socially reinforced.
That is, the expert presenters at the state’s trusted research and medical sciences university were a decade or two behind the research evidence, with dissemination of health practice misinformation with associated predicted public harm.
Progress against an opioid crisis and national substance use epidemic will require system-level changes, most importantly rethinking of substance use itself and its treatment. It will require a shift to institutions and managers of public healthcare funds with the capacity for competence, critical thought, and ethical behavior.
Research References and Links
- National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. doi: 10.17226/24625.
- Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018;178(5):667–672. doi:10.1001/jamainternmed.2018.0266
- Scott JC, Slomiak ST, Jones JD, Rosen AFG, Moore TM, Gur RC. Association of Cannabis With Cognitive Functioning in Adolescents and Young Adults A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online April 18, 2018. doi:10.1001/jamapsychiatry.2018.0335
- Ditre, J. W., Brandon, T. H., Zale, E. L., & Meagher, M. M. (2011). Pain, nicotine, and smoking: Research findings and mechanistic considerations. Psychological Bulletin, 137(6), 1065-1093.
- Smita Pakhale, Tina Kaur, Catherine Charron, Kelly Florence, Tiffany Rose, Sadia Jama, Robert Boyd, Joanne Haddad, Gonzalo Alvarez, Mark Tyndall. Management and Point-of-Care for Tobacco Dependence (PROMPT): a feasibility mixed methods community-based participatory action research project in Ottawa, Canada. BMJ Open, 2018; 8 (1): e018416 DOI: 10.1136/bmjopen-2017-018416
- Jin H. Yoon, Scott D. Lane & Michael F. Weaver (2015) Opioid Analgesics and Nicotine: More Than Blowing Smoke, Journal of Pain & Palliative Care Pharmacotherapy, 29:3, 281-289, DOI: 10.3109/15360288.2015.1063559