Medical marijuana in Pennsylvania can be prescribed for some of the same conditions that opioid painkillers treat, and can even be used to help with opioid abuse.
Not everyone in the medical community is sold.
“There are no adequate studies showing marijuana is effective for general medical use, let alone to treat opioid addiction — a chronic and fatal disease that requires tested and proven lifesaving treatment,” says Dr. Joseph Garbely, vice president of medical services and medical director at Caron Treatment Centers, which specializes in addiction.
Leah Heise, on the other hand, has both a personal and professional stake in cannabis' promise for replacing or reducing opioid use.
Heise is chief experience officer for 4Front Holdings LLC, owner of the Mission medical marijuana dispensary at 2733 W. Emmaus Ave. in Allentown.
“I was diagnosed with chronic pancreatitis in 2001 and at the time I was told that I would never be able to work again and that I would only live five years,” Heise said last week. “The treatment for chronic pancreatitis is to starve yourself because you don't want your digestive system working, your pancreas to work — and very high levels of methadone and Xanax. That was my pain protocol for 16 years, was 80mg of methadone, Xanax.
“I was pretty much a zombie.”
Today, Heise uses a 20:1 CBD-to-THC-ratio medication, meaning it is heavy on the CBD extracted from cannabis and very light on the plant's THC component that gets users high.
“For me it reduced the inflammation in my digestive system completely and I'm now down to 10mg a day of methadone,” she said. “So I still use the cannabis as both a pain relief, the inflammation reduction and to help with any particular side effects I may have as I go through the weaning process to get off of methadone finally.”
Heise, who lives in the Baltimore area, gave lehighvalleylive.com a tour of Mission's sales floor last week, along with Matt Pulcini, a doctor of pharmacy and one of several pharmacists on staff there.
“It's a miracle plant for sure, it really is, a miracle plant,” Heise said.
Pennsylvania permits medical marijuana for 21 conditions, and Health Secretary Rachel Levine is reviewing a Medical Marijuana Advisory Board recommendation to add anxiety and Tourette's syndrome to the list. There is no timetable on her approval, Pennsylvania Department of Health spokesman Nate Wardle said last week.
Open since last June 12, the Allentown dispensary is one of several Mission locations in Illinois, Maryland, Massachusetts and Pennsylvania. The company has licenses to open up two more in Northeast Region 2 that covers the Lehigh Valley and extends along the borders with New Jersey and New York.
“When I first came to this location, we had a couple of open houses and I started to see the outpour of patient support and who was here looking for this other option of therapy. It really blew me away,” Pulcini said. “I remember thinking, if we can just help some of these patients this is going to be great, and it's been more than I could have even imagined.”
Mission, like other Lehigh Valley dispensaries in South Whitehall Township and Bethlehem, offers a patient-focused experience to see what cannabis products are appropriate. “Start low and go slow and find a right dose for patients,” is how Pulcini describes the approach.
Cannabis can offer relief without the risk of overdose, according to Mission. Opioids attach to brain receptors in much the same way cannabis works with the body's endo-cannabinoid system. But a big difference is cannabinoids don't tell the brain to depress respirations like opioids can, which is how an opioid overdose kills.
“So you cannot overdose on it,” Heise said.
One of the shortcomings with cannabis, however, is a lack of peer-reviewed research, stemming from its federal status as an illegal narcotic. That's why dispensaries need to take a one-on-one approach with patients, rather than simply prescribe an FDA-approved dose.
But it's that lack of research that has pain-management and addiction specialists skeptical, particularly when it comes to using marijuana to reduce opioid abuse.
“While some patients report pain relief or decreased opioid use when they use marijuana, there are no medical studies that demonstrate that it is effective for treatment of opioid use disorder,” Dr. Thomas Nappe, director of the Department of Medical Toxicology at St. Luke's University Health Network, said in a statement.
“However, there are several accepted treatments for opioid use disorder, with proven efficacy, including buprenorphine and methadone. Marijuana continues to be studied in many aspects, but it is yet to be determined if it will help alleviate or contribute to the opioid crisis,” Nappe continued.
Caron Treatment Centers, based in Wernersville, Pennsylvania, has declared marijuana is not a Band-Aid for the opioid crisis.
“We should be focusing on proven addiction treatment methods that we know work and have been studied extensively, not bringing in another substance that has known and documented addictive qualities and little to no research on its use and efficacy as a medical treatment,” Garbely, the Caron medical director, said in a statement last April urging the state health secretary to cut opioid use disorder from the list of medical marijuana-approved conditions.
In New Hampshire, the plague of opioid-related overdoses and addiction has Gov. Chris Sununu putting the brakes on legalization of recreational marijuana, The New York Times reported last month: “When we are dealing with opioids as the single biggest health crisis this state has ever had, you are going to tell me legalizing more drugs is the answer?” Sununu said. “Absolutely not.”
Dr. Andrew Koons, an emergency medicine physician and medical toxicology fellow at Lehigh Valley Health Network, is working to establish a local observational study to track opioid addicts who are prescribed medical marijuana, to see whether their dependence goes down. There is a strong need for studies like these in people for whom other opioid-reduction treatments have failed, he said.
“This is all based on the fact that really this has to be initially very closely medically managed by a physician or a pharmacist or some sort of specialist just because we don't know all the side effects so far,” Koons said, calling known side effects of marijuana “pretty benign” compared to opioids.
Pennsylvania has been filling marijuana prescriptions since February 2018, with Keystone Canna Remedies in Bethlehem the first to begin selling it. Transactions are still cash-based, due to cannabis' federal status, but dispensaries like Mission have begun using cash-transfer apps to help patients avoid ATM and other fees. Health insurance doesn't cover it.
A patient experimenting with medical marijuana can expect to pay about $100 on their first visit, according to Mission. That's on top of the doctor's fee of $200 to $250 to be approved for a marijuana card, which itself costs $50.
“But as you grow with the products you’re using and how often you’re using it and what your maintenance dose will look like, it could grow it could be less,” said Pulcini, the pharmacist.