Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review

Background Medical cannabis (MC) is currently being used as an adjunct to opiates given its analgesic effects and potential to reduce opiate addiction. This review assessed if MC used in combination with opioids to treat non-cancer chronic pain would reduce opioid dosage. Methods Four databases--Ovid (Medline), Psyc-INFO, PubMed, Web of Science, and grey literature--were searched to identify original research that assessed the effects of MC on non-cancer chronic pain in humans. Study eligibility included randomized controlled trials, controlled before-and-after studies, cohort studies, cross-sectional studies, and case reports. All databases were searched for articles published from inception to October 31, 2019. Cochrane's ROBINS-I tool and the AXIS tool were used for risk of bias assessment. PRISMA guidelines were followed in reporting the systematic review. Results Nine studies involving 7222 participants were included. There was a 64-75% reduction in opioid dosage when used in combination with MC. Use of MC for opioid substitution was reported by 32-59.3% of patients with non-cancer chronic pain. One study reported a slight decrease in mean hospital admissions in the past calendar year (P = .53) and decreased mean emergency department visits in the past calendar year (P = .39) for patients who received MC as an adjunct to opioids in the treatment of non-cancer chronic pain compared to those who did not receive MC. All included studies had high risk of bias, which was mainly due to their methods. Conclusions While this review indicated the likelihood of reducing opioid dosage when used in combination with MC, we cannot make a causal inference. Although medical cannabis' recognized analgesic properties make it a viable option to achieve opioid dosage reduction, the evidence from this review cannot be relied upon to promote MC as an adjunct to opioids in treating non-cancer chronic pain. More so, the optimal MC dosage to achieve opioid dosage reduction remains unknown. Therefore, more research is needed to elucidate whether MC used in combination with opioids in the treatment of non-cancer chronic pain is associated with health consequences that are yet unknown. Systematic review registration This systematic review was not registered. Keywords: Opioid epidemic, Medical cannabis, Opioid substitution, Opioid crisis