Michael Schatman, PhD, is the director of research and network development at Boston Pain Care, an adjunct clinical assistant professor of public health and community medicine at Tufts University, and the editor-in-chief of the Journal of Pain Research. Here he discusses pain medicine in the midst of the opioid crisis and the rise of medical marijuana.
Considering the consistent public pressures against opioid medication, what is the current state of opioid prescribing?
Michael Schatman, PhD: Right now, there are two factions out there: those who want to take away opioids from everyone and those who, it seems, believe that everyone who has chronic pain should be on opioids. And it’s a real problem because somewhere in between the truth lies. Unfortunately, we’re not getting the truth. We’re not getting the truth, for example, from the CDC in terms of opioid mortality. Dr. Steve Ziegler and I published an article last October on prescription opiate mortality and the CDC’s gross exaggeration of it in order to further their agenda, which is to get rid of opioid analgesia for chronic pain in this country.
What is the breaking point for this war? Is there any possibility for a stand-down?
On the other side are the people who are the anti-opioid faction. The CDC is part of that; they want to do away with opioid analgesia altogether. The moderate position is that opioids can be effective. Yet they’re associated with very dangerous, iatrogenic complications. Yet, sometimes—particularly in underserved areas—there aren’t a lot of real good options. Playing into this is the insurance industry that each year seems to pay for fewer and fewer safe and effective options.
So, right now you have the two sides at each other’s throats. And what I’ve been working on lately is connecting with people who are seen as anti-opioid and talking about rapprochement. And interestingly, they have been very receptive, and these are people whom I’ve fought in the past because they saw me as pro-opioid, and I’m not pro-opioid. I’m not anti-opioid. I’m pro-patient. And interestingly, that seems to be very unpopular stances for people who are fixated for or against opioid analgesia for chronic pain and unfortunately now for acute pain as well, including postsurgical pain.
Dr. Schatman: So you know, the marijuana of yesterday was not taken seriously and perhaps didn’t have to be taken very seriously. However, what’s out there now [and] what is being called medical in many states—because it’s so poorly regulated—is a very dangerous, addictive drug that has physical, cognitive and psychiatric risk factors. And the psychiatric risk factors are primarily around psychosis [and] anxiety; none of these things are good. One of the things that makes me absolutely crazy is I do continuing medical education for numbers of states around medical cannabinoids, and when they take “oh, medical marijuana, it’s an approved [therapy] for post-traumatic stress disorder [PTSD],” this is not good. Again, the marijuana of my youth was primarily an indica, which is very relaxing. People used to refer to the effects of it as “couch lock.” [Today’s medical marijuana] is primarily sativa, which is uplifting, spacey, hallucinogenic [and] activating. And the last thing I want to do as a clinician is give someone who’s come back from fighting in the Middle East, who’s suffering from PTSD, who’s already anxious, agitated and—oh, by the way, paranoid and trained to kill—a substance which is going to make them more anxious, paranoid [and] activated. So we have to get our priorities right, and hopefully individual states, which have control over their own medical marijuana laws, will make these changes.
The other side of the coin is cannabidiol, which has been around isolated since 1934, if I’m not mistaken, and cannabidiol has proven in study after study after study, since the early ‘80s, to be almost devoid of side effects, certainly unpleasant side effects.
And even though most of the research up to this point is preclinical, we know that it’s an anxiolytic. We know that it’s anti-inflammatory. We know that it mixes well with other drugs that are commonly used for pain, particularly opioids. It’s neuroprotective. It’s cardioprotective, and if you remember [the movie] “My Big Fat Greek Wedding” and the Windex, which is good for everything. This is what we’re going to see with cannabidiol.
Is it a cure for chronic pain? No, but we have to, as a society, move away from looking for a single cure—including opioids—and look at chipping away at chronic pain with different tools, one of which can be and oftentimes should be cannabidiol.