Cannabis for Opioids…Will it work?

A friend asked me to write about this. The science and the politics of each of these drugs is so fraught that no one seems to be able to make any sense out of it. He asked me if I could, so here’s my attempt.

First, addiction is a single brain illness. It doesn’t care what drug you use as long as that drug normalizes the tone at a group of cells in the midbrain called the Nucleus Accumbens. Those cells are stimulated by a neurotransmitter called dopamine that is sent from a group of cells called the Ventral Tegmental Area (VTA). In response to dopamine stimulation, the Nucleus Accumbens sends endorphins, the brain’s own opioid back to the VTA to stimulate more dopamine. This positive feedback loop is the source of the “high,” the exhaustion of the high, and the following crash, which leads to craving and compulsive use. No high, no crash. If only that was it, we’d have this thing solved.

But there’s an additional fly in the ointment. About 10 to 20% of people have low tone at the Nucleus Accumbens and crave feeling better even without a crash. They feel restless, irritable, and discontented until they take something that raises the Nucleus Accumbens tone. One way to do that is to take an opioid stimulating the VTA to release dopamine. Another is to take THC which directly stimulates the Nucleus Accumbens via the cannabinoid receptor (CB1).

So, does it make sense that if low tone at the Nucleus Accumbens leaves a person with craving, and that craving is for anything that will raise the tone, then cannabis can be a successful substitute for opioids in people with addiction involving opioids? Yes, it does. And it’s entirely understandable that people have found that opioid use goes down when cannabis is more available. It doesn’t have to have anything to do with pain or medical benefit of cannabis. It only has to do with the midbrain reward system biology. But does this mean that cannabis can be an effective treatment for addiction involving opioids? Well it depends.

When we look for a treatment for addiction, we look for something that will raise the tone at the Nucleus Accumbens without causing a high and crash. So, we don’t look for something that has immediate onset; such things are popular as drugs, but they don’t make good medicines. We look for things that last a long time, not just a few hours. In short, we are looking for something to stabilize tone, not just raise it. We also want to look for something that will raise tone in the most natural way possible. By that I don’t mean natural ingredients, but by using the systems own parts.

So, consider a person who has low tone at the Nucleus Accumbens because they have less dopamine tone than normal at the receptors on the Nucleus Accumbens. We’d want to find a long acting, slow onset way of raising dopamine via the brain’s own mechanisms. Such a thing would be buprenorphine, a partial agonist at the opioid receptor that causes the tonic release of dopamine without a high and crash if prescribed and taken correctly. Stimulating the CB1 receptor to fool the Nucleus Accumbens into thinking it’s getting enough dopamine would be a second-best alternative, because the brain has feedback systems we want to work with, not against.

Are there people who have low Nucleus Accumbens tone because they have a mutation of the CB1 receptor and for whom THC is the most natural treatment? Probably so, but no one has done the work. And the work has not been done because cannabis is schedule I and hard to study.

I’m not for or against medical use of cannabis. I don’t know enough to have an opinion and frankly no one else does either. But rather than run ourselves through logical fallacies in order to reach a goal, I’d like to reach that goal directly. Let’s just deschedule cannabis. It will get studied and we’ll figure out who needs it and who doesn’t. Then decisions can be made on science and not politics.

But it’s dangerous? Sure, so is coal, and alcohol, and cigarettes. There’s nothing that isn’t dangerous. But if you can’t treat addiction without drugs being illegal, then you don’t know how to treat addiction. Just say no has never worked, and it’s not going to start now.