Managing Opioid Therapy with Concurrent Cannabis Use

Introduction to Clinical Decision-Making

The Centers for Disease Control and Prevention (CDC) recommends continuing opioid medication despite a positive marijuana screen, but with enhanced monitoring, risk mitigation strategies, and a clear treatment plan addressing both substances 1, 2
The CDC guideline states that clinicians should carefully weigh the benefits and risks of continuing opioid therapy, and when benefits outweigh risks, work closely with patients to optimize nonopioid therapies while continuing opioid therapy 1, 2

Abrupt discontinuation of opioids based solely on a drug screen result is contraindicated and potentially dangerous, according to the CDC 1, 2
The CDC warns against abruptly discontinuing opioid therapy or rapidly reducing dosages unless there are indications of life-threatening issues such as warning signs of impending overdose 1, 2

Verify marijuana use directly with the patient through non-judgmental discussion before making any medication changes, as recommended by the CDC and supported by JAMA 3, 4
Assess for central nervous system depression risk, as cannabis can potentiate respiratory depression when combined with opioids, similar to benzodiazepines and alcohol 5, 1, 2
Evaluate current pain control and functional status to determine whether the patient is using cannabis as an adjunct for pain management or as a substitute attempt for inadequate opioid analgesia 1, 2

Increase follow-up frequency to monthly or more often, as recommended by the CDC for patients at greater risk, including those with concurrent CNS depressant use such as cannabis 1, 2, 6
Implement additional precautions if opioid dosage is ≥50 MME/day, including increased surveillance for signs of misuse, abuse, or overdose risk, as recommended by JAMA and the CDC 6, 1
Check the prescription drug monitoring program (PDMP) for concurrent controlled substances from other prescribers, particularly important when patients are using multiple CNS depressants 4

Provide naloxone and overdose prevention education immediately, as recommended by the CDC and JAMA, for patients with risk factors for overdose, including concurrent use of other CNS depressants 6, 1, 2
Optimize nonopioid pain management strategies, working with the patient to maximize non-pharmacologic approaches and nonopioid medications to potentially reduce opioid requirements, as recommended by the CDC 1, 2

The Society for Perioperative Assessment and Quality Improvement identifies multiple concerns with cannabis use, including sympathetic hyperactivity, airway irritability in smokers, impaired temperature regulation, and interaction with anesthetic and analgesic drugs 5
Cannabis has a multitude of CNS effects that can increase overdose risk when combined with opioids, underscoring the importance of viewing cannabis co-use as a risk factor requiring enhanced monitoring rather than a therapeutic intervention 5

Do not dismiss the patient from care based on the drug screen result, as this could have adverse consequences for patient safety, including missed opportunities to facilitate treatment for substance use disorder, according to the CDC and JAMA 4
Do not assume legal status equals safety, as federal law still classifies marijuana as illegal, and the Society for Perioperative Assessment and Quality Improvement does not recommend its use due to multiple physiological risks 5
Do not fail to screen for other concurrent CNS depressants, checking specifically for benzodiazepines, alcohol, and other sedating medications, as the combination of multiple CNS depressants with opioids dramatically increases overdose risk, according to JAMA 4

Document discussion with patient about marijuana use, including frequency, route, timing relative to opioid doses, and patient's stated reasons for use, as well as assessment of current pain control, functional status, and presence/absence of overdose warning signs 3, 1, 2
Include risk-benefit analysis supporting continuation of opioid therapy, naloxone provision and overdose education provided, enhanced monitoring plan with specific follow-up intervals, and treatment agreement reviewed or established 1, 2, 6, 7