Should medical cannabis be avoided when starting Suboxone?
There is some confusion over the use of marijuana during medication assisted treatment for opioid use disorder. People who are starting Suboxone therapy want to know: Are Suboxone and weed safe together?
First, we should address the issue of how safe it is to consume marijuana. Is weed a safe drug?
For children and young adults, weed should be avoided. The human brain is still developing, undergoing the process of myelination until about the age of 25.
THC, the active drug in marijuana, can cause permanent damage to the developing brain. Pot users may experience permanent short-term memory loss, as well as a lack of motivation.
However, for older adults who have experienced life traumas, physical and emotional, regulated cannabis products may be useful, and safer than many prescription drugs. A person who experiences serious ongoing pain may be at risk for developing a heroin addiction, or other addiction. Marijuana use is clearly safer than the use of heroin, fentanyl, meth, cocaine, or alcohol.
But, what about Suboxone and weed? Is this a safe combination? Typing Suboxone and weed into a drug interaction checker does reveal an interaction warning, yet it is not an absolute contraindication.
What is the drug-drug interaction between Suboxone and THC?
Does Suboxone interact with cannabis? An excellent resource available to the public is the Medscape drug interaction checker. When typing Suboxone and marijuana into the tool, the result shows an interaction that instructs the healthcare provider to monitor closely.
The issue is that both buprenorphine, the active drug in Suboxone, and marijuana are known to be sedating drugs. Drugs that increase sedation must be used together cautiously.
For example, if Suboxone is prescribed to an elderly person with osteoporosis, and then they are also given medical marijuana, the risk for an accidental fall is increased. People with osteoporosis are at higher risk for hip fractures and other types of bone fractures.
A hip fracture is a serious issue and must be avoided. For younger people who might combine two sedating drugs, there is a high risk of accident and injury with the use of heavy machinery.
Can you smoke marijuana on Suboxone safely?
While the cannabis and Suboxone interactions checker does not say the two cannot be used together, doctors (MD and DO), advanced registered nurse practitioners, masters of science nurses (MSN) and doctors of nursing practice (DNP), and physician’s assistants who prescribe Suboxone should take care in discussing the issues of concurrent use of buprenorphine and medical cannabis carefully with their patients.
And, if a patient brings up the topic of marijuana concentrates, dabs, dummies, oils, tinctures, waxes, and other types of alternate cannabis products, including delta-8 THC and delta-9 THC, hemp, and CMD lotions, creams, salves, oils, and balms, the healthcare practitioner should be knowledgeable about these supplements as well.
People who start therapy with new medications, particularly medications that can be sedating early on should avoid driving a car, riding a motorcycle, using dangerous power tools, such as chainsaws, operating boats and other marine craft, operating construction equipment, such as forklifts and cranes, and flying helicopters, piloting small planes, military aircraft, and commercial aircraft.
For people starting a new sedating medication who are software engineers who write mission-critical code, such as software that manages air-traffic control, municipal water filtration systems, power grid management, and space exploration missions, may want to take time off, or have their code thoroughly checked. We can come up with many other examples of people who should take it easy when getting used to a new medication.
For example, if you have paid hundreds of dollars to see your favorite music artist perform live on stage, while you would applaud their starting Suboxone to treat opioid addiction, you would not want to be disappointed in a lackluster show because they chose to start Suboxone therapy right before the concert. Of course, the effects of starting a potentially sedating medication will have varying effects on pop vs rock, or jazz vs classical performances.
Will your Suboxone doctor kick you out on the street because your drug test is positive for THC?
From the perspective of harm reduction and saving lives, I would like to be able to say that patients who go in for opiate addiction treatment should not have to worry about testing positive for THC. Street opioids are deadly, containing dangerous fentanyl analogs, and Suboxone treatment is life-saving.
Unfortunately, there are backwards-thinking Suboxone clinics that will stop prescribing or dispensing Suboxone when they see a positive THC result on a urine drug screen or other drug test. With opioid use and overdose deaths on the rise, public health experts should promote more liberal policies with respect to the Suboxone/weed issue.
First, if a person is using multiple substances, including opioids, and they are receiving Suboxone therapy, turning them away, may lead them to resume substance abuse with opioids, risking overdose. The focus in opioid dependence and opioid addiction treatment should be on helping the patient to stop using opioids.
Another important point is when is a person considered to be in recovery. The 1935/1953 views of recovery are complete abstinence from all drugs in order to be in recovery. 1935 is the founding year of Alcoholics Anonymous and 1953 is the founding year of Narcotics Anonymous.
Is it possible to be in recovery, on Suboxone, and in the weed business or using weed?
Of course, with such a sweeping policy, these programs have had to develop complex and conflicting directives on various medically prescribed and approved therapies. For example, a person who is prescribed opioids for pain by their doctor can consider themselves to be “clean” and in recovery in NA.
In fact, an NA member can take Suboxone or Methadone, if the drug is prescribed off-label by their doctor for chronic pain, and still be considered in recovery. Yet, if those same drugs are prescribed for addiction treatment, the patient is no longer considered to be in recovery by the NA program.
With this confusing policy, NA has stumbled into the dangerous gray area of medical decision making without a medical license. Two NA members, sitting side-by-side, may be taking the exact same prescribed medication, but one is considered to be in recovery, and the other is not, based on their medical diagnoses.
A better policy for healthcare professionals would be to recommend to their patients that any drug consumed should be of medical grade and prescribed or recommended by their doctor, in order to be in recovery. Some experts have referred to this as “the new recovery.”
For example, if a person has a medical marijuana card and uses cannabis products, and they take Suboxone for opioid use disorder, they are not using street drugs, and can be considered to be in recovery. Medical cannabis use is known to help with mental health issues, such as anxiety disorders, as well as physical health conditions, such as glaucoma, and chronic pain.
Does Suboxone block the effects of weed, or does weed block the effects of Suboxone?
Suboxone contains buprenorphine and naloxone. Both drugs are potent blockers of opioid receptors. If a person is taking opioids, either buprenorphine, or naloxone will block the effects of the opioid drug, causing precipitated opioid withdrawal and significant opioid withdrawal symptoms.
Marijuana contains THC, the drug that causes the effects of intoxication that are associated with cannabinoids. THC binds to cannabinoid receptors in the central nervous system, not to opioid receptors.
Suboxone does not block THC, and THC does not block Suboxone. Suboxone’s ingredients, buprenorphine and naloxone, do not interact directly with active substances in cannabis.
Yet, there is one situation where Suboxone may cause a marijuana-smoker to go into precipitated withdrawal. How can Suboxone cause opioid withdrawal when a person is only smoking pot?
Is it okay to smoke pot on Suboxone, or will smoking pot cause an opioid reaction with Suboxone?
Here is how Suboxone and THC may interact directly. If a person uses street-bought marijuana, it may be contaminated with the highly potent, and deadly opioid, fentanyl. Even a small amount of fentanyl can be toxic.
Fentanyl analogs that are being found as contaminants in nearly every street drug imaginable, are opiate drugs. Why would a drug dealer add fentanyl to marijuana?
There are several reasons why an opioid dealer who also sells pot on the streets might contaminate the weed with fentanyl. One reason is that they may want to make the weed more potent, to give the user a more intense high.
Another reason might be to get the pot smoker hooked on their “special strain” of weed. The marijuana user might not even know why, but they find themselves hooked on the pot from their dealer because they are actually hooked on the fentanyl sprinkled or soaked into their weed.
Street weed can be very dangerous because of the risk of contamination.
Another common reason to find fentanyl mixed in with drugs such as marijuana, heroin, cocaine, or meth, is actual accidental contamination. A drug dealer may weigh all of their drugs on the same scale, without cleaning the scale carefully between use.
Fentanyl residue may then contaminate any other drug that is weighed on the same scale. While it seems like traces of fentanyl would not cause a problem, fentanyl is a drug that is highly potent, with active dosages measured in micrograms.
Another drug sometimes found on the streets, related to fentanyl, is carfentanil. This elephant tranquilizer is 100 times stronger than fentanyl, and 1,000 times stronger than morphine. Small traces of carfentanil can cause an overdose easily.
In the case of a marijuana user who uses pot bought on the streets, they may go into precipitated withdrawal, experiencing withdrawal symptoms, when they start Suboxone. The withdrawal is caused by an interaction between buprenorphine and traces of fentanyl or carfentanil contaminating the street-purchased weed.
In conclusion, while healthcare professionals do not have to endorse, or recommend use of weed, they may also do their part in resolving the opioid crisis by providing medication-assisted treatment without judgement.
If a patient is using any street drug, they should be encouraged to consider a medical, legal alternative. For example, if a patient is using meth, their doctor may recommend a psychiatric consultation to see if the patient would benefit from ADD or ADHD treatment.
Or, if a patient is using street marijuana for therapeutic reasons, their doctor can recommend that the patient schedule an appointment with a medical marijuana doctor to see if medical cannabis would be helpful. A patient who is starting on the path to recovery should not use any drug that is not prescribed to them or recommended, in the case of medical cannabis.
People in recovery should not consume any substance purchased on the streets. Street substance use is always very risky.
Medical cannabis has been found to have medical uses in addiction treatment. Some experts claim that cannabis can ease the discomfort of opioid withdrawal.
It is even possible that some people will be able to more easily taper off of Suboxone after long-term treatment with the use of medical cannabis. The final stage of treatment, when a patient discontinues Suboxone, can be difficult because of the physical dependence to buprenorphine that develops during therapy.
While it is important to still be careful in recommending medical pot across the board, since it does have risks, especially for young adults and children, we should also be aware of possible therapeutic uses in treating both addiction, and conditions that may lead people to use addictive drugs.
The essence of harm reduction is to help protect the health and lives of people who are struggling with addiction. Taking a hardline position against marijuana use, when a person is in active addiction to opioids is not the best way to address the addiction problem.
In order to reduce harm to the patient most effectively, we must be understanding of what the patient is going through. As noted in my podcast interview with American Addiction Centers, it is important to meet patients where they are at.
By working with a patient to address the most serious issues first, meaning that we help them to get off of dangerous opioids as the first step, we may then have further conversations over time about reducing use of other substances, such as marijuana. In the future, it is possible that cannabis products will become FDA approved medical products, with approved uses in treating conditions requiring pain relief as well as addiction-related uses.
Currently, medical cannabis exists with a unique status, of not being FDA approved, or even legal at the federal government level. Medical cannabis is legal in many states, and with further experience and scientific studies, the federal government may determine at some point in the future that cannabis should not be illegal, but should be a properly regulated healthcare product that doctors may prescribe to their patients when appropriate.