A Conversation with Dr. Adie Poe
This conversation was originally published on The Highly
It’s unsettling to see the number of tent cities grow along the West Coast. Portland, a cared-for city loaded with progressive thinkers and eco-friendly warriors, paradoxically hosts a high population of homeless, strung-out people, which is why it’s fitting that Dr. Poe and I came together here. In the face of funding restrictions for her work at Habu Health, she remains resourceful, tenacious, and tireless in the chase for the next breakthrough that could improve the lives of chronic pain sufferers and opioid users.
The Highly: How did you arrive at your research interest in cannabis?
Adie Poe, Ph.D.: When I was an undergrad in psychology, I was spending a lot of time in Vancouver, BC, where the heroin problem was and remains quite bad. I had a friend who was an outreach coordinator and through my contact with this population, I observed that although heroin was the drug of choice, cannabis use was incredibly prolific. My hypothesis was that since both are pain relieving, combining opioids and cannabinoids could reduce the amount of opioids you need to get pain relief, minimizing tolerance. That was the inception of my work, and my central hypothesis remains the same to this day.
TH: There’s the line that cannabis is a gateway drug. What’s your reaction to that?
AP: The evidence suggests it’s the opposite of a gateway drug. It’s an an exit drug. This is one of the most exciting frontiers we have in cannabis science at the moment.
The gateway theory stems from a lot of federally funded research in the '70s and '80s that correlated cannabis use with the use of harder drugs like methamphetamine, cocaine, and heroin. However, correlation and causation are not the same thing. What all of these people have in common--you know, "addicts" or people who suffer from substance use disorders--is that they have risk-taking behavior. That risk-taking component within you that may be partially derived from genes and partially derived from your experiences.
TH: How many people get addicted to opioids by accident? The people who are not risk takers but who have back surgery and get addicted to their post-surgery meds?
AP: The best proxy for that is new heroin users. Ted Cicero, who's at Washington University in St. Louis, found that 80% of new heroin users made the switch directly from a single prescription opioid analgesic drug. The reason they switched was either cost or availability. You keep taking the meds so you don't get sick, and then the doctor won't give them to you anymore because your accident was six months ago. People are literally making the switch [to heroin] just because they're spending more on drugs than they are on groceries for their family.
You want to save federal dollars on healthcare? Here’s your chance: Exempting cannabis from the Controlled Substances Act could save us $1 billion per year in fee-for-service Medicaid costs alone.
TH: What are the most current stats on cannabis usage and how it affects opioid abuse?
AP: In states with [medical] cannabis laws, there is a 25 percent reduction in opioid overdose deaths. 25 percent is the average, but this effect gets bigger the longer a state has had a medical [cannabis] program. For instance, in California, the reduction is actually 33 percent. They've had their laws since 1996.
Who are these people who are not dying, and how has cannabis protected them from overdose? We know that both of these drugs (cannabis and opioids) are pain relieving, so maybe it's that these users don't need as many opioids to get their pain relief. If they're not taking as many opioids, then maybe they're not ramping up their dose and accidentally overdosing.
TH: How do cannabis and opioids function differently in pain management?
AP: It’s almost statistically impossible to separate chronic bodily pain from depression. Cannabis is really good at improving people’s mood, even if it’s slightly less effective than opioids at relieving the bodily sensation of pain.
Cannabis relieves pain through several mechanisms. When you consume whole-plant cannabis, you’re attacking pain with dozens or even hundreds of molecules with different mechanisms of action at many sites within the body and brain--including the important component of the emotional, or affective, component of pain.
CBD appears to relieve pain much in the same way that other anti-inflammatory drugs do: by reducing the body’s inflammatory responses. Terpenes like limonene also have anti-inflammatory effects. The most powerful pain relief is produced by agonists like THC, which bind to the CB1 receptor. [Ed.: Agonists are chemicals that bind to receptors to produce biological responses.]
Some of these effects use the exact same mechanisms as opioids: The molecules in cannabis bind to receptors in the pain control headquarters in the midbrain (the periaqueductal gray area) and minimize the transmission of a neurotransmitter called GABA--and this is a very well characterized and powerful component of pain relief.
It’s really easy to take too many oxycodone pills and have your breathing rate slow down entirely. Cannabis doesn’t act on the brain region that controls the respiration rate, so it physically can’t make you overdose in that way. Even an alcohol overdose can slow down breathing, create hypothermia, and induce seizures. Again, cannabis physically cannot do these things, even at very, very high doses. Anyone who has eaten a potent edible cannabis product could tell you that a cannabis overdose is not a pleasant psychological experience. You may feel like you’re going to die, but in reality, you’d have to consume about 1,500 pounds of cannabis in 15 minutes in order fatally overdose.
TH: Is the problem opioids or prolonged use of opioids?
AP: The difficult thing about prolonged drug use is that it makes people feel heightened anxiety and depression. Drugs of abuse hijack the brain’s reward system. There is emotional sensitivity, and in the science world, we call it "negative affect, negative mood,” a.k.a. toilet bowling: a rumination process of "that thing happened, and then I feel bad about that thing. And then I feel like a bad person because I did that bad thing." Then that keeps going in a downward cycle.
People’s moods fluctuate all the time. That's normal. Over a long period of time, if you abuse opioids, it's constantly drifting downward. There's evidence that constantly shifting moods can actually be reset with cannabis, and you can get back to this baseline level of normal fluctuation. There's a really brilliant scientist, George Koob, who's been studying this darker side of addiction.
There’s a lot of really exciting work that suggests that cannabis can actually relieve the bodily symptoms that a person goes through when they're going through opioid withdrawal.
TH: How hard is it to get off opioids and stay off? Where does cannabis come into play?
AP: If you look at the literature, opioid replacement therapy combined with social support is a person's absolute best weapon against relapse. One of them on its own is not enough. What people are starting to do is look at using opioid replacement therapy not with another opioid but with cannabis.
There’s a lot of really exciting work that suggests that cannabis can actually relieve the bodily symptoms that a person goes through when they're going through opioid withdrawal, also known as the “dope sick.” We're talking seventh-level-of-hell human suffering. One of the things that traditional detox centers have always done is sedate people so they can sleep through most of that suffering. If you take RSO (Rick Simpson Oil) or any sort of extremely concentrated oral cannabis preparation, it is very likely to put you to sleep. This is one of the strategies that people are using in the short-term detox stage. What's harder is for people to stay sober and to stay away from opioids long-term.
What we know is that people want to be normal and functional, to have a job and to be in touch with their families. They don't want to be completely couchlocked when they're supposed to be engaged. Taking the lowest possible dose of cannabis to achieve those things is a good option in the long-term phase of recovery.
TH: Could you stay on cannabis long-term?
AP: For most, yes. But it’s not true for everyone.
There are particular people who have a vulnerability to substance abuse. For those people, cannabis may not be the best treatment option for them. However, it could still be a better treatment option than all the other nasty drugs they're on. It's really quite dependent on the person.
People can absolutely develop a dependence on cannabis and qualify for a cannabis use disorder. That's a diagnosable condition that totally exists. What we know is that in adolescents, there's been a 24 percent drop in cannabis use disorder diagnoses over the last 13 years.
To qualify for the disorder, you have to have cannabis interfere with your life--your social relationships or your economic performance are suffering as a result of your cannabis use.
Then there is tolerance and dependence. If you have such a high tolerance that maybe smoking an entire joint doesn't do anything for you anymore, now you're escalating to constantly using because nothing else will get you high. That’s one indication that you have developed a dependence. Tolerance is the first step on the way to physical dependence. Physical dependence appears when you experience withdrawal. Cannabis withdrawal looks more like irritability, a lack of appetite, insomnia, and sort of "I'm having a really bad day.”
People who quit cannabis cold turkey can definitely experience withdrawal, but compared to if they quit heroin cold turkey, it’s two completely different levels of suffering there.
TH: Where are we in cannabis research?
AP: Most of the biomedical research that is done in the United States is funded by the federal government. The federal government cannot issue any grant funds to anyone who's looking at the beneficial effects of cannabis because cannabis is a Schedule I drug, [defined as a substance] with no accepted medical purpose. The only way I get my funding is by asking the National Institute on Drug Abuse (NIDA). The reason NIDA is interested in my work is because my work is specifically related to diminishing our reliance on opioids.
We're talking seventh-level-of-hell human suffering.
TH: So having it classified as a Schedule I drug really impedes the proper research. What could we do to change things?
AP: Something everyone should do every single day is call their congressman. Don't write. Call them even if you are in a prohibition state. They have publicly available phone numbers on their websites. My job is based out of Missouri, and I call [Rep. Lacy] Clay all the time, and I say, "Hey, I'm just calling to tell you...you need to support every single bill of legislation that takes cannabis off Schedule I." Even a downgrade to Schedule II would completely remove those barriers to research so we could actually study it for medicinal purposes. If you look closely at cannabis, it doesn't even belong on the schedule at all. It's more like a nutraceutical product, like nutritional supplements.
TH: What other forms of wellness do people need to work through addiction?
AP: Social support, mindfulness, meditation, and nature will help you stay sober.
When we put people on a brain scanner when they're doing mindful meditation, the brain activation looks totally different than on a placebo drug. We know that whatever it is that mindfulness is doing, it's a not a placebo. It’s actually turning off pain in a different way than a drug or a placebo is. Spending time in nature also alleviates the rumination process that is closely tied with negative mood. Pain and negative mood are very prevalent in recovery from addiction. It makes sense to treat all the facets of this disorder simultaneously.
TH: Do you have a relationship with cannabis?
AP: I didn't actually try cannabis until I was 25 or so.
I use cannabis when I'm in Oregon. I definitely don't travel with it. I have always been of the mindset of moderation and having one foot on the ground. Alcohol is just not a desirable experience for me, whereas cannabis has been. It's a true privilege to be able to be in a city like Portland, where I can go home and experience this beautiful plant after my kid goes to bed.
All of those connections that people lose when they are on 'drugs of abuse'-- those are real connections: connections with nature, connections with people around them, connections with their hearts, connections with music. That stuff gets enhanced by cannabis.
TH: Any encouragement for people experiencing the negative effects of hard drugs or prescription drugs?
AP: I guess I would say that the evidence and the personal stories associated with cannabis use for medical purposes are incredibly compelling. All of those connections that people lose when they are on "drugs of abuse”--those are real connections: connections with nature, connections with people around them, connections with their hearts, connections with music. That stuff gets enhanced by cannabis. It does make your life better if you can find a way to use it that works for you. Don't get discouraged. Keep at it. Get some help. Ask me for help.
TH: If you had 30 seconds with President Trump, what would you tell him?
AP: The single greatest impact we could possibly make on the opioid epidemic would be to enable coast-to-coast access to cannabis. Both medical and recreational cannabis laws are associated with significant drops in opioid overdose deaths, and when chronic pain patients are given access to cannabis, they reduce their opioid consumption by half. Considering that 30-40 percent of this country is in pain at any given moment, we are talking about unprecedented improvements in mortality, quality of life, employee productivity, and health care costs. You want to save federal dollars on healthcare? Here’s your chance: Exempting cannabis from the Controlled Substances Act could save us $1 billion per year in fee-for-service Medicaid costs alone.
TH: Your favorite saying?
I love you.