Prescribing cannabis for harm reduction

Neuropathic pain (NP) is defined as pain caused by a lesion or disease of the central or peripheral somatosensory nervous system [1]. NP affects between 5% and 10% of the US population [2] and examples include diabetic neuropathy, complex regional pain syndrome, radiculopathy, phantom limb pain, HIV sensory neuropathy, multiple sclerosis-related pain, and poststroke pain [3]. Neuropathic pain is difficult to treat and opioid analgesics are often prescribed [4]. Recent science has demonstrated efficacy in treating NP with cannabis, [5-7] a safer drug than opioids [8]. This paper suggests that physicians who treat neuropathic pain should prescribe cannabis prior to using opioids as a harm reduction (HR) strategy. Topics covered include how harm reduction applies to prescription opioid substitution, the legality of medicinal cannabis, a comparison of cannabis to opioids, the science on treating NP with cannabis and cannabinoids, and the ethics of prescribing a drug which is deemed illegal on the federal but not the state level.Medicine relies upon the principle of, "First, do no harm," and one might supplement the axiom to read - "First, do no harm, and second, reduce all the harm you can." "Harm reduction" or "harm minimization" can be defined in the broadest sense as strategies designed to reduce risk or harm [9]. Those harmed may include the individual, others impacted by the harmed person, and society [9]. The substitution of a safer drug for one that is more dangerous is considered harm reduction [10]. Specific examples of HR include prescribing methadone or buprenorphine to replace heroin, [11] prescribing nicotine patches to be used instead of smoking tobacco, [12] and prescribing intranasal naloxone to patients on opioid therapy to be utilized in case of overdose [13]. Substituting cannabis for prescribed opioids may be considered a harm reduction strategy.Under the Federal Controlled Substance Act "marihuana" is illegal and classified as a schedule I substance