Would you rather be addicted to heroin or marijuana?

Would you rather be addicted to heroin or marijuana?
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Would you rather be addicted to heroin or marijuana? That seems like a dumb question. When I think back about the patients and friends who have struggled with addiction, what they wanted was to be clean. And to have their lives back.

And yet, oddly, this is a question that a lot of people are asking lately.

One such person is Joe Schrank, the founder of an addiction treatment facility in Los Angeles with the cheeky name “High Sobriety.” As Steven Ross Johnson reported recently in Modern Healthcare, High Sobriety is based on the philosophy that this isn’t a dumb question at all. The answer is simple Schrank says: Most people would much rather be addicted to marijuana than to opioids like heroin. That’s why High Sobriety includes marijuana as part of its detox regimen.

If that sounds crazy, it’s not. Or at least, not entirely. There are at least three reasons to think that cannabinoids might be helpful as an adjunctive therapy in treating opioid addictions.

First, marijuana and opioid addiction operate in similar ways. That’s the conclusion of a line of research that’s examined addicted brains. In those studies, researchers have found remarkable similarities in the way that the addicted brain responds to cannabinoids and opioids. For instance, when people with an opioid addiction and marijuana addiction are exposed to images of heroin needles or joints, respectively, the same parts of the brain light up on scans. These are the so-called limbic areas of the brain, like the amygdala and hippocampus, that are responsible for learning, associations, and pleasure-related rewards. So it seems that those images trigger the same flood of dopamine, it the same way. That’s why it makes sense that maybe one can substitute for the other.

Second, there’s good reason to believe that the cannabinoids in marijuana might be helpful in alleviating some of the symptoms of withdrawal. For instance, we know that marijuana can be helpful in relieving anxiety and promoting sleep. Of course, dose matters. Too much can produce paranoia and even hallucinations, which would make already intolerable withdrawal symptoms much worse. But at the right dose, moderate amounts of THC—the cannabinoid responsible for feelings of euphoria and paranoia—might be very helpful. CBD is another cannabinoid that is present in large amounts in marijuana might be helpful, too.

(There’s a third reason to choose marijuana addiction over opioid addiction, but we’ll come back to that one in a moment.)

Marijuana isn’t a perfectly safe alternative, though, because it’s addictive, too. And people who use marijuana regularly and who suddenly stop can experience marijuana withdrawal, just as people who stop using opioids experience opioid withdrawal. But the symptoms of marijuana withdrawal (irritability, anxiety, insomnia) are generally short-lived, self-limited, and not nearly as severe as opioid withdrawal can be.

Even if marijuana can help people stop opioids, can it help keep them clean? That question is arguably the most important one that programs like High Sobriety should be asking. It’s one thing to help people alleviate the symptoms of withdrawal, but what we really need is something—anything—that will reduce the craving for opioids that pulls people back into the cycle of dependence and addiction.

Unfortunately, we don’t know whether substituting marijuana for opioids helps to get people clean. Nor do we know—yet—whether it can help people stay clean. Hopefully, some day we’ll have clinical trials that answer those questions.

Until then, I think substituting marijuana for opioids seems like it’s worth a try. That’s because of the third reason that proponents cite: Marijuana won’t kill you.

Although marijuana is addictive, and it has risks, you can’t fatally overdose on marijuana the way you can with opioids like heroin or oxycodone or morphine. Especially now that the opioid epidemic is responsible for more than 50,000 deaths every year, we need to look for out-of-the box solutions, because existing treatment and prevention efforts aren’t saving the lives that they need to.

You could say that programs like High Sobriety are substituting one addiction for another. That’s true. But addictions aren’t equal. And when one of those addictions is lethal and the other isn’t, a choice like the one that High Sobriety offers is one we need to consider.

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