After Opiate Recovery Can I Ever Take Opiate Again Without Withdrawal Reddit

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Peer-reviewed

Research Article

"I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis apply reported in online opioid and opioid recovery community discussion forums

• Meredith C. Meacham,
• Alicia 50. Nobles,
• D. Andrew Tompkins,
• Johannes Thrul

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• Published: February 8, 2022
• https://doi.org/ten.1371/journal.pone.0263583

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Abstract

A growing body of enquiry has reported on the potential opioid-sparing furnishings of cannabis and cannabinoids, simply less is known virtually specific mechanisms. The nowadays research examines cannabis-related posts in ii large online communities on the Reddit platform ("subreddits") to compare mentions of naturalistic cannabis use by persons cocky-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (eastward.1000., "weed", "cannabis", "marijuana") from December 2022 through August 2022 from an opioid apply subreddit and an opioid recovery subreddit. To investigate how cannabis is discussed at-scale, we identified and compared the most frequent phrases in cannabis-related posts in each subreddit using term-frequency-inverse certificate frequency (TF-IDF) weighting. To contextualize these findings, we besides conducted a qualitative content analysis of 200 random posts (100 from each subreddit). Cannabis-related posts were nigh twice as prevalent in the recovery subreddit (northward = 908; v.4% of xvi,791 posts) than in the active opioid employ subreddit (n = 4,224; 2.half-dozen% of 159,994 posts, p < .001). The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a "handling." The nigh frequent phrases from the opioid subreddit referred to concurrent use of cannabis and opioids. The about common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-feet and GI-distress "comfort meds," and to enhance the "high" when used in combination with opioids in the opioid subreddit. Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis utilize in relation to opioid use identified withdrawal symptom management every bit a common motivation. Future inquiry is warranted with more structured assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.

Commendation: Meacham MC, Nobles AL, Tompkins DA, Thrul J (2022) "I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis use reported in online opioid and opioid recovery community discussion forums. PLoS ONE 17(2): e0263583. https://doi.org/10.1371/periodical.pone.0263583

Editor: Lucy J. Troup, University of the West of Scotland, UNITED KINGDOM

Received: May xix, 2021; Accepted: January 21, 2022; Published: February 8, 2022

Copyright: © 2022 Meacham et al. This is an open access commodity distributed nether the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in whatsoever medium, provided the original writer and source are credited.

Data Availability: The data underlying the results presented in the study are available from the Pushshift Reddit Dataset: https://ojs.aaai.org//index.php/ICWSM/article/view/7347.

Funding: This inquiry was supported by U.S. National Establish of Drug Abuse grants K01DA046697 (MCM), K25DA049944 (ALN), R21DA047520 (DAT), and R21 DA048175 (JT). URL: https://www.drugabuse.gov/. The funders had no role in study design, information collection and assay, decision to publish, or preparation of the manuscript.

Competing interests: I accept read the journal's policy and the authors of this manuscript have the post-obit competing interests: In the terminal 3 years, DAT has received consulting fees from Alkermes, Inc. and Clinilabs. The other authors accept alleged that no competing interests exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

The opioid epidemic in North America is characterized by dramatic increases in opioid-related overdoses [ane] and unmet treatment need for opioid use disorder (OUD) [ii]. As Canada and most U.South. states enact decriminalization and legalization of cannabis for medical and recreational developed use, there is considerable interest in determining whether cannabis and cannabinoid products are viable alternatives to opioids for pain management or a potential adjunctive therapy for OUD. Contempo interest is spurred in part by several studies that plant relationships between cannabis legalization at the state level and reductions in opioid-related deaths [three–8], though the ecological clan betwixt country-level medical cannabis legislation and reduced opioid overdose bloodshed reported previously [three] was not replicated in a study examining additional years [9]. Additionally, several studies have establish that medical cannabis patients report pain direction as one of the most common reasons for cannabis apply [10–12] and that cannabis apply was associated with lower opioid use among people who apply illicit drugs [13, 14]. Notwithstanding, in that location are also ongoing concerns about cannabis use increasing the adventure for non-medical opioid use and opioid and cannabis use disorders, specially among adolescents and young adults [15–18], and that cannabis use may lead to return to opioid utilize by people with a history of OUD [19–22].

The National Academies of Science, Engineering, and Medicine (NASEM) 2022 written report on the Health Effects of Cannabis and Cannabinoids found some testify that cannabinoids may be an constructive treatment for some types of chronic hurting in adults, but no bear witness to support or refute the employ of cannabinoids for treating addiction [23]. One reason for the limited scientific testify is that cannabis is a Schedule I drug in the United States with "no currently accepted medical utilise," limiting funding and approval to study real earth cannabis as a potential therapy in randomized controlled trials [24].

In the meantime, a broad range of experiences with substances are shared on social media. These unsolicited reports have go an culling information source to surveys, administrative, and clinical information regarding the use of cannabis, opioids, and other substances in natural settings [25]. One place where people share experiences with illicit substance utilise is Reddit, a social media and news aggregation platform that allows users to interact through topic-specific forums called subreddits, instead of effectually personal profiles or hashtags every bit with Twitter or Facebook. In addition to the subreddit organization, users contribute through pseudonyms, which may lead to greater tendencies to disclose subconscious or stigmatized behaviors than on other identity-linked social media platforms. The Pew Inquiry Eye reports that in 2022 over i in 10 U.Southward. adults used Reddit [26]. In 2020, Reddit was the 7^th nearly visited website in the United States [27], with most of the global traffic to Reddit coming from the United States and Canada.

Both qualitative and computational approaches have been used to examine discussions about cannabis and opioid use on Reddit. Content analyses have reported banter, disclosure, instruction, and advice as common types of posts and comments in cannabis and opioid employ subreddits [28], and have identified posters disclosing DSM-5 criteria for cannabis apply disorder [29] and opioid use disorder [30] in cessation and recovery-oriented subreddits. A thematic assay of posts to popular opioid-related subreddits during the early stages of the COVID-19 pandemic found bear witness of robust mutual assist and social support [31]. In a computational text analysis across 1.4 million Reddit posts in 63 subreddits, previous work identified common terms used to describe alternative treatments for opioid use recovery, the about common of which was kratom [32]. Through a word embedding analysis, that report found that cannabis had the highest cosine similarity with kratom (indicating that the give-and-take "cannabis" was the most contextually similar word to "kratom" in these opioid recovery posts). In another analysis of two.3 million posts to a large cannabis subreddit, emerging forms of cannabis (vaping, edibles, concentrates, dabbing) were increasingly mentioned from 2011 to 2022 [33]. However, no written report to our knowledge has focused specifically on the intersection betwixt cannabis and opioid content on Reddit.

Objective

In this written report, we apply computational and qualitative research methods to appraise and compare betwixt an active opioid use subreddit and an opioid recovery subreddit: ane) the proportion of posts that mention cannabis, 2) the most mutual words and phrases in posts that mention cannabis, and iii) motivations for cannabis use in relation to opioid use equally described in cannabis-related posts.

Materials and methods

Ethical considerations

Both subreddits from which sampled posts were fatigued are publicly attainable and findings are presented in aggregate. This enquiry was categorized as human discipline exempt category four by the University of California San Francisco Institutional Review Lath. Usernames were not examined. Sample quotations are composites or lightly reworded to reduce the run a risk of identification.

Data collection

All posts (title and content) and associated metadata posted from December 2022 to August 2022 (45 months) on an opioid use subreddit and an opioid recovery subreddit were downloaded from the Pushshift Reddit database [34] via Google Big Query. Data were analyzed in R Studio version 1.2.5019. Duplicate posts were removed (i.5% of posts), which were identified with the "duplicated" base R role applied to post text.

Proportion of cannabis-related posts in each subreddit

Posts mentioning cannabis were selected using a keyword search strategy that identified whether the mail service contained at least one of eight cannabis-related terms (weed, cannabis, marijuana, pot, reefer, ganja, thc, and cbd). A sample of posts were read individually to run across if these posts were indeed cannabis related. To avoid capturing false positives detected through this sample reading (e.thousand., "spot," "potency," and "healthcare"), white space was added effectually "pot" and "thc." In later readings of individual posts, the word "weed" picked up some additional false positives (east.g., "pulling weeds"), but also some typos (e.g., "weeds" instead of "weed is").

The proportion of cannabis-related posts in each subreddit was compared using a chi-square test. The median number of words per a cannabis-related post was compared between subreddits using a Wilcoxon rank sum test. Given the increase in the number of U.S. states with cannabis legalization during the study flow (2015–2019), the potential modify in the frequency of cannabis-related posts over time was examined using linear regressions with proportion of cannabis-related posts per calendar month (relative to all posts) as a function of time in months.

Most frequent and distinctive words and phrases in cannabis-related posts

Kickoff, the most frequent words and phrases in the cannabis-related posts for each subreddit were determined using term frequency-inverse document frequency (tf-idf). 2d, the most distinctive words and phrases contained in the cannabis-related posts for each subreddit were identified using likelihood ratio for a keyness analysis [35].

Punctuation, numbers, urls, symbols, html strings, and cease words (due east.chiliad., prepositions) were removed from the cannabis-related posts. Then the post was tokenized into unigrams (singular words like "opioid"), bigrams (two-word phrases like "opioid employ"), and trigrams (three-word phrases like "opioid use disorder"). After this pre-processing, weighted frequency of each n-gram was ranked using TF-IDF, which balances the occurrence of an n-gram in a post relative to its frequency in the entire corpus of posts. TF-IDF avoids the potential bias of using just term frequency (i.due east., raw counts of n-grams). The top ten unigrams, bigrams, and trigrams, identified by the highest TF-IDF, were identified for each subreddit.

Adjacent, the textstat_keyness function in the quanteda [36] package in R was used to identify the most distinctive unigrams and bigrams of each subreddit. This part calculates a "keyness" score for each n-gram indicating its uniqueness in a "target" corpus (i.due east., the cannabis-related posts in the recovery subreddit) compared to a reference corpus (i.due east., the cannabis-related posts in the opioid use subreddit), specified equally a likelihood ratio (Yard ² ) [37, 38] with William'southward continuity correction. Keyness scores were sorted by G ⁱⁱ , and the unigrams and bigrams with the 15 highest and lowest Yard ² values were identified.

Motivations for cannabis utilise

To further contextualize these automated text analysis results, we conducted a qualitative analysis of 200 random cannabis posts (100 from each subreddit). A codebook was initiated past MM with open coding of random twenty posts per subreddit with the goal of identifying (one) disclosure of cannabis and/or opioid use and (ii) motivations for using cannabis (or not) in relation to using opioids or the reduction or cessation of opioid utilize. This initial codebook was shared and discussed with other investigators (AN, JT). A refined codebook was then practical independently to l random posts (25 from each subreddit) past three investigators (MM, AN, JT) with substance utilise-specific expertise in public health, information science, and psychology, respectively. Investigators were blinded to the original subreddit source. The iii sets of applied codes were compared and discussed over email and in video conference meetings. Discordant codes were flagged and discussed, and the codebook was refined one more fourth dimension and applied over again to the same l posts. Inter-rater agreement was calculated (.82–one.00), and discordant codes were discussed until consensus was reached.

A final codebook was applied past three investigators (MM, AN, JT) to an additional l posts (150 single coded posts + 50 triple coded posts), split evenly by subreddit and with investigators blinded to subreddit source. The terminal codebook included prompts, definitions, subcodes, and quotation examples of 10 codes, summarized in Table iv. Codes included noting false positives, disclosure and timing of opioid or cannabis utilise, and whether CBD (cannabidiol) was the form of cannabis used, given growing interest in CBD [39] and the legalization of hemp-derived CBD in the United States in early 2018. Motivations for cannabis use in relation to opioid utilize included using cannabis to manage opioid withdrawal symptoms, at the same fourth dimension as an opioid (co-utilize/ polysubstance use), or for hurting direction, too equally questions virtually cannabis use in longer term desistence of opioid utilize or cocky-identified recovery. Interactions with healthcare providers in general and regarding cannabis were also noted.

Percentage of times the codes were applied were tabulated and compared between subreddits. Posts with similar codes were read together to confirm coding consistency, explore intra code variability, and examine contextual factors.

Results

Proportion of cannabis-related posts

Over 45 months from late 2022 to mid 2019, there were 16,791 total posts to the recovery subreddit and 159,994 posts to the opioid subreddit. Cannabis-related posts were about twice as prevalent in the recovery subreddit (n = 908, 5.four%) than in the opioid subreddit (northward = 4224, 2.6%) (p < .001). Full number of posts, proportion of posts mentioning cannabis, and word count distributions are presented in Table 1. The median wordcount for cannabis-related posts in the recovery subreddit was 279 words, which was significantly longer than the median wordcount of 173 words for cannabis-related posts in the opioid subreddit (p < .001). In that location was no significant change over these 45 months in proportion of cannabis-related posts in the recovery subreddit. Nevertheless, there was a slight subtract in proportion of cannabis related posts in the opioid subreddit. When 17 simulated positive posts containing the cord "weeds" were removed from counts of cannabis posts, analyses of proportions were no different.

Most frequent and distinctive words and phrases in cannabis-related posts

The acme 10 well-nigh frequent unigrams, bigrams, and trigrams in cannabis-related posts from each subreddit are presented in Table ii. Of annotation, the most frequent phrases in the recovery subreddit included mentions of cannabis as a "treatment" or "substitution." References to "recovery," "commutation," and "care for" and words indicating corporeality of time ("days", "years") were also frequent. "CBD" is mentioned along with "kratom" and "benefits" and longer phrases referred to using "marijuana [to] treat addiction", "success stories [with] marijuana," and "planning [to] taper Subutex." This is reflective of posts commonly discussing fourth dimension in treatment and recovery, often reporting or questioning using cannabis as a "treatment."

The most frequent words and phrases in the opioid subreddit included "smoking weed" and combinations of different substances (opioids, cannabis, alcohol, stimulants). References of "CBD" were in n-grams with hydrocodone and oxycodone. Specific anti-feet pills ("Xanax", "Valium") and opioid pills ("oxy", "Tramadol", "Dilaudid", "hydro") and formulations of heroin ("h", "tar") are too mentioned. Frequent phrases also noted interactions between opioids and cannabis ("weed potentiate opiates", "combining tramadol weed"). This is reflective of posts ordinarily discussing active polysubstance use and inquiring about the potential for these substances to interact.

In general, cannabis-related posts in the recovery subreddit contained terms regarding the apply of cannabis every bit a potential treatment, while cannabis-related posts in the opioid subreddit contained terms referring to concurrent use of cannabis and opioids.

Table 3 presents the tiptop 15 most unique unigrams and bigrams relative to the other subreddit. In dissimilarity to the most frequent terms in Table 2, the nigh unique terms in Table three comprise fewer cannabis-related terms. Unique recovery subreddit terms in cannabis posts mention time "clean," withdrawal, paws [mail service-astute withdrawal syndrome], and relapse, every bit well as challenges with recovery ("physical symptoms," "hard fourth dimension") and messaging to readers to "stay potent." Unique opioid subreddit terms in cannabis posts mention people ("guy", "dude"), profanity, "tolerance", and references to amounts or quality of drugs or effects ("bag", "loftier like"). Messaging to other readers are reminders to "stay prophylactic" and take "happy nods."

Motivations for cannabis use

The nigh mutual motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit and to enhance the high when used in combination with opioids in the opioid subreddit. People described using cannabis products, sometimes as CBD oil, as i of many "comfort meds" to manage withdrawal associated anxiety, indisposition, malaise, and hurting both during acute withdrawal and longer-term mail-acute withdrawal syndrome (PAWS) [twoscore, 41]. Most people, but not everyone, who described using cannabis for withdrawal symptom management described information technology every bit being helpful, only frequently in the context of a list of other medications and strategies. People also questioned the effectiveness of using cannabis in recovery and seemed to adopt interacting with healthcare providers with whom they could discuss their cannabis employ. A summary of how often each disclosure or motivation lawmaking was practical is presented in Tabular array four, with Venn diagrams showing overlaps in motivations disclosed in Fig ane. Sample quotations are presented in Table v.

Disclosure—Opioid utilize

Personal opioid employ was disclosed in the majority of sampled posts and at a similar proportion in the recovery subreddit compared to the opioid subreddit (88/100 in recovery subreddit, 78/100 in opioid subreddit; p = .06). Posts that did not include personal disclosure described employ by a friend or family fellow member or commented on depiction of opioid utilise in the media.

Within the recovery subreddit the well-nigh mutual disclosure (74/88, 84%) was about efforts to reduce opioid use ("10 days off today … it'south a miracle"). In contrast, within the opioid subreddit the most mutual disclosure (40/78, 51%) was about recent or planned employ ("Just did a speedball woohoo…. Talk to me!") and in that location were fewer disclosures (29/78, 37%) of efforts to reduce opioid use ("The fourth dimension has come for me to quit heroin").

Disclosure—Cannabis use

Disclosure of any cannabis utilize was similar across both subreddits: 77/100 posts in the recovery subreddit and 68/100 posts in the opioid subreddit disclosed personal cannabis use (p = .68). In both subreddits the most common type of disclosure was recent or planned use (52/77, (68%) in the recovery subreddit, 49/68 (72%) in the opioid subreddit). Disclosures of by cannabis apply (xiv in each subreddit) often referred to initial life experiences with cannabis ("Began smoking weed in loftier school"). In both subreddits (14/77 (eighteen%) recovery, 5/68 (7%) opioid) people mentioned cutting dorsum or intentionally avoiding cannabis use equally office of efforts to reduce the use of all substances ("I'grand a week clean of all substances including weed").

Motivations—Withdrawal symptom direction

The most common motivation for cannabis use was withdrawal symptom direction. Almost half the posts (43/100) in the recovery subreddit and a small number of posts (12/100) in the opioid subreddit mentioned using cannabis to manage symptoms of withdrawal like feet, nausea, body aches, insomnia, and general malaise.

Sometimes people in both subreddits who were anticipating going into withdrawal shared their plan to apply cannabis when they ran out of an opioid or as they were intentionally trying to quit without medical assistance: "The programme after today … is to utilise weed and booze to help with the withdrawal symptoms."

Other people were seeking immediate communication and support because they were experiencing acute withdrawal symptoms. Common motivations for cannabis apply were non-specific, including to mitigate full general withdrawal discomfort and distress ("I'thousand taking a few hits of pot every 4 hours … information technology's been making it tolerable") and symptom-specific, including to address insomnia, nausea, depression appetite, feet, and restless leg syndrome ("Restless leg is my worst enemy …. Incommunicable to become whatever sleep … I plan to apply benadryl and thc for sleep").

Notably, cannabis employ was often mentioned in conjunction with what people referred to equally "comfort meds" like benzodiazepines and other medications for anxiety and Imodium/loperamide for diarrhea. People also mentioned using gabapentin, anti-emetics, anti-hypertensives, sleep medications, and over the counter (OTC) hurting medications (ibuprofen, acetaminophen), as well as alcohol and herbs like kratom, kava, and valerian root. Occasionally people mentioned trying meditation, vitamins, like shooting fish in a barrel to assimilate foods, water, practice, and social support: "I detoxed totally cold turkey with nothing simply vitamins, exercise, the Practiced Lord's honey and guidance, and a ton of weed." While the majority of posts describing cannabis utilise for withdrawal symptom management were positive towards cannabis (42/55), information technology was non always clear whether the perceived helpfulness was due to cannabis lone or to other strategies.

A few people, primarily in the recovery subreddit, described non using opioids for over a calendar month merely nevertheless feeling withdrawal symptoms, often referred to as post-astute withdrawal syndrome (PAWS): "How do you part while going through paws? …. I get to 45 days and nevertheless feel terrible and then I relapse. Weed is the but affair that helps" Some people who had not used in several weeks to months likewise described how cannabis did non assist ("Day 75 … weed doesn't fifty-fifty help much [with low appetite and nausea]") or fifty-fifty made them feel worse: "What to practice with your life after drugs? …. Recently I've turned to weed to help with the anxiety and boredom only that is making me feel like more of a piece of crap."

9 posts mentioned CBD specifically, primarily every bit beingness helpful for withdrawal symptoms ("WD anticipation … I take a few Xanax and Valium and some cbd weed to ease the pain"). Nearly mentions of CBD were in the recovery subreddit sample (7/100) and many referred to "CBD oil" as the method of utilise ("Detoxing off heroin … I also have just started taking CBD oil about two weeks ago which has been helping my feet a lot"). 3 of these posts described using CBD lonely with THC-containing cannabis.

Motivations—Questioning compatibility with recovery

Nigh 1 in x posts in the recovery subreddit sample (12/100) and very few (3/100) in the opioid subreddit sample posed questions to the subreddit members soliciting their opinions and experiences on the effectiveness and social acceptability norms surrounding using cannabis in recovery: Marijuana and recovery from opiates? What'due south your idea of "make clean"? I know it's a sensitive subject for some people simply I'm just looking for honesty and maybe some personal experience stuff. In contrast, one person noted how using cannabis while in recovery from opiates may accept been a trigger for returning to apply: "Smoking weed is all practiced until yous get a instance of the fuck-it's and get on a run!"

Motivations—Polysubstance use

About i in 5 posts in the opioid subreddit (18/100) but very few posts in the recovery subreddit (3/100) described using cannabis and an opioid at the same time. Sometimes people shared descriptions ("55 Percocet 7.5mg and 50 100mg thc indica") or images of substances they were looking forrard to using ("Gonna be a fun weekend") with the intention of enhancing their high and feeling pleasance. Others reported their recent habits or experiences combining opioids and cannabis and how they felt subsequently.

Motivations—Hurting management

A like proportion of posts in each subreddit (6/100 of recovery subreddit posts, v/100 of opioid subreddit posts) mentioned using cannabis to control pain due to a chronic hurting condition or for painful withdrawal symptoms (e.grand., body aches), with mixed opinions on its effectiveness in alleviating pain vs. serving every bit a mental distraction. As with withdrawal symptom management, cannabis was 1 several strategies people used to manage hurting. Other people mentioned injury or chronic pain as being related to the first fourth dimension they used opioid pills (simply not in relation to cannabis utilize).

Healthcare provider interactions regarding cannabis

Health providers or programs were referred to in both subreddits (26/100 in recovery subreddit, fourteen/100 in opioid subreddit), as people shared by experiences with rehab programs or specific providers or noted an upcoming medical appointment. However, cannabis was mentioned in only a quarter of these interactions (10/xl), mostly in the recovery subreddit sample (vii/ten). Some people related their provider'southward stance on their cannabis use, with preference for providers that allow them to use cannabis ("[My suboxone dr.] knows and allows me to fume weed, and we take a pretty good rapport") vs. providers who disallow information technology ("They won't let me smoke weed which is my biggest complaint"). A few other people referred to the policies and attitudes of treatment programs, again speaking preferentially well-nigh programs where cannabis utilise was permitted.

Word

In this report examining the prevalence and content of cannabis-related posts in an opioid use subreddit and an opioid recovery subreddit, we found that cannabis mentions were more than common in the recovery subreddit and that a principal motivation among those posting in the recovery subreddit about cannabis was the use of cannabis every bit a strategy to address opioid withdrawal symptoms. Although cannabis-related posts were relatively uncommon in these subreddits as a whole, cannabis-related posts were twice as prevalent in the recovery subreddit than in the opioid subreddit. Within these posts, posters disclosed several motivations for cannabis use in relation to opioid employ. Frequent and unique phrases in the recovery subreddit alluded to utilise of cannabis as a treatment, commutation, or as one of several "comfort meds" for opioid withdrawal. In the opioid utilise subreddit, frequent and unique phrases alluded to employ of cannabis in conjunction with opioids, with the most mutual motivations being polysubstance utilize, followed by withdrawal symptom management.

A master finding of this study is that posters reported that the potential of cannabis to address OUD or reduce opioid employ may derive from the use of cannabis to manage acute and persistent opioid withdrawal symptoms, a mechanism that has received less attending in the opioid-cannabis literature. While there are many interactions betwixt the endocannabinoid and opioid systems, particularly with respect to rewarding properties of each drug [seven, 42], cannabis itself does not accost primary physiological opioid withdrawal mechanisms. The etiology of opioid withdrawal symptoms is related to complex adaptations in the opioid receptor-rich nervous and gastrointestinal systems resulting from repeated utilise of opioids [43]; withdrawal is idea to come from a sudden loss of tonic opioid receptor blockade resulting in increased activation of norepinephrine and epinephrine. A more likely mechanism supporting our findings may exist psychological relief, particularly anxiety relief and distracting or calming the mind from catastrophizing thoughts, especially if the person has had difficult withdrawal experiences before. For example, in a daily dairy study with chronic pain patients, negative affect and pain catastrophizing mediated the clan between withdrawal symptoms and opioid peckish [44]. Every bit astute opioid withdrawal can be a distressing event, more enquiry is needed on these cognitive and melancholia aspects of withdrawal, besides as not-opioid pharmacological and psychosocial options for withdrawal direction.

In an online survey written report of 200 adults who used cannabis and opioids and had experienced opioid withdrawal, nearly two-thirds reported using cannabis to treat withdrawal, reporting particular relief from feet, tremors, and trouble sleeping [45], which mirrors the accounts posted in the recovery subreddit. However, in an observational report of cannabis use among 116 patients undergoing methadone taper, opioid-withdrawal symptom scores did not differ significantly betwixt patients who used cannabis and those who did not, even in time-lagged and sensitivity analyses [46]. While most cocky-reports in the present report focused on acute withdrawal symptoms, several posters reported using cannabis to manage what they described as longer-term PAWS symptoms [40, 41].

In contrast to substantial research involvement in cannabis for pain management, hurting was a rarely mentioned motivation for cannabis employ in posts sampled from these subreddits for the current report. Posters also reported using cannabis at the aforementioned time as opioids to achieve a desired "high," though primarily in the non-treatment-seeking opioid subreddit. Posters likewise expressed uncertainty and ambivalence about the effectiveness and social acceptability of using cannabis while trying to abjure from opioids or in a methadone or buprenorphine treatment programme. Many treatment program goals are focused primarily on achieving consummate forbearance from all substances, and resistance to using pharmacotherapy for substance use disorder persists in some treatment modalities and 12-step programs [47–49]. Additionally, in the United States, federal Substance Abuse and Mental Health Services Administration (SAMHSA) guidelines require urine drug screens (including for THC) from patients in methadone and buprenorphine treatment programs at intake. Although many programs do non enact sanctions for positive urine drug screens for THC during treatment, some do, which may human activity as an additional barrier for engagement and retention in OUD treatment [fifty, 51]. Research from Canadian settings has constitute mixed prove for the role of cannabis apply in treatment retention [52, 53].

Previous research has institute cannabis use motivations described by people who use illicit drugs include to "get high," relieve pain, and reduce opioid employ [54], among a wide spectrum of therapeutic and recreational motivations that demonstrate unmet healthcare needs amidst opioid-using populations [55]. Despite the existence of FDA-approved medications for OUD including methadone, buprenorphine, and extended-release naltrexone, access to and engagement with these medications and other evidence-based psychosocial handling modalities is limited [56–59]. Posters in the present written report often reported using cannabis every bit i of several strategies to self-manage withdrawal symptoms in the context of limited involvement in or admission to OUD treatment.

In that location have been few randomized controlled trials on the use of cannabis or cannabinoids in OUD treatment [7]. In a double-bullheaded, placebo-controlled study with threescore patients, the FDA-approved THC analog dronabinol was administered orally (10mg-30mg) as an adjunct to extended-release naltrexone for OUD during inpatient detoxification and for 5 weeks follow up, with findings of lower severity of opioid withdrawal symptoms in the dronabinol grouping compared to the placebo grouping, simply similar rates of induction and handling completion [60]. In a smaller human being laboratory study with 12 opioid-dependent patients, higher doses of oral dronabinol (20mg and 30mg vs. 5mg and 10mg) were associated with modest suppression of withdrawal severity merely also with objectively measured increases in eye rate [61]. In a systematic review of 23 studies, McBrien et al. institute no consensus that cannabis use was associated with reductions in opioid use or retention in treatment among patients in methadone maintenance therapy, though overall quality of prove was depression with a high risk of bias, in part due to primarily observational studies and large heterogeneity in cannabis utilise measurement [62]. A recent exploratory double-blind, placebo-controlled trial examined the effect of oral 400mg and 800mg CBD on drug cue-induced craving and anxiety among 42 abstinent patients with heroin use disorder, finding that participants in the CBD group had significantly reduced craving and anxiety compared with the placebo grouping [63]. In addition to the need for additional clinical and randomized controlled studies, more research is needed on the safety and efficacy of whole plant cannabis vs. specific cannabinoids (e.1000., THC, THCA, CBD, CBN), dosages, and routes of administration (due east.g., inhalation vs. ingestion), likewise as participant groups from diverse OUD treatment and community settings (e.thousand., buprenorphine dispensary patients, non-treatment seeking individuals).

At that place are several limitations to this research. A chief i is limited generalizability to people who employ opioids, or who are in opioid employ disorder handling or in clinically or self-defined recovery, as nosotros practice not have demographic or geographic information most people who post on this pseudonymous forum. A related set of limitations is that posters may be more likely to share short term "success" stories with cannabis, which may in turn be due to positive expectancies or placebo effects. It is unknown how successful individuals were in the longer term or how often posters might report negative experiences with cannabis in these online venues. Another limitation is that our initial cannabis term filter list may take been incomplete (in not picking up specific slang or misspellings). Nevertheless, this exploratory analysis of naturalistic cannabis employ in the context of opioid use has identified additional information virtually the potential impact of cannabis legalization on opioid utilise and related morbidity and mortality, particularly in the context of unmet treatment needs for opioid employ disorder.

Despite these limitations in generalizability, this examination of reports of naturalistic cannabis employ in relation to opioid utilise identified withdrawal symptom management equally a mutual motivation, likewise as interest and uncertainty virtually cannabis among some people who use opioids or place as in recovery from opioids. Future enquiry is warranted with more structured survey and dispensary-based assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.

Acknowledgments

The authors wish to thank the members and moderators of these online communities for their open conversations.

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