The title of the study is "Emerging Evidence for Cannabis' Role in Opioid Use Disorder" ... so it is not exactly about the use of cannabinoids in RLS, however because I always had an interest in treating opioid dependence I kept reading. The article makes a few very interesting points and arguments who I think are highly relevant for RLS patients, too, especially when you have to take opioids or when your RLS will require opioid treatment in the future.
For those who want to read the full article I will provide the direct link here. The article is "open access". So you don't need to pay or need an expensive subscription to access it. For those who do not have the time or motivation to read it, I will quote the most relevant parts who are of interest for us.
Emerging Evidence for Cannabis' Role in Opioid Use Disorder: https://www.liebertpub.com/doi/10.1089/can.2018.0022 (Cannabis and Cannabinoid ResearchVol. 3, No. 1, published September 1st, 2018
Although there are a number of FDA-approved opioid replacement therapies and maintenance medications to help ease the severity of opioid withdrawal symptoms and aid in relapse prevention, these medications are not risk free nor are they successful for all patients. Furthermore, there are legal and logistical bottlenecks to obtaining traditional opioid replacement therapies such as methadone or buprenorphine, and the demand for these services far outweighs the supply and access.
I think the very same is true when you need opioids for RLS. Many doctors are unaware that opioids are a safe and effective treatment option for severe RLS cases. This and the new CDC guidelines and state laws who try to limit the overall use of opioids dramatically affect legitimate RLS patients and can make it (almost) impossible for patients to obtain long-term access to opioids. And even when patients find a doctor, state laws and guidelines limit the opioid dose arbitrarily to an equivalent of 90 mg of Morphine daily even though some cases do require significantly higher doses. I even found a few case reports in medical journals where patients had such severe symptoms that they need to implant a "pain pump" to deliver Morphine directly into the central nervous system after all other treatment options failed.
The two main questions for RLS patients in this context are: what can we do if we need opioids but fail to find a doctor who is willing to prescribe them and 2nd: what can we do when we are about to exceed the daily maximum dose of 90 mg Morphine equivalent and our doctor is not willing to prescribe more?
The endocannabinoid and opioidergic systems are known to interact in many different ways, from the distribution of their receptors to cross-sensitization of their behavioral pharmacology. Cannabinoid-1 (CB1) receptors and mu opioid receptors (MORs) are distributed in many of the same areas in the brain. (...) The extent of this overlapping expression and frequent colocalization of the CB1 and MOR provide clear morphological underpinnings for interactions between the opioid and cannabinoid systems in reward and withdrawal.
There is a bidirectional relationship between MORs and CB1 receptors in the rewarding properties of drugs of misuse.20,24–28 That is, modulation of the CB1 receptor has profound effects on the rewarding properties of opioids, and vice versa.
The article goes into way more detail than I am quoting here ... but as a main take away it is important to understand that cannabinoid & opioid receptors are distributed in the same areas of the CNS, therefore explaining the close interaction between those receptors and why cannabinoids can have similar effects than opioids.
The article goes on:
The primary use for both prescription opioids and cannabis is for analgesia. Currently, up to 90% of patients in state-level medical cannabis registries list chronic pain as their qualifying condition for the medical program. In an exhaustive review, the National Academies of Science and Medicine recently confirmed the efficacy of cannabis for chronic pain in adults. Interestingly, when given access to cannabis, individuals currently using opioids for chronic pain decrease their use of opioids by 40–60% and report that they prefer cannabis to opioids.
I can report that after only two weeks of using cannabis based medication I was able to reduce my opioid dosage by about 25 to 30% without even trying. It just happened automatically. Most likely I could reduce the dose even more but that would mean I had to take relevant amounts of THC during the day and since I do not like being high 24/7 I don't consider this to be an option for myself.
However: I do have one cannabis strain who only contains 0,5% THC while the more common strains have between 10 and 25% THC. Still: even the strain with only 0.5% THC has some significant analgesic properties who are strong enough to deal with a variety of symptoms I have in the afternoon and early evening. Additionally it does not create any high. So I think even people who either do not like or tolerate THC Cannabis can offer alternatives and additional options to reduce the opioid dose and opioid side effects.
Patients in these studies reported fewer side effects with cannabis than with their opioid medications (including a paradoxical improvement in cognitive function) and a better quality of life with cannabis use, compared to opioids. Despite the vast array of cannabis products and administration routes used by patients in states with medical cannabis laws, cannabis has been consistently shown to reduce the opioid dose needed to achieve desirable pain relief.
The improvement of cognitive function is indeed kinda weird. There are a lot of studies who have shown that THC can impair short-term memory, especially when under the acute influence of it. But overall the effects might be different in selected populations. My sleep was so bad before I started taking cannabis meds and the improved sleep alone made me way more active. I started writing and communicating more again and this slowly makes optimistic that I will be able to continue study medicine.
Also for those who suffer from libido problems and impotence as a side effect of opioids ... I can tell that cannabis normally improves these problems and just a few weeks ago a new study was published that shows that cannabis users have more sex than people who do not use it. And a healthy sex life alone can do much to improve quality of life.
One of the mechanisms that may explain the opioid sparing effects of cannabis is its ability to produce synergistic analgesia. In humans, subanalgesic doses of THC and morphine are equally unsuccessful at reducing the sensory or affective components of pain; however, when the same doses of THC and morphine are coadministered, they produce a significant reduction in the affective component of pain. These synergistic effects are also observed when patients using opioids for pain vaporize whole-plant cannabis, as opposed to experimentally administered isolated THC. Adjunct whole plant cannabis has no effect on the pharmacokinetics of opioids, which further supports a synergistic mechanism behind the opioid sparing and enhanced analgesia produced by cannabis. Furthermore, in pre-clinical models, coadministration of opioids and cannabinoids attenuates the development of opioid tolerance.
I believe the last point is really important to us. RLS is one of the very few disorders where opioids are prescribed for many years. So avoiding and managing tolerance can become a major issue after a few years. I was close to running into serious issues and the strategies I'd used in the past were not working anymore. This forced me into taking more and more but after I realised that this is not really helping, I limited my dose and accepted the suffering.
Combined, these clinical and pre-clinical data suggest that analgesic synergy produced by coadministered cannabis and opioids could be harnessed to achieve clinically relevant pain relief at doses that would normally be subanalgesic. This strategy could have significant impacts on the opioid epidemic, given that it could entirely prevent two of the hallmarks of opioid misuse: dose escalation and physical dependence.
I must say, I have to agree. Based on my experience, the reports from other cannabis user and the so far only very limited research of cannabis and its use for RLS already paint a clear picture.
I wish there would be more research to better understand what the long-term impact of medicinal cannabis is. It appears that Cannabis can target almost all the primary symptoms associated with RLS. However it is unclear to me how strong the effect on the "urge to move" is since opioids even in very small doses have an effect on this, I can't really tell what the effect of Cannabis is.
Anyway, it would be very interesting to know if low THC strains are already powerful to enough to treat the "urge to move" part of RLS and maybe the use of such strains is an option to delay the use of opioids for a few years ... but even when not it would help with avoiding / reducing tolerance, keeping the opioid dose low and reduce or even eliminate opioids side effects all together.
Especially potential opioid side effects like libido problems, impotence, depression, fatigue and alertness at night can be influenced by cannabis in a positive way.
Overall I think it is clear that cannabis has huge potential to improve the quality of life of a lot of RLS patients. And considering that even low THC strains who do not make you stoned and high already have so many positive effects makes Cannabis even more interesting.
However if you want to use Cannabis as some kind of sleeping medication it seems that you really need the THC. Yesterday I was able to sleep until 02:00 am with the low THC product ... but then I woke up with so many symptoms that it was obvious I had to use a high THC strain to deal with it.
One thing I really like: when you use a vaporiser, you get the analgesic effects within a few minutes ... when using opioids, I have to wait at least 20 to 30 minutes .... and over 60 minutes for full effect.
So, ya, I know this is a lot of text but I think this study contains so many valuable informations that it is worth the effort.