Is the argument inductive or deductive. Opioids, the most effective analgesic for acute pain, had started to be highly prescribed for chronic pain in the 1990s.Citation¹ However, the opioid epidemic in the past few years has led to increased awareness of the risks associated with opioids, such as misuse and death from overdose.Citation² In parallel to the opioid epidemic, the cannabis "no harm" and legalization trend has led physicians to reexamine the therapeutic potential of cannabis for chronic pain. Thus, even though a recent meta-analysis for the treatment of chronic non-cancer pain patients with cannabis found a lower effect,Citation³ cannabis is still gaining popularity as an alternative to prescription opioids for the treatment of chronic pain, with patients reporting symptomatic benefit in adding cannabis to opioids for pain relief.Citation¹ They describe a more significant pain relief when using cannabis in conjunction with opioids than when opioids are used alone,Citation⁴ and even reported that they substituted cannabis for opioids in a recent study.Citation⁵ The question of cannabis and opioid use disorders among the population of patients with chronic pain, particularly the younger patients, is of significant importance.

Various studies have examined the prevalence of opioid use disorder and its otherwise problematic use among patients with chronic non-cancer pain.Citation^6-8 Several questionnaires and criteria are used both for research and for the clinical evaluation of misuse. In studies that applied DSM-based diagnostic criteria, the prevalence of opioid use disorder ranged from 1.9% to 37%. However, some experts contend that a significant drawback to adopting DSM-based criteria is that they emphasize physical dependence, predicted response to chronic opioid use.Citation^9,Citation¹⁰ As a result, alternative measures that take into account the behavioral aspects of misuse have been proposed. One common alternative is Portenoy's criteria, a selfreport questionnaire for assessing addiction among pain patients treated with opioids.Citation¹¹ Criteria for prescription opioid use disorder include a positive response to both items A (an intense desire for the drug) and B (concern about the drug's availability), as well as at least one additional positive reply to any of the other criteria shown in Figure 3.It has high concurrent validity, high interrater agreement (0.93), high sensitivity (0.85) and specificity (0.96) compared to ICD-10 in chronic pain populations.Citation¹²

Cannabis use, however, is associated with a variety of adverse effects, including the risk of cannabis use disorder.Citation¹³ A recent study from Israel found that the prevalence rate of problematic use of cannabis was 10.6% according to Portenoy's criteria and 21.2% according to DSM-IV criteria among patients suffering from chronic pain and treated with cannabis. This was the only study to date that presented data on the problematic use of cannabis among Israeli chronic pain patients.Citation⁶

Cannabis is classified as an illicit drug under Israeli law.Citation¹⁴ It is currently listed for specific indications and only after the failure of all other recognized forms of treatment. For the most part, physicians cannot issue permits to patients directly but instead recommend that the "Israeli Medical Cannabis Agency", which provides governmental supervision and regulation of cannabis use, issues such permits.Citation¹⁵ These regulations developed following a sharp increase in the prescription of cannabis in Israel and are likely driven by increased patient demand due to social forces (e.g., positive media coverage and public attitudes toward medical cannabis).Citation¹⁶

We aimed to investigate in a random sample of chronic non-cancer pain patients who had been prescribed medical cannabis, whether medical cannabis usage was associated with a reduction in the use of opioids. We hypothesized that medical cannabis chronic pain patients would report reduced opioid usage. We also sought to measure the rates of misuse of medical cannabis and opioids, as medical cannabis patients in the US are at heightened risk for developing cannabis use disorder than adults without pain.Citation¹⁷ Participants were stratified by age, as substance use disorder is commonly thought to be more frequent with younger adults than among the elderly.Citation^18,Citation¹⁹