5 Myths About Cannabis and the Opioid Crisis


By Roger Chriss, PNN Columnist

Cannabis has a glowing halo of health around it. Claims of medical efficacy abound, including a recent article in The Street that asks, “Can Legal Cannabis Help Slow the Opioid Drug Epidemic in the U.S.?”

Another article in The Charlotte Observer is more of a plea than a question:  "What’s it going to take for us to recognize the value of cannabis in combating the opioid epidemic?"

These articles perpetuate five key myths about cannabis. The opioid crisis requires a significant response, but enthusiasm needs to be tempered by fact.

“I think we need to be very circumspect in what we are expecting from cannabis with respect to the opioid epidemic,” Dr. Susan Weiss of the National Institute on Drug Abuse (NIDA) said at a recent forum at the Center for the Study of Cannabis at the University of California, Irvine.

We also need to be accurate. Cannabis has significant medical potential, but if we lose sight of facts, we may fall into one or more risky myths. 

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Myth 1: Cannabis is Not Addictive

According to NIDA, 30 percent of those who use marijuana may have some degree of marijuana use disorder. In current parlance, a “use disorder” is a broad term that includes all forms of misuse, abuse and addiction. 

The World Health Organization estimates that about one of every eight cannabis users is dependent in some way. Since the U.S. has about twice the world average for cannabis use disorder, this puts the U.S. rate at an estimated 25%, close to the number from NIDA.  

“There should be no controversy about the existence of marijuana addiction,” Dr. David Smith, who has been treating drug addiction in San Francisco for 50 years, told The Pew Charitable Trusts. “We see it every day. The controversy should be why it appears to be affecting more people.”

Myth 2: There Has Never Been a Fatal Cannabis Overdose

In May, the Journal of Forensic Science reported on two fatal cases of chronic nausea and vomiting, apparently caused by persistent cannabis use.

Although cannabis has a very wide therapeutic window, it is not infinite. And cumulative effects become significant for regular users, including medical cannabis patients. There is extensive literature on non-fatal cannabis toxicity, along with increasing rates of unintentional cannabis intoxication among children.

In addition, Israeli pharmacists have been cautioning that “for older patients who suffer from cardiovascular diseases, use of the drug can lead to increased risks of blood pressure fluctuations, heart attacks, ongoing cardiac distress and even sudden cardiac death.”  

Myth 3: Cannabis Can Treat Chronic Pain

In the wake of the 2017 National Academies report on cannabis, a number of major reviews and meta-analyses have been performed. A recent review in the journal Pain concluded that “it appears unlikely that cannabinoids are highly effective medicines" for chronic non-cancer pain. 

Cochrane came to similar conclusions in two recent reviews, one on cannabis for fibromyalgia and the other on cannabis for chronic neuropathic pain in adults.

In other words, cannabis may not be quite the panacea that some people hope. Instead, it may be like most other medications, effective in some people for certain conditions but not for others.

Myth 4: Medical Cannabis Reduces Prescription Opioid Use

A recent study by the RAND Corporation found little evidence that states with medical marijuana laws have reduced prescribing of opioid pain medication.

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids,” said Rosalie Liccardo Pacula, co-director of the RAND Drug Policy Research Center.

And rather than reducing opioid abuse, statistical analyses of drug databases found that people who use medical marijuana may be at higher risk for misusing or abusing prescription drugs.

Many studies on medical cannabis look at people in state medical cannabis programs. But such programs act as biased filters that select people who are most likely to benefit from medical cannabis or believe they already have. These patient self-reports are often inaccurate and have to be interpreted with caution.

Myth 5: Cannabis Helps Recovering Drug Addicts

Pain Medicine News reported on a study that found many people undergoing addiction treatment self-medicate with cannabis to relieve their pain, anxiety, depression and poor sleeping habits.  The researchers cast doubt on the effectiveness of that strategy, saying “cannabis may have an odd but unproductive effect on symptoms in some people.” 

Similarly, a new study in the Journal of Clinical Psychiatry found that: "cannabis use was associated with negative long-term symptomatic and treatment outcomes” for anxiety and mood disorders.

There are plenty of anecdotal success stories about cannabis treating chronic pain, addiction and other conditions, but the plural of anecdote is not data. That hasn’t stopped 29 states and the District of Columbia from legalizing the medical use of cannabis.

“Public policy is light years ahead of the science right now,” Ziva Cooper, a professor of clinical neurobiology at Columbia University told The State Journal Register.  “There seems to be this nationwide experiment on the effects of cannabis that is happening in the absence of rigorous studies.”

We have to treat cannabis with the same respect we give to any medication. Cannabis can be used medically, but we should be aware of the risks involved. And it is vital that myths be dispelled so that people who benefit from medical cannabis can use it safely and effectively. 

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Medical Marijuana Reduces Opioid Use in Older Adults

By Pat Anson, Editor

Medical marijuana can significantly reduce pain levels in older adults and reduce their need for opioid pain medication, according to a small study of cannabis users. The findings add to growing -- and sometimes conflicting evidence -- that medical marijuana reduces demand for prescription opioids.

To gauge how effective medical marijuana is at managing chronic pain and reducing opioid use, researchers at Northwell Health, a healthcare network based in New York State, surveyed 138 patients who started using medical marijuana in the previous month. The patients have chronic conditions such as osteoarthritis, spinal stenosis, and chronic hip and knee pain.

The 20-question survey focused on how often they used marijuana, in what form they took it, how much it reduced pain and whether they were able to cut back their use of painkillers.

A month after they started using medical marijuana, most patients reported that their average pain score dropped from 9 (on a scale of 0-10) to a more moderate pain level of 5.6.

Nearly two-thirds said they were able to reduce or stop their use of painkillers, with 27% saying they were able to stop completely. Over 90% said they would recommend medical marijuana to others.

DRUG POLICY ALLIANCE

DRUG POLICY ALLIANCE

"My quality of life has increased considerably since starting medical marijuana," one patient said. "I was on opiates for 15 years."

"It (medical marijuana) is extremely effective and has allowed me to function in my work and life again. It has not completely taken away the pain, but allows me to manage it," another patient said.

About 45% of patients said they ingested marijuana using vaporized oil, 28% used pills and 17% used marijuana-laced oil. Most said they used marijuana daily, with 39% using it more than twice a day.

"What I'm seeing in my practice, and what I'm hearing from other providers who are participating in medical marijuana programs, is that their patients are using less opioids," said Diana Martins-Welch, MD, co-author of the study and a physician in the Division of Geriatric and Palliative Medicine at Northwell Health. "I've even gotten some patients completely off opioids."

Research in Israel also found that cannabis can significantly reduce chronic pain in elderly patients. But the evidence is less certain that it reduces opioid use.   

A recent study of Medicare and Medicaid patients found that prescriptions for morphine, hydrocodone and fentanyl dropped in states with medical marijuana laws, but daily doses for oxycodone increased. A second study found nearly a 6% decline in opioid prescribing to Medicaid patients in states with medical marijuana laws.  Both studies were conducted during a period when nationwide opioid prescribing was in decline.

A recent study by the RAND corporation found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioids. RAND researchers believe some pain patients may be experimenting with marijuana, but their numbers are not large enough to have a significant impact on prescribing. 

Despite the uncertainty of the evidence, the Illinois Senate recently passed legislation that would expand the state’s medical marijuana program by allowing doctors to prescribe marijuana to any patient who is prescribed opioid medication.  The idea is to get patients off opioids before they become addicted or dependent on the drugs.

"We know that medical cannabis is a safe alternative treatment for the same conditions for which opioids are prescribed," said Sen. Don Harmon, the bills’ sponsor. "This legislation aims to stop dependence before it begins by providing an immediate alternative."

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law.

Medical Marijuana Offers Little Benefit for Acute Pain

By Roger Chriss, Columnist

Colorado lawmakers are considering a bill that would let doctors recommend cannabis for short-lived acute pain. According to the Denver Post, the bill would allow doctors to recommend marijuana for any condition “for which a physician could prescribe an opiate for pain.”

State law currently allows Colorado doctors to recommend marijuana for nine long term medical conditions, including severe chronic pain. But Dr. Larry Wolk, the executive director of the Colorado Department of Public Health and Environment, cautioned that there isn’t enough evidence to support marijuana’s use for acute pain.

“We’re not set up … for this acute pain situation,” Wolk said at a hearing. “This would last maybe three days to a week. But, when you receive a (medical marijuana) card, it’s good for a year.”

Cannabis is one of the most studied substances in the world, but many basic questions about its medical use remain unexplored. Research has found that cannabis doesn’t work well for acute pain.

In 2008, Dr. Birgit Kraft led a small study of cannabis for acute inflammatory pain. Kraft used a double-blind, crossover protocol on 18 healthy female volunteers, evoking pain in several ways and treating it orally with a cannabis extract. It did nothing to reduce acute pain and may have increased it in some subjects.

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"The surprising result of our study was the absence of any kind of analgesic activity of THC-standardized cannabis extract on experimentally induced pain using well-established human model procedures,” Kraft said in an interview with Science Daily. “Our results also seem to support the impression that high doses of cannabinoids may even cause increased sensitivity in certain pain conditions.”

A similar study with a more limited scope was performed in 2007 using smoked cannabis. In a randomized, double-blind, placebo-controlled, crossover study with 15 healthy volunteers, researchers tested sensitivity to capsaicin-induced pain. They concluded that there was a "window of modest analgesia for smoked cannabis, with lower doses decreasing pain and higher doses increasing pain.”

In other words, the best cannabis could muster was a mild benefit if a person could manage to hit a sweet spot between too little and too much.

A clinical study in 2006 on cannabis for post-surgical pain did not go so well. Researchers in Berlin used Cannador (a cannabis plant extract) on patients after surgery. None of the patients was able to achieve sufficient pain relief at any dose of Cannador. Several experienced significant side effects, including sedation and nausea. Importantly, the study had to be halted because of a severe adverse event in one patient.

And a 2018 study on “the good, the bad, and the ugly” about medical cannabis came to this conclusion: “Cannabinoids appear to be most effective in controlling neuropathic pain, allodynia, medication-rebound headache, and chronic noncancer pain, but do not seem to offer any advantage over nonopioid analgesics for acute pain.”

There is thus little evidence to suggest that cannabis may be useful for acute, short-lived pain. Instead, the available research points to nontrivial risks, including the possibility of increased pain and adverse reactions.

Better Options Available

Moreover, there are a wide variety of options for treating acute pain, from ibuprofen and other NSAIDs to acetaminophen, topical analgesics, lidocaine and other local anesthetics, and ultrasound therapy. It is more than a bit puzzling that Colorado would be seeking to replace opioids with cannabis when so many well-established options are readily available for acute pain.

For instance, the Journal of the American Dental Association published an analysis of the benefits and risks of analgesic medications in the management of acute dental pain. Results showed that ibuprofen plus acetaminophen offered the best outcome, with acetaminophen with oxycodone and diclofenac, ketoprofen, and difunisal also giving good results. The article concludes that the risks of opioid analgesics, in particular for children and adolescents, can be minimized by medically appropriate use of NSAIDs and acetaminophen.

Furthermore, cannabis does have side effects and risks. Some people do not tolerate it well, and cannabis use disorder reportedly develops in 9% or more of people who use it. Even CBD oil, arguably the safest form of cannabis, has side effects that include fatigue, diarrhea, and possible effects on liver enzymes.

Untreated or undertreated pain has significant clinical consequences, from impeding appropriate diagnostic testing and evaluation to impacting follow-up care and recovery. There are already reliable and effective options for acute and short-term pain management, with fewer risks and side effects than cannabis, few issues with misuse or abuse, and no legal conflicts between federal and state law.

Cannabis has important medical benefits, from controlling chemotherapy-induced nausea and reducing seizures in childhood epilepsy to helping with some chronic pain conditions. But the available evidence does not support cannabis for the management of short-lived acute pain.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

FDA Staff Recommends Approval of Marijuana Drug

By Pat Anson, Editor

The U.S. Food and Drug Administration may be on the verge of approving its first prescription drug derived directly from marijuana.

In a report posted online, FDA staff said there was “substantial evidence” that Epidiolex, a liquid formula containing cannabidiol (CBD), was effective in reducing seizures in children with Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS), two severe forms of childhood epilepsy.

GW PHARMACEUTICALS IMAGE

GW PHARMACEUTICALS IMAGE

Epidiolex is made by GW Pharmaceuticals, a British drug maker that specializes in developing drugs from marijuana.

“The applicant has provided positive results from three randomized, double-blind, placebo-controlled studies conducted in patients with LGS and DS,” FDA staff reported.

“The studies are adequate and well-controlled. The statistically significant and clinically meaningful results from these three studies provide substantial evidence of the effectiveness of CBD for the treatment of seizures associated with LGS and DS.”  

CBD is one of the active ingredients in marijuana. It does not contain THC (tetrahydrocannabinol), the chemical compound in marijuana that makes people high. Many oils and tinctures containing CBD are already sold online and in states were medical marijuana is legal, but the FDA has not approved any of them.  The agency has only approved a handful of synthetic cannabinoids such as Marinol (dronabinol) to treat loss of appetite and nausea.

Although some children in the clinical trials experienced side effects from Epidiolex such as liver toxicity, anemia and drowsiness, the FDA staff report said the risks were “mild to moderate” and could be managed with warning labels. The report also found there was low risk of the strawberry flavored Epidiolex being abused.

“Although the review is still ongoing, the risk-benefit profile established by the data in the application appears to support approval of cannabidiol for the treatment of seizures associated with LGS and DS,” the report concludes.

(4/18/18 Update: An FDA advisory committee unanimously recommended that the FDA accept the staff findings and approve Epidiolex) 

In a briefing paper for the committee, GW Pharmaceuticals said there were few effective treatment options for children with LGS and DS, who often have severe intellectual and developmental disabilities and a high risk of mortality.

A final decision by the FDA is expected this summer. There is no guarantee the agency will follow the advice of its staff or advisory committee. If Epidiolex is approved, it would only be for the treatment of childhood epilepsy. However, doctors would presumably be able to prescribe it “off label” for other conditions such as chronic pain.  

GW Pharmaceuticals also makes Sativex, an oral spray that contains both CBD and THC. Sativex has been approved in Europe, Canada, Australia, New Zealand and several other countries for the treatment of muscle spasticity caused by multiple sclerosis. In Israel, Sativex is also approved for the treatment of pain and chronic non-cancer pain.  

Medical Marijuana’s Catch-22: Policy Before Science

By Marisa Taylor and Melissa Bailey, Kaiser Health News

By the time Ann Marie Owen turned to marijuana to treat her pain, she was struggling to walk and talk. She also hallucinated.

For four years, her doctor prescribed the 61-year-old a wide range of opioids for her transverse myelitis, a debilitating disease that caused pain, muscle weakness and paralysis.

The drugs not only failed to ease her symptoms, they hooked her.

When her home state of New York legalized marijuana for the treatment of select medical ailments, Owens decided it was time to swap pills for pot. But her doctors refused to help.

“Even though medical marijuana is legal, none of my doctors were willing to talk to me about it,” she said. “They just kept telling me to take opioids.”

While 29 states have legalized marijuana to treat pain and other ailments, the growing number of Americans like Owen who use marijuana and the doctors who treat them are caught in the middle of a conflict in federal and state laws — a predicament that is only worsened by thin scientific data.

ANN MARIE OWEN (ALLYSE PULLIAM FOR KHN)

ANN MARIE OWEN (ALLYSE PULLIAM FOR KHN)

Because the federal government classifies marijuana a Schedule 1 drug — by definition a substance with no currently accepted medical use and a high potential for abuse — research on marijuana or its active ingredients is highly restricted and even discouraged in some cases.

Underscoring the federal government’s position, Health and Human Services Secretary Alex Azar recently pronounced that there was “no such thing as medical marijuana.”

Scientists say that stance prevents them from conducting the high-quality research required for FDA approval, even as some early research indicates marijuana might be a promising alterative to opioids or other medicines.

Patients and physicians, meanwhile, lack guidance when making decisions about medical treatment for an array of serious conditions.

“We have the federal government and the state governments driving a hundred miles an hour in the opposite direction when they should be coming together to obtain more scientific data,” said Dr. Orrin Devinsky, who is researching the effects of cannabidiol, an active ingredient of marijuana, on epilepsy. “It’s like saying in 1960, ‘We’re not going to the moon because no one agrees how to get there.’”

The problem stems partly from the fact that the federal government’s restrictive marijuana research policies have not been overhauled in more than 40 years, researchers say.

Only one federal government contractor grows marijuana for federally funded research. Researchers complain the pot grown by the contractor at the University of Mississippi is inadequate for high-quality studies.

The marijuana, which comes in a micronized powder form, is less potent than the pot offered at dispensaries, researchers say. It also differs from other products offered at dispensaries, such as so-called edibles that are eaten like snacks. The difference makes it difficult to compare the real-life effects of the marijuana compounds.

Researchers also face time-consuming and costly hurdles in completing the complicated federal application process for using marijuana in long-term clinical trials.

“It’s public policy before science,” said Dr. Chinazo Cunningham, a primary care doctor who is the lead investigator on one of the few federally funded studies exploring marijuana as a treatment for pain. “The federal government’s policies really make it much more difficult.”

Cunningham, who received a five-year, $3.8 million federal grant, will not be administering marijuana directly to participants. Instead, she will follow 250 HIV-positive and HIV-negative adults with chronic pain who use opioids and have been certified to get medical marijuana from a dispensary.

“It’s a catch-22,” said Cunningham, who is with the Albert Einstein College of Medicine. “We’re going to be looking at all of these issues — age, disease, level of pain — but when we’re done, there’s the danger that people are going to say ‘Oh, it’s anecdotal’ or that it’s inherently flawed because it’s not a randomized trial.’’

Don’t Ask, Don’t Tell

Without clear answers, hospitals, doctors and patients are left to their own devices, which can result in poor treatment and needless suffering.

Hospitals and other medical facilities have to decide what to do with newly hospitalized patients who normally take medical marijuana at home.

Some have a “don’t ask, don’t tell” approach, said Devinsky, who sometimes advises his patients to use it. Others ban its use and substitute opioids or other prescriptions.

Young adults, for instance, have had to stop taking cannabidiol compounds for their epilepsy because they’re in federally funded group homes, said Devinsky, the director of NYU Langone’s Comprehensive Epilepsy Center.

“These kids end up getting seizures again,” he said. “This whole situation has created a hodgepodge of insanity.”

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The Trump administration, however, has resisted policy changes.

Last year, the Drug Enforcement Administration had been gearing up to allow facilities other than the University of Mississippi to grow pot for research. But after the DEA received 26 applications from other growers, Attorney General Jeff Sessions halted the initiative.

The Department of Veterans Affairs also recently announced it would not fund studies of using marijuana compounds to treat ailments such as pain.

The DEA and HHS have cited concerns about medical supervision, addiction and a lack of “well-controlled studies proving efficacy.”

Patients, meanwhile, forge ahead.

While experts say they don’t know exactly how many older Americans rely on marijuana for medicinal purposes, the number of Americans 65 and older who say they are using the drug skyrocketed 250 percent from 2006 to 2013.

Some patients turn to friends, patient advocacy groups or online support groups for information.

Owen, for one, kept searching for a doctor and eventually found a neurologist willing to certify her to use marijuana and advise her on what to take.

“It’s saved my life,” said the retired university administrative assistant who credited marijuana for weaning her off opioids. “It not only helps my pain, but I can think, walk and talk again.”

Mary Jo, a Minnesotan, was afraid of being identified as a medical marijuana user, even though she now helps friends navigate the process and it’s legal in her home state.

“There’s still a stigma,” said Mary Jo, who found it effective for treating her pain from a nerve condition. “Nobody helps you figure it out, so you kind of play around with it on your own.”

Still, doctors and scientists worry about the implications of such experimentation.

In a sweeping report last year, the National Academies of Sciences, Engineering and Medicine called on the federal government to support better research, decrying the “lack of definitive evidence on using medical marijuana.”

The national academies’ committee reviewed more than 10,000 scientific abstracts related to the topic. It made 100 conclusions based on its review, including finding evidence that marijuana relieves pain and chemotherapy-induced nausea. But it found “inadequate information” to support or refute effects on Parkinson’s disease.

‘I Broke Federal Law’

Yet those who find that medical marijuana helps them can become fierce advocates no matter what their doctors say.

Caryl Barrett, a 54-year-old who lives in Georgia, said she decided to travel out of state to Colorado to treat her pain from her transverse myelitis and the autoimmune disease neurosarcoidosis.

“I realized it worked and I decided to bring it back with me,” she said. “I broke federal law.”

Georgia, meanwhile, permitted limited medicinal use of marijuana but did not set up dispensaries. As a result, patients resort to ordering it online or driving to another state to get it.

The conflict in the law makes her uneasy. But Barrett, who had been on opioids for a decade, said she feels so strongly about it working that “if someone wants to arrest me, bring it on.”

Others experience mixed results.

Melodie Beckham, who had metastatic lung cancer, tried medical marijuana for 13 days in a clinical trial at Connecticut Hospice before deciding to quit.

 “She was hopeful that it would help her relax and just kind of enjoy those days,” said her daughter, Laura Beckham.

Instead, it seemed to make her mother, who died in July at age 69, “a little more agitated or more paranoid.”

The marijuana “didn’t seem effective,” nor did it keep her mother from hitting her pain pump to get extra doses of an opioid, her daughter said.

The researchers running the trial at Connecticut Hospice spent two years getting necessary approvals from the Food and Drug Administration, the National Institute on Drug Abuse (NIDA) and the DEA.

Started in May, the trial has enrolled only seven of the 66 patients it plans to sign up because many patients were too sick, too close to death or simply couldn’t swallow the pills. So far, the trial has shown “mixed results,” said James Prota, director of pharmacy for the hospice.

Researchers point out they are still exploring the basics when it comes to marijuana’s effects on older adults or the terminally ill.

“We just have no data on how many older adults are using medical marijuana, what they are using it for and most importantly what are the outcomes,” said Brian Kaskie, a professor at the University of Iowa’s College of Public Health. “It’s all anecdotal.”

Kaskie, who specializes in public policy and the aging, received grants from the state of Colorado and the Chicago-based Retirement Research Foundation to survey the use of medical marijuana by older Americans.

In many quarters, there’s a growing appetite for solid information, he said.

“When I first started this, my colleagues joked we were going to find all the aging hippies who listen to the Grateful Dead,” said Kaskie, who has been studying medicinal marijuana for years. “Now, they’re starting to realize this is a legitimate area of research.”

drug policy alliance

drug policy alliance

Twenty researchers received marijuana from the federal program last year, which was more than any previous year since 2010, according to NIDA statistics.

In a recent funding announcement, the National Institutes of Health requested grant applications to study the effects of marijuana and other drugs on older adults and pain.

NIH, however, continues to funnel much of its funding into studying the adverse effects of marijuana, researchers said.

Although NIH acknowledged in one of the announcements that some research supports “possible benefits” of marijuana, it emphasized “there have not been adequate large controlled trials to support these claims.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente. KHN’s coverage of end-of-life and serious illness issues is supported in part by the Gordon and Betty Moore Foundation.

A Pained Life: My Medical Marijuana Experiment

By Carol Levy, Columnist

I just got my medical marijuana ID card.

I never tried marijuana as a teen. The one time someone gave me a sample of their medical marijuana, it made me feel terrible, as though I had taken a large dose of opioid medication -- fuzzy mouthed and cloudy brained.

It made me leery, but once it became legal in Pennsylvania there was no way I would not try it.

First thing you have to do is find a state certified doctor. There are only a few, so you are pretty much stuck with whomever is nearby. Before I could see the doctor, I had to give a urine sample. I have never been asked before to do this. All patients are required to – so they can weed out those who may be abusers.

That does not make it any less uncomfortable. I felt, as many do, as though I had been convicted of something and now had to prove my innocence.

The expense seems to be created to make it very hard to access. I am on a fixed disability income. The first visit with the doctor cost $125. This fee was required at the time of the appointment. The doctor told me that I would have to come in once a month for the first six months of use. This would cost $50 per visit, again payable at the time of the appointment.

Next you must send in $50 to get the state ID card.

Once that arrived, I had to find a dispensary. There was one about a half an hour from my home.  I called first to make sure they were open. They were very nice, but the feeling of doing something untoward was hard to ignore. I watch Law and Order. The drug dealers invariable say they have “product.”

“Are you open yet?” I asked the receptionist at the dispensary. “Yes. But we are out of product at this time.” Product? But this is supposed to be a legitimate medical medication, not something clandestine.

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Product? But this is supposed to be a legitimate medical medication, not something clandestine.

I went as soon as they had “product.” When I arrived, another person was waiting outside at the entrance, where there was a security guard. He looked at me and said, “Sorry you have to wait outside. We're only allowed to let one person in at a time.”

A security guard? I get that. You never know who might try to worm their way in. But I had the ID card. Why did we have to wait outside before each person was cleared?

Inside was lovely. Nice personnel, a waterfall, plants, real wood tables, coffee, tea and cookies waiting for us on a sideboard. It almost puts you off balance. A security guard at the door. Only one customer inside a time. Is something nefarious going on? But once inside it is warm, embracing and inviting.

I was escorted to a private room, where I spoke with the dispensary pharmacist. She explained how the medication works and what would be best for me, at least to start with. After the consultation I went back to the dispensary room.

The cost was less than I expected. Again, the fee was required at the time of purchase. It was cash only, no checks and no credit cards. Just like with a drug dealer. Apparently, banks are not able to accept checks or credit card charges because of the federal prohibition against marijuana.

Aside from feeling like I was doing something wrong, because of the urine test, security guard, “product” and cash up front, I am glad I tried it. The product I bought has not helped my pain, but the good thing is there are other concentrates and combinations I can try.

It is ironic that there is this war on opioids, yet marijuana remains a Schedule I controlled substance, making it very hard for researchers to get permission to study it. Studies that are available show it helps many disorders, including some forms of chronic pain  If the government truly wanted to help us get off opioids, they should make marijuana readily available for study and for patients..

Then, for many of us, there would be one more avenue of hope.

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Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.” Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represent the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Fewer Opioids Prescribed in Medical Marijuana States

By Pat Anson, Editor

The availability of medical marijuana has significantly reduced opioid prescribing for Medicaid and Medicare patients, according to two large studies published in the Journal of the American Medical Association (JAMA).

In one study, researchers at the University of Georgia looked at Medicare Part D prescription drug data from 2010 to 2015. They found that the number of daily doses prescribed for morphine (-14%), hydrocodone (-10.5%) and fentanyl (-8.5%) declined in states with medical marijuana laws. However, daily doses for oxycodone increased (+4.4%) in those same states.

The drop in opioid prescribing was most pronounced in states that have medical marijuana dispensaries, as opposed to those that only allow home cultivation of cannabis for medical purposes.

“We found that prescriptions for hydrocodone and morphine had statistically significant negative associations with medical cannabis access via dispensaries,” wrote lead author W. David Bradford, PhD, Department of Public Administration and Policy at the University of Georgia.

“Combined with previously published studies suggesting cannabis laws are associated with lower opioid mortality, these findings further strengthen arguments in favor of considering medical applications of cannabis as one tool in the policy arsenal that can be used to diminish the harm of prescription opioids.”

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The second study, by researchers at the University of Kentucky, looked at Medicaid prescriptions from 2011 to 2016, and found a 5.88% decline in opioid prescribing in states with medical marijuana laws.  Opioid prescribing for Medicaid patients fell even more -- by 6.38% -- in states where the recreational use of marijuana is legal.

“These findings suggest that medical and adult-use marijuana laws have the potential to reduce opioid prescribing for Medicaid enrollees, a segment of population with disproportionately high risk for chronic pain, opioid use disorder, and opioid overdose,” wrote lead author Hefei Wen, PhD, University of Kentucky College of Public Health.

One weakness of both studies is that they did not determine if Medicaid and Medicare patients reduced their use of opioid medication because they were using cannabis.  They also only included patients that were elderly, poor or disabled. And they were conducted during a period when nationwide opioid prescribing was in decline.

A recent study by the RAND corporation found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioid medication. RAND researchers believe some pain patients may be experimenting with marijuana, but their numbers are not large enough to have a significant impact on prescribing. 

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids," the RAND study found. "Either the patients are continuing to use their opioid pain medications in addition to marijuana, or this patient group represents a small share of the overall medical opioid using population." 

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law.

Medical Cannabis Effective for Elderly Pain Patients

By Pat Anson, Editor

Medical marijuana can significantly reduce chronic pain in elderly patients without adverse effects, according to a new study by Israeli researchers that found many patients were also able stop or reduce their use of opioid medication.

Researchers at the Ben-Gurion University of the Negev (BGU) surveyed over 2,700 patients 65 years or older who received medical cannabis. Over 60 percent of the patients were prescribed cannabis for chronic pain due to cancer, Parkinson's disease, post-traumatic stress disorder, ulcerative colitis, Crohn's disease, multiple sclerosis or other medical issues.

drug policy alliance image

drug policy alliance image

After six months of treatment, more than 93 percent of respondents reported their pain dropped from a median of eight to four on a 10-point pain scale. Nearly 60 percent who originally reported "bad" or "very bad" quality of life said their lives had improved to "good" or "very good." And over 70 percent reported moderate to significant improvement in their medical condition.

About a third of the patients used cannabis-infused oil, about 24 percent smoked marijuana, and about six percent used a vaporizer. The most common side effects from cannabis use were dizziness and dry mouth, researchers reported in The European Journal of Internal Medicine .

"We found medical cannabis treatment significantly relieves pain and improves quality of life for seniors with minimal side effects reported," said Victor Novack, MD, a professor of medicine at BGU and head of the Soroka Cannabis Clinical Research Institute.

"While older patients represent a large and growing population of medical cannabis users, few studies have addressed how it affects this particular group, which also suffers from dementia, frequent falls, mobility problems, and hearing and visual impairments."

The survey found that nearly one in five patients stopped using opioid medication or reduced their dose. The findings are at odds with a recent study by the RAND Corporation, which found that medical marijuana laws in the U.S. have not reduced demand for prescription opioids.

Medical marijuana has been legal in Israel since the early 1990s. Israel’s Ministry of Health still considers cannabis a “dangerous drug,” but adds “there is evidence that cannabis could help patients suffering from certain medical conditions and alleviate their suffering.”

A recent survey found about 27 percent of Israeli adults have used cannabis in the past year, one of the highest rates in the world.

Medical Marijuana Not Reducing Demand for Rx Opioids

By Pat Anson, Editor

A new study by the RAND Corporation is throwing some shade on theories that medical marijuana reduces demand for prescription opioids and saves lives by lowering rates of opioid overdoses.

RAND researchers analyzed data from 1999 to 2010 and found a 20 percent decline in opioid overdose deaths associated with the passage of state medical marijuana laws. That is in line with previous studies. However, when researchers extended their analysis through 2013, they found that the association between medical marijuana and lower rates of opioid deaths completely disappeared.

Researchers say there are two possible explanations for this. First, states that recently adopted medical marijuana laws are more tightly regulating dispensaries -- which may have reduced access to cannabis. Second, beginning in 2010, the primary driver of the overdose crisis became illicit opioids such as heroin and fentanyl, not prescription opioids.

“This is a sign that medical marijuana, by itself, will not be the solution to the nation's opioid crisis," said Rosalie Liccardo Pacula, co-director of the RAND Drug Policy Research Center and co-author of the study published in the Journal of Health Economics.

"Before we embrace marijuana as a strategy to combat the opioid epidemic, we need to fully understand the mechanism through which these laws may be helping and see if that mechanism still matters in today's changing opioid crisis."

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The RAND study also found little evidence that states with medical marijuana laws experience reductions in the volume of legally prescribed opioid medication.

"If anything, states that adopt medical marijuana laws... experience a relative increase in the legal distribution of prescription opioids. This result suggests that our findings are not driven by a decrease in the legal supply of opiioids," researchers found.

While many patients are using medical marijuana products to treat their pain, researchers say they do not represent a significant part of the opioid analgesic market.

"Either the patients are continuing to use their opioid pain medications in addition to marijuana, or this patient group represents a small share of the overall medical opioid using population," said Pacula.

Although 29 states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use, marijuana remains illegal under federal law. Attorney General Jeff Sessions recently ordered U.S. Attorneys to resume enforcing federal laws that outlaw the cultivation, distribution and possession of marijuana. Session rescinded the Cole memo, a lenient policy adopted by the Justice Department in 2013 that instructed U.S. Attorneys not to investigate or prosecute marijuana cases in states that have legalized cannabis..

Lawmakers Ask Trump to Restore Marijuana Policy

By Pat Anson, Editor

A bipartisan group of lawmakers led by Sen. Elizabeth Warren (D-MA) and Rep. Jared Polis (D-CO) has urged President Trump to reinstate an Obama-era policy that instructed U.S. Attorneys not to investigate or prosecute marijuana cases in states that have legalized cannabis.

Earlier this month, Attorney General Jeff Sessions rescinded the so-called Cole memo, the lenient marijuana policy adopted by the Justice Department in 2013.  Sessions, who is a longtime critic of marijuana legalization, said the Colo memo was “unnecessary” and “undermines the rule of law.” He authorized U.S. Attorneys to use their own discretion in investigating and prosecuting marijuana cases.

In a letter to President Trump signed by 54 members of Congress (51 Democrats and 3 Republicans), the lawmakers said Sessions’ order will “have a chilling effect” in states where medical or recreational marijuana has been legalized.

“This action has the potential to unravel efforts to build sensible drug policies that encourage economic development as we are finally moving away from antiquated practices that have hurt disadvantaged communities. These new policies have instead helped eliminate the black market sale of marijuana and allowed law enforcement to focus on real threats to public health and safety,” the letter said.

The letter also pointed out that Trump promised during the 2016 campaign that he would not change the federal enforcement policy on marijuana.

“I wouldn’t do that, no,” Trump said in an interview. “I think it’s up to the states. I’m a states’ person. I think it’s up to the states, absolutely.”

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“We trust that you still hold that belief, and we request that you urge the Attorney General to reinstate the Cole Memorandum. This step would create a pathway to a more comprehensive marijuana policy that respects state interests and prerogatives,” the letter from lawmakers said.

Although 29 states and the District of Columbia have legalized marijuana in some form, federal law still prohibits its sale or possession under the Controlled Substances Act.

According to a recent Gallup Poll, 64% of Americans believe marijuana should be legalized. The issue has broad bipartisan support, with 51% of Republicans and 72% of Democrats supporting legalization.

New Jersey Gov. Philip Murphy (D) signed an executive order this week instructing the state health department to expand access to medical marijuana. Although cannabis has been legal in the state since 2010, New Jersey’s medical marijuana law was so rigid that only 15,000 patients qualified for it in a state with 9 million people.

Murphy’s order directs the health department to lift restrictions on doctors that can prescribe cannabis, review the number of medical conditions for which it can be prescribed, allow more dispensaries to open, and consider the sale of edible marijuana products.

Medical Cannabis Laws Cause Confusion for Travelers

By Roger Chriss, Columnist

Health problems do not care about maps. But the patchwork of medical marijuana laws in different states does make a map handy for anyone who travels and uses cannabis for a medical condition.

The recent decision by Attorney General Jeff Sessions to resume enforcing federal marijuana law further muddies this already complicated landscape. Even if medical cannabis remains insulated from prosecution by the Rohrabacher-Blumenauer Amendment, there is one important issue for people with chronic pain and related disorders that remains unaddressed.

What happens when someone who is using medical cannabis lawfully for an approved use in their own state has to travel to another state for diagnosis or treatment?

The rarer a medical condition is, the more likely local healthcare providers will prove inadequate and travel will be necessary. A wide range of disorders, including inborn errors of metabolism like porphyria, muscle diseases like nemaline myopathy, and hereditary neuropathies like Charcot-Marie-Tooth disease, require visits to specialists for evaluation and diagnosis. These specialists are often not nearby, making travel an essential step in medical care.

But state rulings on the approved uses for medical cannabis vary significantly and are changing rapidly.

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In Colorado, for example, a person simply has to have “severe pain” to be considered for medical cannabis. By contrast, Connecticut and Illinois maintain extensive and detailed lists of dozens of qualifying medical conditions, from rheumatoid arthritis to Hepatitis C to Tourette syndrome.

Oregon compromises by giving examples of what it calls “debilitating medical conditions” and allows for specific symptoms such as cachexia and severe pain.

Moreover, states like Minnesota, Pennsylvania and Washington define intractable pain as pain unrelieved by standard medical treatments or medications. But they do not agree on what constitutes standard care, with Pennsylvania including “opiate therapy” while Minnesota does not.

Thus, a person could be in full compliance with his or her own state’s laws and regulations, but be unable to qualify for medical cannabis in another state. This would impact out-of-state travel for medical care.

In general, traveling with medical cannabis is very challenging. State governments can only pass laws within their borders. This means that air travel is effectively out of the question, because federal law says that it is illegal to carry marijuana in airline baggage or transport it across state lines.

Obtaining medical cannabis outside of one’s home state is similarly problematic. Some states accept out-of-state medical cannabis cards, but the number remains small and acceptance is at the discretion of the dispensary owner. Each such state has its own rules about medical cannabis possession as well, and these rules change frequently.

All of this creates a difficult landscape for people trying to navigate the U.S. healthcare system outside their home state. As state laws now stand, people with chronic pain disorders could end up breaking both federal and state law while seeking medically recommended cannabis products.

Further, a person who is on a stable regimen of medical cannabis in one state may not be able to visit or relocate to another state without losing that regimen. This may impact education and professional opportunities in a way presumably not intended by state laws.

Medical science and clinical practice should not change with state boundaries. State laws and accepted indications for medical cannabis need to be revised in order to create an environment that benefits people in need and does not inadvertently create legal conflicts or pitfalls. At present, there is simply too much room for error and harm.

Roger Chriss.jpg

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Little Evidence Cannabis Can Treat Chronic Pain

By Roger Chriss, Columnist

There is an abundance of research on medical cannabis. Everything from basic science to clinical trials and even major reviews have been conducted on the effectiveness of cannabis in treating chronic pain and other conditions. But the results don’t necessarily say what people want to hear.

As Leafly shows in a comprehensive list, most states in the U.S. that have legalized medical cannabis include chronic pain or painful conditions among the accepted indications for use. But these same states also note that research supporting medical cannabis for chronic pain is thin.

Minnesota, for example, accepts “intractable pain” but then says that “the literature assessing the effects of medical cannabis treatments for non-cancer chronic pain is sparse and patchy.”

Similarly, the California Medical Association’s “Physician Recommendation of Medical Cannabis” states that the approved list of 12 serious medical conditions that cannabis can be used for “is broad, and in most cases not supported by solid clinical research.”

In other words, medical cannabis has been approved for use, despite having not been rigorously demonstrated to be useful.

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The existing research supports this view. A recent systematic review of two dozen clinical trials published in the journal Pain Physician found that “the majority of studies did not show an effect.” The review concludes that cannabis-based medications “might be effective for chronic pain treatment, based on limited evidence, primarily for neuropathic pain (NP) patients.”

Another recent review of randomized placebo-controlled studies of smoked cannabis published in the journal Pharmacotherapy found that “cannabis did not outperform placebo on experimentally evoked pain.”

And a systematic review of the efficacy of cannabis in patients with neuropathic pain, multiple sclerosis or receiving  chemotherapy concluded that “there is incomplete evidence of the efficacy and safety of medical use of cannabis” and that “confidence in the estimate of the effect was again low or very low.”

Even reviews of medical cannabis for disorders that involve a chronic pain component are lackluster. A 2017 systematic review looked at randomized controlled trials of cannabis and its derivatives in treating psychiatric, movement, and neuro-degenerative disorders. The review found that "definitive conclusion on its efficacy could not be drawn” because the trials were low quality and had methodological limitations.

These results run contrary to the public perception of cannabis efficacy and the exuberance of media coverage about marijuana in any form. This has not escaped the notice of researchers. A 2017 study from Europe found that “public perception of the efficacy, tolerability, and safety of cannabis-based medicines in pain management and palliative medicine conflicts with the findings of systematic reviews and prospective observational studies conducted according to the standards of evidence-based medicine.”

Moreover, the Pain Physician study notes another significant trend: More recent studies tend to report more favorable results. It is not clear why this is happening, though a shift in cultural attitudes, ongoing advocacy in favor or cannabis legalization, and changes in the available strains of cannabis have been suggested. In particular, an increasingly positive attitude toward cannabis among study participants may be augmenting the placebo effect.

There are other limitations to the existing research -- from problems with blinding, lack of a good placebo and small study size – that make it open to criticism. Much of the commentary on cannabis research seems to have less to do with a close reading of the literature than with a desire for cannabis to gain widespread acceptance.

There is, of course, growing evidence for the use of cannabis in the treatment of some disorders, such as epilepsy and chronic neuropathic pain.  Medical cannabis may also have some value for people who are not benefiting from or cannot tolerate pharmaceutical drugs and other established therapies. So cannabis should remain an option -- intractable pain is sufficiently horrible that we need as many options as possible.

Medical research is about accumulating evidence through clinical trials and laboratory study. One trial is rarely ever enough to demonstrate efficacy. Even one major review is not sufficient. But an abundance of reviews all pointing in one direction should not go ignored.

Medical cannabis certainly merits further study. But the above reviews clearly show that efficacy is limited in many cases. Cannabis may well prove useful in treating certain disorders, but it is not a panacea and not likely to outperform existing treatments.

Roger Chriss.jpg

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Sessions Resumes Enforcement of Marijuana Laws

By Pat Anson, Editor

Attorney General Jeff Sessions has followed through on his threat to resume enforcing federal laws that outlaw the cultivation, distribution and possession of marijuana.

Session has rescinded the Cole memo, a lenient policy adopted by the Justice Department in 2013 that instructed U.S. Attorneys not to investigate or prosecute marijuana cases in states that have legalized cannabis. Although 29 states and the District of Columbia have legalized marijuana in some form, federal law still prohibits its sale or possession under the Controlled Substances Act.

ATTORNEY GENERAL JEFF SESSIONS

ATTORNEY GENERAL JEFF SESSIONS

In a one-page memorandum sent to U.S. Attorneys around the country, Sessions called the Cole memo “unnecessary” and authorized prosecutors to use their own discretion in investigating and prosecuting marijuana cases.

"It is the mission of the Department of Justice to enforce the laws of the United States, and the previous issuance of guidance undermines the rule of law and the ability of our local, state, tribal, and federal law enforcement partners to carry out this mission," Sessions said in a statement.

"Therefore, today's memo on federal marijuana enforcement simply directs all U.S. Attorneys to use previously established prosecutorial principles that provide them all the necessary tools to disrupt criminal organizations, tackle the growing drug crisis, and thwart violent crime across our country."

“This change will allow any US Attorney who is looking to make a name for themselves to take unilateral action, thus depriving any semblance of certainty for state-lawful consumers or businesses moving forward," said Justin Strekal, NORML Political Director.

Sessions released his memo just three days after California legalized the recreational use of marijuana by adults – the eighth and largest state to do so. California was the first state to legalize medical marijuana in 1996.

It is not yet clear how rigidly Sessions plans to enforce federal marijuana laws. Since 2013, Congress has attached a rider to the Justice Department budget that prevents it from using federal funds to enforce federal law in states where medical marijuana is legal. The Rohrabacher-Blumenauer amendment is still in force, but is set to expire on January 19 unless it is extended by Congress.

Sessions’ memo drew a swift and angry response from some members of Congress.

“This reported action directly contradicts what Attorney General Sessions told me prior to his confirmation. With no prior notice to Congress, the Justice Department has trampled on the will of the voters in CO and other states,” Sen. Cory Gardner (R-CO) said in a tweet. “I am prepared to take all steps necessary, including holding DOJ nominees, until the Attorney General lives up to the commitment he made to me prior to his confirmation.”

“This is outrageous. Going against the majority of Americans -- including a majority of Republican voters -- who want the federal government to stay out of the way is perhaps one of the stupidest decisions the Attorney General has made,” said Rep. Earl Blumenauer (D-OR), one of the co-authors of the Rohrabacher-Blumenauer amendment.

“One wonders if Trump was consulted -- it is Jeff Sessions after all -- because this would violate his campaign promise not to interfere with state marijuana laws.”

In an interview during the 2016 campaign, President Trump said he would not change the federal enforcement policy on marijuana. “I wouldn’t do that, no,” Trump said. “I think it’s up to the states. I’m a states’ person. I think it’s up to the states, absolutely.”

According to a recent Gallup Poll, 64% of Americans say marijuana should be legalized. The issue has broad bipartisan support, with 51% of Republicans and 72% of Democrats supporting legalization.

“The rollback of this policy towards state legalized marijuana will only create chaos and confusion for an industry that is currently responsible for creating over 150,000 American jobs and generating countless millions in state tax revenue. This instability will only push consumer dollars away from these state sanctioned businesses and back into the hands of criminal elements," said Erik Altieri, NORML Executive Director.

"This is not just bad policy, but awful politics and the Trump Administration should brace itself for the public backlash it will no doubt generate."

Enthusiasm for Medical Marijuana Ahead of Science

By Roger Chriss, Columnist

There is a tsunami of enthusiasm for medical cannabis. Rolling Stone is touting “medical pot” as the best hope to fight the opioid crisis. Newsweek has introduced the world to the “father of marijuana research” and even offered suggestions for using cannabis in holiday cooking.

But underlying all this cannabis coverage are confusing claims about the efficacy of medical marijuana for chronic pain and other conditions.

Although still in its infancy, the science behind medical cannabis is growing rapidly.  ClinicalTrials.gov lists 139 research studies underway. PubMed.gov lists 5,615 articles about “medical cannabis” and over 25,000 articles about “marijuana.” By comparison, PubMed lists only 112 articles about kratom.

The results of these thousands of studies involving scores of medical conditions are mixed, with an extensive list and reviews of clinical studies available on Cannabis-Med.org.  

The National Academy of Science released “The Health Effects of Cannabis and Cannabinoids” report in January 2017, stating that there is “evidence to support that patients who were treated with cannabis or cannabinoids were more likely to experience a significant reduction in pain symptoms.”

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But a review article from September 2017 called "Cannabinoids in Pain Management and Palliative Medicine" concluded that public perceptions about the effectiveness of cannabis in providing pain relief “conflicts with the findings.”

"There is limited evidence for a benefit of THC/CBD spray in the treatment of neuropathic pain. There is inadequate evidence for any benefit of cannabinoids (dronabinol, nabilone, medical cannabis, or THC/CBD spray) to treat cancer pain, pain of rheumatic or gastrointestinal origin, or anorexia in cancer or AIDS," German and Canadian researchers reported.

This apparent contradiction is often a result of limited research findings. Studies on medical cannabis are usually small-scale, preliminary, methodologically poor and statistically underpowered, and thus of limited value for drawing general conclusions.

The biggest issue in many studies is the lack of a good placebo for marijuana, as described in a recent JAMA Internal Medicine article: “Many trial subjects can distinguish between active cannabis and placebo.” This means that blinding subjects to obtain unbiased results is difficult, which makes the findings insufficient to get FDA approval as a medication.

"Unfortunately, there are almost no uses of medical marijuana that have been subjected to the kind of rigorous testing you'd want for a pharmaceutical," says Dr. Kenneth Mukamal, associate professor of medicine at Harvard-affiliated Beth Israel Deaconess Medical Center.

But there is progress. As the JAMA Internal Medicine study noted, “Some of the strongest evidence is for neuropathic pain, spasticity associated with multiple sclerosis, and anorexia in the setting of serious illness.”

A recent phase III clinical trial supports this.  Nearly 250 patients with moderate to severe neuropathic pain from multiple sclerosis saw “clinically relevant” reductions in pain intensity due to dronabinol, a synthetic marijuana derivative.

Marijuana Not Risk Free

Studies are also showing that medical cannabis is not risk-free. Some media reports state that there is no known instance of a fatal overdose involving marijuana. This is accurate, but fatal overdose is not the only measure of risk for a substance. Non-fatal toxicity, including cannabinoid hyperemesis syndrome (recurring nausea, vomiting and stomach pain), and other side effects are not trivial risks.

“Chronic effects of cannabis use include mood disorders, exacerbation of psychotic disorders in vulnerable people, cannabis use disorders, withdrawal syndrome, neurocognitive impairments, cardiovascular and respiratory and other diseases,” researchers warned in a 2014 article in the journal Current Pharmaceutical Design.

Research on the long-term effects of daily marijuana use is also limited. Fortunately, the National Institutes of Health is sponsoring major research on medical cannabis, including a 5-year study to see if medical cannabis reduces opioid use in adults with chronic pain. Similar efforts are underway at the UCLA Cannabis Research Initiative and elsewhere.

Therefore, it is premature to assume that medical cannabis is a thoroughly understood substance that will safely solve all chronic pain problems. Chronic painful conditions are complex, and the treatments that work for one condition may be contraindicated for another. Moreover, not everyone tolerates cannabis, just as not everyone tolerates NSAIDs or opioids. And a person’s medical condition and treatment plan may or may not be able to accommodate cannabis.

Medical cannabis has the potential to become another resource for pain management. It is showing promise for some neuropathic pain disorders, but does not seem to be as effective for visceral or rheumatic pain. In time, we will know how to use medical cannabis safely and reliably. But the present enthusiasm is running ahead of the science, and conclusions are preceding analysis.

Roger Chriss.jpg

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Medical Marijuana Will Not Cure the Opioid Crisis

By Roger Chriss, Columnist

There is a strong push underway to utilize medical marijuana as an alternative to opioid pain medications.

“There’s a large group of patients who have chronic pain who rely on opioids,” Dr. Charles Bush-Joseph recently told the Chicago Tribune. “Those are the patients who would benefit from medical cannabis.”

Indeed, medical marijuana and synthetic forms of cannabis are showing promise in treating chronic pain and related disorders. Recent research has shown that the marijuana-based medication dronabinol is effective in the management of neuropathy in multiple sclerosis. Similarly, another novel cannabidiol made by GW Pharmaceuticals has been found to help manage treatment-resistant epilepsy.

But while medical marijuana is showing potential in treating many medical problems -- including chronic pain conditions -- it will not have a significant impact on the rate of opioid addiction or overdoses.  

Media reports from outlets like Big Think erroneously associate the opioid crisis with chronic pain management and misinterpret recent studies on opioid overdose rates in states with legal medical cannabis.

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In fact, chronic pain management is not a significant causal factor in the opioid crisis. The National Institute on Drug Abuse estimates that between 8 and 12 percent of people on long-term opioid therapy develop some form of opioid use disorder.  A Cochrane review put the number even lower – with less than 1% of chronic pain patients becoming addicted.

In other words, people who need opioid pain medication are rarely the ones who become addicted and reports of doctor-shopping pain patients are greatly exaggerated.  It is also clear from recent reports by the CDC that the prescribing of opioid pain medication has been dropping steadily since 2010 and that the main drivers of the opioid crisis are now heroin and illicit fentanyl.

Moreover, research only shows an association, not a causal relation, between legal medical cannabis and opioid overdose rates. A recent study from the University of New Mexico showed that people with chronic musculoskeletal pain preferentially used medical cannabis over opioid analgesics. But this result is only preliminary and small-scale, and is unrelated to opioid addiction or overdose.

A 2014 study in JAMA also found an association between medical marijuana laws and a decline in opioid overdose mortality rates. But the authors of the study were careful to note that “our findings apply to states that passed medical cannabis laws during the study period and the association between future laws and opioid analgesic overdose mortality may differ.”

Recent data from Colorado, which legalized medical cannabis in 2000, shows the number of newborns in the state addicted to opioids jumped 83 percent from 2010 to 2015, a result that suggests rising levels of opioid use. Similarly, significant increases in fatal overdoses involving opioids are emerging in Washington state, where medical marijuana has been legal since 1998.

Opioid overdoses are also increasing in other states that recently legalized cannabis, although the increase is most likely caused by heroin and illicit fentanyl, not opioid pain medication.

Medical cannabis has been mentioned as potentially helpful in treating opioid addiction. But a small new observational study from Washington State University concludes that cannabis use by patients in an addiction treatment program may actually strengthen the relationship between pain, depression and anxiety.

"For people who are using cannabis the most, they have a very strong relationship between pain and mood symptoms, and that's not necessarily the pattern you'd want to see," said lead researcher Marian Wilson, PhD, of the Washington State University College of Nursing. "You would hope, if cannabis is helpful, the more they use it the fewer symptoms they'd see."

About two-thirds of the 150 patients surveyed by Wilson said they had used marijuana in the past month.

"Some are admitting they use it just for recreation purposes, but a large number are saying they use it to help with pain, sleep, and their mood," Wilson said. "We don't have evidence with this study that cannabis is helping with those issues."

None of this is meant to downplay the potential of cannabis in pain management or other areas of medicine. Medical cannabis has long been recognized for its use in treating chemotherapy-induced nausea, in loss of appetite due to end-stage cancer, and in treating pain in disorders like multiple sclerosis. More research will help clarify what else medical cannabis may be able to do.

But the legalization of medical cannabis is not going to cure the opioid crisis. Instead, the excessive and uncritical enthusiasm for it in some recent media reports and research publications is creating unrealistic expectations. These expectations could be used to justify reductions in pain medications that are working, complicating the lives of people with intractable pain disorders for no good reason.

If medical cannabis works, let's use it. But let’s make sure we’re using it for the right reasons.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

DEA Gives Final Approval to Synthetic Marijuana Drug

By Pat Anson, Editor

The U.S. Drug Enforcement Administration has approved a synthetic form of THC (tetrahydrocannabinol) – the active ingredient in marijuana that makes people “high” – as a Schedule II controlled substance. The move is the final regulatory hurdle for dronabinol (Syndros), an oral solution already being prescribed for the treatment of nausea and vomiting in chemotherapy patients, and as an appetite stimulant for AIDS patients.

Schedule II substances include oxycodone, hydrocodone and other drugs that have an accepted medical use, but a high abuse potential.  

The DEA announced the scheduling of dronabinol in a notice quietly published in the Federal Register the day before Thanksgiving. The agency adopted an interim rule classifying dronabinol as a Schedule II substance in March, and the Food and Drug Administration approved a new drug application for dronabinol in July, recommending that DEA make its rule final.

This week’s action was not unexpected, but is weirdly ironic on several levels.

The classification of dronabinal as a Schedule II substance means that a synthetic version of marijuana can be legally prescribed throughout the country, while real marijuana is still classified as a dangerous Schedule I substance and remains illegal under federal law – except in the 29 states and the District of Columbia where medical cannabis is legal.

Dronabinol is sold under the brand named Syndros by Insys Therapeutics, a controversial Arizona drug maker beset by allegations that another one of its products – a potent fentanyl spray called Subsys – is responsible for hundreds of overdose deaths.

The DEA has been aggressively going after doctors who prescribed Subsys and accepted speaking fees from Insys, and several company officials have been indicted on fraud, racketeering and kickback charges.

Snydros is similar to Marinol, another medication derived from marijuana that comes in pill form.

insys therapeutics photo

insys therapeutics photo

The DEA's action is also notable because it gives Insys the exclusive right to manufacture and sell its liquid formulation of dronabinol without having to worry about competition. Any other synthetic version not sold as Syndros will still be considered a Schedule I substance, on par with LSD, heroin and marijuana.

 “It should be noted as a preliminary matter that any form of dronabinol other than in an FDA-approved drug product remains a schedule I controlled substance, and those who handle such material remain subject to the regulatory controls, and administrative, civil, and criminal sanctions, applicable to schedule I controlled substances set forth in the CSA (Controlled Substance Act) and DEA regulations,” the DEA said.

According to Healthcare Bluebook, a one-month supply of Syndros will cost about $2,000 at major pharmacy chains. A "fair price" for Syndros is listed as $1,000.

Insys Thereapeutics drew the ire of marijuana advocates last year when it donated $500,000 to a campaign against the legalization of marijuana in Arizona.

The company is worried about the medical use of “natural cannabis,” but has petitioned the DEA to reschedule another synthetic cannabidiol (CBD) that is derived from marijuana from Schedule I to Schedule IV.

Most Cannabidiol Oils Sold Online Mislabeled

By Pat Anson, Editor

With opioid medication increasingly harder to obtain and other types of pain relievers often ineffective, many chronic pain sufferers have turned to cannabidiol-based medication for relief.

But a new study published in JAMA has found that nearly 70 percent of all cannabidiol (CBD) products sold online are either over or under-labeled. Researchers say a number of CBD products that are used to treat pain, anxiety, epilepsy and other medical conditions also contain high-levels of tetrahydrocannabinol (THC), the substance in marijuana that makes people high.

“The biggest implication is that many of these patients may not be getting the proper dosage; they’re either not getting enough for it to be effective or they’re getting too much,” said lead author Marcel Bonn-Miller, PhD, an adjunct professor of psychology at the Perelman School of Medicine at the University of Pennsylvania

“This is a medication that is often used for children with epilepsy, so parents could be giving their child THC without even knowing it.”

Like THC, CBD is one of the active ingredients in marijuana, but it is not generally known to produce euphoria or make people high. CBD is currently classified as a Schedule I controlled substance by the federal government, even though it has been legalized for medicinal use in 29 states and the District of Columbia.

DRUG POLICY ALLIANCE

DRUG POLICY ALLIANCE

Bonn-Miller says the mislabeling and poor quality control of CBD products is a direct result of inadequate regulation.

“The big problem, with this being something that is not federally legal, is that the needed quality assurance oversight from the Food and Drug Administration is not available. There are currently no standards for producing, testing, or labeling these oils,” Bonn-Miller said. “There is no way to know what is actually in the bottle. It’s crazy to have less oversight and information about a product being widely used for medicinal purposes, especially in very ill children, than a Hershey bar.”

Bonn-Miller and his colleagues searched the Internet and purchased 84 CBD products from 31 different companies. They found that four out of ten products were under-labeled, meaning they contained a higher concentration of CBD than indicated. Another 26 percent of products purchased were over-labeled, meaning they contained a lower concentration of CBD than indicated.

Only 30 percent of CBD products purchased contained an actual CBD content that was within 10% of the amount listed on the product label. THC was detected in 21% of the samples.

“This is a wake up call for the CBD industry to standardize their products,” said co-author Jahan Marcu, PhD, Chief Science Officer for Americans for Safe Access (ASA).

“CBD product manufacturers need to adopt best practices and accept guidance from AHPA (American Herbal Products Association) and other groups to improve consistency and safety for consumers.”

ASA and AHPA supports the Patient Focused Certification (PFC) program, a non-profit, peer reviewed, third party certification program for the medical cannabis industry. Products that carry the PFC label have met their standards and been certified.

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“I am constantly contacted for suggestions for a safe company that sells CBD - and it would be helpful to steer people in the right direction,” said Ellen Lenox Smith, a medical marijuana user, advocate and PNN columnist.

“Although less or more CBD won't hurt you, it makes sense to develop a method for people to know they are getting the correct product that is being claimed. If THC is found in the product, then someone out there is not abiding by the law and is using a form of cannabis, thus breaking the law.”

The problem isn’t limited to CBD oils and extracts. In a previous study, Bonn-Miller and his colleagues analyzed cannabinoid dose and label accuracy in edible marijuana products and found similar discrepancies. He hopes this and future studies will call attention to the impact of inconsistent cannabis product labelling.

“Future research should be focused on making sure people are paying attention to this issue and encouraging regulation in this rapidly expanding industry,” Bonn-Miller said.

Can Marijuana Improve Your Sex Life?

By Roger Chriss, Columnist

A new study by researchers at Stanford University, published in the Journal of Sexual Medicine, shows that marijuana use is associated with greater sexual frequency in both men and women. There has been a lot of enthusiasm about the findings, but relatively little understanding of what the research actually says.

Marijuana has intriguing medical potential, from symptom relief in terminal cancer patients to pain management in chronic conditions. And the possibility that it may improve sexual function is enticing in particular for people with health problems. Thus, it’s important to understand what any new results are really saying. So let’s use this paper as a case study on how to read a research paper.

We start with the study methodology. Because the gold-standard of a double-blind placebo-controlled randomized prospective trial is not possible with marijuana, the authors had to engage in data mining, the process of using an existing data set to ask new questions.

For a data source, the study uses the National Survey of Family Growth (NSFG), a large database assembled by the CDC. The study results were drawn from an analysis of 28,176 women (average age = 29.9 years) and 22,943 men (average age = 29.5).

It is important not to be impressed by these large numbers. Increasing a sample size beyond a certain point offers no additional reliability, and it may create more problems with confounding variables and hidden biases. Because the authors did not assemble this data themselves, there was no way for them to address these issues.

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A sanity check of the data is the next step. This study looks at sexual frequency at various levels of marijuana use. A check of the International Encyclopedia of Human Sexuality shows that “on average, men and women engage in sexual intercourse approximately six times per month.”

This is consistent with the Stanford study findings, but with a caveat: recall of the previous month’s sexual activity or marijuana use may be imperfect. Some researchers try to get around this problem by having participants keep written logs or by using apps, but this study did not.

It is also important to keep in mind that the study variable of sexual frequency is an imperfect number. You cannot have sex 0.73 times!  Any change in sexual frequency has to occur in increments of one per unit time. In this study, the unit time is a 4-week period. The increase reported in the study represents the smallest possible increase, or one additional sexual event. The authors found that regular marijuana use was associated with one more sexual event every four weeks.

The study mentions the use of the NSFG data as a limitation. The authors note that “survey responses were self-reported and represent participants only at a specific point in time.” But there is a deeper issue here. As noted above, the data set may contain flaws, biases, or other issues beyond the control or even the awareness of the authors. Formally speaking, randomness is lost. In election polls, for instance, pollsters follow strict protocols to ensure randomness because doing so makes for more reliable results.

In practice, large data sets often contain many associations because life is complicated and even seemingly simple activities like sex are subject to a variety of influences. So posing questions to large data sets requires caution, or as statisticians sometimes say, “give me a large enough data set and I can prove anything.”

The Stanford study’s conclusion is that a “positive association between marijuana use and sexual frequency is seen in men and women across all demographic groups.”

But in an interview with The Washington Post, the authors qualify that by noting that the study “doesn't say if you smoke more marijuana, you'll have more sex,” appropriately warning that correlation is not causation.

Spurious Correlations

But the mantra of “correlation does not imply causation” is simplistic. In reality, association does not even imply direction. It is equally reasonable here to say that greater sexual frequency is associated with increased marijuana use. But changing the word order alters the implication.

The second problem is that the association may be meaningless, an artifact of our data-rich world. Such spurious correlations can even be a source of entertainment. For instance, coital frequency may be correlated with living in an even-numbered zip code or marijuana use may be associated with banana slug activity.

Not to make light of overdoses, but there is even a spurious correlation between deaths caused by opioids and the price of potato chips:

SOURCE: TYLERVIGEN.COM

SOURCE: TYLERVIGEN.COM

These associations could be tested, but a positive result would probably not get the kind of media attention the Stanford study is receiving.

Moreover, sexual activity is influenced by a wide range of factors. It is possible that regular marijuana users have a lifestyle more conducive to sex, making lifestyle a lurking variable that affects both sexual frequency and marijuana use. Or it may be that daily marijuana users have more disposable income, more time to enjoy the effects of marijuana, and a more drug-tolerant work situation. In this case, marijuana use would act as a proxy for other potentially causal factors that influence coital frequency.

Because these issues are always found in large data sets, the potential for finding meaningless associations is ever-present. Or as statisticians say, “if you torture the data enough, you can get it to confess to anything.”

Thus, a study of this nature has inherent limitations that mean its results must be interpreted with caution. As the authors note in their conclusion, “the effects of marijuana use on sexual function warrant further study.”

So our final task is to consider what would constitute further study. Obviously, this result needs to be confirmed, ideally with a prospective study that controls for confounders. If the result is reproduced, then the hard work of identifying the causes begins. Once identified and confirmed through human testing, then and only then can we say that marijuana increases sexual frequency. For now the best we can do is read such studies with care and caution.

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Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society.

Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Sessions Seeks to End Protection for Medical Marijuana

By Ellen Lenox Smith, Columnist

If you’re one of the millions of Americans who uses medical marijuana, you need to be aware of something going on in Congress that could affect your legal right to use cannabis.  

A few months ago, Attorney General Jeff Sessions wrote a letter to congressional leaders urging them to ditch an amendment that effectively prevents the Department of Justice from investigating or prosecuting cannabis users or sellers in states where medical marijuana is legal.

The Rohrabacher-Farr amendment first became law in 2014. It forbids the Justice Department from using any funds to prevent states from “implementing their own State laws that authorize the use, distribution, possession, or cultivation of medical marijuana.” Last year the Ninth Circuit Court of Appeals ruled that the provision protects marijuana growers, patients and dispensaries who are complying with medical marijuana laws in 29 states and the District of Columbia.

Those of us involved in our own state's medical marijuana programs felt safe and legally protected – until the Attorney General wrote his letter.

ATTORNEY GENERAL JEFF SESSIONS

ATTORNEY GENERAL JEFF SESSIONS

Although the amendment has been attached to spending bills for years, Sessions wants to make sure it’s not in appropriations legislation for 2018. He stated in his letter that the court ruling gives dangerous criminals a loophole to protect themselves from prosecution. 

Sessions says the country is “in the midst of an historic drug epidemic and potentially long-term uptick in violent crime,” and the Justice Department “must be in a position to use all laws available to combat the transnational drug organizations and dangerous drug traffickers who threaten American lives.” 

Sessions appears to be deliberately equating medical marijuana use with the so-called opioid epidemic. But an emerging tide of research indicates otherwise. Opioid overdoses have actually declined in states where marijuana is legal and many pain patients prefer cannabis over opioid medication.

John Hudak of the Brookings Institution called Session’s letter a "scare tactic” that just might work. He told The Washington Post that Sessions "could appeal to rank-and-file members or to committee chairs in Congress in ways that could threaten the future of this Amendment."

So far Session’s arguments haven’t gained much traction in the U.S. Senate. In July, the Senate Appropriations Committee voted to keep the Rohrabacher–Farr  amendment in the appropriations bill for 2018.

“The federal government can't investigate everything and shouldn’t, and I don’t want them pursuing medical marijuana patients who are following state law,” Vermont Sen. Patrick Leahy (D) told The Hill. “We have more important things for the Department of Justice to do than tracking down doctors or epileptics using medical marijuana legally in their state."

But the Senate and House must work out a compromise, and it’s unclear how the House will vote. Last month the House Committee on Rules voted to remove the amendment from the House appropriations bill after Republican leaders said it was too “divisive.”

In the past, there has been broad bipartisan support for the amendment in Congress. One of its sponsors, California Rep. Dana Rohrabacher, is a conservative Republican who has long supported marijuana legalization. Without his amendment, Rohrabacher says Congress would be undermining the rights of states to make their own laws.

“The status quo for four years has been the federal government will not interfere because the Department of Justice is not permitted to use its resources to supersede a state that has legalized the medical use of marijuana,” Rohrabacher told his colleagues.

Many Americans agree. Support for medical marijuana is at an all-time high, reaching as much as 94 percent in one poll. 

Where do you stand? Where does your congressman? Should medical marijuana be protected from federal prosecution in states where it is legal?

I, for one, depend on cannabis for life. And will do all I can to let my voice be heard.

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Ellen Lenox Smith lives with Ehlers Danlos syndrome and sarcoidosis. Ellen and her husband Stuart are co-directors for medical marijuana advocacy for the U.S. Pain Foundation and serve as board members for the Rhode Island Patient Advocacy Coalition.

For more information about medical marijuana, visit their website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Is Medical Marijuana Causing More Fatal Crashes?

By Rochelle Odell, Columnist

Medical marijuana’s role in fatal auto accidents is a subject that’s rarely addressed by those who support full legalization of cannabis. But I found numerous articles about it online and all show there is cause for concern.

An NBC News story warned that “Pot Fuels Surge in Drugged Driving Deaths” back in 2014, the year after Colorado became the first state to legalize recreational marijuana:

“During each shift at her drive-through window, once an hour, Cordelia Cordova sees people rolling joints in their cars. Some blow smoke in her face and smile.

Cordova, who lost a 23-year-old niece and her 1-month-old son to a driver who admitted he smoked pot that day, never smiles back. She thinks legal marijuana in Colorado, where she works, is making the problem of drugged driving worse.”

“Drugged driving” is a term I had not heard before. Police agencies and medical professionals usually refer to it as driving under the influence or operating a vehicle while intoxicated. It is a perfect description, not only for marijuana, but for any substance that alters your ability to safely operate a vehicle.

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The NBC News story quotes researchers at Columbia University, who looked at toxicology reports on over 23,000 dead drivers in six states were medical marijuana was legal. Cannabis was detected in the bodies three times more often in 2010 than in 1999.  

"This trend suggests that marijuana is playing an increased role in fatal crashes, said Dr. Guohua Li, co-author and director for Injury Epidemiology and Prevention at Columbia University Medical Center.

But alcohol was the most common mind-altering substance detected, appearing in the blood of nearly 40 percent of the drivers who died in 2010.

Research on this subject can be somewhat contradictory. A second study at Columbia found that states with medical marijuana laws had an 11 percent decrease in traffic fatalities. They also found there were fewer alcohol related accidents, suggesting that some younger drivers were substituting marijuana for alcohol.

Marijuana, like opiates and alcohol, should never be consumed by someone intending to drive. Even cannabidiol (CBD) based medications, which marijuana supporters tout as safe, may contain trace amounts tetrahydrocannabinol (THC), the chemical ingredient in cannabis that makes people high.

I am not an active proponent of medical marijuana, although I realize there are those who benefit from its use. But cannabis is not always the "magic bullet" when it comes to pain relief, and not all pain patients support it.

I tried CBD medication for three weeks and it did nothing for my pain. Being asthmatic precludes me from smoking or vaping, and I have been told using edibles in the amount required to achieve pain relief would require a large amount. Medical marijuana is also costly and can be cost prohibitive for those of us on fixed incomes.

I did vote for full legalization last year when it was on the California ballot. I also believe those who buy it from medical marijuana dispensaries have a right to know where it is cultivated, along with what pesticides, fertilizers or other harmful substances may have been used in its cultivation. People are going to use marijuana whether it is legal or illegal, so state and federal governments should legislate accordingly.

Studies show that Colorado, Oregon and Washington State have all seen an increase in car crashes since they fully legalized marijuana, although the number of fatal crashes has remained about the same. A recent analysis by the Denver Post found the number of drivers in Colorado who tested positive for marijuana after fatal crashes has risen by 145 percent since 2013.

Like everything else, we can draw our own conclusions from these statistics. I only ask that readers who are medical marijuana users check your state’s laws before smoking or vaping, consuming CBD, or ingesting the popular edibles.

THC is a known psychoactive and can affect your ability to safely operate a vehicle. CBD can also show up in toxicology reports and will reflect on the driver if they’re involved in an accident. Please educate yourself and be sober from any substance, legal or illegal, before driving.

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Rochelle Odell lives in California. She’s lived for nearly 25 years with Complex Regional Pain Syndrome (CRPS/RSD).

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.