Marijuana Use May Affect Patient Anesthesia

By Kata Ruder, Kaiser Health News

When Colorado legalized marijuana, it became a pioneer in creating new policies to deal with the drug.

Now the state’s surgeons, nurses and anesthesiologists are becoming pioneers of a different sort in understanding what weed may do to patients who go under the knife.

Their observations and initial research show that marijuana use may affect patients’ responses to anesthesia on the operating table — and, depending on the patient’s history of using the drug, either help or hinder their symptoms afterward in the recovery room.

Colorado makes for an interesting laboratory. Since the state legalized marijuana for medicine in 2000 and allowed for its recreational sale in 2014, more Coloradans are using it — and they may also be more willing to tell their doctors about it.

Roughly 17% of Coloradans said they used marijuana in the previous 30 days in 2017, according to the National Survey on Drug Use and Health, more than double the 8% who reported doing so in 2006. By comparison, just 9% of U.S. residents said they used marijuana in 2017.

“It has been destigmatized here in Colorado,” said Dr. Andrew Monte, an associate professor of emergency medicine and medical toxicology at the University of Colorado School of Medicine and UCHealth. “We’re ahead of the game in terms of our ability to talk to patients about it. We’re also ahead of the game in identifying complications associated with use.”

One small study of Colorado patients published in May found marijuana users required more than triple the amount of one common sedation medicine, propofol, as did nonusers.

Those findings and anecdotal reports are prompting additional questions from the study’s author, Dr. Mark Twardowski, and others in the state’s medical field: If pot users indeed need more anesthesia, are there increased risks for breathing problems during minor procedures?

Are there higher costs with the use of more medication, if a second or third bottle of anesthesia must be routinely opened? And what does regular cannabis use mean for recovery post-surgery?

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But much is still unknown about marijuana’s impact on patients because it remains illegal on the federal level, making studies difficult to fund or undertake.

It’s even difficult to quantify how many of the estimated 800,000 to 1 million anesthesia procedures that are performed in Colorado each year involve marijuana users, according to Dr. Joy Hawkins, a professor of anesthesiology at the University of Colorado School of Medicine and president of the Colorado Society of Anesthesiologists. The Colorado Hospital Association said it doesn’t track anesthesia needs or costs specific to marijuana users.

As more states legalize cannabis to varying degrees, discussions about the drug are happening elsewhere, too. On a national level, the American Association of Nurse Anesthetists recently updated its clinical guidelines to highlight potential risks for and needs of marijuana users. American Society of Anesthesiologists spokeswoman Theresa Hill said that the use of marijuana in managing pain is a topic under discussion but that more research is needed. This year, it endorsed a federal bill calling for fewer regulatory barriers on marijuana research.

Should Patients Disclose Marijuana Use? 

No matter where patients live, though, many nurses and doctors from around the country agree: Patients should disclose marijuana use before any surgery or procedure. Linda Stone, a certified registered nurse anesthetist in Raleigh, N.C., acknowledged that patients in states where marijuana is illegal might be more hesitant.

“We really don’t want patients to feel like there’s stigma. They really do need to divulge that information,” Stone said. “We are just trying to make sure that we provide the safest care.”

In Colorado, Hawkins said, anesthesiologists have noticed that patients who use marijuana are more tolerant of some common anesthesia drugs, such as propofol, which helps people fall asleep during general anesthesia or stay relaxed during conscious “twilight” sedation. But higher doses can increase potentially serious side effects such as low blood pressure and depressed heart function.

Limited airway flow is another issue for people who smoke marijuana. “It acts very much like cigarettes, so it makes your airway irritated,” she said.

To be sure, anesthesia must be adjusted to accommodate patients of all sorts, apart from cannabis use. Anesthesiologists are prepared to adapt and make procedures safe for all patients, Hawkins said. And in some emergency surgeries, patients might not be in a position to disclose their cannabis use ahead of time.

Even when they do, a big challenge for medical professionals is gauging the amounts of marijuana consumed, as the potency varies widely from one joint to the next or when ingested through marijuana edibles. And levels of THC, the chemical with psychoactive effects in marijuana, have been increasing in the past few decades.

“For marijuana, it’s a bit of the Wild West,” Hawkins said. “We just don’t know what’s in these products that they’re using.”

Marijuana’s Effects On Pain After Surgery

Colorado health providers are also observing how marijuana changes patients’ symptoms after they leave the operating suite — particularly relevant amid the ongoing opioid epidemic.

“We’ve been hearing reports about patients using cannabis, instead of opioids, to treat their postoperative pain,” said Dr. Mark Steven Wallace, chair of the pain medicine division in the anesthesiology department at the University of California-San Diego, in a state that also has legalized marijuana. “I have a lot of patients who say they prefer it.”

Matthew Sheahan, 25, of Denver, said he used marijuana to relieve pain after the removal of his wisdom teeth four years ago. After surgery, he smoked marijuana rather than using the ibuprofen prescribed but didn’t disclose this to his doctor because pot was illegal in Ohio, where he had the procedure. He said his doctor told him his swelling was greatly reduced. “I didn’t experience the pain that I thought I would,” Sheahan said.

In a study underway, Wallace is working with patients who’ve recently had surgery for joint replacement to see whether marijuana can be used to treat pain and reduce the need for opioids.

But this may be a Catch-22 for regular marijuana users. They reported feeling greater pain and consumed more opioids in the hospital after vehicle crash injuries compared with nonusers, according to a study published last year in the journal Patient Safety in Surgery.

“The hypothesis is that chronic marijuana users develop a tolerance to pain medications, and since they do not receive marijuana while in the hospital, they require a higher replacement dose of opioids,” said Dr. David Bar-Or, who directs trauma research at Swedish Medical Center in Englewood, Colo., and several other hospitals in Colorado, Texas, Missouri and Kansas. He is studying a synthetic form of THC called dronabinol as a potential substitute for opioids in the hospital.

Again, much more research is needed.

“We know very little about marijuana because we’ve not been allowed to study it in the way we study any other drug,” Hawkins said. “We’re all wishing we had a little more data to rely on.”

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.

The Marijuana Ad You Won’t See During the Super Bowl

By Pat Anson, PNN Editor

The hype over Super Bowl LIII between the Los Angeles Rams and New England Patriots took a back seat this week to a debate over the benefits of medical marijuana.

The February 3 game is being broadcast by CBS, which rejected a 30-second Super Bowl ad by Acreage Holdings -- the cannabis company that recently hired former House speaker John Boehner as a spokesman. Along with the other broadcast networks, CBS currently does not accept any cannabis related advertising.

The Acreage ad features 3 cannabis users -- a boy who suffers from epilepsy, a man who took opioid medication for 15 years for back pain, and a military veteran who suffers from phantom limb pain after losing a leg in the service. The ad doesn’t promote Acreage products, but urges viewers to call their congressional representatives and advocate for medical marijuana.

“We’re disappointed by the news but somewhat unsurprised,” Acreage President George Allen told CNN Business. “Still, we developed the ad in the spirit of a public service announcement. We feel it’s our responsibility to advocate on behalf of our patients.”

The chief marketing officer for Acreage was less diplomatic.

“You will see countless ads (during the Super Bowl) for beer and erectile dysfunction medications but our ad with an educational goal to help people who are suffering is rejected. That is the irony we are looking to highlight,” Harris Damashek told the Green Entrepreneur.

A 30-second ad during the Super Bowl would have cost Acreage over $5 million, but the company is getting a lot of free publicity over the controversy.  A 60-second version of the ad was posted on YouTube.

Medical marijuana is legal in 33 states and Washington DC, but remains illegal under federal law. Although cannabis is a banned substance in the NFL, many current and former players use it for pain relief.

“When you compare it to what the alternative is in their training rooms; pills, pills, pills, that are being put into these guys’ hands and turning them into addicts,” former NFL player Nate Jackson told PNN. “I was never big on those pills. I medicated with marijuana and it helped me and I think it helped save my brain.”

Although the NFL has a reputation as a league that closely monitors and disciplines players for illegal drug use,  Jackson estimates over half its players currently use marijuana to relieve pain and stress after games.

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.

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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.

Strong Support for Cannabis Rx in Comments to FDA

By Pat Anson, Editor

The Food and Drug Administration may have gotten more than it bargained for when it asked for public comments about the medical value and abuse potential of 17 different drugs.

The agency wound up getting over 6,400 comments in the Federal Register, the vast majority of them from people advocating for cannabidiol (CBD) -- one of the active ingredients in medical marijuana.  

Unlike tetrahydrocannabinol (THC), the substance in marijuana that makes people high, CBD-based oils and medications relieve pain, and are increasingly being used to treat a variety of medical conditions.  

“CBD's are not a way to get high as THC is. These oils have so many beneficial uses for anxiety, stress, pain, joint issues, muscular issues, arthritis, seizures, Parkinson's, cancer,” wrote Tami Camp in her public comment. “We need natural herbs, not man-made poisons!”

“CBD helps me with my chronic nerve pain, in a way that prescription medications can't match,” wrote Jason Turgeon.

“I've been consistently using CBD oil now for three months and have noticed an uptick in my moods, a reduction of joint pain, and my sleeping cycles at night have improved as my sleep is deeper and I wake up feeling refreshed,” wrote Kerry Meier.

Public opinion polls show that these are not isolated comments or marijuana supporters trying to game the system by flooding the Federal Register with comments. A recent poll by CBS News found 85% of Americans favor medical marijuana use.

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drug policy alliance photo

But while medical cannabis may be legal in 29 states and the District of Columbia, marijuana is still classified as an illegal Schedule I controlled substance by the Drug Enforcement Administration, right alongside heroin and LSD.

The FDA opened the cannabis can of worms at the behest of the World Health Organization (WHO), which is not only reviewing the safety and effectiveness of CBD, but 16 other drugs -- including pregabalin, tramadol, ketamine, and several chemical cousins of fentanyl, a synthetic opioid blamed for thousands of overdose deaths. 

WHO is seeking input from the FDA on whether international restrictions should be placed on any of the drugs. Under the Controlled Substances Act, the FDA was required to seek public comment in the Federal Register before responding to WHO -- perhaps not anticipating the overwhelmingly positive response that CBD would get. 

“Cannabidiol should not be restricted because CBD is not addictive, nor does it have the potential for abuse nor should it be tied to hallucinogenic drugs. Therefore, no international restrictions should be placed on CBD,” wrote Steve Easterly.

“For cannabis to be scheduled as a class I drug is ludicrous especially when the entire prohibition of cannabis was based on lies,” wrote Mike Copple. “What a shameful spectacle that we the people still have to argue about the usefulness of the cannabis plant. Cannabis has and continues to help me in many ways both physically and mentally.”

“I want cannabis to be legalized and available for over the counter sale. I have known several people who have benefited for various conditions from anxiety, depressions, MS, arthritis and epilepsy,” wrote Nancy Scott-Puopolo.

The public comment period ended on Wednesday. You can look at other responses in the Federal Register by clicking here

Mixed Reviews of Lyrica

There were only a few dozen comments about pregabalin (Lyrica), a prescription medication that millions of Americans take for fibromyalgia, neuropathy and other chronic pain conditions. As PNN has reported, WHO is investigating reports that pregabalin is being abused by addicts.

“Patients are self-administering higher than recommended doses (of pregabalin) to achieve euphoria, especially patients who have a history of substance abuse, particularly opioids, and psychiatric illness,” WHO told the FDA..

The public comments about pregabalin were mixed at best.

“I have been on several medications prior to being switched to Lyrica about six months ago. I actually feel nothing while taking the drug, and assume you would indeed have to take lots to maybe feel high,” wrote Mary. “Not sure if it helps my fibromyalgia or not since I still have lots of pain.”

“I take pregabalin in Lyrica form twice a day currently for nerve pain and fibromyalgia. I cannot accurately express the relief this has brought me,” wrote Renee.

“I have tried many, many medications. When I tried Lyrica, the side effects were horrible. I couldn't even lift my head without severe dizziness and the room spinning,” said Lora Berry.  

“I take Lyrica and all I got from it was fatter,” said Debra Winegar. “CBD oil is wonderful. Take a few drops under the tongue and I'm good to go. Narcotics are needed when my pain is out of control. I'm tired of waiting to be pain free. Legalize pot now!”

Will the FDA now report to WHO that thousands of American citizens want CBD-based medications fully legalized?  The FDA notice in the Federal Register only notes that public comments “will be considered” when the FDA prepares its scientific and medical evaluation. The FDA report to WHO is due September 30.

9 out of 10 Patients Prefer Cannabis Over Opioids

By Pat Anson, Editor

A survey of nearly 3,000 medical marijuana users has found that 9 out of 10 patients prefer cannabis over opioid medication when managing their chronic pain. A similar number prefer cannabis over non-opioid pain relievers such as Tylenol or Advil.

The survey was conducted by researchers at the University of California Berkeley and HelloMD, a website that links patients to doctors in California and New York that prescribe medical marijuana. The survey was administered by email to a HelloMD database of cannabis patients who were asked how marijuana affected their consumption of opioids and other pain relievers.

Eighty percent of those surveyed said that cannabis was more effective at relieving pain than opioid medication and 97 percent said they decreased their opioid use when using cannabis. The latter finding supports previous research that found use of prescription pain medication declining in states where medical marijuana is legal.

“The results of our study were striking, showing 97% of people were able to decrease the amount of opioids that they used in conjunction with cannabis use. This was more than double the amount shown in any previous studies conducted,” said Perry Solomon, MD, Chief Medical Officer of HelloMD.

DRUG POLICY ALLIANCE

DRUG POLICY ALLIANCE

“The (study) clearly showed that chronic pain is one of the medical conditions that cannabis can be used for with great efficacy. Our study not only supports this but also goes further in that the clear majority of patient’s state that they prefer it. Hopefully this will awaken the public, medical professionals and legislatures to the fact that there is a safe, non-addictive product available to help fight the opioid epidemic, and that is cannabis.”

Other key findings from the survey of medical marijuana users:

  • 93% said they prefer cannabis to opioids
  • 92% said cannabis' side effects were more tolerable than side effects from opioids
  • 90% said cannabis works well with non-opioid pain relievers
  • 96% said they need fewer non-opioid pain relievers when using cannabis
  • 89% said cannabis was more effective than non-opioid pain relievers

"With cannabis not only becoming more accepted in the mainstream but also coming in a variety of preparations, some of which are nonintoxicating, more people are looking at cannabis as a viable treatment for everyday ailments such as muscle soreness and inflammation,” wrote Amanda Reiman, PhD, of UC Berkeley and the Drug Policy Alliance, lead author of the study published in the journal of Cannabis and Cannabinoid Research.

“Participants in this study overwhelmingly supported the notion that they would be more likely to use cannabis as a substitute for pain medication if it were less stigmatized and more available, suggesting that there are populations of people who could benefit from this practice but are shying away due to the stigma and legal restrictions related to cannabis use.”

The survey should not be considered a scientific study on the effectiveness of cannabis, because participants were self-selected and reported their perceptions about cannabis use, as opposed to an objective measurement by a third party. There was also no control group of pain patients who only had access to opioids and other pain relievers.

A small study last year by the University of Michigan found that nearly two-thirds (64%) of medical marijuana patients reported a reduction in their use of prescription pain medications.

A 2014 study published in JAMA Internal Medicine found that opioid overdoses declined by nearly 25 percent in states where medical marijuana was legalized.

A Safe Way to Healthy, Restorative Sleep

By Ellen Lenox Smith, Columnist

For many of us suffering from chronic pain, coping with our medical issues can be physically and emotionally draining. Often, the lack of healthy sleep is the culprit.

Living with Ehlers Danlos syndrome (EDS) and sarcoidosis, I used to constantly wake up in the middle of the night with so much pain it was impossible to get any form of rest. When I was teaching, I somehow went for years trying to teach on “empty” due to a chronic lack of restorative sleep.

I remember having to cheat and use a seating chart to remember the names of my wonderful students, who were sitting right in front of me. These were students I had known, loved and taught for months. It was embarrassing, heartbreaking, and created a sense of loss and hopelessness.

Thankfully, those days are gone. I have gone from years of almost no quality sleep to being someone who goes to bed at night and wakes up in the morning feeling well rested. I don’t even remember any dreams, so I am getting the real REM sleep!

How did I do it? A teaspoon of oil made from medical marijuana. I take it before bedtime, mixed with a little applesauce or a small amount of food.

Within an hour, my body is ready for bed and sleep. 

For years I made this oil at home on top of the stove, but today enjoy using the Magical Butter machine. We find that oil made from the indica strain of marijuana works best for sleep. Directions for making the oil can be found on our website. 

I am now both a medical marijuana patient and a caregiver in the state of Rhode Island. Patients visit us with a variety of different illnesses, but the one thing they all have in common is lack of sleep. Without sleep, you lose hope and courage to move forward with your life. Each patient that has tried this oil has found that it gives them rest and hope.

Recently, a young woman and her husband came to our home. Living with both EDS and Chronic Regional Pain Syndrome (CRPS), she had a difficult life, but was hoping to find something to make it easier. We have the same pain doctor and he suggested she get in touch with us to learn about cannabis. 

The first night that she tried the oil, she slept for eight hours and was both thrilled and shocked. She said even her face looked calmer and more rested.  She is now happier, hopeful and has more strength to get through the day.

There was another patient sent to us who was a paraplegic in constant pain. He was angry, miserable and wished he hadn’t been given life-saving surgery after his accident. He was at a loss as to what to do to cope with the life he was now given. 

He tried the oil and was shocked what it did for him. From that point on, the desperate man who first called me and couldn’t even be understood due to his level of pain, was happy, laughing and finding some meaning in his difficult life. He later passed, but the oil gave him a better quality of life and a sense of purpose again.

We have seen one success after another of pain patients getting real quality sleep and rest. We have seen it work for cancer patients, and those suffering with post-traumatic stress disorder, multiple sclerosis, back pain, fibromyalgia, arthritis and other conditions.

For those of you who are caught up in opioid hysteria and can no longer get medication, I hope you take a moment and think about trying cannabis oil at night for rest. I have used it safely for a decade, since I am not able to metabolize even an aspirin or Tylenol, let alone any opiate. May you find the courage to try it and get the same results.

Ellen Lenox Smith suffers from 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 or to contact the Smith's, 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.

Do Men Get More Pain Relief From Marijuana?

By Pat Anson, Editor

Experts tell us that women are more likely to experience chronic pain than men, feel pain more intensely, and are more likely to be undertreated for pain than men are.

The gender gap in pain grew a little wider this week with a new study, published in Drug and Alcohol Dependence, which claims women get far less pain relief from smoking marijuana than men do.

"These findings come at a time when more people, including women, are turning to the use of medical cannabis for pain relief," said lead author Ziva Cooper, PhD, associate professor of clinical neurobiology at Columbia University Medical Center. "Preclinical evidence has suggested that the experience of pain relief from cannabis-related products may vary between sexes, but no studies have been done to see if this is true in humans."

Cooper and her colleagues conducted two double-blinded, placebo-controlled studies that looked at the analgesic effects of cannabis in 42 healthy recreational marijuana smokers – half of them men and half women.

All smoked marijuana at least four times a week prior to enrolling in the study. Participants were excluded if they had pain.

After smoking the same amount of cannabis or a placebo, the participants immersed one hand in a cold-water bath until the pain could no longer be tolerated. Following the immersion, the participants answered a short pain questionnaire.

Among those who smoked cannabis, men reported a significant decrease in pain sensitivity and an increase in pain tolerance. But the women who smoked cannabis did not experience a significant decrease in pain sensitivity, although they did report a small increase in pain tolerance shortly after smoking.

No gender differences were found in how intoxicated the participants felt or how much they liked the effect of cannabis.

“These results indicate that in cannabis smokers, men exhibit greater cannabis-induced analgesia relative to women,” said Cooper.  “Sex-dependent differences in cannabis’s analgesic effects are an important consideration that warrants further investigation when considering the potential therapeutic effects of cannabinoids for pain relief.”

A marijuana advocate and caregiver for patients in Rhode Island said she was shocked by the study findings.

"This study concerns me that some women will read this and not even try the most magical pain relief out there," said Ellen Lenox Smith, a columnist for Pain News Network. "We have never, in the nine years of growing for myself and as caregivers for patients, ever had a time that this was not successful because of one's sex. We have had equal amounts of men and women and the only person that did not have success was an elderly woman that was not able to follow the directions due to her anxiety of using it. That was due to the stigma from society, not the product."

Do women really respond differently to marijuana or is there a flaw in the study itself?

Previous research has found that women respond differently to the cold water test and have far less tolerance for pain induced by cold water immersion than men.

“Most studies have used some form of the cold pressor test in which subjects immerse their arm or hand in circulating cold water for a defined period of time, and their results support the hypothesis that cold pain sensitivity is more pronounced in females,” researchers reported in a 2009 review of nearly two dozen studies that used the cold water test.  “Based on the present set of studies, it appears that sex differences in cold pain are consistent, particularly for suprathreshold measures such as tolerance and pain ratings.”

The Columbia University study was funded by the U.S. National Institute on Drug Abuse. Ziva Cooper also received salary support from Insys Therapeutics, which is developing cannabis-based drugs.