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.

Seniors in Pain Hop Aboard the Canna-Bus

By Stephanie O’Neill, Kaiser Health News

Shirley Avedon, 90,­­ had never been a cannabis user. But carpal tunnel syndrome that sends shooting pains into both of her hands and an aversion to conventional steroid and surgical treatments is prompting her to consider some new options.

“It’s very painful, sometimes I can’t even open my hand,” Avedon said.

So for the second time in two months, she’s climbed on board a bus that provides seniors at the Laguna Woods Village retirement community in Orange County, Calif., with a free shuttle to a nearby marijuana dispensary.

The retired manager of an oncology office says she’s seeking the same relief she saw cancer patients get from smoking marijuana 25 years ago.

“At that time [marijuana] wasn’t legal, so they used to get it off their children,” she said with a laugh. “It was fantastic what it did for them.”

Avedon, who doesn’t want to get high from anything she uses, picked up a topical cream on her first trip that was sold as a pain reliever. It contained cannabidiol, or CBD, but was formulated without THC, or tetrahydrocannabinol, marijuana’s psychoactive ingredient.

“It helped a little,” she said. “Now I’m going back for the second time hoping they have something better.”

As more states legalize marijuana for medical or recreational use — 30 states plus the District of Columbia to date — the cannabis industry is booming. Among the fastest growing group of users: people over 50, with especially steep increases among those 65 and older. And some dispensaries are tailoring their pitches to seniors like Avedon who are seeking alternative treatments for their aches, pains and other medical conditions.

On this particular morning, about 35 seniors climb on board the free shuttle — paid for by Bud and Bloom, a licensed cannabis dispensary in Santa Ana.

After about a half-hour drive, the large white bus pulls up to the parking lot of the dispensary.

About half of the seniors on board today are repeat customers; the other half are cannabis newbies who’ve never tried it before, said Kandice Hawes, director of community outreach for Bud and Bloom.

“Not everybody is coming to be a customer,” Hawes said. “A lot are just coming to be educated.”

STEPHANIE O’NEILL FOR KHN

STEPHANIE O’NEILL FOR KHN

Among them, Layla Sabet, 72, a first-timer seeking relief from back pain that keeps her awake at night, she said.

“I’m taking so much medication to sleep and still I can’t sleep,” she said. “So I’m trying it for the back pain and the sleep.”

Hawes invited the seniors into a large room with chairs and a table set up with free sandwiches and drinks. As they ate, she gave a presentation focused on the potential benefits of cannabis as a reliever of anxiety, insomnia and chronic pain and the various ways people can consume it.

Several vendors on site took turns speaking to the group about the goods they sell. Then, the seniors entered the dispensary for the chance to buy everything from old-school rolled joints and high-tech vaporizer pens to liquid sublingual tinctures, topical creams and an assortment of sweet, cannabis-infused edibles.

Jim Lebowitz, 75, is a return customer who suffers pain from back surgery two years ago.

He prefers to eat his cannabis, he said.

“I got chocolate and I got gummies,” he told a visitor. “Never had the chocolate before, but I’ve had the gummies and they worked pretty good.”

“Gummies” are cannabis-infused chewy candies. His contain both the CBD and THC, two active ingredients in marijuana.

Derek Tauchman rings up sales at one of several Bud and Bloom registers in the dispensary. Fear of getting high is the biggest concern expressed by senior consumers, who make up the bulk of the dispensary’s new business, he said.

“What they don’t realize is there’s so many different ways to medicate now that you don’t have to actually get high to relieve all your aches and pains,” he said.

Limited Research

But despite such enthusiasm, marijuana isn’t well researched, said Dr. David Reuben, the Archstone Foundation professor of medicine and geriatrics at UCLA’s David Geffen School of Medicine.

While cannabis is legal both medically and recreationally in California, it remains a Schedule 1 substance — meaning it’s illegal under federal law. And that makes it harder to study.

The limited research that exists suggests that marijuana may be helpful in treating pain and nausea, according to a research overview published last year by the National Academies of Sciences, Engineering and Medicine. Less conclusive research points to it helping with sleep problems and anxiety.

STEPHANIE O’NEILL FOR KHN

STEPHANIE O’NEILL FOR KHN

Reuben said he sees a growing number of patients interested in using it for things like anxiety, chronic pain and depression.

“I am, in general, fairly supportive of this because these are conditions [for which] there aren’t good alternatives,” he said.

But Reuben cautions his patients that products bought at marijuana dispensaries aren’t FDA-regulated, as are prescription drugs. That means dose and consistency can vary.

“There’s still so much left to learn about how to package, how to ensure quality and standards,” he said. “So the question is how to make sure the people are getting high-quality product and then testing its effectiveness.”

And there are risks associated with cannabis use too, said Dr. Elinore McCance-Katz, who directs the Substance Abuse and Mental Health Services Administration.

“When you have an industry that does nothing but blanket our society with messages about the medicinal value of marijuana, people get the idea this is a safe substance to use. And that’s not true,” she said.

Side effects can include increased heart rate, nausea and vomiting, and with long-term use, there’s a potential for addiction, some studies say. Research suggests that between 9 and 30 percent of those who use marijuana may develop some degree of marijuana use disorder.

Still, Reuben said, if it gets patients off more addictive and potentially dangerous prescription drugs — like opioids — all the better.

Jim Levy, 71, suffers a pinched nerve that shoots pain down both his legs. He uses a topical cream and ingests cannabis gelatin capsules and lozenges.

“I have no way to measure, but I’d say it gets rid of 90 percent of the pain,” said Levy, who — like other seniors here — pays for these products out-of-pocket, as Medicare doesn’t cover cannabis.

“I got something they say is wonderful and I hope it works,” said Shirley Avedon. “It’s a cream.”

The price tag: $90. Avedon said if it helps ease the carpal tunnel pain she suffers, it’ll be worth it.

“It’s better than having surgery,” she said.

Precautions to Keep in Mind

Though marijuana use remains illegal under federal law, it’s legal in some form in 30 states and the District of Columbia. And a growing number of Americans are considering trying it for health reasons. For people who are, doctors advise the following cautions.

Talk to your doctor. Tell your doctor you’re thinking about trying medical marijuana. Although he or she may have some concerns, most doctors won’t judge you for seeking out alternative treatments.

Make sure your prescriber is aware of all the medications you take. Marijuana might have dangerous interactions with prescription medications, particularly medicines that can be sedating, said Dr. Benjamin Han, a geriatrician at New York University School of Medicine who studies marijuana use in the elderly.

Watch out for dosing. Older adults metabolize drugs differently than young people. If your doctor gives you the go-ahead, try the lowest possible dose first to avoid feeling intoxicated. And be especially careful with edibles. They can have very concentrated doses that don’t take effect right away.

Elderly people are also more sensitive to side effects. If you start to feel unwell, talk to your doctor right away. “When you’re older, you’re more vulnerable to the side effects of everything,” Han said. “I’m cautious about everything.”

Look for licensed providers. In some states like California, licensed dispensaries must test for contaminants. Be especially careful with marijuana bought illegally. “If you’re just buying marijuana down the street … you don’t really know what’s in that,” said Dr. Joshua Briscoe, a palliative care doctor at Duke University School of Medicine who has studied the use of marijuana for pain and nausea in older patients. “Buyer, beware.”

Bottom line: The research on medical marijuana is limited. There’s even less we know about marijuana use in older people. Proceed with caution.

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.

App Helps Document Effectiveness of Medical Cannabis

By Pat Anson, PNN Editor

Two innovative studies have found evidence that medical marijuana can provide significant relief from a wide range of symptoms associated with chronic pain, including insomnia, seizures, depression, anxiety and fatigue.

Unlike many clinical trials that evaluate a small number of patients with surveys, researchers at the University of New Mexico relied on data from the Releaf App, a free mobile software program that collected user-entered, real-time information from over 2,800 people on their use of cannabis and its effects.

"If the results found in our studies can be extrapolated to the general population, cannabis could systematically replace multi-billion dollar medication industries around the world. It is likely already beginning to do so," said co-author Jacob Vigil, PhD, a UNM psychology professor.

releaf-press-splash-sml.png

In the first study, published in the journal Frontiers in Pharmacology, users reported an average symptom reduction of nearly 4 points on a 1-10 scale after the consumption of cannabis in various forms, including vaporizers, joints, oils and topicals.

Twenty-seven different health conditions were evaluated, from inflammation and tremors to muscle and nerve pain. Over 94 percent of cannabis users reported some type of symptom relief, with patients suffering from anxiety and depression having the greatest improvement.

“Clinically and statistically significant reductions in patient-reported symptom severity levels existed in every single symptom category, suggesting that cannabis may be an effective substitute for several classes of medications with potentially dangerous and uncomfortable side effects and risky polypharmaceutical interactions, including opioids, benzodiazepines, and antidepressants,” said Vigil.

“Our results indicate that patients report greater symptom relief for treating agitation/irritability, anxiety, depression, excessive appetite, insomnia, loss of appetite, nausea, gastrointestinal pain, stress, and tremors than they do for treating back pain. Patients reported less symptom relief for treating impulsivity, headache, and nerve pain as compared to relief for treating back pain.

source: frontiers in pharmacology

source: frontiers in pharmacology

The second study, recently published in the journal Medicines, focused on the use of cannabis flower (also known as “buds”) in treating insomnia. Over 400 patients self-reported their symptoms using the Releaf app. Researchers found the use of pipes and vaporizers to ingest cannabis was associated with greater symptom relief and fewer negative side effects than the use of joints. Cannabidiol (CBD) was also associated with greater symptom relief than tetrahydrocannabinol (THC), the active ingredient in marijuana that causes euphoria.

A major weakness of both studies is that there was no control group or use of a placebo. Participants were also more likely to have previously used cannabis and may have been biased when reporting on their own symptoms. But UNM researchers say their findings are more representative of what cannabis users will actually experience.

“Observational studies are more appropriate than experimental research designs for measuring how patients choose to consume cannabis and the effects of those choices,” said Vigil. “By collecting massive amounts of patient-entered information on actual cannabis used under real-life circumstances we are able to measure why patients consume cannabis, the types of products that patients use, and the immediate and longer-term effects of such use.”

In addition to its therapeutic benefits, cannabis use was associated with frequent, although not serious side effects. Patients reported more positive feelings (relaxed, peaceful, comfy) than they did negative ones (paranoid, confused, headache).  

"If the short-term risk-benefit profile of cannabis found in our studies reflects its longer-term therapeutic potential, substitution of cannabis for traditional pharmaceuticals could reduce the risk of dangerous drug interactions and the costs associated with taking multiple medications by allowing patients to treat a constellation of comorbidities with a single treatment modality,” said co-author Sarah See Stith, PhD, a UNM economics professor.

Marijuana Use by Baby Boomers Growing

By Pat Anson, Editor

Marijuana use by middle-aged and older adults in the U.S. has grown significantly over the past decade, in part because more baby boomers are seeking relief from neuropathy and other painful conditions associated with aging.

In a survey of over 17,600 adults aged 50 and older, researchers found that 9 percent of adults aged 50-64 reported marijuana use in the past year, double the percentage that used it a decade earlier. Nearly 3 percent of adults 65 and older also reported marijuana use, seven times the number that used it a decade ago.

DRUG POLICY ALLIANCE

DRUG POLICY ALLIANCE

The 2015-2016 National Survey on Drug Use and Health asked respondents about their marijuana use, including when they first used it and whether they used it in the past year. The researchers also looked at several health issues, including substance use and chronic disease.

"Marijuana has been shown to have benefits in treating certain conditions that affect older adults, including neuropathic pain and nausea,” said lead author Benjamin Han, MD, MPH, a professor of Geriatric Medicine and Palliative Care at NYU School of Medicine.

“However, certain older adults may be at heightened risk for adverse effects associated with marijuana use, particularly if they have certain underlying chronic diseases or are also engaged in unhealthy substance use.”

Han and his colleagues say adults who used marijuana were more likely to also report alcohol use disorder, nicotine dependence, cocaine use, and misuse of prescription medications (including opioids and sedatives) than non-users.

The new findings, published online in the journal Drug and Alcohol Dependence, builds on an earlier study by the same researchers that found a significant increase in cannabis use among adults over 50.

Twenty-nine states and the District of Columbia have legalized medical marijuana and a handful of states allow its recreational use. Although today's marijuana users are more likely to be young adults, the baby boomer generation is unique, having more experience with recreational use of drugs than previous generations. Many baby boomers first tried marijuana when they were 21 or younger.

“The baby boomer generation grew up during a period of significant cultural change, including a surge in popularity of marijuana in the 1960s and 1970s. We're now in a new era of changing attitudes around marijuana, and as stigma declines and access improves, it appears that baby boomers -- many of whom have prior experience smoking marijuana -- are increasingly using it," said Han.

Many older adults who used marijuana in the past year (15% of users aged 50-64 and nearly 23% of those 65 and older) reported that a doctor had recommended it to them.

A recent survey by the American Association of Retired Persons (AARP) found that most older Americans think marijuana is effective for pain relief, anxiety and nausea and should be available to patients with a doctor’s recommendation.

Australian Study Finds Cannabis Does Little for Pain

By Roger Chriss, PNN Columnist

A controversial study recently published in The Lancet Public Health followed over 1,500 Australian adults with chronic non-cancer pain for four years – one of the longest studies of its kind. All used prescription opioids and about half tried using cannabis for pain, some occasionally and others daily or near daily.

Advocates of medical marijuana as a treatment for pain may be surprised by the findings.

In the Pain and Opioids IN Treatment (POINT) study, Gabrielle Campbell, PhD, and colleagues at the University of New South Wales found "no evidence that cannabis use improved patient outcomes.”

"At each assessment, participants who were using cannabis reported greater pain and anxiety, were coping less well with their pain, and reported that pain was interfering more in their life, compared to those not using cannabis," said Campbell, who was lead author of the study. "There was no clear evidence that cannabis led to reduced pain severity or pain interference or led participants to reduce their opioid use or dose."

These findings are not unique. Campbell was co-author of a recent review in the journal Pain that found that “evidence for effectiveness of cannabinoids in chronic non-cancer pain is limited.”  Cochrane reviews came to similar conclusions about cannabis for treating fibromyalgia and neuropathic pain.

In short, cannabis helps, but maybe not that much.

The POINT study would seem to contradict the 2017 National Academies of Sciences (NAS) report, which found “substantial evidence” that cannabis is an effective treatment for chronic pain, but in only five good-to-fair quality studies. Overall, the NAS report found that “cannabinoids demonstrate a modest effect on pain.”

About a third of the cannabis users in the POINT study reported reduced opioid use, but the prescription data showed that there was actually no difference.

The study also found that most cannabis users believed they were benefiting from cannabis, but there was no objective improvement in their pain scores.

“It is really difficult to disentangle the reasons for this,” Campbell told Cosmos. “One hypothesis is that it may improve sleep and subjective well-being.”

bigstock-Medical-marijuana-and-pipe-46731607.jpg

This is consistent with other findings that cannabis doesn’t reduce pain, but helps people feel better. The book “A New Leaf: The End of Cannabis Prohibition” states that “patients often say that cannabis mostly disassociates them from the pain, like it’s placed in another room instead of eliminated.”

Similar results were obtained in an Oxford study, which found that “an oral tablet of THC, the psychoactive ingredient in cannabis, tended to make the experience of pain more bearable, rather than actually reduce the intensity of the pain.”

Masking pain may seem like a good thing. But as Grant Brenner, MD, points out in Psychology Today, believing that there is a benefit when there isn't one is problematic. Making pain more bearable may improve mood and sleep, but it could also lead patients to underestimate the significance of a serious health issue. This problem applies to many forms of pain management and requires further research.

“The illusion that a drug is helping with a condition when it is not can get in the way of seeking effective treatment and obtaining real relief,” said Brenner. “Rather than helping with actual pain, difficulty from pain, and need for opioid medication, cannabis consumption may lead people to believe they are improving when in reality they are not.”

The POINT study found what many other studies have been finding about cannabis and chronic pain: Some people experience some benefits some of the time. But the study also has limitations. Participants had chronic pain severe enough to merit opioid therapy, so they may not be representative of people with chronic conditions in general. They also only had access to illicit cannabis that was not part of structured pain management program.

Still, as an editorial in The Age points out: "The findings do not mean medical cannabis does not merit a place in the treatment of various other ailments."

Cannabis and cannabis-derived pharmaceuticals like Epidiolex are proving useful for managing seizures, reducing chemotherapy side effects, and treating multiple sclerosis. There may yet be other uses to be discovered. For instance, cannabis may be effective for more rare disorders. And cannabis may be a viable add-on therapy or alternative for people who cannot tolerate or do not do well with conventional therapies.

The POINT study shows that cannabis is not a panacea for pain. Instead, cannabis is a drug, and we have to treat it with the respect we give any drug if we're going to learn how to use it effectively.

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.

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. 

bigstock-The-words-medical-marijuana-su-17121803.jpg

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. 

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 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.

bigstock-Medical-marijuana-and-pipe-46731607.jpg

"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.

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’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.”

marijuana-trichomes-buds-closeup.jpg

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.

Medical-marijuana-sign.jpg

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.

Carol Levy250.jpg

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.