Marijuana No ‘Magic Bullet’ for Pain in Minnesota

By Pat Anson, Editor

Minnesota may be one of 23 U.S. states where medical marijuana is legal, but getting a prescription for cannabis there is difficult – especially for chronic pain patients.

Since Minnesota enacted one of the nation’s strictest medical marijuana laws last year, less than 700 people have enrolled in the state’s cannabis registry. Only nine health conditions qualify for a marijuana prescription in Minnesota – and chronic pain isn’t one of them – a status that appears unlikely to change after an advisory panel voted 5-3 not to allow pain patients into the cannabis registry.

The reason? Medical marijuana is “not a magic bullet” and there’s not enough evidence that it can treat pain.

“Panel members expressed concern that patients eligible to use medical cannabis for pain have expectations that it would provide total relief and that such a perception may leave patients to abandon other proven pain-management methods, such as physical therapy,” the recommendation said.

“Panel members cited the recent opioid crisis, where good medications were demonized because prescribers used it to treat pain without knowing its proper uses. Even after studying the information available on medical cannabis, panel members said providers do not feel prepared to certify patients for its use.”

The panel recommended that marijuana not be prescribed to anyone with a history of substance abuse or patients with mental health problems. If marijuana is allowed for intractable chronic pain, the panel suggested that patients should be disqualified if they are under 21, have a history of psychosis, are pregnant or breast feeding.

The final decision is in the hands of Minnesota’s Health Commissioner, who has until the end of the year to decide if medical marijuana should be allowed for intractable pain.

The nine conditions that qualify for medical marijuana in Minnesota are cancer, glaucoma, HIV/AIDS, Tourette Syndrome, Amyotrophic Lateral Sclerosis (ALS), seizures, severe muscle spasms, Crohn’s Disease and terminal illness.

Terminally ill cancer patients – many of whom are in pain – are allowed to use medical marijuana. And many say they’ve been able to reduce their use of opioids since they started taking marijuana, according to the Minneapolis StarTribune.

“What are we going to do about patients? What do we tell patients who we know we can help, but we currently can’t help them? That’s the remarkably frustrating thing about this process that gets to me,” said Manny Munson-Regala, CEO of LeafLine Labs, one of the state’s two medical marijuana producers.

In addition to limits on the conditions it can be prescribed for, medical marijuana is not available in leaf form and cannot legally be smoked in Minnesota.  It is only legal in a pill, vapor or liquid form.

Heroin: The Coming Tsunami

By Percy Menzies, Guest Columnist

The unintended consequences of legalization of marijuana in several states, coupled with the political unrest in the Afghanistan, Pakistan and Burma, are combining to create a heroin epidemic of a magnitude that has never before been seen in the United States.

Non-medical use of marijuana is legal in Colorado and Washington, and medical use of the drug is legal in 23 states. States are developing plans to grow marijuana in their respective counties to meet the expected demand for medicinal marijuana.

With the availability of legal marijuana growing nationwide, demand for Mexican marijuana is drying up. So, Mexican farmers are switching to opium, the easy-to-grow crop that is used to produce heroin.

More Mexican heroin is being smuggled every year into the United States, hidden in vehicles or carried across the border in backpacks. The number of heroin seizures along the southwest border has quadrupled since 2008, according to the Drug Enforcement Agency.

As the supply increases, heroin is becoming cheaper and more available than ever before.

Exacerbating the problem is that Afghanistan and Burma, which together produce 90 percent of the world's heroin supply, have borders that are insecure, making smuggling into Iran, India, China, Thailand, Pakistan, the former Soviet Republics and Russia relatively easy.

With the availability of legal marijuana growing nationwide, demand for Mexican marijuana is drying up. So, Mexican farmers are switching to opium, the easy-to-grow crop that is used to produce heroin.

More Mexican heroin is being smuggled every year into the United States, hidden in vehicles or carried across the border in backpacks. The number of heroin seizures along the southwest border has quadrupled since 2008, according to the Drug Enforcement Agency.

As the supply increases, heroin is becoming cheaper and more available than ever before.

Exacerbating the problem is that Afghanistan and Burma, which together produce 90 percent of the world's heroin supply, have borders that are insecure, making smuggling into Iran, India, China, Thailand, Pakistan, the former Soviet Republics and Russia relatively easy.

As a result, there are 1.6 million heroin addicts in Afghanistan, which translates to 5.3 percent of the population – one of the highest heroin addiction rates in the world. There are 1.8 million heroin addicts in Pakistan. Heroin is so ubiquitous in parts of Afghanistan and Pakistan that it is easier to find than life-saving medications.

Burma's Shan State is its main area for heroin production, and it is regaining its notoriety as part of the Golden Triangle. The heroin is smuggled from Burma primarily into three countries, China, India and Thailand.

Drug traffickers are becoming bolder, and rather than relying on land routes, they are increasingly shipping heroin through sea routes to lightly patrolled coasts in African, where it is then distributed to Europe, and eventually North America.

During the past 18 months, the Combined Maritime Forces, a partnership of 30 seafaring nations including the U.S., Canada and Saudi Arabia, has seized 4,200 kilograms of heroin traveling on that route, according to the Wall Street Journal.

It is simple economics: as supply goes up, price goes down. As price goes down, use goes up.

Heroin use in the United States has already reached a new high since people addicted to prescription opiates switch to heroin because it's so much cheaper. Street prices range from $5 to $10 for one button of heroin, good for one use, compared to $50 or more for one tablet of a prescription opiate.

Heroin addiction has been growing steadily in the United States for more than a decade, and overdose deaths more than doubled from 2010 to 2012, according to the Centers for Disease Control and Prevention report released in October.

The U.S. is unprepared for the coming tsunami. We were caught unprepared for the “man-made” addiction to prescription pain medications. Heroin quickly became the “generic” version for the prescription opioids and may well become the primary drug of choice.

The treatment of opioid addiction is further complicated by the fact that the two most widely used medications to treat opioid addiction, methadone and buprenorphine, are abusable and their use is restricted. The widespread use of buprenorphine has inadvertently contributed to increased addiction.

We have a lot of work to do, especially in the area of prevention and offering evidence-based treatment programs. It's not going to be enough to just expand needle exchange programs and distribute Narcan (naloxone) kits that can reverse opioid overdoses. Few patients, policymakers, medical and law enforcement professionals are aware of treatment options, especially the class of non-addicting medications like naltrexone (a drug closely related to naloxone) that protect patients from relapsing.

We need to aggressively combat this problem by educating people on the danger of heroin addiction and by offering viable treatments options for those addicted to heroin.

Percy Menzies is the president of the Assisted Recovery Centers of America, a treatment center based in St Louis, Missouri.

He can be reached at: percymenzies@arcamidwest.com

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.

New Setback for Medical Marijuana Spray

By Pat Anson, Editor

A British drug maker has announced more disappointing results from clinical studies on the use of a medical marijuana spray to treat cancer pain.

GW Pharmaceuticals (NASDAQ: GWPH) said results from two new Phase III studies showed that its Sativex oral spray worked no better than a placebo in treating cancer pain. That was the same finding the company reported in January from an earlier study involving nearly 400 patients in the United States, Mexico and Europe.

However, patients in the U.S. did show “statistically significant improvement” in their pain levels when Sativex was taken along with an opioid pain medication. GW and its partner, Otuska Pharmaceutical, have requested a meeting with the U.S. Food and Drug Administration to explain that finding. Sativex is getting a “fast track” review from the agency as a treatment for cancer pain.

"In light of the missed primary endpoint in the first trial earlier this year, these additional results are not a surprise. Nevertheless, we are encouraged by data across the trials which consistently show positive outcomes for U.S. patients when analysed as a separate cohort," said Justin Gover, GW's Chief Executive Officer.

image courtesy of gw pharmaceuticals

"We believe that this finding may provide important guidance in determining the optimal target patient population for Sativex and look forward to a discussion with the FDA on a potential path forward."

Sativex is composed primarily of two cannabinoids, CBD and THC, which are administered in an oral spray. Sativex is already being sold in Europe, Canada and Mexico to treat muscle tightness and contractions caused by multiple sclerosis. Canada also allows Sativex to be used for the treatment of neuropathic pain and advanced cancer pain.

The spray is not currently approved for use in the U.S. for any condition. It is estimated that over 400,000 cancer patients in the U.S. suffer from pain that is not well controlled by opioid pain medications.

"While the results overall have been disappointing, and not necessarily wholly consistent with clinical experience, nonetheless they suggest that Sativex may have a useful role in the treatment of certain subgroups of patients with advanced cancer pain who have exhausted opioid treatments," stated Dr. Marie Fallon, Professor of Palliative Care, University of Edinburgh and a principal investigator in the Phase III program.

"In particular, the U.S. patients enrolled in this program showed a useful therapeutic benefit whereas results in European patients were generally not favorable. These U.S. patients were less frail, hence the Sativex intervention was subjected to less ‘noise,’ providing clearer results and valuable guidance in determining the optimal target patient population for Sativex. This is a patient population with a significant unmet need and I believe that this important observation for Sativex warrants further investigation."

Cancer patients in all three studies were given Sativex or a placebo spray 3-to-10 times a day over a 5-week period. Patients remained on opioid therapy during the studies. Sativex was well tolerated, with the only side effects in some patients being dizziness and somnolence.

GW is developing other cannabis-based medicines to treat epilepsy, glioma, ulcerative colitis, type-2 diabetes, and schizophrenia.

Patients Say Non-Opioid Therapies Often Don’t Work

By Pat Anson, Editor

Pain treatments recommended by the Centers for Disease Control and Prevention (CDC) as alternatives to opioids often do not work and are usually not covered by insurance, according to a large survey of pain patients.  Many also believe the CDC’s opioid prescribing guidelines discriminate against pain patients.

Over 2,000 acute and chronic pain patients in the U.S. participated in the online survey by Pain News Network and the Power of Pain Foundation. Most said they currently take an opioid pain medication.

When asked if they think pain patients are being discriminated against by the CDC guidelines and other government regulations, 95% said they “agree” or “strongly agree.”  Only 2% said they disagree or strongly disagree.

The draft guidelines released last month by the CDC recommend “non-pharmacological therapy” and “non-opioid” pain relievers as preferred treatments for chronic non-cancer pain. Smaller doses and quantities of opioids are recommended for patients in acute or chronic pain.  A complete list of the guidelines can be found here.

“Many non-pharmacologic therapies, including exercise therapy, weight loss, and psychological therapies such as CBT (cognitive behavioral therapy) can ameliorate chronic pain," the CDC states in internal briefing documents obtain by PNN.

DO THE CDC GUIDELINES AND OTHER GOVERNMENT REGULATIONS DISCRIMINATE AGAINST PAIN PATIENTS?

“Several nonopioid pharmacologic therapies (including acetaminophen, NSAIDs, and selected antidepressants and anticonvulsants) are effective for chronic pain. In particular, acetaminophen and NSAIDs can be useful for arthritis and low back pain, and antidepressants such as tricyclics and SNRIs as well as selected anticonvulsants are effective in neuropathic pain conditions and in fibromyalgia.”

Most patients who were surveyed said they had already tried many of these non-opioid treatments and had mixed results, at best.

“Does the CDC really believe that a pain patient on long term opiates hasn't already tried everything else possible?” asked one patient.

“The CDC says don't do something but comes up with NO viable, realistic alternatives. Tylenol, etc., are unrealistic. Exercise is unrealistic when you are in too much pain to move! “ said another patient.

“Anti-anxiety meds are just as addictive. Over the counter pain medicines are not strong enough to cover the pain in a patient with chronic pain. And there are hundreds of pain patients who can't take NSAIDs because of an allergic reaction. Same thing with steroids,” wrote another.

When asked if exercise, weight loss or cognitive behavioral therapy had helped relieve their pain, only about a third of the patients surveyed said they “helped a lot” or “helped a little.” Nearly two-thirds said they “did not help at all.”

Over half said non-opioid medications such as Lyrica, Cymbalta, Neurontin, anti-depressants and anti-anxiety medications “did not help at all.”

Over the counter pain relievers such as acetaminophen and NSAIDs were even less helpful. Three out of four patients said they “did not help at all.”

“We must be mindful of the treatment options that the CDC guidelines stress over opioids,” said Barby Ingle, president of the Power of Pain Foundation. “For instance in my case, taking NSAIDS for an extended period (a little over 1 year) caused internal bleeding and ulcers which lead to being hospitalized, a surgical procedure, and months of home nursing and physical therapy that could have been avoided.

HAVE EXERCISE, WEIGHT LOSS, OR COGNITIVE BEHAVIORAL THERAPY HELPED RELIEVE YOUR PAIN?

“It is important to include a multi-disciplinary approach to care. We have to use non-pharmacological treatments and non-opioid medications in conjunction with more traditional treatments. Using chiropractic care, nutrition, good dental health, better posture, meditation, aqua therapy, etc., can go a long way in the management of chronic pain conditions.”

But the survey found that many of those treatments are simply out of reach for pain patients because they’re not covered by insurance.

When asked if their health insurance covered non-pharmacological treatments such as acupuncture, massage and chiropractic therapy, only 7% said their insurance covered most or all of those therapies.

About a third said their insurance “covers only some and for a limited number of treatments” and over half said their insurance does not cover those treatments. About 4% do not have health insurance.   

“I tried acupuncture and massage, paying out of my pocket, but neither helped. In fact, they hurt. I tried Lyrica, Savella, and Cymbalta. No luck. I do warm water aerobics three days a week WHEN I CAN TAKE MY OPIATES FIRST,” wrote one patient.

Although the CDC didn’t even raise the subject of medical marijuana in its guidelines, many patients volunteered that they were using marijuana for pain relief and that it worked for them.

DOES YOU INSURANCE COVER ALTERNATIVE TREATMENTS SUCH AS ACUPUNCTURE, MASSAGE AND CHIROPRACTIC THERAPY?

“Alternative medicine is needed. I am a huge advocate of medicinal marijuana, in addition to opioids to treat my disease,” wrote a patient who suffers from CRPS (Chronic Regional Pain Syndrome).

“If cannabis was legal and accessible, it would greatly lessen the need for prescription pain medication,” said another patient.

“I should be able to get the proper medical marijuana legally. I have tried it from a friend and it helps tremendously. However, I will not purchase it because it is illegal. I pray every day I can get it someday,” said a patient who suffers from lupus, arthritis and other chronic conditions.

The survey found patients were evenly divided on whether they should be required to submit to urine drugs tests for both prescribed medications and illegal drugs.

"In order to receive my monthly pain medication, I must submit to a urine screen and a pill count each and every month. I must (whether they work or not) agree to have steroid injections every few months. While I don't have any problem to submitting to urine screenings or pill counts, I do not like having injections that provide no help. I am trapped playing this game,” said a patient.

“99.9% of pain patients are responsible adults but are treated like toddlers who need constant supervision. Pain patients are sicker, fatter, and poorer because they are pumped full of chemicals and steroids. Forced to be experimental guinea pigs or forced to suffer if they say NO,” said another patient.

DO YOU THINK PATIENTS PRESCRIBED OPIOIDS SHOULD BE REQUIRED TO HAVE URINE DRUG TESTS?

"As both a chronic pain patient and a provider I get to view this issue from multiple perspectives. Of course opioids aren't the first line treatment for chronic pain, and when they are used they shouldn't be the only treatment. They are one part of a larger toolkit for managing chronic pain," wrote a registered nurse practitioner.

"There are many fortunate people who are able to manage their pain without medication, or even recover from pain completely using some of the wonderful new interventions we now have available. But there are large numbers of patients out there who have tried all the other medications and dietary changes and injections and PT (physical therapy) modalities and mindfulness. And they are still left with pain that only responds to opiates."

For a complete look at all of the survey result, visit the "CDC Survey Results" tab at the top of this page or click here.

CDC Should Consider Marijuana as Alternative to Opioids

By Ellen Lenox Smith, Columnist

Presently in our country, those that are successfully using opioids for pain relief are feeling dirty and lost -- largely due to fears about addiction and  overdoses. Pain patients often have to cope with physicians who are reluctant to prescribe opioids and pharmacies that are sometimes unwilling to fill their prescriptions.

The Centers for Disease Prevention and Control (CDC) is considering new guidelines that would encourage doctors to shift even further away from prescribing opioids, leaving the patient with little effective medication to turn to.

Why is the CDC not even considering the use of medical marijuana to help these people in need?

The Boston Herald recently reported that hundreds of opioid addicts are being treated successfully in Massachusetts with medical marijuana.

“We have a statewide epidemic of opioid deaths,” said Dr. Gary Witman of Canna Care Docs, which issues medical marijuana cards in seven states. “As soon as we can get people off opioids to a non-addicting substance — and medicinal marijuana is non addicting — I think it would dramatically impact the amount of opioid deaths.”

Witman is treating about 80 patients at a Canna Care clinic who are addicted to opioids, muscle relaxants or anti-anxiety medications. After enrolling them in a one-month tapering program and treating them with cannabis, Witman says more than 75 percent of the patients have stopped taking the harder drugs. Medical marijuana gave them relief from pain and anxiety — and far more safely than opioids.

Patients across the country are also learning they can use cannabis for pain relief, decreasing or even eliminating their use of opioids.  Marijuana works far better than other substitutes since it is not synthetic and does not cause organ damage or deaths like opioids can in some circumstances.

Medical marijuana works naturally on what is known as the “endocannabinoid system,” binding to neurological receptors in the brain that control appetite, pain sensation, mood and memory.

Here in Rhode Island, my husband and I have witnessed the amazing transition of pain patients on opioids that chose to transition to medical marijuana.  Most that turn to cannabis do so to eliminate the side effects of opioids and concerns about their long term use. They still achieve pain relief but know they are gaining that relief in a safer manner -- no organ damage, no teeth getting destroyed, no concerns of addiction and no deaths.

Marijuana may still be illegal at the federal level, but it is legal in 23 states and the District of Columbia, and millions of people are discovering its therapeutic benefits. The CDC should consider adding medical marijuana to the list of “non-opioid” therapies in its guidelines.

Ellen Lenox Smith and her husband Stuart live in Rhode Island. They 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.

Medical marijuana is legal in 23 U.S. states and the District of Columbia, but is still technically illegal under federal law. Even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.

Daily Marijuana Safe and Effective for Chronic Pain

By Pat Anson, Editor

Chronic pain patients who use medical marijuana daily for a year suffered no serious side effects and significantly improved their levels of pain, mood and quality of life, according to a new study in Canada.

The clinical study by researchers at McGill University in Montreal is one of the first to test the long term safety and efficacy of medical marijuana. It’s been published online in the Journal of Pain, the official journal of the American Pain Society.

“Quality-controlled herbal cannabis, when used by cannabis-experienced patients as part of a monitored treatment program over one year, appears to have a reasonable safety profile,” wrote lead author Mark Ware, an associate professor in Family Medicine and Anesthesia at McGill University and one of the world’s leading experts on medical marijuana.

Pain News Network had a lengthy interview with Ware about his research earlier this year.

In his most recent study, Ware and his colleagues assessed the long-term health of 216 medical marijuana users with chronic non-cancer pain who consumed a standardized dose (12.5% THC) of up to 5 grams of marijuana daily through inhaling or vaporization. They were compared to a control group of 215 chronic pain sufferers who did not use marijuana. Both groups were monitored over the course of the one year study.

Researchers said the cannabis users had no serious side effects compared to the control group, and had a significant improvement in their pain, anxiety, depression, anger and fatigue.

“We noted significant improvements in pain intensity and the physical dimension of quality of life over one year among the cannabis users compared to controls; there was also significant improvement among cannabis users in measures of the sensory component of pain, symptom distress, and total mood disturbance compared to controls. These findings, while not the primary outcomes of the study, are nevertheless important in considering the overall risk-benefit ratio of medical use of cannabis,” Ware wrote.

IMAGE COURTESY DRUG POLICY ALLIANCE

“The results suggest that cannabis at average doses of 2.5g/d in current cannabis users may be safe as part of carefully monitored pain management program when conventional treatments have been considered medically inappropriate or inadequate.”

The marijuana group did report more non-serious side effects, such as headache, nausea,  dizziness, and respiratory problems associated with smoking.

Visiting a Medical Marijuana Dispensary

By Ellen Lenox Smith, Columnist

Many people who are considering medical marijuana for pain relief are reluctant to visit a marijuana dispensary, fearing it might be in a bad part of town or that they may encounter some unsavory characters.

Since I am a home grower of marijuana, I felt it was best to visit a dispensary in my home state of Rhode Island to get a fresh, first hand view of what the experience is like. Through the kindness of Barbara Pescowolido at the Thomas C. Slater Compassion Center in Providence, this visit was made possible.

The first thing that I noticed was the professional layout that included informed, pleasant and knowledgeable employees who were there to greet me. There is 24 hour surveillance of the premises, a well-lit parking area, and a professionally trained security team.

I had to show to identification, which requires a Rhode Island medical marijuana patient or caregiver card,  and another form of ID, like a driver's license. After my information was put into the computer and confirmed, I was buzzed into the center. If a patient is not able to walk without assistance, he or she can be accompanied by a licensed caregiver, who would also be required to present credentials.

Every new patient is given an orientation session that includes a one-to-one educational conversation, and a folder of information to take home and review for future visits.The folder includes the different methods of ingesting marijuana, the concentrated forms available, their laboratory testing procedures, how to use your medicine sensibly, and a form that explains cannabis and the difference between sativa and indica plants.

There’s also a patient journal so you can record the type of marijuana you tried, how you ingested it, the date/time of taking, and the duration/effect. This is to help both the patient and staff make educated decisions on your next purchase.

Also included is a “Good Neighbor Agreement” the patient is to read and sign. You are expected to follow the guidelines to be able to continue using their services. They include:

• Not to smoke or consume marijuana on site or in the parking lot
• Refrain from using cellphones or cameras while in the building
• No minors allowed unless they are a patient and accompanied by a parent or legal guardian
• No minors left in your vehicle unattended while visiting the center
• No animals except guide/service animals are allowed inside
• Keep all medicine and money our of plain sight
• No weapons allowed.
• Do not invite individuals who are not patients or caregivers, unless special arrangements are made with management
• Do not throw litter in the parking lot or surrounding area
• Marijuana purchased in the center is not for resale. Any member found reselling will have their membership revoked
• Keep all conversations respectful and appropriate

New patients also learn about a wide range of free ancillary services, such as massage, reiki, hydrotherapy bed, cultivation, and classes on cooking and methods of consumption. There are also product showcases and live demo’s that include weekly open house tours, 1:1 consultations, loyalty rewards program, a community newsletter and a cannabis library/DVD section.

The next step for me was to take a number while relaxing in a tastefully designed waiting area. When you are called up to the counter, you get to work 1:1 with a knowledgeable patient advisor/employee.

A menu hangs over the counter sharing what medications are available. A variety of edibles, capsules, concentrates in syringes, flowers, exilers, and topicals are for sale.

This center has come up with a novel idea. For just $20, you can purchase a sampler packet that includes small samples of medicine that includes THC capsules, CBD capsules, elixir, a cookie, hard candy and gummy bears. This allows the patient to return home and try these different methods to decide what fits best for their needs.

The center is still not able to grow all that is needed to accommodate patients, so there are times customers return for a specific product to find it is not available. It is difficult for the center to have to rely on others growing for them, so their goal is to one day be totally self sufficient.

Patients are allowed to purchase 2 ½ ounces every fifteen days. Records are kept in a computer so that no one ever goes over that amount unintentionally or intentionally. You are able to check the center’s website for a "menu" of the current product being sold, but you are not allowed to purchase online.  

Prices presently range from $25 to $50 for an eighth of an ounce of product. Prices can fluctuate if the marijuana tests out to be stronger. All marijuana, either grown on site or purchased from growers, is tested and cleaned.

My experience there was pleasant and educational. For a closer look at the Thomas C. Slater Compassion Center, you can watch this short video the center has on YouTube:

Uploaded by Slater Center on 2015-06-09.

If you live in a state that allows medical marijuana, but does not permit you to grow your own or have a caregiver grow for you, then a dispensary like the one I visited can probably meet your needs. But each state has different laws and regulations for both patients and dispensaries, so your experience may differ from mine.

Visiting a dispensary and trying medical marijuana for pain relief could result in a significant improvement in your quality of life.

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis.

Ellen and her husband Stuart live in Rhode Island. They 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.

Medical marijuana is legal in 23 U.S. states and the District of Columbia, but is still technically illegal under federal law. Even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.

'Telehealth' Doctor Visits for Medical Marijuana

By Pat Anson, Editor

With medical marijuana legal in 23 U.S. states and the District of Columbia, millions of Americans can now legally obtain cannabis to treat chronic pain and other health conditions.

But many pain patients are leery about asking their doctors for a medical marijuana card or about visiting a marijuana dispensary in some shady part of town.

Into this void has stepped HelloMD, the first “telehealth” provider to offer live online video consultations with a physician about medical marijuana. For $49 – a fraction of the cost of visiting a doctor in their office -- the company says it will provide a private consultation with a licensed physician via a desktop computer, laptop or mobile device. If the doctor agrees on the need, they will write a medical marijuana recommendation for immediate use.

HelloMD also provides links to trusted marijuana dispensaries and delivery services – meaning the patient never has to leave the comfort of their own home.

“Delivery service is really what they’re interested in,” says Mark Hadfield, CEO and Founder of HelloMD. “The patients that we’re talking about, the elderly, infirm, professionals, moms and dads, are people that are concerned about confidentiality; they don’t want to end up in a state database, they don’t want to be filmed going in and out of a dispensary. Those people were never going to get their (marijuana) cards prior to this service.”

HelloMD began providing medical marijuana consultations in March, but the San Francisco based company has actually been around for two years, at first providing online access for patients interested in reaching neurologists, oncologists and other medical specialists.

“It’s a very hot space. Digital health care is a multi-billion dollar segment growing very, very rapidly. It’s also very competitive. There are at least five or six companies with tens of millions of dollars in funding competing for that space. The latest one is Walgreens,” Hadfield told Pain News Network.

Faced with that kind of competition, HelloMD decided to focus exclusively on medical marijuana.

“There’s obviously a big need. A lot of doctors are leery, uninformed or uncomfortable with cannabis. A lot of people go to their traditional doctors and they’re told they’re just not able to advise them on that,” Hadfield said.

“We think there’s a much bigger demographic that until now has not been involved in cannabis products. So millions of Americans are coming into the industry for the first time and are curious to try those products. And so our goal is to be the resource for those patients, starting off with connecting them with the right medical assistance and keeping them compliant with the law.”

For now, HelloMD can only provide medical marijuana consultations to people in California. It has about a dozen doctors “on call” in the state to meet online with patients. Many of the physicians are retired or semi-retired and work from their own homes.

The company plans to expand into other medical marijuana states later this year and to recruit about 300 doctors nationwide. Doctors must be licensed to practice medicine in the state where their patient is located.

About 150 patients a week are currently getting consultations on HelloMD.

"We were quite surprised to find that the majority of folks coming through our service were not recreational users at all.  Instead we met retirees, veterans, and working professionals looking for alternative medicinal treatments to a wide variety of conditions spanning chronic pain through everyday anxiety and stress,” says Perry Solomon, MD, Chief Medical Officer at HelloMD.

“All of them had heard about marijuana as an alternative but found their general practitioner lacking the knowledge to offer good advice. They didn't know where to go for more information on medical marijuana, who to talk with, or how to go about becoming a legal patient. Many had difficulty leaving their homes while others were afraid to venture into the parts of town where medical marijuana practitioners were likely to be found."

According to a new report by the National Business Group on Health, telehealth services are saving companies more than $6 billion in healthcare costs.  American Well, Doctor on Demand, MD Live and Teladoc offer online consultations with a physician for about $40 to $50.

Success Stories of Real Medical Marijuana Patients

By Ellen Lenox Smith, Columnist

My husband and I have been licensed medical marijuana caregivers in the state of Rhode Island for over five years. Our lives have been touched by the many people who have been sent our way by doctors for education about medical marijuana. Some of the people below are either our present or past patients, along with some from other states we met and have kept in touch with.

We hope their stories will help you gain the courage to give this safe, non-invasive pain medication a try.

Bob - Paraplegic

Bob arrived at our house in his handicap equipped van and we met him in the driveway. It was difficult to understand Bob’s speech at first due to his intense level of pain. He seemed overwhelmed and lost.

The doctor who saved Bob’s life when he fell off a roof and was impaled and paralyzed, warned him when he awoke from surgery that he would experience intense pain for the rest of his life.  

However, things changed when Bob tried medical marijuana. He vaporized marijuana right there in the driveway, proceeded to tell us that he felt no change, and before he knew it was having a conversation with us. At times, the effects of marijuana are so gentle you don’t realize what is changing.

Bob became an advocate for medical marijuana and almost daily would call on the phone to make sure we were doing okay. He became a gentleman that was able to share, care and feel again.

Bob has since passed and is missed, but we know that his dignity was restored by cannabis relieving his pain. Vaporizing medical marijuana allowed Bob to have a peaceful ending.

image courtesy drug policy alliance

Scott -- Multiple Sclerosis

42-year old Scott, who has a severe case of multiple sclerosis, told me that turning to medical marijuana saved his life. The former customer service representative was thrilled when he found an alternative to using Avonex for his condition. He did not like using the drug because it caused flu like symptoms and a high fever.

By smoking cannabis, Scott is able to control his pain and is thrilled how he is able to move his stiff legs. He also says it relieves his neuropathic pain too.

School Teacher - Ehlers Danlos Syndrome

An elementary school teacher, who asked that we not use her name, was diagnosed with Ehlers Danlos Syndrome (EDS). She was not sleeping and had a terrible time functioning in her job. Then she decided to try medical marijuana. She began taking an indica oil at night before going to bed and a sativa tincture during the day after work. Just 10 minutes after each dose, her pain levels are diminished or completely relieved.  

She finds the night time dose carries into the following day, but doesn't hinder her either mentally or physically.  It allows her to function and be the teacher she was before --- vibrant and focused.

“Without this gift of oils, I would be in continuous pain 24 hours a day, 365 days out of the year,” she told me.  “This does not change who I am. It just changes how I am, functioning and living each day, which should be to its fullest.”

Lori - Spinal Injury

57-year old Lori had been employed as a medical coding technician at a local hospital. In 2007, she had an injury to her spine. Unfortunately, back surgery led to epidural fibrosis. After months of failed alternative treatments and medications, Lori's doctor suggested she try medical marijuana.

She found immense relief using a portable vaporizer (PAX) two to three times a day. Lori no longer has to rely on narcotics for pain relief and her entire lifestyle has changed.

“I have at least half of my life back,” she says. “I am not severely depressed, I get out alone more often, and the pain is there but not ruling my life!”

Stryder - Ehlers-Danlos Syndrome and Epilepsy

We met 5-year old Stryder at an EDS conference in 2013. A pain clinic doctor got in touch with us after meeting with his mother, Angela.

Our hearts broke to see a gorgeous young man crippled from the joys of life by severe medical issues. Stryder barely noticed us and was not conversing. He was pale and exhausted.

We talked with Angela, gave her a donation of our night indica oil (not made from any high CBD plants) and carefully gave directions on how to use it.

They were sharing a room with a woman, and Angela told us Stryder had driven the woman crazy with the seizures he had during the night. But, after the second night of trying the oil, she asked Angela in the morning what she had done differently. When she told her the truth, the woman was amazed with the changes.

Stryder was a different boy. He was talking and interacting like he hadn’t before. Angela believes this was caused by a combination of sleep and brain rest from the seizures. Stryder was alert, smiling, walking, and even went off to play with other children at the conference.

Today, Angela says Stryder is a legal marijuana patient in his state, takes his oil based medication in a dropper and sometime uses cannabis candy to suck on. He is sleeping better at night and is happier.

Angela advocates for medical marijuana to help others get educated with correct facts. When someone said they were against putting cannabis in candy, here is how she responded:

“Would you rather a child smoke it? The drugs that these kids are put on for seizures are devastating, have a lot of side effects and are addicting,” Angela said. “Children are often told to just suck it up when it comes to pain management and that's just not fair. Stryder's success has been unmatched and I will always be an advocate for something that is natural and less harmful as well as effective.”

Maureen - Postural Orthostatic Tachycardia Syndrome (POTS)

The day Maureen arrived to our house, we wondered how she even made it driving to us. Her POTS (a syndrome that causes an abnormally high blood pressure and heart rate) was so severe, she was shaky and extremely pale. Her cardiologist had wanted her try marijuana since he had observed other POTS patients get relief from it.

Maureen’s POTS was diagnosed at age 54, where she was working as an ER technician.  She chose to use the oil and the tincture as needed, until she was put into an experimental cardiac rehab program and began getting saline infusions.  After several months, she found that this helped to keep her blood pressure at a normal level and made her symptoms less severe.

“When you're sick every day for a long period of time, anything that helps is worth it; not just for the physical symptoms but for your mental state as well,” Maureen told me.  

Today, at age 57, she no longer has to use marijuana at all. She keeps her symptoms under control with exercise and saline infusions. However, if the need arrives again, Maureen says she wouldn’t hesitate to use marijuana again.   

Bonnie - Pudendal Neuralgia and Post-Fusion Pain

At 75, retired college professor Bonnie arrived at our home in severe pain. After much education and consideration, she decided to give medical marijuana a try.

In time, as she gained her confidence, Bonnie found that eating brownies with marijuana, along with taking indica oil at night, provided her relief from unrelenting pain.  It also provided some hope, thus improving her outlook on life.

"The only real relief I have had from my pain has been with medical marijuana.  My medicine allows me to enjoy life again," Bonnie says.

Elizabeth - Chronic Regional Pain Syndrome, EDS and Chiari Malformation

29-year old Elizabeth was sent to us by a pain clinic doctor. This beautiful, terribly thin, and discouraged young lady and her mother arrived at our home and it broke our heart. Elizabeth’s CRSP was so severe on her head that she was no longer able to touch it, let alone consider running a comb or brush through her hair.

Elizabeth was a former piano teacher and a recording artist, struggling to hold onto her career.  She clearly wanted to get back control of her life. While in our home, she started to rub our topical on her scalp and we were startled when she said she felt some immediate relief. So began her magical way to help get some quality of her life back.

Elizabeth now administers her medical marijuana in a variety of ways. She eats it with edibles, drinks it, massages her joints with it, vaporizes it, and occasionally smokes it.  She enjoys using a Magical Butter machine that it makes potent tinctures and oils, and appreciates the "no heat" option, which she uses to make CannaMilk.  

Elizabeth found she requires high doses of THC, because she doesn’t absorb it at a normal rate.  As a slow absorber, she doesn't get a big peak in relief, followed by a sharp drop-off. Instead it gives her a pretty consistent relief and doesn’t make her feel “stoned."

drug policy alliance

With medical marijuana, she feels her muscles are not as rigid. She can relax, sleep better, and can touch areas of her skin that used to be too sensitive to touch.

“It has changed my life for the better,” Elizabeth says.

Melvin - Renal Failure, Degenerative Lumbar Disc, PTSD, Headaches

43-year old Melvin is employed as an agricultural-inspector. We met this very intelligent, kind man at our home a few years ago and hoped that using medical marijuana would provide the relief he needed to be able to function better in life.

Melvin did a lot of research about how to use marijuana, what strains to consider, and in time found the best way for him to administer it was with vaporizing and using extracts.

He found that his PTSD was mostly relieved by using the higher CBD strains. Melvin’s PTSD causes unwanted and uncontrollable visions and thoughts. Marijuana slows them down, without triggering emotional responses. Its’ not a cure for his PTSD, but has made it more manageable.

There are two damaged discs causing nerve pain which radiate down Melvin’s legs – making them feel numb, burning and painful. He alleviates this pain using marijuana strains like Bubble Gum, Lucy and Pineapple Express. Without them, Melvin says his back would be in constant pain and he would have to lie in bed for most of the day. With marijuana, he is a functioning employed worker.

“With a huge help from my caregiver I was able to find the correct THC to CBD ratio that works for my PTSD and disc/nerve degeneration. Medical marijuana is my freedom!” Melvin says.

Bill - Cardiac Issues

We met Bill and his wife, Joan, a few years ago. Despite his failing health, the love and commitment between them was so clear. We hoped that medical marijuana would provide the relief needed to allow Bill dignity with the time left in his life.

A former firefighter for 30 years, Bill was diagnosed with just 20% cardiac output. This caused him severe pain while breathing.

Bill found that administering the marijuana in an oil night and using the tincture during the day gave him relief. He was able to sleep again for more than one or two hours. For the severe pain in the center of his ribcage, due to an unhealed fracture, the topical cream gave Bill relief that lasted for hours.

Bill used this form of medication for about a year and wished he had been able to use it even sooner, so that he could have had a better quality of life.  

Sadly, Bill recently passed away at the age of 73.

drug policy alliance

Diana - Ehlers-Danlos Syndrome

53-year old Diana was a national award-winning composer, pianist, singer, violinist, dancer, and actress. She had to turn down a Master's fellowship because of her recurrent back, shoulder, and elbow/wrist pain.  Instead, she worked as lab technician.

Cortisone shots and bed rest were the "treatment" for her pain. For five long years, she wore hard braces from her wrists to her elbows, yet also managed to perform lead roles in musicals (with braces hidden beneath costumes).  

After she was finally diagnosed with EDS, she turned to medical marijuana two years ago. Now, every night, Diana uses an indica oil. Without it, she would sweat throughout the night profusely.  Medical marijuana has also reduced her pain from EDS.

Sally - Stage IV Cancer

Courageous 71-year old Sally has been successfully using medical marijuana for over five years. She began using it after being diagnosed with Stage IV uterine cancer.

Sally has defied all odds by remaining active and engaged in life. She found that using the oil at night gave her much needed quality sleep and lowered her pain. For daytime relief, she found vaporizing controlled her nausea.

“Marijuana has few, if no side effects. It is benign in terms of overall functioning,” she says.

Sally, who was recently told by her doctors that she doesn’t have much time left.

Sally, who was recently told by her doctors that she doesn’t have much time left, is a role model to us all; determined, positive and caring. She touches lives in a positive way and will always be in the hearts of those that have had the honor to know her.

These are just a few of the amazing success stories that I have experienced with patients using medical marijuana. Most people that try marijuana are able to find relief from the different conditions they are striving to live a better life with. 

We look forward to the future when more research is allowed in our country.  This, in turn, would provide the needed support and education for those in the medical field, so they could understand and encourage their patients to try marijuana. Not as a last resort, but as the first choice.

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis.

Ellen and her husband Stuart live in Rhode Island. They 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.

Medical marijuana is legal in 23 U.S. states and the District of Columbia, but is still technically illegal under federal law. Even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.

Marijuana Effective for Diabetic Neuropathy Pain

By Pat Anson, Editor

New research shows that inhaled medical marijuana can significantly reduce pain from diabetic neuropathy within minutes of treatment.

The study, published in The Journal of Pain, also found there was a dose dependent reduction in pain depending on the strength of marijuana used.

Researchers at the University of California San Diego followed 16 patients with diabetic peripheral neuropathy (DPN) in a double-blind study as they were exposed to low, medium and high doses of tetrahydrocannabinol (THC), the psychoactive compound in marijuana that makes people “high.”

Patients used a Volcano vaporizer to inhale marijuana with 1%, 4% and 7% THC, as well as a placebo. A vaporizer was used because it is less harmful than smoking and delivers THC into the bloodstream rapidly.

“We hypothesized that inhaled cannabis would result in a dose-dependent reduction in spontaneous and evoked pain with a concomitant effect on cognitive function,” said lead author Mark Wallace, MD, professor of anesthesiology, University of California San Diego School of Medicine. 

Results showed that the highest dose of THC reduced pain by nearly 70%, with the analgesic effect starting within minutes of inhaling and reaching its peak about an hour after treatment. The analgesic effect of the low and medium doses of THC was slightly lower.

All of the patients experienced either euphoria or somnolence, regardless of the dose, with modest effects on attention, memory and impairment.

“These findings along with previous studies suggest that cannabis might have analgesic benefit in neuropathic pain syndromes, including treatment-refractory DPN,” said Wallace.

Nearly 26 million people in the United States have diabetes and about half have some form of neuropathy, according to the American Diabetes Association.  Diabetic peripheral neuropathy causes nerves to send out abnormal signals. Patients feel burning, tingling or prickling sensations in their toes, feet, legs, hands and arms.

There are only two drugs approved by the Food and Drug Administration to treat DPN -- Cymbalta and Lyrica – and many patients say they don’t work or have unpleasant side effects.

Marijuana Helps Heal Broken Bones

Meanwhile, researchers in Israel have discovered that a compound in marijuana can help heal fractures and rebuild bones.

In an animal study published in the Journal of Bone and Mineral Research, researchers at Tel Aviv University reported that cannabinoid cannabidiol (CBD) – a non-psychoactive ingredient in marijuana – significantly enhanced the healing process in rats with broken legs.

Earlier studies by the same research team found that cannabinoid receptors in the human body stimulate bone formation and inhibit bone loss. The findings suggest that cannabinoid based drugs could be used to treat osteoporosis and other bone-related diseases.

"The clinical potential of cannabinoid-related compounds is simply undeniable at this point," said Dr. Yankel Gabet of the Bone Research Laboratory at the Department of Anatomy and Anthropology at Tel Aviv University.

The researchers injected one group of rats with CBD alone and another with a combination of CBD and THC. They found that CBD by itself provided the most therapeutic benefit.

"We found that CBD alone makes bones stronger during healing, enhancing the maturation of the collagenous matrix, which provides the basis for new mineralization of bone tissue," said Gabet.

"Other studies have also shown CBD to be a safe agent, which leads us to believe we should continue this line of study in clinical trials to assess its usefulness in improving human fracture healing.”

Searching for Medical Marijuana’s ‘Therapeutic Window’

Dr. Mark Ware is one of the world’s leading experts on medical marijuana. Ware is an associate professor in Family Medicine and Anesthesia at McGill University in Montreal and director of clinical research at the Alan Edwards Pain Management Unit at McGill University Health Centre. He practices pain medicine at Montreal General Hospital.

Although medical marijuana is legal throughout Canada, and in 23 U.S. states and the District of Columbia, mainstream medicine still frowns upon its use. Research into the therapeutic benefits of cannabis -- particularly for pain management -- has also been limited.

Pain News Network editor Pat Anson recently spoke with Ware at the annual meeting of the American Pain Society. The interview has been edited for content and clarity.

DR. MARK WARE.

Anson: You’ve called medical marijuana an “incredible social experiment.” What do you mean by that? 

Ware: I think what we’re seeing is the lid coming off something that’s been going on for a long time. I think people have been self-experimenting with marijuana for years and years. People have been growing it in their basements and backyards. So there’s been a social experiment with cannabis since the 1960’s in the Western world.

I think the medical aspect of it has kind of followed through with that, because as you get thousands of people using cannabis, eventually somebody with an illness is going to stumble upon it. Lester Grinspoon (a marijuana researcher) reported on this in 1971. So that’s how long we’ve known or suspected the potential medical properties. The fact that the drug has been illegal has suppressed the possibility of there being much in the way of good quality research. So the experiment has been going on underground, out of sight and out of the public eye.

What we’re seeing now is that suddenly we’re able to talk about it. We’re able to look at this seriously. And we’re beginning to realize how much was already going on. So I think it’s an experiment that’s been going on for a long time and we’re beginning to put some parameters around it now, which allow us to track it more carefully. And hopefully it can yield some important results that can help inform the patient and the physician about what to do with this.

Anson: Some doctors have told me they don’t think marijuana will ever go mainstream until big companies like Pfizer and Purdue Pharma start backing marijuana research and doing clinical studies. Would you agree with that?

Ware: I don’t know if I would agree with that. That’s true for new pharmaceutical drugs. If you’re developing a molecule from the lab up, you need Big Pharma to come along and take that and move it to the point where they can do the big clinical trials.

With an herbal medicine, I think you almost don’t want to look at the pharmaceutical model for drug development. It’s more like how we regulate natural health products in Canada. We want good quality cultivation techniques, we want good quality processing, and we want to know what it is that we’re giving to patients.

I think fundamentally what we have to figure out is what we want to know about this drug. What is it that we need to know and how do we go about getting that information?

I think if we wait for Big Pharma to come along it’s going to be a long wait.  They would have been on this long ago if they thought this was important.

It’s a plant based medicine that’s already in our society at some level and we need to recognize the reality that mainstream doesn’t mean mainstream prescription availability. It’s going to mean mainstream figuring out how to put cannabis in a safe place in our society.

Anson: Medical marijuana is so widely available today, it’s like we’re already past the clinical trial phase.

Ware:  Exactly.  And to go back and do the Phase III study now, it’s expensive and would take hundreds of millions of dollars. And that requires knowing whether you’re going to get your money back. Companies invest that money when they know they’ve got a patent and they can make money back on the drug in the ten years after it’s launched. It’s much harder to see that happening with an herbal material like cannabis.

Why invest the money? It’s already available. You can already buy it at the dispensary. So now the question is how do we improve that process? How do we improve the quality of the product? How do we label them so people know what’s in them? How do we provide information to the patients that are buying them? What they should be looking for and what they should be careful about?

And how do we inform the physicians and health professionals who should be managing that whole process or at least informing it? What kinds of patients should be avoiding this? This isn’t for young kids. This isn’t for women who are pregnant. Some of this is obvious, but some of it needs to be specified and mandated.

I don’t think there’s strong enough evidence to start using cannabis in younger people. I think that the risks of cannabis on the developing brain in teenagers is significant enough that, unless there is a very real reason like a younger person with a severe intractable illness, this is a drug that should be held for the 25 and older crowd.

I would caution people who have unstable heart problems against using cannabis. It does increase your heart rate, can open up your blood vessels, and that could precipitate some heart problems.

Anson: What are the pain conditions that you think medical marijuana can be beneficial for?

Ware: I think for sure it’s more likely effective for chronic pain than acute pain. It’s never been reported for acute pain syndromes, but it has been reported for chronic pain.  There are clinical trials now that bear out that chronic neuropathic pain is one of the relieved conditions that it seems to respond to. We’ve seen reports for spinal cord injury, fibromyalgia, and PTSD (post-traumatic stress disorder). Cannabinoids appear to have some signals in some of these conditions.

And then you go beyond that to abdominal pain with Crohn’s disease, diabetic neuropathy, and so on. The list of conditions where it looks like it may work is as long as your arm.  There are individual case reports of cannabis being used on a huge range of conditions.

Anson: What is the most effective delivery system? Everyone thinks of smoking, but there are plenty of other ways to ingest marijuana.

Ware: There are. And I think the key thing is the difference between inhaling and taking it by mouth. The inhaled route is a very quick onset, has a very rapid effect on the patient, and then a fairly quick half-life; whereas the oral route takes much longer to absorb and takes a longer time for the patient to feel the effects. But then it lasts a lot longer. 

courtesy drug policy alliance

So it’s almost like a short acting versus a long acting medication. I don’t think there’s any way of saying one is more effective than the other. I think they’re effective in different ways.

If I was vomiting because of chemotherapy, I’d want something I could inhale to control the vomiting quickly. But if I’m not able to sleep because of my chronic pain, I want something that would be longer lasting so I could sleep through the night.  I don’t want to wake up three hours later and have to do it again. So I think we just have to figure out how to use the different administrative techniques for different clinical conditions.

Anson: Most of our readers are pain patients and when this subject comes up many of them say, “I’ve never tried marijuana. I’m curious about it and I’d like to try it, but I’m worried about getting high.” Can they get pain relief without getting high?

Ware: We’ve done studies where we kept the doses very, very small -- to the point where people have read the protocols and said you’re not giving these patients enough to feel the effect. And in fact, what happens is patients are still able to find analgesic benefit and avoid that euphoric or psychoactive effect.

That’s important for most patients. They want to be able to use a drug or any kind or a therapy that doesn’t impair them from doing the things that they need to do. They need to drive. They need to work. They need to hang out with their families. They need to do their sports and their activities. And this is part of pain management generally. We want people to be living as full and as active a life as possible. We don’t want them collapsing on the couch all day long.

So can we find that window, what we call that therapeutic window, that dose where you get the benefit but you don’t get the sedative or psychoactive effect? And I think we can. I think for patients who are considering this approach, they really have to learn to be very patient and use very, very small doses. Try very small amounts first and allow your body to feel what the drug is doing to you. And if nothing happens, that’s okay. You’ve started with a low enough dose that you felt nothing. You gradually work your way up.

The interesting thing about cannabis is that there are two ways of thinking about dose. One is the amount of the drug itself, the number of grams, joints or pipes, if you will. The other is the THC level of the cannabis itself.

courtesy drug policy alliance

If patients have access to material where the THC level has been standardized or has been measured, they should be trying to use THC cannabis that is as low as possible, because the likelihood of having a psychoactive reaction to a high THC cannabis is much higher.

If it’s high in THC, it doesn’t take much to get that effect, where if they use very low THC levels, less than 10 percent THC, and they use a small quantity of the material, then potentially they can find that therapeutic window that can be effective.

Anson: What about taking marijuana with opioids? Can you do that?

Ware: You can. There’s no medical reason why you shouldn’t. I think the key thing for patients who are doing that, and again I emphasize with the knowledge and support of their physician, is that they can reduce the doses of other medications which may not be helping as much.

Cannabis use can be seen in terms of improving patients in two ways. One is in reducing the medications that they’re already taking, which may have side effects. And the other is in improving their functioning state so that they’re doing more. This is where I think the responsibility lies with the patient to prove to the doctor that this drug is helping. And you do that by reducing your other medications with the doctor’s support, by increasing your functioning and by showing that you’re doing things that you weren’t doing before. That is what doctors want to see.

There appears to be evidence, at least in animal studies, that opioids and cannabinoid drugs work synergistically. So if you take the two separately and you take the two combined, you get a greater effect with the combination than if you took either of the others by themselves.

This synergism, we’ve seen it in patients who started using cannabis successfully and they were able to reduce their other medications. In some cases they find that the dose of opioids they were taking, they can lower it and get a similar effect with much lower doses. With others, they don’t need the opioids any longer and they can taper off it and stop completely. 

Anson: One fear of using medical marijuana is that it could make you more prone to abusing other substances.

Ware: I think patient selection is very important when you’re considering as a physician whether to authorize or prescribe cannabis, because cannabis is a drug with a known risk of abuse and dependence by itself. There are people who struggle with their marijuana use and withdrawal when they try to get off it. Physicians need to be sure they’re not making things worse for a patient that has a dependency disorder by authorizing cannabis.

Screening for dependence means looking for abuse of other substances, such as alcohol. If you’ve done that carefully, prescribing cannabis to a patient who doesn’t have that addiction risk appears to be fairly safe.

Medical cannabis should be used as an option only when all the conventional therapies have failed; when all of the other approaches to pain management, and I’m not just talking about pharmacology, but when all of the non-pharmacological approaches have all been considered and tried. Cannabis is not at the point where it can be thrown in as a first line agent for a patient struggling with pain management.

Anson: Thank you, Dr. Ware.

Which Marijuana Strain Works Best for Pain?

By Ellen Lenox Smith, Columnist

Unfortunately, “one size does not fit all” when it comes to using medical marijuana for pain relief. You and I could have exactly the same medical condition and use the same strain, but we will not necessarily react in similar fashion.

Because of that, it may take time to find your effective strain. This process will require patience and holding onto hope that you will eventually succeed. I was lucky. The first time I tried some Indica oil, I literally slept the entire night. However, we have had patients who sampled numerous strains before they found what works for them.

a leaf of cannabis sativa

There are two strains of marijuana plants, both of which provide pain relief: Indica has a calming and soothing effect that can help you sleep, while Sativa helps stimulate the brain and body so you can have a more productive day.

The other thing you have to pay attention to is the THC (Tetrahydrocannabinol) and CBD (Cannabidiol) content of the strain you are selecting. THC is known to provide the “high” sensation that people refer to when marijuana is used recreationally.

Those of us who use marijuana for pain generally do not have that experience, unless we take too high of a dose or just react wrong to a strain. 

CBDs are believed to be responsible for the therapeutic and medical benefits of cannabis.  They don’t make people feel “stoned” and can actually counteract the psychoactive effects of THC.  The fact that CBD-rich cannabis doesn’t get you high makes it an appealing treatment option for patients seeking anti-inflammatory, anti-pain, anti-anxiety, anti-psychotic, and/or anti-spasm effects, without the troubling side effects of lethargy or depression.

However, we don’t all experience pain relief without a higher content of THC. In fact, we have seen some patients be more successful in reducing seizures with more of the THC included. So do not become discouraged if you don’t have success at first.

Please know that THC and CBD levels don’t mean that every plant ever produced of a specific strain will always have the same percentages and ratios. Due to different growing methods, those levels can vary. So, always make sure what you are buying has been tested by a reputable testing facility if cannabinoid levels are important to you.

One successful thing I would like to pass on to you is a trick we discovered making our sleep inducing pain relief oil and day tinctures. 

We now mix all of our five types of Indica strains or Sativa strains together to create the oil or tincture. We make it from the small clippings around the bud, instead of the whole bud. Patients seem to prefer it made this way. You are exposed to the benefits of each plant, along with it being very gentle and less expensive.

female flowers of cannabis indica

In conclusion, remember that you may have to test several strains of medical marijuana to find the right match for your personal needs. It is worth the time and effort, because the pain relief is gentle, non-invasive, and allows you to return to a more productive life without worrying about organ damage from pharmaceuticals.

Ellen Lenox Smith suffers from Ehlers Danlos syndrome and sarcoidosis.

Ellen and her husband Stuart live in Rhode Island. They 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.

Medical marijuana is legal in 23 U.S. states and the District of Columbia, but is still technically illegal under federal law. Even in states where it is legal, doctors may frown upon marijuana and drop patients from their practice for using it.

Study Finds ‘Moderate' Evidence Marijuana Treats Pain

By Pat Anson, Editor

The American Medical Association, the nation’s largest medical group, still officially considers medical marijuana “a dangerous drug and as such is a public health concern."

But studies being published this week in JAMA, the AMA’s official journal, highlight the slim but growing body of evidence that cannabis can be used to treat pain – as well as the lack of standards regulating medical marijuana in states where it is legal.

In a review of nearly 80 clinical trials involving over 6,400 patients, researchers found “moderate-quality evidence” that cannabinoids –  chemically active compounds in marijuana – are effective in treating chronic neuropathic pain and cancer pain, as well as muscle spasms and stiffness caused by multiple sclerosis.

There was “low-quality evidence” suggesting that cannabinoids are effective in treating sleep disorders, weight loss, Tourette syndrome, and symptoms of nausea and vomiting caused by chemotherapy; and “very low-quality evidence” for treating anxiety.

Some of the side-effects associated with medical marijuana were dizziness, dry mouth, nausea, fatigue, somnolence, euphoria, vomiting, disorientation, drowsiness, confusion, loss of balance, and hallucination.

"Further large, robust, randomized clinical trials are needed to confirm the effects of cannabinoids, particularly on weight gain in patients with HIV/AIDS, depression, sleep disorders, anxiety disorders, psychosis, glaucoma, and Tourette syndrome are required. Further studies evaluating cannabis itself are also required because there is very little evidence on the effects and AEs (adverse events) of cannabis," the authors write.

An accompanying editorial in JAMA also called for more research and lamented the lack of evidence supporting the legalization of medical marijuana in 23 U.S. states and the District of Columbia.

"If the states' initiative to legalize medical marijuana is merely a veiled step toward allowing access to recreational marijuana, then the medical community should be left out of the process, and instead marijuana should be decriminalized," wrote Deepak Cyril D'Souza, MD, and Mohini Ranganathan, MD, of the Yale University School of Medicine.

"Conversely, if the goal is to make marijuana available for medical purposes, then it is unclear why the approval process should be different from that used for other medications… Since medical marijuana is not a life-saving intervention, it may be prudent to wait before widely adopting its use until high-quality evidence is available to guide the development of a rational approval process."

The Trouble with Edibles

A second study published in JAMA looked at marijuana edibles – cookies, brownies, candies and other foods containing cannabis – that are being sold at dispensaries in Los Angeles, San Francisco and Seattle.

An estimated 16% to 26% of cannabis patients consume edibles. Many are essentially homemade products that vary from dispensary to dispensary.

Researchers found that many of the edibles had lower amounts of THC (tetrahydrocannabinol) – the active ingredient in marijuana that makes people “high” – than their labels indicated. Over half had significantly higher amounts of THC, putting patients at risk of unintended side-effects.

Of the 75 edible products that were analyzed in a laboratory, only 17% were accurately labeled with THC, 23% were “overlabeled” and 60% were “underlabeled.” The greatest likelihood of obtaining an underlabeled edible was in Seattle.

A little over half (59%) of the edibles tested had detectable levels of cannabinoids.

"Edible cannabis products from 3 major metropolitan areas, though unregulated, failed to meet basic label accuracy standards for pharmaceuticals," the authors write. "Because medical cannabis is recommended for specific health conditions, regulation and quality assurance are needed."

The lack of regulation was highlighted last year in Colorado – where both medical and recreational use of marijuana is legal. A brand of brownie mix, Rice Krispy treats and candy made with cannabis was recalled after inspectors found the edibles contained marijuana that had been “cleaned” in a washing machine.

All Forms of Medical Marijuana Now Legal in Canada

By Pat Anson, Editor

Medical marijuana advocates are cheering – and some health officials are jeering – a landmark ruling by the Supreme Court of Canada allowing patients to use cannabis in any form they choose.

The unanimous decision greatly expands the use of medical marijuana in Canada beyond the traditional means of smoking it – to include everything from cookies and teas to ointments and tinctures that are laced with THC and cannabinoids, marijuana’s active ingredients.

Many users believe smoking marijuana is harmful to their health. But under Canada’s Controlled Drug and Substances Act, use of marijuana outside of its “dried” form could result in possession and drug trafficking charges.

That’s what happened to Owen Smith, a baker for the Victoria Cannabis Buyers Club, who was arrested in 2009 for making over 200 cookies containing marijuana, as well as various oils and lotions.

The Supreme Court upheld two lower court decisions that acquitted Smith, saying the government’s marijuana law violated his right to liberty and security "in a manner that is arbitrary and hence is not in accord with the principles of fundamental justice." 

The court declared the marijuana section of the law “null and void” immediately, rather than give Parliament a chance to rewrite it. To do otherwise, the court said, would "leave patients without lawful medical treatment.”

"I'm proud and really happy today for all those people who are going to benefit from this ruling," Smith said at a press conference in Victoria, British Columbia. “Across the country there will be a lot more smiles and a lot less pain.”

“How exciting is this! I am thrilled with this decision,” said Ellen Lenox Smith, a medical marijuana advocate and columnist for Pain New Network. 

Smith, who is not able to smoke marijuana because of a medical condition, wrote a column earlier this month about ways to consume marijuana for pain relief without smoking it.  She prefers a nightly dose of a marijuana oil that she makes herself.

“It all depends on the patient, condition, type of medicine used and how your body reacts. This is a wonderful alternative. We all have to find the magical way to administer,” she said. “I applaud them for having the courage to understand the reality of this medication. One size does not fit all and allowing for the variety is wonderful and something I hope we will always be allowed to turn to for help.”

Canadian health officials are angry about the court’s decision.

"Frankly, I'm outraged by the Supreme Court," said Health Minister Rona Ambrose, according to CBC News.

"Let's remember, there's only one authority in Canada that has the authority and the expertise to make a drug into a medicine and that's Health Canada," she said. "Marijuana has never gone through the regulatory approval process at Health Canada, which of course, requires a rigorous safety review and clinical trials with scientific evidence."

Ambrose said the government would fight against the court's "normalization" of marijuana with a public relations campaign outside the courtroom.

"We will continue to combat it. We will continue our anti-drug strategy, we will target youth with the message that marijuana pot is bad for them," the minister said. "We'll continue to work with medical authorities across the country to make sure they're involved in the message."

British Columbia’s chief medical health officer says edible marijuana products should come with labels listing the strains used and their potency, to help ensure that users don’t accidentally overdose and get sick.

“Quality control, certainly for medical use, should be labelled and analyzed,” Dr. Perry Kendall told the Vancouver Sun. “It would be better for people, if they’re taking an illegal product by mouth, to know how much and what, is in it.

“It can take a half an hour to an hour to absorb through the stomach.  If you’re a naive young user you might go on eating and eating because you don’t feel anything and then you take more than you want to.”

Medical marijuana – in all its various forms -- is legal in 23 U.S. states and the District of Columbia. However, there are no regulations governing its quality, dosage or labeling.  

“Evidence in the U.S. is that wider availability of these products is causing increased poisonings in children, and we want to prevent this from occurring here in Vancouver,” the city of Vancouver warned in a news release after the Supreme Court’s ruling. “Unregulated edible products also pose a greater risk to adults than other forms of marijuana.”

How to Use Medical Marijuana Without Smoking

By Ellen Lenox Smith, Columnist

It can be overwhelming to try anything new, especially something like medical marijuana. Many people are afraid to try it – not only because of the stigma associated with cannabis – but the smell that comes from smoking it.  

There are many different ways besides smoking that I have learned to administer medical marijuana. But remember, I am not an expert, just a woman who was desperately trying to find a solution as to how to address her pain. I have been learning this slowly, through reading, help from others, and trial and error.  

Due to having sarcoidosis in my chest, smoking anything could be fatal. I had to find an alternative method that I could use to safely administer medical marijuana. Acting on the advice of a friend, I started my journey utilizing this medicine in an oil form. 

Oils             

ELLEN LENOX SMITH

I start by grinding up dried marijuana buds in a simple coffee grinder, always being careful to use only an indica strain of cannabis. Indica plants give you pain relief and allow you to rest. I take my oil at night to help me to sleep. If I ever took this same oil during the day, I would be sleepy and groggy.

Next, I heat up oil (I use extra virgin olive oil, but you can use other types you prefer) and when it gets hot, but not to a boil, I sprinkle the ground product over the oil. When you get it just right, there is a sound similar to putting an Alka Seltzer tablet in water, and you can hear the THC and CBD being released into the oil. 

You then allow the oil to cool, strain it, and store it away from the sun. It lasts for a long time.

At night, one hour before I want to go to sleep, I take my medication. I presently use one teaspoon of the oil mixed with some applesauce or something I enjoy eating. You do not want to take this on an empty stomach. 

You should start slowly with a small amount, and gradually introduce the medication to your body. If you need to increase the dose, you can add a quarter of a teaspoon until you have reached an appropriate level. When you can sleep through the night, and awake relatively clear headed and not groggy --then you know your dose is appropriate.  

Keep in mind that by utilizing this method the medication takes time to kick in because it is being ingested. Plan your evening carefully and be sure to be ready for bed once you have medicated. It usually takes 30-60 minutes. We all react differently, so be safe.

If you want to make this oil even easier, then purchase a machine called Magical Butter, and it will do all the work for you after you grind, measure and plug it in. It costs about $175.

Vaporizers

Most days, I do not need any medication after having had a good night’s sleep. But on the days I need something else for help, I find vaporizing simple and easy. 

I have found two portable vaporizers that I love. One is called the Vape-or-Smoke and the other is named PAX. They require a small amount of marijuana, are small enough to fit in a purse, and are simple to use. 

Many people use the Volcano, which is a larger, table top model seen in the picture to the right. There are so many types; you just have to decide what you are willing to spend. Some vaporizers cost several hundred dollars.

Now be careful, for you want to vaporize the correct type of cannabis. I could list all fifteen strains we grow, but I can tell you that there would be no guarantee they would be your magic.

The main thing to remember is if you are going to vaporize during the day, then you need to use a sativa strain of cannabis. This type of plant allows you to gain pain relief and also helps to stimulate you and keep you awake, not sleep like the indica plant does. If I vaporized an indica during the day, I would want to sleep. So be careful you have selected the correct type of plant.

Use a grinder to prepare the marijuana and follow the directions on the vaporizer. You will notice when you first use a vaporizer that it looks like you are blowing out smoke. However, what you are observing is actually a vapor. 

I have permission from my pulmonologist to vaporize because it is safe to use. Take a simple hit, see how you feel in a few minutes, and if you need more to help with the pain, just use it one puff at a time to find your needed dose. This method should provide you with short, yet quick relief, unlike the oil that takes awhile to kick in, but last so much longer.

Tinctures

Sometimes I also use a tincture during the day.  As with vaporizing, it is fast acting and also fast to leave the system. We have recipes for a few types. One is made with alcohol, such as lemon schnapps and it takes two months to cure. The other is made with glycerin and can be made in less than an hour in a crock pot or using the Magical Butter machine. 

When making a tincture, you again have to be careful you are using the correct strain. I make day tincture, so I only use a sativa plant. Alcohol based tinctures require the product to be put into a jar, the alcohol of choice poured over it, and then covered tightly. 

Twice a day, take a moment to shake the jar. After two months, the THC and CBD are released, and you should strain and store the liquid away from the sun.

The tincture can be taken one teaspoon at a time or with an eye-dropper, putting a few drops under the tongue or in the side of the cheek. You hold it there for about 20 seconds and then swallow. Feel free to repeat this every half hour. Remember, this is made with the plant that stimulates, so do not take at night!

The glycerin recipe is easy and can be made in an hour using a crock pot. You administer it the same way as above. The difference with this method is it has no alcohol and tastes sweet -- even though a diabetic can use it for it is not sugar based. 

It’s just a matter of preference of which type you prefer and how long you want to wait for the finished product to use.

Topical Ointments

We have had good success using topical ointments. The recipes are simple and the results are amazing. I know people with Complex Regional Pain Syndrome who have turned their lives around with topicals. 

All it requires is the tincture (not the oil), some bees wax, and then we add essential oils to mask any marijuana odor. Peppermint extract seems to be the favorite additive -- it provides a tingling sensation as it absorbs into the skin along with the cannabis.

Recipes for topicals, tinctures, and oils can all be found on our website at the end of this article.

As stated in the beginning, I am not an expert on all the various way to administer medical marijuana. Many people love using edibles, such as brownies and cookies, but I live with so many food allergies that I have no interest in even trying them. 

It also concerns me, being so drug reactive, how much I should eat or not eat because I don’t feel the effects immediately. Like the oil, edibles are slow to activate and sometimes people eat more than they should -- and suddenly they’re shocked at how strange they feel. 

Go slowly and give it time to kick in before deciding you need to eat more!

We try to steer people away from smoking to keep the lungs as safe as possible. However, if that is the only way that works for you and the smell is not an issue for you, then smoking is one of the faster ways to get pain relief from marijuana.

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, 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.