Kratom vs. Nutmeg: Which Is More Dangerous?

By Pat Anson, PNN Editor

Here’s a trick question for you. Which substance is more dangerous – kratom or nutmeg?

News reports about a recent study that analyzed calls to U.S. poison control centers leave little room for doubt:

“Life-threatening kratom exposures rose by 5000% in 6 years,” is how the Daily Mail reported it.

“Poison Control Centers See Spike in Calls About Kratom Exposure,” was the headline used by WOSU Public Media.

While the headlines are technically accurate, the study published in the journal Clinical Toxicology did not focus solely on kratom. The herbal supplement was one of many naturally occurring psychoactive substances that resulted in over 67,000 calls to U.S. poison control centers from 2000 to 2017.

Marijuana was involved in about half of those calls, followed by plants and mushrooms that act as stimulants or cause hallucinations. Kratom ranked 7th on the list, behind substances like peyote and nutmeg. Yes, nutmeg.

POISON CONTROL CALLS (2000-2017)

1. Marijuana (31,628)

2. Anticholinergic Plants (14,236)

3. Hallucinogenic Mushrooms (10,482)

4. Morning Glory Plants (3,643)

5. Nutmeg (1,962)

6. Peyote (1,717)

7. Kratom (1,631)

8. Kava Kava (1,331)

9. Salvia (622)

10. Absinthe (65)

11. Khat (52)

In most cases, the calls to poison centers involved minor symptoms like upset stomachs or dizziness, but some were serious enough to result in hospitalizations and even deaths. Researchers said marijuana is particularly concerning because it is being sold in candies, cookies and other edibles that a child could get their hands on.

“These substances have been associated with a variety of serious medical outcomes including seizures and coma in adults and children,” said co-author Henry Spiller, director of the Central Ohio Poison Center at Nationwide Children’s Hospital.  “As more states continue to legalize marijuana in various forms, parents and health care providers should treat it like any other medication: locked up, away, and out of sight of children.

Why Did Kratom Calls Spike?

There were only 1,631 calls involving kratom made to poison control centers over an 18-year period. But the numbers started to rise sharply in recent years as more Americans discovered kratom — from 13 kratom calls in 2011 to 682 calls in 2017 — that’s where the 5,000% spike comes from.

The American Kratom Association estimates several million Americans now use kratom to treat chronic pain, addiction, anxiety and other medical conditions.

Side effects from kratom are relatively rare. But researchers say a high percentage of the calls to poison control centers about kratom resulted in hospital admissions and serious medical problems. The chief complaint for many of the calls, according to another study, was that kratom caused agitation, tachycardia (rapid heartbeat), drowsiness, vomiting and confusion.

Kratom comes from the leaves of a tree that grows in southeast Asia, where it has been used for centuries as a natural stimulant and pain reliever. Critics say calls to U.S. poison control centers are misleading and a poor choice for research.

“The data drawn from the Poison Control Centers are notoriously unreliable, inasmuch as they are anecdotal reports from the public that are gathered and reported in an unscientific fashion,” said Max Karlin, a spokesman for the Kratom Information & Resource Center. “In the absence of good data, you just end up with a garbage-in, garbage-out situation.”

Kratom has been banned in a handful of states, but is widely available online and in smoke shops. Spiller and his colleagues say it should be regulated in all 50 states.

“The continued rise in kratom usage coupled with the serious medical outcomes identified in our study support the need for federal regulation of kratom along with further research on this public health problem,” they concluded. “While rates of exposure to most natural psychoactive substances decreased during the study period, rates for marijuana, nutmeg, and kratom increased significantly.”

The study offered no explanation for the significant increase in nutmeg calls. Nor did it suggest that nutmeg be regulated.

Nutmeg is a spice known for its pungent fragrance and sweet taste, but in large doses it can also have a psychoactive effect.

As far back as the Middle Ages, people used nutmeg as a medicine and to get high. There is even a page for nutmeg on Reddit, where drug users swap stories and try to figure out the best way to ingest it.

“Do I need to ground them up to a powder or can I just make little pieces and swallow them with water? Can I smoke nutmeg? Can I snort it?” asked a nutmeg newbie.  Most people who tried nutmeg said it made them sleepy, nauseated and wasn’t worth the effort.

While any call to a poison control center is concerning, the number of calls about kratom and nutmeg that came in over an 18-year period pales in comparison to the calls that come in every day about children ingesting hand sanitizers, laundry detergent packets and other toxic products.

Which brings us back to our original question. Is kratom or nutmeg more dangerous?  When used in moderation and with common sense, millions of people will tell you neither one is.

Hold the CBD and Pass the Gravy

By Pat Anson, PNN Editor

You can now buy cannabis-infused juice, beer, popcorn, gummies, breakfast cereal, and just about every food and drink imaginable with CBD or even THC.  

But you know things are getting out of hand when a company starts selling cannabis-infused turkey gravy – just in time for Thanksgiving.

KIVA Confections – a California company that makes a line of cannabis chocolates and edibles -- has introduced a “groundbreaking” turkey gravy infused with 10mg of THC, the psychoactive compound in marijuana. Thanksgiving dinner will never be quite the same.

“Awkward family dinner conversation? In just under 15 minutes you’ll start feeling the effects, so you can sit back, relax, and let the holiday cheer wash over you,” said Kiva in a tongue-in-cheek blog post

The company plans to introduce a cannabis-infused hot cocoa mix by Christmas.  

KIVA CONFECTIONS

FDA Warns CBD Companies

Federal health officials are finally blowing the whistle on cannabis marketing. The Food and Drug Administration has issued warning letters to 15 companies for illegally selling and marketing cannabis infused products.

Ironically, the FDA’s focus is not on THC, but on cannabidiol (CBD), the seemingly harmless and over-hyped compound in cannabis associated with many health claims. The FDA has revised a Consumer Update to more clearly state that CBD is not recognized as safe for use in human or animal food.

“We remain concerned that some people wrongly think that the myriad of CBD products on the market, many of which are illegal, have been evaluated by the FDA and determined to be safe, or that trying CBD ‘can’t hurt.’ Aside from one prescription drug approved to treat two pediatric epilepsy disorders, these products have not been approved by the FDA,” Amy Abernethy, MD, FDA Principal Deputy Commissioner, said in a statement.

“We recognize the significant public interest in CBD and we must work together with stakeholders and industry to fill in the knowledge gaps about the science, safety and quality of many of these products.”

What most concerns the FDA is that CBD is being marketed as a treatment for chronic pain, arthritis, depression, addiction, anxiety and other medical conditions with no clinical evidence that it actually works.

Red Pill Medical of Phoenix, one of the companies that received a warning letter, claims CBD can cure cancer.

“We’ve seen CBD kill prostate cancer cells, kill colon cancer cells…there’s just thousands of anecdotal stories on the internet where people have cured themselves when they were told they had weeks or months to live using CBD,” Red Pill claims in a promotional video.

Another company, Whole Leaf Organics of Los Angeles, was warned about selling CBD products for pets.

“Beneficial and safe for both people and animals, CBD has been known to reduce inflammation, assist with chronic fatigue, alleviate joint and muscle pain, and help in regards to the management of stress and anxiety,” Whole Leaf claims on its website.

One company was warned about marketing CBD products for infants and children, while another was warned about selling CBD for food-producing animals such as chickens and cows.

This isn’t the first time the FDA has warned cannabis companies to be more discerning in their marketing. Similar warning letters were sent in March to three companies for making unsubstantiated health claims about their CBD oils, extracts and edibles.

One of the companies, NutraPure, now has a disclaimer on its website stating that its products “have not been evaluated” by the FDA and “are not intended to diagnose, prevent, treat, or cure any disease.” As PNN reported, however, that didn’t stop a NutraPure representative from recommending the company’s hemp oil to this reporter as a treatment for fibromyalgia.

The FDA says it will “explore potential pathways” for CBD products to be marketed legally and would be providing an update in coming weeks.

In the meantime, pass the gravy.

Cannabis Cuts Headache and Migraine Pain in Half

By Pat Anson, PNN Editor

Inhaled cannabis can significantly reduce both headache and migraine severity, according to a large new study that looked at patients who self-reported their symptoms. But researchers say the effectiveness of cannabis diminished over time, as patients used larger doses for pain relief and appeared to develop a tolerance to the drug.

Researchers at Washington State University analyzed data from the Strainprint app, which allows patients to track their symptoms while using medical cannabis. Data was collected from nearly 2,000 patients who used the app almost 20,000 times to track their headache and migraine pain before and after inhaling cannabis by smoking or vaping. The cannabis was obtained from licensed medical cannabis distributors in Canada.

"We were motivated to do this study because a substantial number of people say they use cannabis for headache and migraine, but surprisingly few studies had addressed the topic," said lead author Carrie Cuttler, PhD, a WSU assistant professor of psychology. "We wanted to approach this in an ecologically valid way, which is to look at actual patients using whole plant cannabis to medicate in their own homes and environments.”

The study, published online in the Journal of Pain, is the first to use data from headache and migraine sufferers using cannabis in real time. Previous studies have asked patients to recall the effect of cannabis use in the past.

Cuttler and her colleagues found that self-reported headache severity fell by 47.3 percent and migraine severity declined by 49.6 percent. Cannabis concentrates, such as cannabis oil, produced a larger reduction in headache severity than cannabis flower.

There was no evidence that cannabis caused "overuse headache," a pitfall of opioid medication and other pain relievers that can make headache pain worse over time. However, researchers did see patients using larger doses of cannabis over time, indicting they may be developing tolerance.

There was no significant difference in pain reduction among cannabis strains that were higher or lower in levels of tetrahydrocannabinol (THC) and cannabidiol (CBD). Since cannabis is made up of over 100 cannabinoids, the finding suggests that different cannabinoids or organic compounds like terpenes may play a central role in headache and migraine relief.

Cuttler acknowledged the limitations of using an app to collect data, since it relies on a self-selected group of people who may already anticipate that cannabis will work to alleviate their symptoms. It was also not possible to use a placebo control group.

"I suspect there are some slight overestimates of effectiveness," said Cuttler. "My hope is that this research will motivate researchers to take on the difficult work of conducting placebo-controlled trials. In the meantime, this at least gives medical cannabis patients and their doctors a little more information about what they might expect from using cannabis to manage these conditions."

PNN columnist Mia Maysack, who suffers from chronic migraine and cluster headache, reluctantly agreed to try cannabis after her first cluster headache lasted 54 straight days. Mia said she “almost instantaneously felt better.” Now she uses cannabis regularly.

“It helps me combat nausea, cultivate an appetite, gives a slight boost in morale, and get quality rest,” Mia wrote in a column. “Cannabis works for me about half the time.  But that goes deeper than a glass half empty or half full.  It's a matter of having a resemblance of a life or not.”   

Medical Cannabis Not Recommended for Chronic Pain in UK

By Pat Anson, PNN Editor

It was a little over a year ago that the UK’s Home Secretary announced that medical cannabis would be legalized in Britain and become available by prescription – a move that was cheered by cannabis activists.

“This is a major victory for our campaign and will mean a lot of people will have a much better quality of life,” said Clark French, a multiple sclerosis patient.

It turns out the celebration was premature. After a lengthy review, the UK’s National Institute for Health and Care Excellence (NICE) recently recommended to the National Health Service (NHS) that medications containing cannabidiol (CBD) only be used to treat epilepsy, multiple sclerosis and chemotherapy-induced nausea.

CBD was not recommended as a treatment for chronic pain, at least not yet.

“There is evidence to suggest that CBD reduces chronic pain,” NICE said. “However, where cannabis-based medicinal products reduced chronic pain, the benefit is small and economic analysis shows that this compares poorly with the high costs of (CBD products).”

Cannabis medications containing THC were also ruled out, even when combined with CBD.  Most cannabis products contain at least trace amounts of THC, the psychoactive ingredient in cannabis.

NICE said further research was needed to see if CBD can be used to treat fibromyalgia, neuropathy and cancer pain. It recommended that patients suffering from those conditions should only use CBD if they are part of a clinical trial.

One cannabis activist called the NICE guideline “a massive missed opportunity.”

“It is particularly devastating that there is no positive recommendation that the NHS should allow prescribing of whole-plant medical cannabis containing both CBD and THC in appropriate cases of intractable childhood epilepsy,” Millie Hinton, from the patient advocacy group End Our Pain, told The Guardian. “This restrictive guidance is condemning many patients to having to pay for life-transforming medicine privately, to go without, or to consider accessing illegal and unregulated sources.”

According to a recent survey, up to 1.4 million adults in the UK are self-medicating with illegal cannabis products.

The one big winner in the NICE report is GW Pharmaceuticals, the UK based company that developed Epidiolex and Sativex, two cannabis-based medicines that are used to treat childhood epilepsy and muscle spasms caused by multiple sclerosis. NICE had previously rejected Epidiolex because of its high cost, but is now recommending it.

“This is a momentous occasion for UK patients and families who have waited for so many years for rigorously tested, evidenced and regulatory approved cannabis-based medicines to be reimbursed by the NHS,” said Chris Tovey, GW’s Chief Operating Officer. “This is proof that cannabis-based medicines can successfully go through extensive randomised placebo-controlled trials and a rigorous NICE evaluation process to reach patients.”

Last year, the FDA approved the use of Epidiolex in the U.S. to treat seizures caused by two rare forms of childhood epilepsy, Lennox-Gastaut syndrome and Dravet syndrome. The initial list price per patient was $32,500 a year.

Medical cannabis has been approved in 33 U.S. states and Washington DC, but the qualifying conditions vary from state to state. Click here for a list of qualifying conditions in each state.

How CBD Helped End My Insomnia

By David Eaton, Guest Columnist

Due to a decrease in my opioid pain medication (to fall within the CDC guideline), my pain level increased to the point that I was unable to sleep. Of course, lack of sleep affects your overall health and so I began a downward spiral and needed something to break that cycle.

My son, who has been suffering acute pain from scoliosis in his neck, was having similar insomnia issues. He tried CBD oil and recommended that I do the same.

I knew little about CBD, so I talked to the very knowledgeable and helpful manager of a local CBD store. His recommendation was that I begin by researching CBD myself and then talk about it with the doctor at my pain clinic -- advice that impressed me as being very responsible.

After spending a day or two reading online articles, including some here on Pain News Network, I ran the idea past the physician’s assistant at my pain clinic.  She thought it was a great idea and asked me to try it before my next appointment with her in 4 days.

I placed another call to the manager at the CBD store and he recommended starting with a CBD infused "candy bar." My wife went there the next day and paid $25 for a white chocolate, peach and hazelnut flavored candy bar containing 120 mg of CBD.

DAVID EATON

The chocolate bar was scored in such a way that it can be divided into 4 servings, each with 30 mg of CBD. The manager’s suggestion was for me to try a single piece the first night and then take one and a half sections the following 2 nights. So that's what I did. 

Prior to trying the CBD, I had experienced a lot of pain-induced insomnia and found it difficult to sleep for more than an hour at a time.  It was not uncommon for me to wake up 10 times during a 12-hour effort to sleep. 

Most people do not realize how important a good night's sleep is to your health and well-being.  After my insomnia got severe, I installed an app on my phone (Sleep as Android) to track how much I slept each night.

After taking my nighttime meds and my last "dose" of CBD chocolate, I fell asleep around 8 pm.  According to the sleep app, which amazed me by its accuracy, I slept until 3 am, waking up feeling very rested and refreshed.

I decided to stay awake long enough to write this article before going back to sleep at 4 am. I slept until 10:45 that morning.

In all, I got about eleven and a half hours of deep sleep over the course of about 13 hours!   

As far as I am concerned, the use of CBD to reduce my pain and promote relaxation is an overwhelming success. I will be investing in a bottle of CBD oil on my next trip to town. 

David Eaton is disabled by chronic pain caused by degenerative disc disease, migraines and arthritis. He lives in Georgia.

Pain News Network invites other readers to share their stories with us. Send them to editor@painnewsnetwork.org. 

The information in this column 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.

What Are Health Risks of Vaping CBD?

By Roger Chriss, PNN Columnist

An outbreak of lung illnesses linked to vaping is raising important questions about the safety of vaping cannabis products. The cause is still unclear, but the CDC reports about 76% percent of the patients who became ill vaped products containing THC – the psychoactive ingredient in cannabis. Only about 17% reported vaping a cannabidiol (CBD) product.

At present, very little is known about CBD vaping safety. The World Health Organization’s 2017 report on cannabidiol looked at oral, sublingual and intranasal routes of administration. When the WHO wrote that “CBD is generally well tolerated with a good safety profile,” it was not considering vaping at all.

The Food and Drug Administration still considers CBD in food and drugs sold commercially to be illegal, unless the product falls under the Food, Drug and Cosmetic Act. Vaping CBD does not, and so there has been no testing or regulatory action.

There have been no good human studies on CBD vaping. Research generally looks at CBD in edibles and liquids, or smoked using traditional means.

It is not known what happens to CBD under vaping temperatures, if there are thermal degradants, or important chemical reactions between CBD and other ingredients in vaping liquids or other drugs.

A recent lung tissue study found concerning results about inhaling CBD while using steroids. CBD helps reduce inflammation, but “acts as an antagonist with steroids, overriding the anti-inflammatory potential of steroids when used in combination.”

Last year Vice reported on public health warnings in North Carolina after 90 people became sick with headaches, nausea, hallucinations and other health problems after vaping CBD products. Adulterants appear to have been the problem, and Vice noted that vape oils are poorly regulated and sometimes contain chemicals that “when heated in a vape and inhaled, can cause serious lung irritation.”

A recent study on the quality of CBD liquids used in e-cigarettes is also concerning, finding that “the quality control of manufacturers and the relative safety of these products is uncertain.”

An AP investigation last month found that in lab tests on 30 CBD vape products, ten samples contained synthetic marijuana such as K2 or spice, while others had no CBD at all.

Some states with legalized cannabis do require testing of CBD vapes. But it’s not clear what to test for, and even the lab methods for testing have yet to be validated. It is also not known which cutting agents, adulterants and contaminants should be cause for concern. Lung tissue is fragile, vulnerable in ways the GI tract is not, and not well studied. So testing regimes may ultimately require information we currently lack.

Oversight of cannabis testing is limited. California’s Sequoia Analytical Labs was found to be falsifying lab results last year. Plus, many CBD vapes come from the gray or black markets, or are home-brewed, making attempts at quality control irrelevant. As a result, CBD vaping safety is an open question, assuming it is even possible to make a safe CBD vape.

Fortunately, new research may help. Researchers are testing vaporized cannabis extracts on rats. This will allow for studying the effects of THC and CBD in animal models in a way that closely mimics human behavior.

Such information is urgently needed. Animal studies on vaping are raising concerns about lung cancer risk, but such research may not be representative of how humans vape, limiting their value.

There is ongoing debate on what CBD is good for. And now we also have to consider how CBD should be administered. It may be possible to create a low-risk CBD vape product. But at present we don’t really know how to do it.

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 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.

Has Vaping Hysteria Gone Too Far?

By Anna Maria Barry-Jester and Jenny Gold, Kaiser Health News

On Sept. 16, Tulare County in California announced the nation’s seventh death from vaping-related illness. Its advisory warned about “the dangerous effects of using electronic cigarettes, or e-cigarettes.”

As federal and state health officials struggle to identify what exactly is causing the deadly outbreak, vaping advocates are stepping into the void and crafting an alternative narrative that is being echoed broadly in online communities.

The people getting sick, according to their version of events, all vaped THC — the psychoactive ingredient in cannabis — using products bought on an illicit black market. They also contend federal officials have seized on the crisis to crack down on a nicotine vaping culture they don’t appreciate or understand, a culture proponents insist has helped them and millions of others quit smoking.

As of Oct. 1, the federal Centers for Disease Control and Prevention had identified more than 1,000 cases of vaping-related lung illness in 48 states. Eighteen people have died, including two in California. Of the 578 patients who have reported using specific products, most said they had vaped THC, but a significant portion — 17% — said they had used only nicotine.

CDC officials maintain they can’t identify one product or chemical culprit, and while they recently began emphasizing the risks of vaping THC, they continue to warn against any vape use at all.

Meanwhile, cities and states have responded with a divergent mix of warnings and bans. Michigan, New York and Rhode Island have moved to ban most flavored nicotine vaping products. The California Department of Public Health recently warned against all vaping devices, and the governor of Massachusetts issued a four-month ban on all vaping products.

The actions have sparked a backlash among hundreds of thousands of people who say they’ve been vaping for years without a problem. Compounding their distrust: the political calls to ban flavored nicotine products even though the vast majority of illnesses identified appear to involve people who were vaping THC.

They see a government out to quash nicotine vaping because its popularity with teens has caused a public outcry, ignoring the adults who find it a pleasing alternative to cigarettes. When it comes to vaping, they have stopped looking to the CDC for advice.

Debbye Saladine-Thompson is a registered nurse in Michigan who was a smoker for 32 years before she switched to vaping. She now manages the Michigan Facebook page for Consumer Advocates for Smoke-Free Alternatives Association (CASAA), a nonprofit that advocates for access to e-cigarettes and receives industry funding.

“I do not trust the CDC. Not anymore” Saladine-Thompson said. “I cannot trust an agency that says the product that I and so many people have been using for 10 years and hasn’t caused one death is now causing hundreds of illnesses. No, I do not believe that.”

Online vaping forums are roiling with accusatory messages suspicious of the government response. In Facebook groups, including one called ‘BLACK MARKET THC CARTRIDGES CAUSED THIS QUIT LYING ABOUT VAPOR PRODUCTS,’ vapers have expressed outrage over the bans on nicotine products while cigarettes remain readily available. They’re organizing phone calls to legislators and rallies at state capitols.

“We’re living and dying by these decisions,” said Kristin Noll-Marsh, the member coordinator for CASAA who moderates the group’s national Facebook group. “This vaping panic of 2019 is gonna go down in the history books as being like flat Earth, bloodletting and burning witches.”

CDC Messaging Criticized

Throughout the outbreak, the CDC has said that people who vape to quit smoking should not return to cigarettes. But the emphasis on all vaping devices drowns out that warning, said Dr. Michael Siegel, a professor at Boston University and proponent of e-cigarettes as a smoking cessation tool.

“In an outbreak investigation like this one, you have to be as specific as possible if you want people to listen. If you say ‘Just don’t vape,’ that’s not telling anyone anything they don’t already know.”

Many also are critical of the messaging used by the CDC, states and some media outlets, saying they are out of touch with vaping culture and its terminology. Public officials often use one word — e-cigarettes — to describe what to people who vape is a wide range of products with different names.

People who see headlines about illnesses linked to “e-cigarettes” may not know it applies to them, said Jim McDonald, a journalist with Vaping360, a consumer news site. “Cannabis vapers don’t use the term e-cigarettes. They never, never use that term.”

Even among e-cigarettes, a term many equate with nicotine delivery devices, people differentiate between cartridge-based devices like Juul and the handheld “mods,” which tend to be larger and produce more vapor. E-liquids can come prepackaged in ready-to-use form or can be mixed in stores or at home. Whether cannabis is legal and regulated also varies among states.

The problem with the alternative narrative, say doctors who are treating patients, is that it’s not clear whether only illicit THC is to blame. Dr. Dixie Harris, a critical care pulmonologist with Intermountain Healthcare in Utah, has been reporting five to seven cases a week for the past six weeks. While many patients have reported using illicit THC, she also has had patients who have fallen ill after using products purchased at licensed medical dispensaries in states where cannabis is regulated.

A new study looking at lung tissue samples from 17 patients found the damage resembled chemical burns and included two samples from people who fell ill before the outbreak. The findings cast doubt on a popular theory that vitamin E oil, which has been used as a thickening agent in THC oil, is the culprit.

The investigation is challenging on many fronts. Vaping — both legal and illicit, nicotine and cannabis — has exploded in the past few years with little regulation. There are hundreds of products, do-it-yourself kits and home brews. The potential culprits are many: popular flavorings in nicotine vapes never tested for inhalation. Oils used to dilute THC. Contaminants. Pesticides. Possible toxic residue from the containers themselves.

The CDC is grappling with a dearth of information. The process of alerting the many agencies and entities involved — doctors, hospitals, law enforcement, public health departments — has been slow.

Among 86 cases in Illinois and Wisconsin, where the outbreak first was identified and investigators are further along in their work, people reported using 234 different products involving both nicotine and cannabis, according to a report published last month. Those products, in turn, involved a variety of brands, numerous supply chains and packaging without listed ingredients.

Dr. Anne Schuchat, principal deputy director of the CDC, said the agency wasn’t narrowing the investigation only to cannabis, stressing it needed to “have an open mind” to understand the possible risks.

“Personally, with all the data that I’ve been seeing,” Schuchat said Friday, “I don’t know what ‘safe’ is right now.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

The Risks of Vaping THC

By Roger Chriss, PNN Columnist

An outbreak of vaping-associated pulmonary illness is getting national attention. Over 800 people have been sickened and 12 have died.

The CDC reported last week that vaping products containing tetrahydrocannabinol (THC) -- the psychoactive compound in marijuana – were involved in 77 percent of the illnesses. Several states responded with bans on vaping products and health alerts on vaping THC.

What do we know about the risks of vaping?

Vaping THC is so new that there is very little research. An animal study on vaping THC was published earlier this year. Performed on male and female rats, the study found that “repeated THC vapor inhalation in adolescent rats results in lasting consequences observable in adulthood."

Specifically, both sexes became tolerant to THC and male rats ate more. Interestingly, THC use did not change oxycodone self-administration in either sex, but increased fentanyl self-administration in female rats. There is no mention of lung effects.

While vaping with e-cigarettes is relatively new, inhaling THC via cannabis smoking is old. And there is an extensive literature on multiple harms.

A recent study of nearly 9,000 people found that regular cannabis use was significantly associated with greater risk of respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD) and pneumonia. The study used blood work to confirm use and had a control group, making its results more reliable than a simple population survey.

According to the National Institute on Drug Use, cannabis smoke contains multiple carcinogens and inhalation causes lung inflammation, increased airway resistance and hyperinflated lungs, a symptom of COPD

Josh Bloom at the American Council of Science and Health writes that the solubility and boiling point of THC and CBD in cannabis vaping products may play a role in the lung illnesses.

But complicating matters is the presence of other subtsances in vaping liquids and in the devices themselves. A newly published study in Scientific Reports on aerosols in tank-style e-cigarettes found levels of chromium, lead and nickel, all known carcinogens, in excess of OSHA permissible exposure limits.

Most cases of vaping-associated pulmonary illness involve illicit products. But one fatal case in Oregon involved someone who bought vaping products at two state-licensed cannabis dispensaries.

Some vaping illnesses involve people who report no use of THC products at all, though investigators are finding that these self-reports are not necessarily accurate. According to STAT News, eight patients in Wisconsin initially said they didn’t use THC products, but were later found to have used the drug.

In other words, we may not know what people were really vaping. Given that vaping THC is federally illegal and only marginally regulated in states where cannabis is legal, investigating the role of THC in the vaping outbreak is challenging.

But the emerging risks have led states like Washington to ban all flavored vaping products. And the FDA has asked the DEA to pursue criminal charges against anyone who sells illicit vaping products.

For patients who use cannabis products for pain relief, there are better alternatives than vaping. The Arthritis Foundation recently released new guidelines that recommend CBD oils and tinctures that can be taken orally.

It is not clear what this means for the cannabis industry. But Joe Tierney, known as the "Gentleman Toker,” told the Washingtonian that he would be shutting down his cannabis website.

“I don’t feel good about the industry any longer,” Tierney said. “I don’t think it’s safe to consume cannabis anywhere after all of my travels.”

Sorting out the risks of THC vaping will take time. At present there is only circumstantial evidence and intriguing ideas. It is possible that THC is one of several different causes or is just guilty by association. Beyond that, we have the unknowns of vaping itself, which may be too novel for anyone to fully understand the risks.

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 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.

Green Without Envy

By Mia Maysack, PNN Columnist

In the opinion of some, at various points in my life I could've been considered a "pothead." 

If that is how you refer to the medicinal use of a plant that grows freely in nature, I own the judgement with pride.  

I've known people who sit around and smoke loads of grass to the point of everything being funny -- but they're too stoned to laugh. That has never been my intent or relationship with marijuana.

This is another element of living with chronic pain and illness that is severely misunderstood -- the desperation we feel for relief.  After you've tried countless traditional approaches to no avail or improvement, I don't care what anyone says. Every single person reaches their absolute limit or breaking point.

When others have discovered that marijuana is part of my care plan, I've been shunned and labeled as a drug addict by the very same people who puff cigarettes, drink alcohol into oblivion, cannot get through a day without coffee, and poison themselves with food-like-products from a drive-thru window.  

Please explain how a man-made drug produced in a lab is somehow safer than marijuana. The only difference is that the drug is regulated and thereby taxed. Arguably, that’s what all of this is about: Money.  

I haven't come across anything that eases my head or body pain. I have only been able to accumulate a short list of helpful remedies that can temporarily (but not always) assist in my co-existence with pain. 

For example, marijuana helps combat nausea, which aids with proper nourishment and hydration. And when you haven’t had a good night’s sleep in days or weeks, a marijuana-induced state of relaxation can mean the difference between restful sanity or a trip to the loony bin.  

There will always be people who abuse whenever they get an opportunity, in the same way that every church has sinners and one bad pizza doesn't mean all pizza joints are bad. The unfortunate choices of a few should not outweigh the credibility of many.

When I ingested my first opioid, it lifted the agony in a way I had never experienced before. I remember like it was yesterday. I thought for sure I was too sick to make it into work but chose to attempt this pill, solely out of desperation. It left me smiling ear-to-ear on my way to my beloved nursing job.

But as I pulled into the parking lot, I was struck with an overwhelming wave of sickness and could barely make it to the trash can before completely losing it. I had an allergic reaction to opioid medication and another potential treatment was biting the dust. 

I do not touch the stuff anymore, but that doesn't change the fact that opioids have proven to be extraordinarily helpful for a countless amount of people. And these same people who were given legitimate prescriptions are now being punished by having their medication taken away, often without a follow up plan or any notice. 

Healthcare providers are balancing on a sensitive tight rope between doing no harm while attempting to avoid ruining their good legal standing or that of their practice. This is causing many patients to feel abandoned, lost and isolated, with low quality of life and high suicide rates.

Peering into the window of someone else's life and judging them simply because you don't understand their thoughts, experiences or desperation is unacceptable.

It's easy to be judgemental and not care about the crisis in pain care if you or a loved one hasn't been personally affected by it. But this is a general societal crisis that affects young and old, rich and poor. Someday it will affect you.

Mia Maysack lives with chronic migraine, cluster headaches and fibromyalgia. Mia is the founder of Keepin’ Our Heads Up, a Facebook advocacy and support group, and Peace & Love, a wellness and life coaching practice for the chronically ill.

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.

Arthritis Foundation Releases First CBD Guideline

By Pat Anson, PNN Editor

The Arthritis Foundation has become the first major patient advocacy group to release guidelines on the use of cannabidiol (CBD) to treat arthritis pain.  

About 54 million Americans have been diagnosed with arthritis. According to a recent national survey, 79 percent of arthritis patients are currently using CBD, have tried it in the past, or are considering it.

CBD infused products – from edibles to lotions to beverages -- are rapidly going mainstream, even though there is little scientific evidence to support their use. There has also been little guidance for consumers on what products to use or in what doses — until now.

“We are intrigued by the potential of CBD to help people find pain relief and are on record urging the FDA to expedite the study and regulation of these products,” the Arthritis Ffoundation said in a statement.

“While currently there is limited scientific evidence about CBD’s ability to help ease arthritis symptoms, and no universal quality standards or regulations exist, we have listened to our constituents and consulted with leading experts to develop these general recommendations for adults who are interested in trying CBD.”  

CBD is largely extracted from a hemp, a marijuana strain that has only trace amounts of THC, the active ingredient that makes people high.

"Millions of people in the U.S. are likely trying to use cannabinoids to treat pain, and many are doing this in ways that might cause more harm than good, especially when they use high doses of THC," said Daniel Clauw, MD, a professor of anesthesiology at the University of Michigan who was one of the experts the foundation consulted.

"It's important that the Arthritis Foundation has taken a stand on CBD,” Clauw said in a statement. “Right now, it appears to be fairly safe and might help certain types of pain. It's far better to give this guidance, even if preliminary, because otherwise people will have no guidance whatsoever." 

DRUG POLICY ALLIANCE

The new guideline is largely cautionary and does not explicitly recommend CBD as a treatment, stating only that it “may help” with arthritis-related symptoms such as pain, insomnia and anxiety.

When taken in moderate doses, experts say CBD has no major safety issues, although it may interact with some drugs commonly taken for arthritis, such as naproxen (Aleve), celecoxib (Celebrex), tramadol (Ultram), gabapentin (Neurontin), pregabalin (Lyrica) and some antidepressants.

The Arthritis Foundation recommends taking CBD in oral sprays or tinctures so the liquid can be taken under the tongue and be absorbed directly into the bloodstream.

Experts say a “go slow” approach is best, starting with a few drops twice a day and increasing the dose gradually over a period of weeks until an effective dose is reached.

The guideline strongly discourages inhaling or vaping CBD because of the risk of respiratory problems. It also discourages taking CBD in edibles, such as gummies and cookies, because the dosing is unreliable. Experts say the effectiveness of topical lotions and creams with CBD is unclear because they often contain other ingredients.

Other key takeaways from the guideline:

• CBD should never be used to replace disease-modifying drugs that help prevent permanent joint damage in inflammatory types of arthritis.

• CBD use should be discussed with your doctor in advance, with follow-up evaluations every three months or so.

• Buy from a reputable CBD company that has each batch tested for purity, potency and safety by an independent laboratory and provides a certificate of analysis.  

Unlike prescription drugs approved by the Food and Drug Administration, the manufacturing process for CBD products is not subject to FDA review, and there has been no FDA evaluation of their effectiveness, proper dosage, how they could interact with drugs, or whether they have side effects. 

The Federal Trade Commission recently warned companies that make CBD products to stop making unsubstantiated claims that cannabidiol can be used to treat arthritis and other chronic pain conditions.

Feds Warn CBD Marketers Again

By Pat Anson, PNN Editor

The Federal Trade Commission (FTC) has warned three companies that sell cannabidiol (CBD) oils, tinctures, edibles and other products to stop making claims that CBD can be used to treat pain and other chronic illnesses.

In letters to the companies, which the FTC is not identifying, the agency warned that it is illegal to advertise that a product can prevent, treat or cure illnesses without scientific evidence to support such claims.

One company’s website claims CBD “works like magic” to relieve “even the most agonizing pain.” Another company advertises CBD as a “miracle pain remedy” for both acute and chronic pain, including pain from cancer treatment and arthritis.

The FTC said the third company’s website promotes CBD gummies as highly effective at treating “the root cause of most major degenerative diseases, including arthritis, heart disease, fibromyalgia, cancer, asthma, and a wide spectrum of autoimmune disorders.” The company also claims its CBD creams and oils can relieve arthritis and fibromyalgia pain.

“In the letters, the FTC urges the companies to review all claims made for their products, including consumer testimonials, to ensure they are supported by competent and reliable scientific evidence,” the agency said in a statement.

The letters also warn that selling CBD products without substantiation could violate the FTC Act and may result in legal action. The companies were given 15 days to respond.

In March 2019, the FTC and Food and Drug Administration sent similar warning letters to three companies -- Nutra Pure, PotNetwork Holdings, and Advanced Spine and Pain — for making false and unsubstantiated health claims about a variety of CBD products.

Nutra Pure, which makes a line of hemp oil, now has a lengthy disclaimer on its website stating that its products “have not been evaluated” by the FDA and that they “are not intended to diagnose, prevent, treat, or cure any disease.”

But when we posed as a customer in an online chat with “Kristen,” a NutraPure representative, we were assured that hemp oil can treat pain.  

Customer: “Do your products help treat pain?”

Kristen: “There are numerous studies showing CBD has the ability to provide therapeutic benefits in the treatment of various conditions, including chronic pain, arthritis, anxiety/depression, nausea, epilepsy, fibromyalgia, glaucoma and many other ailments.”

Customer: “Which one of your products helps treat fibromyalgia?”

Kristen: “We recommend starting with our 300 or 600 mg bottle.”

Customer: “Will that help joint pain?”

Kristen: “They are like an all in one type product.”

Customer: “What does that mean?”

Kristen: “One product helps with all types of conditions.”

Customer: “Including pain?”

Kristen: “Yes.”

CBD is a non-psychoactive chemical compound derived from the cannabis plant. Much of it comes from hemp – a less potent strain of marijuana – that was legalized under the 2018 Farm Bill. There are literally thousands of CBD products on the market being sold online and over-the-counter without a prescription, often with dubious claims about their health benefits.

FDA and FTC enforcement actions against CBD marketers are sporadic and have usually only targeted small companies. But an FDA warning letter in July to Curaleaf, a Massachusetts company that sells CBD products nationwide, had an immediate impact on one large retailer. CVS Pharmacy pulled most Curaleaf products from its stores.

Study: Cannabis Flowers Rich in THC More Effective for Pain Relief

By Pat Anson, PNN Editor

Another study by researchers at the University of New Mexico suggests that tetrahydrocannabinol (THC) -- the psychoactive ingredient in marijuana – should not be ignored as a treatment for chronic pain.

In an unconventional survey of nearly 3,000 cannabis users, researchers found that those who used whole cannabis flowers or buds rich in THC reduced their pain levels an average of three points on a 0 to 10 pain score. Those who ingested cannabidiol (CBD) did not experience similar pain relief.

The researchers relied on information collected from the Releaf App, a mobile software program they created that allows cannabis users to self-report their experiences using different cannabis products, including flowers, edibles, tinctures and ointments.. Their findings are published in the journal Complementary Therapies in Medicine.

"Perhaps the most surprising result is just how widespread relief was with symptom relief reported in about 95 percent of cannabis administration sessions and across a wide variety of different types of pain," said Xiaoxue Li, PhD, an assistant professor of economics at UNM.

"Cannabis likely has numerous constituents that possess analgesic properties beyond THC, including terpenes and flavonoids, which likely act synergistically for people that use whole dried cannabis flower," added Jacob Miguel Vigil, PhD, a professor in UNM’s Department of Psychology. "Cannabis offers the average patient an effective alternative to using opioids for general use in the treatment of pain with very minimal negative side effects for most people."

The authors caution that cannabis use does carry the risk of addiction and short-term impairment in cognitive and behavioral functioning.

“Cannabis with high THC also causes mood elevation and adjusts attentional demands, likely distracting patients from the aversive sensations that people refer to (as) pain," explains Vigil.

Previous studies using data from the Releaf app found that cannabis also provides relief from insomnia, seizures, depression, anxiety and fatigue. Despite conventional wisdom, THC was found to be more important than CBD in generating therapeutic benefits.

A significant weakness of the app is that it relies on cannabis users to subjectively self-report their experiences outside of a clinical setting. There is also no way to measure the quality or quantity of the cannabis they are ingesting.   

Two-Thirds of Americans Accept Cannabis as Pain Treatment   

Another new survey – conducted by the American Society of Anesthesiologists (ASA) – found wide acceptance of cannabis as a possible treatment for pain. The online survey 1,005 adults was conducted earlier this month.

More than two-thirds of those surveyed said they have used or would consider using cannabis to manage pain. Nearly three-quarters of millennials fall in that category. Two-thirds of Gen Xers and baby boomers expressed interest in cannabis, with 25% of Gen Xers and 18% of baby boomers saying they have used cannabis for pain.

Most of those who expressed interest in using cannabis products believe they are safer or have fewer side effects than opioids or other medications.

Other key findings:

• 57% believe more cannabis research is needed

• 34% don't feel a need to discuss cannabis use with their doctor

• 13% believe no other type of pain management works for them

• 40% wrongly believe CBD products sold at grocery stores, truck stops, health food stores and dispensaries are approved by the FDA.

The ASA recently endorsed two bills that seek to expand research on CBD and marijuana: the Medical Cannabis Research Act and the Cannabidiol and Marihuana Research Expansion Act. The bipartisan bills would increase the number of manufacturers allowed to grow cannabis for research purposes and streamline the application process.

“As experts in managing pain, physician anesthesiologists are concerned about the lack of research regarding the safety and effectiveness of marijuana and cannabinoids," said ASA President Linda Mason, MD.

Government Grown Cannabis May Be Harming Research

By Roger Chriss, PNN Columnist

Physician researcher Sue Sisley, MD, has filed suit against the federal government over the quality of cannabis provided for her study on post-traumatic stress disorder. Sisley claims that the cannabis supplied by the DEA-sanctioned facility at the University of Mississippi is “suboptimal.”

Sisley told Green Entrepreneur that the DEA provided "standardized green powder that is just cannabis ground up.” She also said that the plants were moldy and contained sticks and seeds. 

Sisley is not the first researcher to say government cannabis intended for research is not the same as the cannabis available in dispensaries. This of course poses a key question: What is research cannabis?

Cannabis is a plant. Specifically, cannabis is the genus of a plant that includes the species C. sativa, C. indica, and C. ruderalis. There is still dispute if C. ruderalis should be included with C. sativa, or if all three species should be considered a single species, C. sativa. 

There is no precise pharmacological definition of medical cannabis. There is no agreed-upon level of THC, CBD, or other cannabinoids, and no accepted terpene profile. In dispensaries, cannabis comes in a large variety of strains used in a wide range of products. 

There is poor consistency among strains. Leafly recently attempted to measure the reliability of cannabis strains and found that even the most reliable ones were far from consistent at the levels necessary for clinical research.

Moreover, cannabis is a moving target. Because it is a commercial product often intended for nonmedical use, it is subject to a variety of market forces involving its various psychogenic effects. And new strains are introduced regularly. 

Further, cannabis products are consumed in many different ways, such as smoking, vaporizing, ingesting and through the skin . The bioavailability of cannabis varies significantly by route of consumption because of different absorption levels and metabolism. So whatever research cannabis is used would have to be specified by strain, amount and route of administration. 

For research purposes, that requires precise information. But as Genetic Engineering & Biotechnology News reported, medical cannabis comes in so many forms and has so many different uses that it presents a "unique challenge to cannabis testing laboratories." No existing test provides a good model on how to proceed.

In other words, there is no clear definition of research cannabis and there is no practical way to reliably test commercial strains with a consistency adequate for clinical studies. 

This means the definition of research cannabis is arbitrary. Researchers and advocates keep adjusting the definition or questioning the quality to explain away poor outcomes. According to Microscopes and Machines, when Dr. Sisley's PTSD study concluded, she unblinded the data and quickly came to realize the quality of cannabis provided by the University of Mississippi "had negatively affected the study’s efficacy data.”

But we cannot define research cannabis as the form of cannabis that only gives the results we were hoping for. This would be circular and self-justifying. It would also be self-defeating since we’d never know what, if anything, cannabis has to offer. 

Cannabis is a plant, not a laboratory-synthesized chemical being turned into a USP-grade pharmaceutical. As Jonathan Stea wrote in Scientific American,“it is best to conceptualize cannabis as a chemical soup with over 500 ingredients that can be served in countless different ways.”

This means that researchers will need to define their cannabis before starting a study. And the U.S. government will need to provide such cannabis. Fortunately, the National Institutes of Health is responding by producing more varieties of cannabis.

A more favorable legal landscape would also help. There may not be any “research cannabis” per se, but cannabis is certainly worth researching. 

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.

Marijuana Use May Affect Patient Anesthesia

By Kata Ruder, Kaiser Health News

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

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

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

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

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

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

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

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

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

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

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

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

Should Patients Disclose Marijuana Use? 

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

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

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

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

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

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

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

Marijuana’s Effects On Pain After Surgery

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

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

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

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

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

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

Again, much more research is needed.

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Medical Cannabis Won’t Solve the Opioid Crisis

By Roger Chriss, PNN Columnist

Medical cannabis legalization isn’t helping reduce opioid overdoses. Two major studies have closely examined over a decade’s worth of data, finding no support for the idea that legalizing medical cannabis reduces prescription opioid use, overdose or mortality.

In June, Stanford researchers led by Chelsea Shover, PhD, published a study in PNAS using the same methodology as a 2014 JAMA study that found a positive association between cannabis legalization and lower opioid mortality from 1999 to 2010. But Shover and colleagues included more recent data and states with legalized medical cannabis.

“Our expanded analysis does not support the interpretation that broader access to cannabis is associated with lower opioid overdose mortality,” they concluded.

The 2014 study was very cautious in its findings, but cannabis advocates and industry representatives used it to support legalization efforts.

“It’s become such a pervasive idea,” Shover told STAT News. “It would be amazing if it was this simple, but the evidence is telling us now that it’s not.”

Early this month, Columbia University’s Mailman School of Public Health published a new study in JAMA Network Open that looked at whether people use cannabis in place of prescription opioids.  Researchers looked at data from 627,000 people aged 12 years and older who took the National Survey on Drug Use and Health from 2004 to 2014.

The results showed that enactment of medical marijuana laws was not associated with a reduction in prescription opioid abuse, contradicting the hypothesis that people would substitute marijuana for prescription opioids.

“We tested this relationship and found no evidence that the passage of medical marijuana laws — even in states with dispensaries — was associated with a decrease in individual opioid use of prescription opioids for nonmedical purposes," said senior author Silvia Martins, MD, PhD, an associate professor of epidemiology at Columbia.

The Shover-PNAS study also made the important point that medical cannabis users comprise only about 2.5% of the U.S. population. The vast majority of cannabis use is recreational. The Washington State Liquor Control and Cannabis Board estimates that only about 20% of so-called medical users are really using cannabis for medical reasons.

In other words, there aren’t enough medical cannabis users to impact nationwide overdose trends. And in state-level analysis, there is no evidence of any substantial effect, positive or negative, from medical cannabis legalization.

There are concerns that cannabis could actually make the opioid crisis worse. A 2018 study published in the American Journal of Psychiatry found that “cannabis use appears to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorder.”

“Scientific evidence does not support claims that marijuana helps people kick opioids.”

— Dr. Nora Volkow, NIDA Director

"My main concern is by basically misinforming potential patients about the supposedly beneficial effects of cannabis, they may forgo a treatment that is lifesaving," NIDA director Nora Volkow, MD, told USA Today. “Scientific evidence does not support claims that marijuana helps people kick opioids.”

The FDA is taking note, warning a large cannabis operator last week to stop making unsubstantiated claims that its products can treat chronic pain, cancer, opioid withdrawal and other medical conditions.

Medical cannabis has uses, of course, but taking it for conditions it is not proven to help may lead to harms. Perhaps a way can be found to incorporate cannabis in addiction treatment, but that is quite different from expecting medical cannabis legalization to be an exit ramp for the opioid crisis.

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.