Thursday, Jan. 3rd 2019

Marijuana and Chronic Pain

Missouri has now become one of the 33 states in the USA to legalize medical marijuana. Ten states and Washington DC have legalized marijuana for recreational use for adults over the age of 21.
The use of marijuana (cannabis sativa) the proper name of the marijuana plant, as a medicinal product dates back to the 1800s. It was widely prescribed by physicians until the Marijuana Tax Act of 1937. This law essentially made it a crime to sell acquire or possess marijuana except for a very small number of people registered under the act. The American Medical Association (AMA) opposed the 1937 Act and felt that physicians were not given the opportunity to discuss medicinal use prior to passage of the law. Marijuana was formally prohibited by the Controlled Substance Act in 1970 and placed in Category Schedule I status, along with Heroin, LSD, Mescaline, Ecstasy, Psilocybin and others. On a federal basis, marijuana remains in that category considered dangerous and physicians can not prescribe it. States can create their own individual laws governing the use of marijuana thus creating a problem, the federal law and state laws in conflict. Nonetheless, marijuana is currently available both for medicinal and recreational use on a state by state basis with state with different regulations and protocols.

The gold standard for medical research is the randomized controlled trial (RCT) which tests medications against a control group. Contrary to what many people believe, there have been a number of RCT’s published involving the use of marijuana that clarify recommended indications for use in conditions including pain management. More studies are coming all the time to clarify benefits and risks. Many physicians still feel uncomfortable recommending marijuana even in states where it has been approved. Since prescribing is illegal, alternate methods have been established such as providing recommendations and “certifications” for treating specific approved diagnoses to meet state requirements while avoiding direct violations of federal law.

If we look at countries and states where medicinal grade marijuana has been available for many years we see some of the criteria for providing recommendations. The first is a known and standardized product. Currently there are some standardized cannabis medications available in the United States however since the FDA provides a federal oversight and is not involved, there is no mandate to a national standardization.

Cannabis possesses hundreds of compounds, the two most abundant of which are, THC and cannabinoids, the most abundant is cannabidiol known as CBD. THC has psychoactive effects, in common parlance it causes one to feel “high”. CBD is non-psychoactive i.e., it doesn’t. CBD does have several potential pain benefits which have been and are currently being intensively studied. In Canada and the Netherlands medicinal marijuana is available in known potencies with THC% / CBD % noted in a variety of combinations. In Canada there are available several potencies varying from 0.7%THC/13%CBD to 22%THC/<1%CBD. Similar products are available state by state in the USA with medicinal delivery by specific routes. New York for example is a "non-smoking, non-edible state and only oral drops or vaporization is allowed. Variable THC/CBD combinations are available with recommendations for appropriate trials to find the right substance and dose for each patient. This allows for consistency for for future treatment of a similar product. Avoiding harm is an important consideration. All medications have side effects even natural substances like marijuana. We must identify and watch for them. Dizziness, lightheadedness, dry mouth, fatigue and muscle weakness are most commonly reported. Many people report anxiety and paranoia associated with THC. These may be dose related. Education and careful patient followup are important similar to the safe prescribing practices other medications. When medical marijuana meets these standards and when legal barriers have been clarified, I believe we will see more physicians recommending trials of marijuana based medicines for management of pain and suffering.

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