Chronic
pain patients expressed high satisfaction with medical cannabis
despite clinically insignificant changes in pain scores, a
prospective study showed.
Of
a subset of chronic pain patients who used both medical cannabis and
opiate drugs, 76% successfully tapered their opioid dose over 3
months, reported Alyson Engle, MD, of UPMC Pain Medicine and the
University of Pittsburgh, and colleagues, at the American
Academy of Pain Medicine annual
meeting.
“The
chronic pain patients we see daily suffer from a complex myriad of
symptoms that goes beyond just pain, including disruption in normal
sleep patterns, exacerbation of anxiety or depression, and increased
stress response,” Engle told MedPage
Today.
In
this study, “we were able to track the percent change in symptom
improvement before and after certification for medical cannabis,”
she added. “The data show that patient satisfaction is high
among medical cannabis users and likely is due more to the improved
sleep and overall mood improvement than from improved pain scores.”
The
National Academies of Sciences, Engineering, and Medicine found
conclusive or substantial evidence
supporting cannabis for
chronic pain in its 2017 report, but data
are lacking about
the health effects of cannabis and the best treatment regimen. “We
believe this research is important since many states, including
Pennsylvania, have legalized medical cannabis for certain qualifying
conditions,” Engle said.
To
conduct their study, the researchers collected data from patients who
signed medical marijuana contracts for chronic pain treatment with a
certified physician, using the CHOIR platform
to assess patient responses. They evaluated satisfaction with medical
cannabis, global impression of change, and changes in pain, mood, and
sleep, and reviewed patient records.
The
study ran from May 2018 through July 2019. The researchers recruited
193 patients and 82 patients were included in the final analysis.
Baseline data was collected at the initial visit and follow-up data
at the next visit, typically 3 months later.
Of
193 patients, 90 (46%) were on opioids at baseline, and 76% of these
patients tapered their opioid dose successfully. Their average
decrease was 11.67 morphine milligram equivalents (MME) over the
3-month period, reflecting a 26.86% reduction in opiate dose.
Patients’
overall impression of change was high with medical cannabis, but
their scores for mood, sleep, and pain were substantially lower. Over
3 months, sleep scores improved most and pain interference scores
improved least; improvement in depression and anxiety scores fell
between.
Patients
who stayed on the same dose of opioids while using medical cannabis
had higher pain satisfaction rates. Patients who were not on opioids
initially or who tapered opioids had lower pain satisfaction scores,
but scored their overall satisfaction with cannabis as high.
It’s
possible that better sleep with medical cannabis is a key driver of
increased patient satisfaction and successful opioid tapering, the
researchers wrote. Unknown confounders also may have influenced
results.
This
finding supports a role for medical cannabis in an appropriate subset
of patients, Engle noted. “We do believe cannabis and
cannabis-derived medication merit further research, given the lack of
randomized studies describing the medical benefit, safety, and
optimal dosing,” she said.
WASHINGTON — Healthcare providers don’t know enough about cannabis to talk with patients about the potential risks and benefits, witnesses said at a mid-January House Energy and Commerce Health Subcommittee hearing.
“We need to have much more education with respect to how the use of
marijuana products can negatively impact or help someone,” said Nora
Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The
problem is we do not have sufficient evidence that could help us mount those
programs in a way that’s actually required. At this point, I don’t feel the
evidence is sufficient to say, ‘We’re going to recommend that this product
should be used by this patient.'” For example, elderly patients who take
marijuana-containing products may be on a lot of other medications, and little
is known about potential interactions between marijuana and prescription drugs.
“So I do believe in the importance of expanding our knowledge so we can
develop educational training programs that are based on knowledge, not on
anecdote.”
Making it Easier to Research Cannabis
Rep. John Sarbanes (D-Md.) noted that a 2015 survey of healthcare providers
concluded that the providers “perceive a knowledge gap related to cannabis
dosing, treatment plans, and different areas related to cannabis products, so
providers themselves realize the need for research and expertise to be
developed in this area.”
The hearing was held to discuss six bills on cannabis, several of which were
aimed at making it easier for researchers to obtain cannabis for research
purposes. Currently, the only cannabis legally available for research comes
from a single farm housed at the University of
Mississippi, and researchers who want to use it must get permission from
three agencies: the FDA, the Drug Enforcement Administration (DEA), and the
NIH. “We need to figure out a way to take advantage of different producers
of cannabis plants to evaluate the diversity of products out there, as opposed
to limiting us to the Mississippi farm,” said Volkow.
Rep. Kurt Schrader (D-Ore.) agreed. “The sad part is we’re not testing the right stuff,” he said. “I fail to understand why we have one bloody facility that is the sole nexus for research and analysis of CBD [cannabidiol] products. It seems to me we ought to be testing products on the marketplace.” Subcommittee chairman Anna Eshoo (D-Calif.) agreed. “I don’t understand why the three agencies before us can’t get this done,” she said, referring to NIDA, the FDA, and the DEA, which all had officials testifying at the hearing.
The Cannabis Research “Catch-22”
Several subcommittee members expressed frustration over what they called the
“Catch 22” problem that cannabis researchers face. “They can’t
conduct cannabis research until they can show cannabis has a medical use, but
they can’t demonstrate cannabis has a medical use until they conduct research.
It doesn’t make sense,” said Eshoo.
“You’ve got to help us figure out how we’re going to get out of this Catch
22,” Rep. Debbie Dingell (D-Mich.) said to the witnesses at the hearing.
“This lack of knowledge poses a public health risk.”
One issue with conducting research on marijuana is its classification as a
Schedule 1 drug; these are substances deemed to have no medical value and have
a high potential for abuse, and their availability is highly restricted.
Several bills the subcommittee is considering, including the Legitimate Use of Medicinal Marijuana Act, the Marijuana Freedom and Opportunity Act, and the Marijuana Opportunity Reinvestment and Expungement (MORE) Act,
would either downgrade marijuana from a Schedule 1 drug to a Schedule 2 drug,
which has fewer restrictions, or remove it from the drug schedule altogether.
Rep. Michael Burgess, MD (R-Texas), the subcommittee’s ranking member, said
the latter “is going too far,” adding that “using our
congressional authority to override this may be a dangerous move, especially
given the lack of research.”
So far, only one marijuana-related drug has been approved by the FDA:
Epidiolex, which contains cannabidiol, was approved
in June 2018 for treating a rare seizure disorder in patients ages 2 and
over.
Diverse Testimony from Both Sides of the Aisle
Both the witnesses and the subcommittee members seemed divided on
marijuana’s potential harms and benefits for patients. Volkow mentioned
research showing that cannabis exposure during pregnancy was associated with
low birthweight and preterm delivery, and added that it was also linked with
episodes of psychosis. She also said that there was some evidence that cannabis
may be useful in treating spasticity, multiple sclerosis, and pain, “but
otherwise there is little benefit for other indications for which patients are
using it.”
Rep. Morgan Griffith (R-Va.) said that his support of medical marijuana
began some years ago when he learned that people were smuggling marijuana into
a Virginia hospital to help a terminally ill father who wanted to be feeling
well enough to spend time with his 2-year-old son. Years later, when he told
that story at a high school town hall, one student raised his hand and said,
“They did that for my daddy too.”
“These communities were 20 years apart, 30 years apart, yet doctors
were turning a blind eye to allow marijuana to be brought into the hospital
because they recognized that for those patients who are dying, that was the
only way they would get relief and get the nutrients they needed to spend a
little more time with their children,” Griffith said.
Rep. Greg Gianforte (R-Mont.) said he was opposed to efforts to “make any Schedule 1 drug legal without adequate research.” Instead, “we should focus on combating addiction,” he said.
Cannabis and politics are at an intriguing crossroads as we creep ever
closer to the next election year. Politicians must decide how to position
themselves on the hot-button issue of cannabis legalization. Many potential
legalization bills have been proposed in the House of Representatives but very
few have ever made it out of committee. National legalization bills have a
history of facing intense scrutiny in the houses of Congress. There are a
number of reasons for this but the vast differences in political opinions of
members of Congress makes compromise on any bill, let alone one about a hot
button issue like cannabis legalization, very difficult.
However, on Wednesday, November 20th, a new bill that would decriminalize cannabis nationally, allow states to make their own laws on full-scale legalization, and create the potential for expunging criminal records related to cannabis arrests passed in the House Judiciary Committee.
Chances of the Bill Passing
Though it is tough to envision a cannabis bill actually seeing the light of
day, there is hope for this most recent iteration. The bill already has 50
co-sponsors, bipartisan support from notable pro-cannabis legalization
Republicans like Matt
Gaetz of Florida, and passed the House Judiciary Committee with a vote of
24-10. It is always encouraging when Republicans and Democrats can agree on
legislation, especially when it comes to a potential cannabis legalization
bill. Recently, the House of Representatives passed the SAFE
Banking Act with bipartisan support. The bill allows for cannabis
businesses to bank safely and discreetly. Its passage shows the willingness of
Congressional Republicans and Democrats to work together to pass a cannabis
bill.
The House cannabis bill is undoubtedly an exciting moment for those in the legalization movement. As promising as the bill seems, it is unlikely that it will be passed without major changes. It may pass the Democrat-controlled House of Representatives, but will face an intense battle in the Republican-controlled Senate. As unlikely as the bill’s passage is, those investing in the cannabis industry seem to believe the bill has a chance to become a part of American law soon.
Impact On The Cannabis Industry
As news of the forwarding of the house cannabis bill was announced, cannabis
company stocks soared. The three biggest cannabis stocks, Canopy Growth, Tilray
Inc., and Aurora Cannabis all saw prices rise between 8% and 15% on Wednesday,
according to Reuters. Investor excitement is palpable, but some experts
warn about the long term future for the House cannabis bill. Alan Brochstein,
managing partner at New Cannabis Ventures, cautioned that the bill is, “such an
early step in a long process that there are no near-term implications for
cannabis stocks.”
The merits of the House cannabis bill will likely debated for the next few
months. Changes will be made and votes will be cast before anything is set in
stone. Whether or not this iteration of a legalization bill becomes law is
unknown, but the fact that some politicians continue to fight for cannabis
legalization is tremendously promising.
The state of Minnesota is making headlines this December, not for its freezing temperatures or a new record snowfall, but for increasing medical cannabis access. Clinical cannabis got its start in the state when former governor Mark Dayton signed the first Minnesota medical cannabis bill into law in 2014. Many criticized the bill for being far too restrictive as it listed only 9 qualifying conditions and stipulates a lengthy patient registration process. However, as of December 3rd, 2019, the state added macular degeneration and the much more generally outlined chronic pain to the list of qualifying conditions. Minnesota can now expect to see more registered medical cannabis patients thanks to the expanded list of qualifying conditions.
Making Medical Marijuana More Accessible
Though many American states have taken steps to legalize clinical cannabis, a number of potential patients still do not have access. In most cases, state regulations prevent people with certain conditions from using medical cannabis. If the state regulatory body does not list a medical condition as qualifying, then people suffering from that condition may not use cannabis for medicinal reasons, even if a medical professional recommends it as a potential treatment. The stringent nature of qualifying condition lists make Minnesota’s addition of chronic pain as a qualifying condition a massive win for medical cannabis advocates.
Chronic pain is a very generally defined medical condition. Any number of ailments can cause it and is usually up to the patient to define. For these reasons, acquiring a recommendation for medical cannabis can be far easier than it is for other conditions. There is little doubt that Minnesota’s clinical cannabis patient registry will expand greatly in the coming months thanks to the addition of chronic pain and macular degeneration. According to the Boston Globe, “As of October, nearly 18,000 patients were certified for the state’s medical marijuana program.” That number is bound to increase as more conditions make the list.
The Future of Medical Cannabis in Minnesota
Many consider Minnesota as having one of the more severely restrictive medical cannabis programs. Though Minnesota’s list of qualifying conditions is still small, it is encouraging that the state continues to implement updates. Lawmakers must work with patients and advocates to continue to pursue the creation of a fair and easily accessible medical cannabis program. If the state continues to update its list of qualifying conditions, it can at least begin to change the narrative.
In recent years, the United States and Canada have become the leaders of the cannabis legalization movement. While these countries have taken charge, England and the rest of the United Kingdom have lagged far behind. This week, the National Health Service (NHS) approved two cannabis-derived medicines for the first time. The news comes as a welcome surprise to some in the English legalization movement.
Cannabis Policy Overseas
There are a number of factors that contribute to the excruciatingly slow pace at which legalization efforts have moved in England. One key reason for this stand still is the division of public opinion. While 66% of Americans support cannabis legalization, only 48% of English citizens favor making the growth, sale, and use of cannabis legal. The U.K. government will be far less likely to push forward any legalization movement that less than a majority of its population supports. Until public opinion shifts, NHS policy will not budge.
While legislative policy in England remains stagnant, the NHS continues to research potential cannabis based medicines. Medical cannabis is not legal in the U.K., but the NHS has the ability to approve medicines derived from the plant if it believes they can improve the lives of people suffering from illnesses.
Though cannabis legalization may seem far away in England, the NHS recently approved two cannabis based medications for use. The two medications, Epidiolex and Sativex, are used to treat epilepsy and multiple sclerosis respectively.
Approving Medicines That Can Change Lives
Epidiolex may be familiar to Americans and Canadians as it was the first cannabis based medication to be approved by the FDA in both countries. Now, the NHS has approved it for use in the UK. This medication is CBD based and treats a specific form of epilepsy called Dravet syndrome.
Despite the fact that Epidiolex features no THC and causes no high, some regulators and medical practitioners have felt uneasy about its approval simply because it is cannabis-derived. Despite its detractors, the safety and efficacy of Epidiolex is something that families of loved ones with Dravet epilepsy appreciate.
Sativex, the second medication that is now NHS-approved for UK patients, has not received prescription approval in the US, but is approved for patients in Canada. This treatment comes in an oral spray form and consists of delta-9 THC and CBD. Practitioners use Sativex to treat spasticity associated with MS. One of the more devastating conditions associated with MS, symptoms include muscle stiffness and severe spasticity. Sativex treats this by alleviating inflammation and aiding in neurotransmission to the affected muscles.
The British public clearly lacks the same enthusiasm about cannabis legalization as the United States and Canada. However, the NHS approval of two cannabis based medicines has a chance to become a tipping point that convinces people that cannabis is a viable medication.
According to the Anxiety and Depression Association of America, anxiety disorders are the most common mental complications in the United States affecting more than 40 million adults in the U.S. or at least 18% of the population every year. Although anxiety disorders are highly treatable, only about 36% of anxiety patients receive treatment.
Several factors can lead to anxiety. Some of
these factors include brain chemistry, genetics, personality, and drastic life
changes. We are all, therefore, prone to anxiety.
Anxiety affects us differently. Some people
might feel unprepared, unsure, or nervous when trying something new or before
giving a speech. These feelings may manifest in physical symptoms such as
headaches, shortness of breath, or clammy hands.
Anxiety is actually an adaptive response that
can help us cope with challenges or day to day threats. These responses can
help identify and avert potential threats, encourage us to work harder, etc.
However, when we don’t respond well to these triggers, they can become
maladaptive leading to clinical anxiety disorders.
There exist many medications to deal with this
condition. Some of the common drugs include tranquilizers like Valium and Xanax
and selective serotonin reuptake inhibitors like Zoloft and Prozac. While some
of these drugs may work, some people may not respond well. There have been
cases where patients fail to see any changes or are unable to tolerate the side
effects. Also, drugs such as Xanax and Valium can be highly addictive.
For this reason, more and more people are
looking for natural alternatives that can help them cope with anxiety
disorders. This is where CBD comes in. But the question is, can it work?
FIRST THINGS FIRST:
WHAT IS CBD?
CBD (Cannabidiol) comes from the cannabis
plant. It is one of the 120+ chemical compounds (cannabinoids) that are
naturally produced by the plant. Unlike THC (tetrahydrocannabinol), another
popular compound in the cannabis plant, CBD is not psychoactive. This means
that you won’t get the ‘high’ that is usually associated with cannabis
consumption.
CAN CBD HELP WITH
ANXIETY?
Cannabidiol has been touted for its many health benefits, including remedying chronic pain, depression, cancer symptoms, and now anxiety.
HOW DOES CBD WORK?
Before we delve deeper into this subject, it
is worth noting that most studies describing how CBD works for anxiety are
preclinical and based on animal models. This means that more research is still
needed to ascertain the effectiveness of CBD as a natural remedy for anxiety.
That said, Cannabidiol exerts several actions
on the brain that may help explain why it may be an effective treatment for
anxiety disorders.
5-HT1A AGONIST
5-HT1A is a subtype of the serotonin receptor.
According to experts, anxiety can be treated using medications or drugs that
target the serotonin system.
Findings indicate that CBD could represent a novel fast antidepressant drug.
Selective serotonin reuptake inhibitors (SSRI)
such as Zoloft and Prozac treat anxiety by inhibiting the re-absorption of
serotonin in the brain. This ensures that serotonin is available in the
synaptic space, which helps the brain cells to transmit more serotonin signals.
It is believed that this can help boost moods and reduce anxiety. (Of course,
the actual biological process is more complicated than this)
Just like selective serotonin reuptake
inhibitors, Cannabidiol may boost serotonin transmission.
According to a study conducted by Spanish researchers,
CBD can enhance 5-HT1A transmission and can actually affect serotonin faster
than standard selective serotonin reuptake inhibitors.
HIPPOCAMPAL
NEUROGENESIS
The hippocampal is a vital brain area
responsible for critical roles such as cognition and brain formation. Scans on
patients suffering from anxiety or depression have often shown a smaller
hippocampus. Depression and anxiety medications, therefore, aim at triggering
neurogenesis (birth of new neurons)
In a study involving mice, it was discovered
that repeated application of Cannabidiol may help boost neurogenesis. A
growing body of research suggests a link between CBD, SSRIs,
neurogenesis and anxiety and depression.
Based on these findings, researchers are
bringing forward data suggesting that CBD may help improve the common
anxiety-disorders in humans.
HUMAN STUDIES
SUGGESTING CBD MAY HELP TREAT ANXIETY
A study carried out in 2010 found out that CBD
could help remedy symptoms in social anxiety disorder (SAD)
patients. Follow up brain scans on the group revealed altered blood flow to the
brain parts concerned with anxiety and mood regulation. In this study, CBD was
not only found to be effective in making people feel better but also altered
the way their brains responded to stress and anxiety.
In 2011, another study was conducted to find out
whether CBD could remedy social anxiety disorder. In a public speaking test
that followed, people who received 600mg CBD experienced less anxiety, had less
cognitive impairment, were more relaxed and comfortable than their counterparts
who received a placebo.
CBD inhibits the fear of speaking in public, a symptom of social anxiety disorder.
A 2015 analysis of existing studies concluded
that Cannabidiol has great potential as a natural remedy for different forms of
anxiety including panic disorder, social anxiety disorder, post-traumatic stress disorder, generalized
anxiety disorder, and obsessive-compulsive disorder.
In 2017, researchers from Sao Paulo University
in Brazil found out that CBD helped reduce anxiety in patients with social phobia.
WRAPPING UP
It is clear that more studies on human are
still needed to ascertain the link between anxiety and CBD. However,
preliminary findings validating CBD’s efficacy as a natural remedy for anxiety
are promising.
It is important that all stakeholders in the
health sector come together and see if there is a way to improve this natural
compound to produce even better results. This should be treated as a matter of
urgency, given the huge economic and social cost that anxiety impacts not only
in the US but across the globe.
