Reefer to the Rescue
Medical cannabis presents new treatment options for pain management
By Erika Napoletano
Medical marijuana advocates are not just blowing smoke. Medical cannabis, now in Illinois, has proven to help manage chronic pain—in some cases working for patients when conventional painkillers do not. Illinois physicians who are willing to discuss the topic say that while cannabis treatments can offer alternatives to pain management medications, monitoring is key for treatment.
With only 41 conditions currently eligible for someone to receive a registry identification card, Illinois has launched one of the most restrictive medical cannabis programs in the nation. Conditions such as various cancers, lupus, epilepsy and HIV lead the list. For pain patients not finding their condition on the currently approved list, the Medical Cannabis Advisory Board will convene periodically to assess new additions.
Chicago Health explored what medical cannabis means for pain management, from the perspective of the patient and the physician. It’s a journey from cautious excitement to heightened caution as Illinois steps forward into the world of medically controlled cannabis.
For physicians with patients suffering from disease-related pain, medical cannabis presents a potential option. “Cannabinoids are yet another agent we can use like a medication or therapy to help manage pain,” says Leslie Mendoza Temple, board-certified family physician. “But like any other treatment, we’ll need to evaluate the benefits and implications of use in every scenario.”
Cannabinoids offer both the patient and physician something that many current pain management treatments do not: a greater duration of efficacy. While ibuprofen or opiate-based medications can offer patients pain- reducing benefits of two to six hours, cannabinoids tend to be metabolized and cleared from the body at a slower rate. This translates to potentially longer-lasting pain management benefits in many disease levels.
Medical cannabis offers an ancillary benefit for pain management patients as well—increased sleep quality; at least initially, depending on the dose of tetrahydrocannabinol (THC) the active ingredient in marijuana. “When patients are resting better, they can catch up on healing—more so than when their sleep is interrupted on account of pain,” Mendoza Temple says.
Many sleep medications like benzodiazepines convert deep sleep into lighter sleep. So, while the total amount of sleep may increase, it may not be of optimal quality. Cannabis can aid in creating deep sleep that’s beneficial for pain management patients, though this effect may disappear after repeated use. Diligent monitoring is called for to ensure that patients continue to benefit after prolonged use.
As every Illinois application for a medical cannabis card must have physician backing, the need for pain management is just the first step in determining whether a patient is a reasonable candidate for cannabinoid treatments.
Here’s where we get down to the reality about marijuana, as the drug has a mind-altering reputation for a reason. Physicians are simply not going to allow medical cannabis access to everyone complaining of pain—no matter how severe. There are several contraindications for medical cannabis treatment.
Previous addiction issues and schizophrenia are two leading warning signs that a pain management patient might not benefit overall from cannabinoids, says Mendoza Temple. She’s also a proponent of exploring complementary therapies for pain management, such as acupuncture, good nutrition, chiropractic, massage and relaxation techniques, before cannabinoids enter into consideration.
“Cannabinoids are an additional option. They’re not pure substitutes for managing pain. They might be, however, something we find that enhances what the patient is already doing to heal. We just have to make sure that medical cannabis is not going to exacerbate key or underlying conditions,” she says.
The myth that cannabis is a completely safe drug is just that—a myth. While a recreational user might say that the greatest danger of being under the influence is downing a whole bag of Cheetos, we can’t forget the under the influence part.
A large majority of medical cannabis treatments still retain the substance’s psychotropic properties. In plain English, they will make you high. That state of euphoria is one of the leading factors considered by Jerrold Leikin, MD, director of medical toxicology at NorthShore University HealthSystem–OMEGA and a medical toxicologist serving as a consultant to both the Illinois and Wisconsin poison centers.
Cannabis poisoning-related incidents have been on the rise since 2001, Leikin says. In Colorado, pediatric-related poison center calls relating to unintentional exposure to cannabis have almost quadrupled (from seven calls in 2001 to 26 calls in 2013), and all cannabis-related poison center calls in the state rose from 61 in 2012 to 151 in 2014.
Despite those escalating numbers, the National Poison Data System’s 2013 annual report cites 26 cannabis-related deaths in that year, with only two of those deaths reporting single-substance exposure to cannabis (in other words, there were no other drugs found in the person’s system).
Are these small numbers cause for concern, considering there were a combined 111 deaths attributed to single-substance exposure to sedatives, hypnotics, antipsychotics, cardiovascular drugs and opioids? It’s enough to make medical toxicologists continue their studies and hope patients and physicians come to the medical cannabis conversation armed with better questions and strict monitoring protocols.
Asking Better Questions
As both patients and physicians explore the pain management applications of medical cannabis and its introduction into the Illinois medical landscape, Leikin says that all parties need to be fully involved in a treatment conversation.
There isn’t data available on all of the potential drug interactions with cannabinoids, Leikin explains, so physicians are using caution when beginning a course of treatment with cannabis—as with any drug that is experimental in nature.
Leikin also stresses the importance of diligent patient monitoring. It’s not just about how much the cannabinoids can potentially control pain. It’s about function. As delivery systems (smoking, vaporizing and edibles) vary when it comes to dosage, physicians must be ready for hyperattentive monitoring procedures.
Patients should also be ready for potentially lengthy trial periods as they explore different delivery systems and dosages that include extensive and regular reporting protocols with their physicians. Therapeutic drug monitoring is a must for patient and physician, as with many other pain medications in which dose titration is essential for effective pain management.
So, where does this leave us in the medical cannabis conversation for pain management? The Illinois medical community will soon have a fresh treatment for carefully vetted patients.
As the daily mantra is to do no harm, both physician and patient are faced with an intricate road ahead as they determine the case-specific delivery method as well as what dosage does the most pain-related good while keeping the patient on the road to a better quality of life.
Originally published in the Fall 2015 print edition
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