Medical Marijuana: kicking opiates to the curb!

I routinely recommend medical marijuana to our patients who suffer with chronic pain. Medical marijuana is recommended by the Canadian Pain Society after a trial of other pharmaceuticals such as Gabapentin, Amitriptyline, Duloxetine, or an opioid-based drug. For many, these commonly prescribed drugs simply don’t work or have side effects that are dangerous or intolerable. Study after study show that opiates are not effective for chronic pain. The recent SPACE Randomized Clinical Trial compared immediate release opioids (e.g. morphine, oxycodone) or sustained-release opioids (e.g. Fentanyl patch) to a nonopioid (e.g. Tylenol, Ibuprofen) for chronic back pain, or hip or knee osteoarthritic pain. The study found that the opiates were no better than over-the-counter Tylenol or Ibuprofen for chronic pain.

Despite what the studies say there are millions of prescriptions written for opiates, like Tramadol, Tylenol #3, Oxycodone, and Hydromorphone every year. Interestingly, the SPACE study noted that patients receiving an opioid compared to a nonopioid had significantly less anxiety. Perhaps this is part of the reason why so many people feel that opiates improve their pain? This is not surprising as opiates mimic our natural endorphins and give us a feeling of well-being. However, they can be incredibly dangerous causing more than 12,800 deaths in Canada between, 2016 and 2019, according to the National Report: Apparent opioid-related deaths in Canada, and 4,588 deaths in 2018 alone – 1 life lost every 2 hours!

This is a staggering number and doctors are undoubtedly under pressure to not prescribe them and to get their patients off altogether. Yet, if our nonopioid drugs are not effective or cause too many unwanted side effects what are we supposed to do? This is a question asked equally by physicians and patients alike. Increasingly, cannabis is being considered as an alternative by mainstream medicine as research is exploding and we are learning the potential benefits of medical marijuana and how safe it is for patients.

What does scientific research say about medical marijuana and chronic pain?

Studies that look at medical marijuana for chronic pain are conflicting. The Lancet journal article, Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study published in 2018, found that patient pain didn’t improve with cannabis, it didn’t reduce opioid-based medications, and patients were more likely to have generalized anxiety. While a meta-analysis, also published in 2018, The Benefits and Effects of Using Marijuana as a Pain Agent to Treat Opioid Addiction describe significant reductions in opiate use, improvement in quality of life and no significant side effects even after taking cannabis for more than a year.

Why would two respected studies draw such opposite conclusions? Part of the reason might be the design of the studies. The Lancet study asked patients who were taking opiates to self-report their marijuana use and then followed them over 4 years to see how they were doing. While in the other study, patients were prescribed cannabis through their, Marijuana Care Program, suggesting that support and guidance from healthcare professionals leads to better outcomes.

Why does medical marijuana work better – isn’t it all the same stuff?

It’s hard to understand why getting medical support results in such stunning differences in health outcomes but I’ve seen this dichotomy with our patients as well. I was initially surprised when I had people who were experienced cannabis users ask for our medical advice. In these cases, our patients used recreational marijuana regularly but didn’t find that it worked for their pain. Should they be taking it differently or trying another strain, they asked? While we didn’t ask them to stop their recreational, or non-prescribed, use of marijuana we did add cannabidiol (CBD) oil and titrated up slowly adding micro doses of tetrahydrocannabinol (THC) oil if needed.

In one instance, our patient had experienced debilitating migraines several days a week for more than 10 years. None of the prescription drugs helped and she was unable to take Tylenol or Ibuprofen. She had started vaping Indica-dominant flower a few years prior in the evenings to help her sleep. Still this made no difference in the frequency or severity of her migraines. We had her start with Avidekel by MedReleaf CBD drops twice a day. After 4 weeks she had increased her dose to 0.5 mLs (containing CBD 25mg/mL and THC < 2 mg/mL) at breakfast and dinnertime. Four weeks later she’d only had one migraine in that entire time! To say that this therapy was life-changing for her is an understatement.

In another example, our patient had unrelenting pain on the right-side of her neck, shoulder, and arm due to a car accident 5 years prior. She had tried physical therapies, steroid and lidocaine injections and several pharmaceuticals, all to no avail. She was also an experienced cannabis user choosing to smoke marijuana in the evenings as a way to relax. The recreational marijuana helped her fall asleep but she still struggled, waking up at 3 or 4 AM unable to fall back to sleep. After working for a few weeks with our team she found that taking Aphria 10:13 oil (10 mg/mL THC and 12 mg/mL) 0.2 mLs sublingually twice daily and 0.4 mLs at bedtime dramatically improved her pain and sleep. If she woke up in the middle of the night she was able to fall back to sleep more easily and didn’t feel groggy in the morning. As well, her 5-year long struggle with pain disappeared. In fact, the pain was so improved that she would forget to take the medical cannabis, only to be reminded when her pain returned 3 or 4 days later.

Will medical marijuana be safe and effective for my chronic pain?

Chronic pain is a difficult-to-treat condition, over-the-counter remedies, like Tylenol or Ibuprofen, are usually not effective and can damage the liver, kidneys and stomach. Prescription drugs like Gabapentin, Amitriptyline, and Duloxetine are routinely recommended but lack convincing evidence and can cause sedation, excessive dry mouth, constipation, and weight gain. Opiates may not be appropriate for chronic pain and come with serious risks.

Marijuana contains THC, CBD, and more than 400 plant molecules that have anti-inflammatory and pain-relieving properties. There has never been a fatality due to overdose reported. Chemical addiction and symptoms of withdrawal don’t happen with marijuana like that seen in opiate-users. However, people can become dependent on marijuana – this is a psychological, not a chemical dependence.

In our practice I’ve seen people have complete resolution of their pain but this is not true for everyone. Even more interestingly, some people find that CBD works wonders while others find no benefit at all and will need to add a micro dose of THC. However, most people describe feeling generally better, with improved mood, focus, and sleep.

How do I get help to try medical marijuana for chronic pain?

Finding medical marijuana that is approved by Health Canada can be confusing and challenging. There are a number of online suppliers of cannabis that look legitimate but are not regulated, tested, or pesticide-free. If you’re unsure if you are buying from a Health Canada approved supplier of medical marijuana check out, Licensed Producers Canada to help you make a safe choice.

The Canadian Pain Society states that treatment of pain is a basic human right, but finding a doctor that has experience and is willing to prescribe can be challenging. That’s why we’re committed to working with our patients to help them get a prescription that is safe and effective for their medical condition. Contact Wellness Pharmacies to find the support and guidance you need to find out if this therapy is right for you.