Today, 14 states have approved the use of marijuana as a medical treatment. According to 12 of the 14 states (New Jersey and Michigan’s registration programs started in 2010 and 2009, respectively, and no data is available), 269, 420 people have registered and been issued a medical marijuana identification card. In California, the number of registered medical marijuana patients as of January 14, 2009, was 202, 416 or 5.6 patients per 1, 000 state residents. Overall in the 12 states that have approved the use of medical marijuana and provided statistics, the penetration rate is 1.90 patients per 1, 000 state residents.
The ten most common reasons patients apply for a medical marijuana card are:
- To relieve the effects of glaucoma
- To relieve such side effects of chemotherapy and AIDS treatment as vomiting and lack of appetite
- To provide pain relief for
- Neurogenic pain including chronic back pain
- Arthritis
- Fibromyalgia
- Migraines
- To relieve some of the symptoms of multiple sclerosis
- To provide pain relief from spinal cord injuries
- To reduce the effects of depression
- To relieve the symptoms from premenstrual syndrome
- To improve breathing in asthma patients
- To relieve the effects of such inflammatory bowel diseases as Crohn’s and ulcerative colitis
- To act as an antispasmodic and/or muscle relaxant
There are several active compounds in marijuana. With approximately 67 peer-review studies published, a number of important insights are emerging. In terms of pain relief, the research appears to be focused on one compound in particular, beta-Caryophyllene. This compound reduces tissue inflammation by acting as a selective activator of the CB2 receptor. Cannabis oil contains about 12% to 35% beta-Caryophyllene.
Interestingly enough, beta-Caryophyllene is also found in clove oil and the cooking spice, rosemary. It is also the chemical compound that contributes to the spiciness of pepper. One pepper in particular is well known in China as the “numbing pepper.”
In a study conducted by Jürg Gertsch et al., from the Swiss Federal Institute of Technology, beta-Caryophyllene was shown to selectively bind to the cannabinoid receptor type-2 and exert significant anti-inflammatory effects in mice. Beta-Caryophyllene, incidentally, is an FDA approved food additive.
Another study we ran across looked specifically at the role of cannabis for spine pain relief when morphine fails. The study was conducted by Dr. Andrew Rice at the Imperial College of London and was published in the June issue of the journal Molecular and Cellular Neuroscience: Vol. 15, No.6, Jun 2000, pp. 510-521.
Dr. Rice’s principal conclusion was: “We have achieved a really important step in terms of divorcing the psychoactive side effects of cannabis from their pain-relieving effects. In order to develop clinically useful drugs based on cannabis, it is important to show that the receptors for cannabinoids are found in the spinal cord, particularly the areas concerned with pain processing. And that’s what we’ve done.
San Diego Drug Enforcement Administration“The potential for cannabis in pain relief can now be developed in several ways: for instance we can either develop drugs based on cannabinoids acting on spinal receptors that don’t have the psychoactive side effects or we can deliver the cannabinoids to the spinal cord site of pain relief without involving the brain.”
Getting to the conclusion, however, was based on tackling one of the more difficult problems in treating chronic or severe back pain—namely the limited effectiveness of morphine and similar drugs that are currently the gold standard for serious pain relief.
Where morphine fails, marijuana may work.
Again, to quote Dr. Rice; “It’s known that if you injure a nerve, the morphine receptors in the spinal cord disappear and that’s probably why morphine isn’t a very effective pain killer for such conditions as shingles, people who have had an amputation or perhaps if cancer has invaded the spinal cord. “
“But what we’ve shown is that the cannabinoid receptors do not disappear when you injure a nerve. So this could offer a therapeutic advantage over morphine for treating such pain.”
For physicians at the front lines of treating spinal injury or chronic pain patients, this is clearly interesting and potentially helpful information, but many hard questions remain. Specifically, clinicians still do not understand such elemental issues regarding medical marijuana as:
- What’s the right dose?
- How does it interact with other medications?
- And what physician in their right mind would prescribe smoking of anything?
In terms of the latter problem, several companies have developed a kind of vaporizer/inhaler that is similar to those used by asthma sufferers. These machines heat the cannabinoid oils in the marijuana leaves and convert them into an inhalable vapor. The marijuana leaves are not burned so no carbon or other “smoke” is released.
With nearly 300, 000 patients self dosing regardless of other medications, clinicians are increasingly asking the question about how they should deal with patients who are using medicinal marijuana and whether medicinal marijuana has a place in the drug armamentarium.
Dr. K. Allan Ward, a pain specialist at Great Falls, Montana Orthopedic Associates, is tackling these issues head on. “Most providers are very concerned and wonder what to do” with medical marijuana patients, Ward said. “In examining the medical literature, there are presently no definitive answers on the basic questions. There are currently, as far as I know, no published studies looking at legal marijuana use on a large scale.”
Dr. Ward is hoping to put in place a survey to ask patients about their drug use and whether they have a history of alcohol or drug dependency, how they get their medical marijuana and how much they pay for it. Those answering the online survey can remain anonymous.
Dr. Ward said he hopes to use his findings to provide lawmakers and medical providers with more comprehensive information on the drug’s usage in Montana. “I’m a pharmacologist and a technician, ” Ward said. “I’m being asked by other doctors for advice, and I don’t have an answer at this time for all of the things that people are asking me.” Dr. Ward is hoping that at least 1, 000 of the state’s 8, 604 registered medical marijuana patients will participate in the online study.
The Canadian Medical Association published on their web site an August 7, 2001 article titled “A Primer For Patients’ Use of Medicinal Marijuana, ” which addressed the issue of dosing:
Dr. Mary Lynch, a pain researcher and head of the Canadian Consortium for the Investigation of Cannabinoids in Human Therapeutics, says there is very little research to guide practice so it’s best to start with the lowest dose possible, particularly for the ‘naïve’ (first-time) user.
Using the protocols she and colleagues are developing for their research on the medicinal use of smoked marijuana, she recommends that naïve users begin with 1 puff (or toke), usually before bed, to help with symptoms such as pain or spasticity and improve sleep quality.
To get the most out of a dose while limiting the amount of smoke exposure, she tells patients to inhale on the pipe or joint and hold it in their lungs as long as possible.
Experienced users often know what dose is most effective, though Lynch recommends that a dose of 2 to 4 puffs per dose, 3 times per day is reasonable and, depending on response, the dose can be titrated accordingly. (Health Canada has suggested a daily maximum dose of 5 grams.)”
In a roundabout way, the U.S. government has established dosing guidelines. For approximately three decades, federally grown (in Mississippi) medical marijuana has been available to a small number of patients under a Compassionate Use Investigational New Drug program. These patients are prescribed 300 pre-rolled marijuana cigarettes per month. Patients with chronic pain conditions receive 50% more than others or 450 per month. Each cigarette is approximately 0.9 grams, not including the paper. In effect, each patient is receiving a little more than one half-pound (8 ounces) per month.
As to what you can say to your patients, it depends on a combination of state and federal law. The federal law is evolving and here is the latest iteration:
The Ninth U.S. Circuit Court of Appeals has ruled that doctors may discuss medical marijuana with their patients and may issue written recommendations for its use as part of a comprehensive treatment plan—Conant v. Walters, 309 F.3d 629 (2002). That ruling was appealed to the U.S. Supreme Court which refused to hear the case, allowing the decision to stand. It is also the current policy of President Obama’s administration not to prosecute medical marijuana cases where no state laws are being violated.
So, under current federal law, physicians can:
- Discuss, fully and candidly, the risks and benefits of medical marijuana with patients
- Recommend (or approve, endorse, suggest, or advise, etc.), in accordance with their medical judgment, marijuana for patient use
- Record in their patients’ charts discussions about and recommendations of medical marijuana. Sign a government form or otherwise inform state or local officials that they have recommended medical marijuana for particular patients
- Testify in court or through written declaration about recommending medical marijuana for a certain patient.
But, under current federal law, physicians cannot:
- Prescribe medical marijuana. This includes writing a recommendation on an Rx form
- Assist patients in obtaining marijuana
- Cultivate or possess marijuana for patient use
- Physically assist patients in using marijuana
- Recommend marijuana without a justifiable medical cause
There is little doubt that medical marijuana will continue to grow as a treatment modality for back pain, arthritis pain and other neurological and orthopedic indications. While there is much more to learn, it is probably time for physicians to educate themselves about these compounds and for researchers to start studying in a more systematic way the emerging and preferred use patterns for medical marijuana.
