03/08/2018
Read about ma*****na use--you decide for yourself.
Commentary
FEBRUARY 7, 2018
When Used Correctly, Medical Cannabis Is
Compassionate, Not a Conundrum
By Stephen Dahmer, MD
Editor’s note: This article is a response to “The Clinical Conundrum of Medical Ma*****na,”
which appeared in the June 2017 issue of Pain Medicine News.
Being an “expert” in diverse disciplines, as required by the profession of family medicine,
requires a quick ability to gather facts and clear awareness of our own limitations. We all
know facts can be interpreted and even inuenced in many ways. I would like to present
another side of the medical cannabis debate. Before we unfairly judge a potential
therapeutic option, we should weigh the facts, recognize our own bias and objectively
compare them to what we already do in our profession. My own bias has been clearly
documented.
Evidence for the use of medical cannabis to treat chronic pain is strong and growing
exponentially. Randomized, double-blind, controlled trials, systematic reviews, metaanalyses
and even expert opinion are more than favorable. Evidence also shows
patients are substituting medical cannabis for opioids, using less medications across the
board, and dying less from opioid overdose when medical cannabis is available as a
therapeutic option.
Lack of FDA approval should not end the discussion. Up to one-fth of all drugs are
prescribed off-label, and among psychiatric drugs, off-label use rises to 31%. Off-label use
of gabapentin is now more common than use for its FDA-approved indications and abuse is
now being seen with opioids. Consistency and quality of product, as with over-the-counter
(OTC) supplements, should be our highest concern. In New York and Minnesota, all
products are third-party tested for heavy metals, growth regulators, and fungal and bacterial
contaminants, and must have within 5% to 10% of the stated dose of major cannabinoids
(tetrahydrocannabinol [THC] and cannabidiol [CBD]). In a practical clinical setting, the vast
majority of our patients with chronic pain have already tried physical therapy, acupuncture,
OTC medications and mind-body therapies. When face-to-face with that patient on a busy
day, we are left with few choices beyond reinforcing those modalities, yet the vast majority
of us want alternatives. The opioid crisis is the tip of the iceberg. The risks of nonsteroidal
anti-inammatory drugs and sedative hypnotics need to be discussed more openly with
our patients when choosing an appropriate treatment regimen.
I encourage my fellow physicians to begin early their perusal of the endocannabinoid
system (ECS) and familiarity with cannabis-based medicines beyond a few, single synthetic
agents that have been funded suciently to pass through the approval process. I also
encourage physicians to look deeper into the debate regarding FDA-approved synthetic THC
versus a whole-plant extract. Despite research challenges and a lack of standardization
across the United States, CBD has tremendous potential as a benecial adjuvant on all
steps of the analgesic ladder. At minimum, familiarize yourself with the numbers needed
to treat in painful sensory neuropathy when compared with other accepted treatments.
The ECS is a fascinating endogenous system with enormous potential to improve health
and alleviate suffering. In New York and Minnesota, medical cannabis is successfully
being used to treat thousands of our sickest patients via a real-dose, medical model.
No discussion of this treatment would be complete without mention of LD50 (lethal dose
for 50%). There are no known cases of medical cannabis lethal toxicity. This is one very
compelling fact, often overlooked, for a physician whose oath is to above all do no harm. I
am very pleased to report that after treating tens of thousands of New York and Minnesota
patients for over two years and offering a 24/7 adverse event call center, zero patients have
experienced a side effect severity coding of major or death in all of the case-reported
adverse events. Medical cannabis may just be the parachute
that helps our medical community out of a very dicult
situation. Even parachutes can be dangerous when used
incorrectly.
Medicine-based evidence is gaining traction in our everyday
empirical practices of clinical care. My professional opinion is that real-dose medical cannabis will prove to be an invaluable
tool for us. Furthermore, I am eager to participate in the
research needed to further support or refute this opinion.28
Dr. Dahmer is an assistant clinical professor of family medicine and community health at
the Icahn School of Medicine at Mount Sinai in New York.
Clinical Pain Medicine
FEBRUARY 14, 2018
Ma*****na Use Impedes Pain Control
Following Trauma
People who used ma*****na prior to being admitted to one of four trauma centers in
Colorado for injuries sustained in a motor vehicle collision were likely to require more
frequent dosing of opioids than patients who had not used ma*****na, according to a pilot
study.
Lead author Laura Peck, DO, MSW, is a third-year resident in general surgery at Swedish
Medical Center, in Englewood, Colo., a state where ma*****na use is legal. “Working at a
level 1 trauma center, I regularly manage pain in many patients who report using ma*****na,”
she said.
The preliminary data suggest that ma*****na use—particularly chronic use—“may have a
detrimental effect on dosing and frequency of opioid administration for acute pain
management following trauma,” Dr. Peck said.
The retrospective study evaluated a total of 261 car crashes over a four-month period, in
which ma*****na use was reported in 21% of cases, with 30% of overall ma*****na use
described as chronic.
The unadjusted mean daily opioid consumption was 8.58 mg among ma*****na users,
compared with 6.05 mg among nonusers; the adjusted consumption was 8.70 and 7.29 mg,
respectively.
The unadjusted mean daily pain numeric rating scale score was 5.14 among ma*****na
users and 4.24 among nonusers; the adjusted score was 5.08 and 4.60, respectively.
Overall, 86% of all analgesics administered were opioids, with the most common being
hydromorphone (27% of cases).
Chronic ma*****na users had the highest daily opioid analgesic consumption relative to
episodic ma*****na users and nonusers: 9.5 versus 8.4 and 7.3 mg.
“These study results are not surprising,” Dr. Peck said. “Prior to conducting this
retrospective review, anecdotally it seemed that ma*****na-using patients required more
frequent dosing of opioids than nonusing counterparts.”
Dr. Peck said with the increasing use of ma*****na, “our ndings have important clinical
implications, as the data suggests that chronic ma*****na users merit special consideration
during the acute pain management phase. Additionally, patients with poorly controlled pain
have worse outcomes.”
The study, however, does not address specic treatment strategies for pain control in
patients who use ma*****na. “More studies are needed to determine the most effective way
to manage pain in these patients,” Dr. Peck said. “Furthermore, using ma*****na derivatives
to control pain in these patients has not yet been studied and would be an important
contribution to our understanding of pain control in this population, as well as other
populations that might benet from an alternative to opioids.”
But given the fact that ma*****na remains illegal according to federal law and that there are
few ma*****na derivatives controlled by the FDA, “using ma*****na itself as a pain control
substance in a hospital setting presents challenges,” Dr. Peck said. “The few ma*****na
derivatives that are controlled by the FDA are not as potent as the tetrahydrocannabinol
products available for sale in the local dispensaries. Moreover, convincing any hospital to
violate federal law and start using substances still classied as illegal and illicit, and still
largely unregulated by the FDA, is a dicult case to make.”
Dr. Peck and her colleagues are interested in conducting a prospective trial looking at
patterns and trends in pain management in trauma patients who use ma*****na. “We are
also designing a study to determine the effects of using dronabinol [Marinol, AbbVie]—one
of the few legal ma*****na derivatives approved by the FDA for pain control—in ma*****nausing
patients who are not managing their pain adequately with opioids.”
The results were presented at the 2017 annual meeting of the American Association for the
Surgery of Trauma and Clinical Congress of Acute Care Surgery, in Baltimore.
—Bob Kronemyer
