Today I’d like to pass on some knowledge that I have gained from both researching the medical evidence and from my own personal experience prescribing medical cannabis. The topic, helping patients with chronic pain.
Let’s start by defining the problem; chronic pain is any pain that has been present for at least three months. This term can represent one or more different types of pain which can be divided in three main categories: nociceptive pain, neuropathic pain and sensory hypersensitivity (see image below for our visual learners). Most chronic pain tends to be neuropathic in nature, meaning the peripheral and central nervous system is involved in producing pain. Common chronic pain disorders include: prolonged muscle/skeletal pain, chronic low back pain (mechanical), nerve entrapment syndromes (ie: carpel tunnel, sciatica, neck impingement), diabetic neuropathy, HIV neuropathy, post-operative pain, complex regional pain syndrome, osteoarthritis, inflammatory arthritis (ie: rheumatoid arthritis, lupus, ankylosing spondylitis), chronic headaches (ie: migraine, tension, cluster), and fibromyalgia just to name only a few. It has been declared a human right, according to the World Health Organization, to have access to pain treatment (http://apps.who.int/medicinedocs/en/d/Js18774en/). Despite our knowledge and access to therapy and medications, it is well known that pain is poorly managed in Canada (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084407/). Many are calling for a national pain strategy to solve this problem.
Ok, so now that we have an idea of what the condition is, why is this such a hot topic right now? Chronic pain is a health epidemic and economic burden for society. In Canada, it is estimated that almost 19% of people over the age of eighteen suffer from chronic pain (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3298051/). Over half of these patients report suffering lasting more than ten years. In America, more people report suffering from chronic pain than diabetes, heart disease and cancer combined (https://report.nih.gov/nihfactsheets/ViewFactSheet.aspx?csid=57). Patients with chronic pain also have three times the average risk of developing psychiatric symptoms such as mood and anxiety disorders. Furthermore, patients who suffer from depression also have three times the average risk of developing chronic pain (http://www.health.harvard.edu/mind-and-mood/depression_and_pain).The combination of these conditions can lead to significant disability in patients. Given that mood disorders and chronic pain conditions commonly go hand in hand, we often see physicians using psychiatric therapies (medications, psychotherapy, etc) to help patients with chronic pain.
Physicians treat patients with pain on a daily basis. Chronic pain can be frustrating for all parties involved given that there is often not a complete, permanent or quick fix for the pain. Physicians often think of treatment in terms of medical, surgical, psychological/psychiatric (ie. cognitive-behavioural therapy), lifestyle (ie. exercise, Yoga, meditation) and rehabilitation. It is important to note that when looking at certain medical therapies, a “success” is often defined by only 30% reduction of symptoms, and the goal is often to make the pain tolerable enough so the patient can take care of themselves independently as opposed to complete pain resolution. Surgery, despite all of the advances we are making, alleviates only very few chronic pain conditions. Rehabilitation may help but often pain relief is temporary, expensive and there is very limited coverage. Getting back to medical therapy, physicians tend to rely on prescription medications to help decrease pain and improve functioning. There are a variety of classes of medications physicians will utilize and combine: anti-inflammatories (ie: Advil/Ibuprofen, Naproxen, Celebrex), neuropathic agents (ie: Lyrica, Gabapentin, Cymbalta, Amitriptyline), opiates (ie: Codeine, Oxycodone, Percocet, Morphine, Hydromorphone, Fentanyl), and recently a more common form of treatment, cannabinoids (ie: herbal cannabis, Nabilone, Sativex)..
Many pharmaceuticals are supported by physicians given they have more research at this point in time compared to that of cannabis. It is important to note, that whenever medications are being used, particularly in combination, there is the potential for side effects. In my personal experience, patients are reporting that cannabis has been far more effective than traditional pharmaceuticals for their pain. They often report this being the “very best” medication they used with the “least” amount of side effects. Note: I said least, not devoid of, side effects. Outcomes have been quite tremendous with many of them getting off numerous prescription medications and have improved functioning. I suspect in the years to come the research will begin to better match what I am witnessing on the front lines.
So how is Cannabis different? Cannabis just works differently from the other medications for pain. First, in terms of herbal cannabis, it is plant-based which contains multiple ingredients that work synergistically to produce an effect (see my previous post for more on cannabis ingredients) compared to pharmaceuticals which is often a single standardized ingredient. This makes cannabis much more complex to study and also means there is a bit of an art combined with trial and error to find the best mix of ingredients to improve symptoms. I often describe to patients that “THC can help with the pain coming from the brain”and “CBD can help with the pain coming from the body”. This is an oversimplification of what these ingredients do but does the job of explaining the differences between them. The components of cannabis lead to a reduction (though, like the other medications, often not complete elimination) in reported pain via multiple ways such as muscle relaxation, inflammation reduction, blocking nervous system pain signals (neurotransmitters) and regulating the immune system. Patients often tell me, “I feel relaxed, and at ease. My mind is also distracted from the pain. My body feels less tight and my thoughts are less intrusive or produce less of an emotional response. I can look at my pain from almost a different perspective. When I use cannabis I can function better”.
Based on thousands of patient conversations with chronic pain patients, I do believe cannabis is working than many other pain medications. I also consider it to be safer than many other medications, especially CBD-derived cannabinoid products that do not cause cognitive impairment. Anti-inflammatories can lead to ulcers, heart disease, hypertension and kidney disease. Neuropathic agents can lead to weight gain, “brain fog”, sedation, drowsiness and mood changes. Opiates, well don’t even get me started. We have created an opiate epidemic that causes close to 20,000 deaths in the United States a year. Once started on opiates many patients become dependent and require escalating, sometimes unsafe, dosages. In my practice I do not prescribe opiates for chronic pain given these risks and lack of evidence on their efficacy for chronic non-cancer pain. Don’t get me wrong: all of these medications do have a time and place with research to back them up for specific conditions. But, I continue to see a high percentage of patients failing these options or not tolerating the side effects. Cannabis on the other hand has zero deaths and is typically well tolerated. It is by no means benign but generally safe for most people. It can also be easily combined other pain-control therapies to help treat the patient’s condition so it is definitely not a be-all end-all approach. Some other pros: addiction and dependence are far lower compared to opiates, and withdrawal from cannabis is typically mild. On the flip side: psychosis and paranoia is a real risk, but this only happens in an extremely small subset of people and can be avoided with proper education and counselling by an experienced physician. Patients often report side benefits, not side effects. In addition to reduced pain patients often feel less anxious, report improved sleep, improved intimacy, feel happier and have improved quality of life. There still remains much to be discovered about cannabis and funded research will help to paint a more accurate picture of the medical uses of cannabis.
I expect in the future we will be more aggressive in using cannabis earlier to help patients, rather than a last line therapy as is is often suggested as in medical guidelines. There is a gap, mind you a closing one, between observational front line data and medical evidence. Companies like Canabo Medical Corp will publish studies to help people draw more accurate conclusions around cannabis as a medicine. As we begin to isolate ingredients in the plant, and bring over pharmaceutical technology to cannabinoids, patients will have a portfolio of cannabis derived medications available to them to help alleviate their pain. The future looks GREEN for pain management and I am excited to be part of this change.