Cannabis for chronic pain, a better option?

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Dear Readers,

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.

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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.

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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)..

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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.

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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.

  • CannabinoidMD

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Image Credits:
1 – http://www.kirbyknoxmd.com/wp-content/uploads/2016/02/You-Are-Leaving-Pain-Sign.jpg
2 – http://www.rethinkopiods.com
3 – http://www.statcan.gc.ca/pub/82-229-x/2009001/c-g/c-g-4/ch4_graph6.2-eng.jpg
4 – http://www.integrativeoncology-essentials.com
5 – http://www.businessinsider.com

How does cannabis work on the mind and body?

There is a lot of confusion and misconception regarding how cannabis works on the body and mind. I thought I would take a second to explain and clarify some of the misinformation.

What is quite fascinating is that our own bodies produce “cannabis-like” molecules which we call endogenous cannabinoids. These cannabis-like molecules then enter the brain and immune system (primarily) and go to work regulating: appetite, mood, inflammation, cardiovascular functioning, metabolic homeostasis, sleep and pain perception. This system is necessary for our survival. What’s fascinating is that even small nematodes have these endogenous cannabinoids in their body.

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Our cannabis molecules act on a system in our body known as the endocannabinoid system. The system has receptors in the brain, immune system and is also found throughout the body lining our organs and skin. When endogenous cannabinoids bind to these receptor areas one begins to experience the benefits of cannabinoid therapy. As you read this article your body is at work making these cannabis-like molecules. We also know that the “runners high” many people report is part of your body releasing larger amounts of endocannabinoids. Yoga and meditation can also boost endocannabinoids. It is no wonder I often prescribe exercise, meditation and yoga to all my patients as part of healthy living. It is part of developing and promoting a healthy endocannabinoid system.

Nature seems to have created the cannabis plant which is far more complex in cannabinoid options than our own bodies can produce. The cannabis plant has closer to 100 cannabinoids compared to our own bodies which make closer to 10 (known to date). The most popular plant cannabinoids are THC (tetrahydrocannabinol) and CBD (cannabidiol). These two are also likely the most medicinal ingredients in cannabis strains given their higher concentrations compared to other ingredients. I like to call cannabinoids level one ingredients in the plant. There are other ingredients known as terpenes and flavonoids, which I call level 2 and level 3 ingredients, respectively. They are also important in producing varied medicinal effects but I will save that for a different discussion. More commonly we appreciate the aromas and colors they produce in the cannabis flower. See below for some terpenes commonly found in the cannabis plant and appreciate the overlap we fine throughout nature.

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When a patient chooses to boost their endocannabinoid system through medical cannabis they are enhancing the effects of their bodies own system with plant cannabinoids. This leads to both mind and body symptoms.

In the brain THC will bind to receptors and lead to deep relaxation, reducing of nerve pain, muscle spasms, reduce pain/inflammation and boost our appetite. THC is also what is responsible for the “high” or euphoria people experience. THC is the ingredient that produces some side effects including: sedation, dizziness, dry mouth, short-term memory loss and a racing heart. Sometimes THC combined with specific terpenes (level 2 ingredients) can cause a racing heart and energy which can make someone feel anxious, paranoid or in rare circumstances hallucinate. This side effect can be eliminated or minimized if a patient is educated well by a knowledgeable physician on which strains to avoid if they are at risk for this side effect (not everyone is at risk for this side effect). Side benefits often reported are happiness, creativity and mental clarity.

CBD on the other hand works more on our body and allows our body to make more serotonin and boost our own endogenous cannabinoids. Interestingly, CBD can block some of the THC from working. CBD is responsible for muscle relaxation, reducing inflammation, stimulating bone production and can improve seizures. CBD does not have the side effect of producing a “high” or euphoria. In fact there are very few reported side effects from patients taking pure CBD (sometimes a bit of fatigue/drowsiness but even this is rarely reported). CBD is being used more commonly today as an anti-anxiety, anti-depressant and being researched as an anti-psychotic. It may have great utility in mental health disease. It can help patients with chronic pain as well, but in my experience it does not always work for these patients. A combination of THC and CBD seems to work best for the majority of pain conditions.

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When I meet patients and prescribe cannabis I try to selectively determine which ingredients or combination of ingredients will be best for them given their condition, medical history and medications. I combine all of this information to produce a very personalized and custom treatment plan designed to improve their health and well-being. There is still experimentation that is often required and no two patients require the same mix of cannabinoids. In Canada, we have a licensed producer system which regulates cannabis production and distribution. The benefits to me as a physician is I can control the THC and CBD amounts patients receive given the regulatory framework in place. This is important when using cannabis as a medicine. As a medical doctor I do not ignore that sometimes pharmaceuticals can be better than cannabis for various conditions and I still recommend these when appropriate.

I hope you feel more knowledgeable on how cannabis work on your mind and body. Drop a comment below if interested in discussing further. Don’t forget your run or yoga session today to boost your endocannabinoid system!

  • Cannabinoid MD
Image Credits:
(Image taken from cell.com)
(Image taken from alchimiaweb.com)
(Image taken from bestcbdoil.com)

How is cannabis effective at treating cancer?

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My week started off with the following from a middle aged female with colon cancer (Let’s call her Mrs. C): “Hi doc, I was hoping I could use some cannabis oil to help cure my cancer. Can you help me?”.

I work at the cannabinoid medial clinic (http://www.cmclinic.ca) and to date I have seen about 300-400 consultations for cannabinoid therapy for patients with cancer. The types of cancers I have seen are varied: colon, breast, leukemia, and lung; and even this list is not exhaustive. Patients also come to me with a variety of different expectations, either aimed at “curing” their cancer, or conversely, to improve the side effects of chemotherapy. These include insomnia, anxiety, pain, nausea, and fatigue. In this article, I would like to both clarify and summarize the medical evidence for treating cancer-related symptoms, and offer my professional opinion as to whether cannabis can “cure cancer.”

There is emerging medical literature dedicated to studying cannabinoid ingredients and cancer. The majority of current studies take place in vitro (animal trial), because access to animals and ethics approval is easier. In vitro studies are also easier to complete. It is important to understand, however, that an in vitro effect may not be replicated in vivo (human trial). A recent summary of the medical evidence regarding cannabinoids and cancer is available online ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5054289/). Perhaps the most fascinating conclusion found in this medical review is the premise that cannabis may be effective in decreasing tumor growth and size.

There have been in vitro studies conducted focusing on the effect of cannabis on brain tumors, cervical cancer, breast cancer and colon cancer. However, there are many flaws in these studies. Such studies tend to be extremely small, often involve the co-administration of chemotherapy and radiation, and are technically designed to see if it is worth pursuing further research. Currently, there are no well-designed, double blinded, placebo controlled trials for cannabis and cancer; this is essentially the “gold standard” of medical research. However, the results published in these limited trials are encouraging. Many of the studies have shown cancers to reduce in size, limit in spread, and conclude consumption of cannabis is safe.

Unfortunately, many patients examine the above evidence and prematurely jump to the conclusion that cannabis can cure cancer. Based on the evidence currently available to us, we are not yet able to draw this conclusion. For now, the only accurate conclusion that can be drawn from reliable research is that cannabis likely has a positive effect on cancer (i.e. reduced spread, tumor growth). The research to date really opens to the door to more questions. What cancers are most favorable to cannabis-related treatment? What combination of cannabinoid ingredients? What dose? Or specifically, what protocol, combination, method of consumption, and duration of treatment?

Conversely, there is moderately good evidence throughout the literature to support the use of cannabinoids for cancer related symptoms and chemotherapy-induced side effects. These include: insomnia, neuropathic pain, anorexia, and nausea/vomiting.

When Mrs. C asked for my professional opinion on cannabinoids and cancer, I educated her on the current evidence in medical literature and explained that currently, the focus should be on improving her symptoms. I was confident that with the right combination of cannabinoids, the negative symptoms associated with her cancer could be alleviated. Perhaps most importantly, with a focus on reducing pain and suffering, improving appetite, sleep, nausea, and fatigue, the body will be better able to heal.

Article also appeared on Lift News: https://news.lift.co/cannabis-effective-treating-cancer/

Cannabinoid Medicine

My name is Dr. Michael Verbora and I consider myself a cannabinoid physician. I have spent the last two years educating myself on cannabinoid therapies and to date have completed over two thousand consultations for consideration of cannabinoid therapy.

But what are cannabinoids?

Cannabinoids are a class of compounds that act on a system in our body known as the endocannabinoid system. This system has been shown to be involved in critical biological processes such as: energy homeostasis, bone development, mood regulation, appetite regulation, pain perception, sleep, cardiovascular function and much more. I find this system to be fascinating! My goal as a physician is to target this system with medications (herbal cannabis “aka marijuana”, or synthetic pharmaceuticals that act on similar parts of the system) to improve the lives of patients with various medical ailments. From neurological disease (MS, Parkinson’s, Huntington’s), to chronic pain (neuropathic pain, arthritis, rheumatoid arthritis, lupus) to cancer or chemotherapy side effects (nausea, appetite suppression, insomnia) cannabinoids can play a role in helping patients with these conditions.

This blog is designed to share patient stories and outcomes. To dispel the many myths around cannabis. To educate physicians and health care providers about cannabinoids. To address the politics surrounding cannabis. My goal is to bring professional experience to the spotlight.  I hope you consider subscribing and reading along. I have so many positive stories I want to share with the world…