UK specialists have reacted to guidance deterring doctors from prescribing cannabis medicines for chronic pain due to a “lack of evidence”.
The International Association for the Study of Pain (IASP) said in a statement on 16 March, that due to a lack of evidence from ‘high quality research’, it could ‘not endorse’ the general use of cannabinoids to treat pain.
The body which brings together worldwide scientists, clinicians, healthcare providers and policymakers, to support the treatment and prevention of chronic pain, also published a list of research priorities in order to determine the efficacy and safety of cannabis medicines.
“While IASP cannot endorse the general use of cannabinoids for treatment of pain at this time, we do not wish to dismiss the lived experiences of people with pain who have found benefit from their use,” said Andrew Rice, professor of pain research at Imperial College London and chair of the IASP’s Presidential Task Force on Cannabis and Cannabinoid Analgesia.
He added: “This is not a door closing on the topic, but rather a call for more rigorous and robust research to better understand any potential benefits and harms related to the possible use of medical cannabis, cannabis-based medicines and synthetic cannabinoids for pain relief, and to ensure the safety of patients and the public through regulatory standards and safeguards.”
The statement was followed in quick succession by the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists (ANZCA) releasing new guidance urging doctors not to prescribe cannabis for patients with chronic, non-cancer pain unless they are enrolled in a clinical trial.
ANZCA, a professional society made up of almost 8,000 anesthesiologists and pain management specialists which sets standards for pain medicine in Australia and New Zealand, said there was a “critical lack of evidence” that cannabis provides a “consistent benefit for any type of chronic non-cancer pain”.
With the UK’s Advisory Council for the Misuse of Drugs (ACMD) recently stating that the IASP report would have a ‘powerful influence’ on the prescribing of cannabis-based medicines for pain, the move could be seen as a setback for millions of patients who use these medicines for chronic pain across the globe.
A “blinkered” approach to medicine
Professor Mike Barnes, an honorary neurologist and chair of the Medical Cannabis Clinicians Society, who obtained the first permanent license to prescribe medical cannabis in the UK, accused the IASP of taking a “blinkered” approach to medicine.
In his view, the statement shows a lack of compassion for patients who suffer from debilitating pain and have exhausted all other treatments.
“It is a great pity that the IASP has chosen to downplay the overwhelming evidence of efficacy and safety of cannabis for pain,” he commented.
“The IASP needs to look beyond their narrow, blinkered view of medicine and show some compassion for those in severe and chronic pain for whom no licensed medicine helps. Cannabis works and, as importantly, is safe.
“Are they saying that millions of people around the globe who use cannabis for pain every day are just wrong and misguided?”
Disappointing but inevitable
One of the country’s leading pain specialists, Dr Anthony Ordman, honorary clinical director of Integro Medical Clinics, a private pain clinic which is expert in using cannabis medicines, told Cannabis Health that he understood the IASP stance would be “disappointing” for many patients.
“Many people around the world living with long-term pain conditions – and many other conditions which are not fully managed by conventional medicines – must have felt very frustrated by the position statement on cannabis medicines,” he said.
“Many will have tried cannabis medicines, and benefitted, and would like to see these become more widely available.”
Despite this Dr Ordman said that on balance, the IASP’s decision not to endorse the use of cannabinoids was understandable – as was the current stance of other regulatory bodies such as UK’s NICE (National Institute for Health and Care Excellence) – due to the lack of “high quality” evidence in support of the routine use of cannabis medicines.
Also to be taken into consideration, he said, are the potential risks facing doctors who prescribe unlicensed medicines.
Cannabis medicines are legal in the UK, but are not yet standard licensed medicines. This means when prescribing an unlicensed medication, the individual clinician is held responsible should anything go wrong or a patient decide to make a claim against the doctor in the future.
“Unfortunately this is an inevitable stage we have to go through before we can give cannabis medicines to everyone who needs them,” Dr Ordman continued.
“Medicine gatekeepers such as NICE and the IASP are correct not to endorse these medicines, they have a huge responsibility to keep patients safe and doctors safe and, indirectly, to protect prescribers.”
“The fact is that we have no ‘Grade A’ randomised control trial (RCT) evidence on the safety and efficacy of these medicines to satisfy the requirements of IASP, NICE and so on.
He added: “On the other hand there is still plenty of supporting material in the medical literature, and there are also a number of reputable medical experts who have stated that the ‘Grade A’ randomised control study is not appropriate for the needs of treating long-term pain.”
Dr Ordman, a former president of the Pain Medicine Section of the Royal Society of Medicine, who recently left the NHS to practice privately has himself treated dozens of patients who report having benefited from using cannabis medicines for long-term pain.
“I have spent the last 25 years as a pain specialist struggling to help some people, and sometimes feeling very frustrated that we don’t have the right conventional medications to help them,” he said.
“Often all of the conventional medicines have failed to work, or imposed intolerable side effects, while patients have told me that they have been helped by cannabis medicines, particularly with long-term pain conditions such as fibromyalgia.”
He continued: “Cannabis medicines are not going to work for everybody and I can’t promise they’re 100 percent safe – any more than conventional medicines – but we make sure that the balance between a patient’s suffering and the benefit they stand to gain from cannabis medicines, almost certainly outweighs any non-specific risk.”
However, this decision is one which must be shared with the patient, and prescribing clinicians take great efforts to ensure patients fully understand the risks when taking unlicensed medicines.
According to Dr Ordman, the NHS would not currently have the time or resources needed to safely treat and support the millions of patients who could stand to benefit from medical cannabis.
“Doctors are taking a degree of professional risk when they prescribe any medicine and each patient’s case must be assessed in detail,” he said.
“In our clinic we can fully inform the patient of the risks of unlicensed medicines, but that takes a considerable amount of work, effort and scrutiny. The NHS – even if it had access to these medicines – simply doesn’t have the time or resources to do that for more than a very few patients.”
The IASP is now calling for the delivery of a ‘comprehensive research agenda’.
Previous president of IASP Dr Lars Arendt-Nielsen, who established and co-chaired the Task Force said: “Priorities include identifying patients with pain who may receive the most benefit from cannabis or cannabinoids, and who may be at risk of the most harm.
“It is also necessary to expand the range of chemical entities tested, identify appropriate doses and their effects, and determine optimal delivery methods.”
Real world evidence
While more research is welcome, it’s as yet unclear where the money for this will come from.
As Dr Ordman pointed out, RCTs – usually funded by “big pharma” – cost millions, and drug companies are unlikely to stump up the cash when they don’t stand to profit from cannabis medicines.
“It’s now up to somebody to generate the research,” he said.
“But at present, it’s difficult to see where that funding will come from, especially with Covid-19 taking up so much of our resources.”
Professor Barnes, meanwhile, is among those who believe too much weight is applied to RCTs, when discussing the safety and efficacy of cannabis medicines for certain conditions.
He argued that as a botanical medicine, cannabis does not need to be treated with the same rigour and regulation as a pharmaceutical product and pointed to existing “real world evidence” reported by patients across the globe.
“The problem is that they are acting in ignorance of the benefit of the plant and dismissing real world evidence in favour of a pharmaceutical paradigm,” he added.
“Cannabis is not a pharmaceutical product, but a botanical product and needs to be assessed as such.”
My endometriosis was misdiagnosed as an eating disorder
Sophie underwent a laparoscopy in December that revealed she had stage four endometriosis.
Endometriosis is a painful, long term condition affecting one in 10 women in the UK. Sophie Harrop talks to Cannabis Health about coping with pain, cannabis and living with a hidden illness.
Endometriosis is a condition where tissue similar to the lining womb starts to grow in other areas of the body. It can grow around other organs causing chronic pain. The condition leaves patients in debilitating pain, feeling sick and with difficulty getting pregnant. It can take on average seven years to diagnose in the UK.
Sophie was diagnosed with endometriosis in 2015 after experiencing pains in her side and severe fatigue which meant she slept a lot.
“I got diagnosed by laparoscopy in 2015 after I developed really bad period pains in the right side of my body. I started to feel like something wasn’t right as I was getting a lot of pain so I decided to go to the doctors,” she said.
“I got lucky in that some people can have endometriosis and wait up to eight or 10 years to get diagnosed but it only took me a year. I’m very grateful for getting to that point because it was very stressful.”
Doctors initially assessed her in terms of her weight and diagnosed her with an eating disorder.
“I’ve always been very thin but I eat like an animal, I just have a high metabolism,” said Sophie.
“When I went to the doctors, they thought it was something to do with an eating disorder or Irritable Bowel Syndrome (IBS). There were so many different things that they suggested to me.”
Her doctor suggested she keep a food diary so they could track the amount she was eating. The diary proved that she was eating as much as she said, but she was disheartened.
“I can’t express to you how much I have something wrong with me, but it’s not an eating disorder,” Sophie continued.
“I’m quite a strong-minded person but to others who aren’t, I feel it’s very damaging. People are brought up to think doctors are always right, but I was annoyed they were coming up with these things.”
Sophie had a laparoscopy in December 2020, which revealed she had endometriosis across her bowel and bladder. The condition is measured in different stages, that map the depth and areas affected by the tissue.
Sophie was told she was stage four which means it is the most severe. At this stage, endometriosis is now widespread and deeply implanted. There may also be cysts on one if not both ovaries.
Life with endometriosis
Sophie had been brought up to be a “tough cookie” and hadn’t realised how bad things were until her laparoscopy. She says her mother also struggled to believe that the pain was that bad, until her scan.
“I never realised how bad it was until the laparoscopy,” said Sophie.
“In your mind, you start to wonder if you have made it up, and my mum never believed me. She came into my room afterwards in disbelief at how bad it was.”
She added: “At the time, I was working at a builder’s merchants as a marketing manager. I was the only woman among 22 men, with a very strict boss. If I had days where I didn’t feel well, he would tell me to get into work. It was hard to be around all these men because I was in so much pain and no one understood it. That’s what I find with endometriosis, it’s so hard to express how you feel.”
Sophie, described a feeling of heaviness, she explained: “When it’s bad, I get this feeling as if I am 90 stone. It’s a feeling like I have something attached to me pulling me down. People can’t relate because no one knows what this feels like, but when you find other endometriosis sufferers, they understand.”
Endometriosis, mental health and ADHD
Sophie now relies on a combination of both medical cannabis and CBD to help her symptoms. She has also been diagnosed with Attention Deficit Hyperactive Disorder (ADHD) and finds this combination of eases the different symptoms of both conditions.
At the time of her laparoscopy, Sophie was already consuming cannabis. She explained that the nurses laughed at her when she said she would prefer to treat her pain with cannabis, rather than the prescription drugs she was being offered. It was a chance encounter with CBD that piqued her interest in what cannabinoids could offer.
“My friend’s dad opened a CBD company and introduced me to it. I had a really bad sunburn with very badly burned thighs. He gave me a little pot of cream which I applied then the next day it was gone. I had to find out more about it, she says.
“Since then I have done a lot of studies and nearly completed a course on medical cannabis and CBD. I spend every day of my life learning more about it.”
The mental health impact of endometriosis which is another area which Sophie feels is misunderstood. She uses CBD to help her mental health, but finds that THC is more effective in helping the pain caused by the condition.
“People don’t understand the mental factor of endometriosis. It’s triggered by stress, so if I’m going through stressful periods in my life then I am more bed-bound and in a lot of pain. I notice with my menstrual cycle that somedays I have days where it feels like the world is against me.
“I take CBD every day without fail but when I had a couple of days off THC, I noticed the pain was still there in the same places, but it was sharper. It was like I had barbed wire in my stomach that was on fire.”
Chronic illness and sports
Sophie is an incredibly active person who takes part in a range of sports, especially hiking which she shares on social media. She wanted to show that not all chronic illnesses are visible and that patients should not be judged by what they post online.
She has now opened an online store and uses her platform to educate customers about the benefits of CBD. She isn’t motivated by the money when it comes to being in business, but wants to provide enough information to empower people to make their own decisions about their health.
“I get a lot of people who say to me that I haven’t got endometriosis, and that I’m not chronically ill by judging me off my social media. It frustrates me because I would never wish the pain or illness on anybody.
“The reason I go out and do these things is that I have a lot of drive and could be in so much pain but will still get up and out as I would rather be in nature. It makes me feel physically better than sitting in my bed,” she said.
“I want to educate people to have the confidence to go try cannabis. Everyone is different and I want to be able to give people the confidence to do their own research and understand their own bodies. I’m not anti-doctor as I wouldn’t be where I am today without my gynaecologist and my amazing surgeon but at the same time, I wish people would think for themselves rather than just going off the doctor’s opinion.”
When it came time to choose the products she would work with, she immediately knew she wanted to include CBD coffee.
“I have my own coffee brand. The reason I introduced coffee into it was that I would always forget to take my dose in the morning but then in the evening, I’m fine. I created the CBD coffee because I thought it could be added into your life quite easily.”
Sophie finds the CBD industry incredibly rewarding to work in.
“I’m so passionate about this industry, she adds.
“People say to me that I’m literally the happiest person ever, but everyone has bad days. We have to have the bad days to appreciate the good days. I definitely feel my happiness and energy comes from cannabis and its helping to balance everything out.”
David Beckham-backed CBG skincare line launches new products
David Beckham-backed CBD brand, Cellular Goods, has launched a new collection of skincare and edibles that contain CBD and CBG.
The Cellular Goods launch is taking place nine months after the announcement of Beckham’s DB Ventures investment back in February 2021. The company managed to raise £13 million in their original public offering.
The Cellular Good skincare line contains serum, face oil and after-shave moisturiser. The ingestible collection includes a tincture, spray and capsules.
The skincare collection is the UK’s first CBG range. Their face oil contains ultra-pure, bio-synthetic CBG, hemp and grapeseed oil. The combination of all three is thought to hydrate, regenerate and smooth the skin while adding a source of essential fatty acids.
CBG is thought to have anti-inflammatory properties which may make it great for acne or blemishes. It may also be an anti-bacterial preventing infection. The essential fatty acids contained within different cannabinoids could have anti-ageing properties as they help to plump the skin and hydrate. All products are suitable for sensitive skin, dermatologically tested and dermatologist approved.
Cellular Good’s shaving gel contains some of the most popular skincare ingredients of the year including hyaluronic acid which locks in moisture to improve skin health and Niacinamide which is used to brighten the complexion.
CBG is the latest cannabinoid to gain interest, especially within the beauty and wellness sector. However, CBG is rarer and harder to extract than CBD which can make it more expensive.
Cellular Goods range
The ingestible collection contains just CBD rather than CBG.
Cellular Goods was established in 2018 to develop research-backed and efficacy led products. The products are made using lab-created CBD and CBG which means the company do not need to cultivate cannabis which they believe is a greener alternative than field grown.
Cannabis Health has reached out to Cellular Goods to determine the level of CBG within the skincare line. They had not replied at the time of publication.
Could medical cannabis help with HIV/AIDS?
To mark World AIDS Day, we examine if medical cannabis could help with symptoms such as nausea, pain and anxiety.
On World AIDS Day, we examine the science behind taking medical cannabis to help manage some of the symptoms.
Wednesday 1 December marks World AIDS Day, dedicated to raising awareness of HIV/ AIDS and also mourning those who passed away.
The UN AIDS estimates that 37.7 million people globally were living with HIV in 2020. They also estimate that since the start of the epidemic, 36.3 million people have died from AIDS-related illnesses.
What is HIV?
The first cases of HIV/AIDS were recorded in the late 70s and early 80s. As the first cases began to originate in the gay community, the disease was originally referred to as ‘GRIDS’ which stood for Gay-Related Immunodeficiency Disease.
Human Immunodeficiency Disease (HIV) is a virus that affects the immune system. It damages and weakens the cells making it easy for opportunistic diseases or infections to get in. The body is unable to defend itself. HIV is found in the semen, vaginal and anal fluids, blood and breast milk of those with the virus. It can be passed from person to person but AIDS cannot. Most people with HIV, thanks to advances in science may go on to develop AIDS but live with the disease for longer periods of time.
How do HIV and AIDS differ?
Acquired Immunodeficiency Deficiency Syndrome (AIDS) is the name given to a collective group of opportunistic illnesses that occur after the immune system has been damaged by HIV.
The most common ways to transfer HIV is through unprotected anal or vaginal sex or sharing unclean needles. The NHS estimate that 80 per cent of those who contract HIV will experience a flu-like illness for one to two weeks after infection. The most common symptoms are sore throat, raised temperature, rashes, tiredness, joint pain or swollen glands.
Could Medical Cannabis help with HIV symptoms?
HIV and Appetite loss
One of the first reasons why patients began to turn to medical cannabis in the 80s to help with symptoms was to counteract AIDS wasting syndrome and associated pain.
The lack of appetite means patients may seldom feel hungry enough to eat or feel well enough to prepare a meal. Cannabis helped patients experiencing this to regain their appetite. It is estimated that the prevalence of wasting syndrome can be between 14 and 38 per cent.
In the late 80s, doctors started to prescribe Marinol which contains synthetic tetrahydrocannabinol.
Peripheral neuropathy, or nerve pain, happens when some of the nerves get damaged. It can cause stabbing pains, burning, or tingling sensations in the hands and feet. HIV and antiretroviral medications may trigger the pain. HIV When the immune system is weakened this makes it easier to get other infections that can cause peripheral neuropathy.
Marinol was often prescribed for neuropathic pain as well as appetite stimulation. Cannabis was thought to help with some of the nerve pain caused by early AIDS medication such as AZT. Neuropathic pain, which is where the exterior sheath covering nerve cells is stripped away exposing nerve endings resulting in chronic pain.
A review from 2018 suggested that medical cannabis may be a tolerable and effective neuropathic agent. The researchers analysed over 16 different studies with 1750 participants.
The authors wrote: “The evidence appears to support the safety and efficacy of short-term, low-dose cannabis vaporization and oral mucosal delivery for the treatment of neuropathic pain. The results suggest medical cannabis may be as tolerable and effective as current neuropathic agents; however, more studies are needed to determine the long-term effects of medical cannabis use.”
THC may help with improving the quality of sleep experienced by HIV+ patients. One of the symptoms of HIV can be night sweats which make it difficult to stay asleep or cause poor quality rest. This results in increased fatigue which can leave a patient feeling more run down and stressed as a result.
Night sweats occur when the body is attempting to fight a disease such as HIV. This often accompanies joint pain, unexplained weight loss, fever and chills.
A study suggested that consuming cannabis with higher THC levels can reduce the amount of REM sleep patients experience. This means a deeper, more restful sleep which can lead to better, restorative rest.
Leaning into terpenes can also help. Some terpenes are thought to be really helpful for better sleep including Linalool which is found in lavender, geraniums and jasmine.
Better cognitive function
A study from New York in the journal, AIDS Care, reported that HIV+ patients who consumed cannabis showed the same or greater cognitive performance than non-users.
Researchers took 138 HIV+ patients of which 47 had a history of cannabis use while 91 did not. Those with a history of cannabis use were found to have ‘better processing speed, visual learning, memory and dominant hand motor ability.’
Reduced neuroinflammation due to HIV
A study from San Diego examined if daily cannabis use might reduce central nervous system inflammation in a cohort of patients with and without HIV.
The researchers noted that those who consumed cannabis had lower levels of chronic inflammation compared to those who did not. Furthermore, the users’ results were similar to the HIV subjects with no history of cannabis use.
This may make it useful for preventing or delaying the development of HIV Associated Dementia which is where the virus spreads to the brain. It can cause memory loss, difficulty thinking, concentrating and speaking clearly. It is a progressive disease that sadly gets worse with time.
It may also help with HIV Associated Neurocognitive Disorder which is often found in the later stages of the disease. It causes progressive loss of memory, behaviour and motor function problems.
Different forms of dementia and some cognitive issues are thought to be caused by inflammation. It has been linked to a number of different conditions such as Alzheimer’s Disease, depression and anxiety. Although more research is needed to understand how cannabinoids interact with our endocannabinoid system and the receptors in our bodies, a study from 2016 shows THC may be neuroprotective.
Authors wrote: “Cannabinoids such as tetrahydrocannabinol stimulate the removal of intraneuronal Aβ, block the inflammatory response, and are protective.”
As with any long term health condition, there can often be a lot of anxiety and depression around diagnosis.
Some cannabinoids such as THC and CBD are thought to potentially help with anxiety. It may induce feelings of calm, improve relaxation and also help with better quality sleep.
There is some debate over the balance of THC and CBD when it comes to anxiety. Some believe that lower doses of THC while higher CBD hybrids may help reduce the risk of worsening symptoms. Alternatively, some patients choose to balance their own ratios depending on their particular symptoms on the day by combining CBD and THC in different ways.
HIV and T-cell count
When HIV enters genetic information into our T cells, it makes copies of itself causing the helper T cells to die. This disrupts our immune response allowing opportunistic infections to get in without detection or fight.
CD4 are referred to as ‘helper cells’ that help the body to recognise pathogens with a protein called CD4. However, CD8 T cells are referred to as ‘killer cells’
Killer T cells seek out pathogens and help to destroy them preventing infection. If T Cells fall below a certain number, a person may go on to receive an AIDS diagnosis. Certain medications, such as chemotherapy, can affect a T cell amount so it is important to note if a new prescription may be safe to take or not with HIV.
One study from 2008 offered a longitudinal analysis of both HIV+ and HIV- men who reported that their cannabis did not have an impact on the CD4 and CD8 T cell counts.
How to get a medical cannabis prescription for HIV/AIDS
This requires self-referring or asking your GP to refer you to a clinic in the UK for assessment. The clinics will not be able to diagnose HIV or AIDS but will be able to discuss the options with you.
Medical cannabis is usually assumed to be the last option if prescription medication has not worked to control the symptoms. After an initial assessment, your doctor at the clinic can discuss if cannabis is the best possible option, what you can expect to experience and how the costs work.
A prescription may be offered in a number of different formulas such as oils, flowers or topicals.
What is the best way to take medical cannabis for HIV/AIDS?
There is no right or wrong way to take medical cannabis or CBD for HIV/AIDS. The best way is to talk to your doctor about what will suit your current condition and lifestyle. If a patient is experiencing problems with a sore throat which is common with the flu symptoms or fungal infection such as oral thrush, then swallowing edibles may be difficult. Alternatively, vaping may aggravate lung pain.
Edibles or vaping may be a better option if the taste of oils creates a problem. Keeping a journal of your medical cannabis intake can be helpful when it comes time to have your first follow up appointment or in assessing how a particular product is working for you.
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