Pain researcher, Dr Kevin Boehnke, PhD of the University of Michigan Medical School, discusses findings from his latest study; Pills to Pot: Observational Analyses of Cannabis Substitution Among Medical Cannabis Users With Chronic Pain.
In a large nationwide survey study (N=1321), my colleagues and I found that individuals using cannabis for chronic pain management reported reductions in the use of opioids and other pain medications.
In our retrospective study, 53 percent (n=691) of participants substituted cannabis for opioids and 22 percent (n=287) for benzodiazepines, with more than 65 percent of substitutors reporting discontinued use of these medications due to better symptom management and fewer side effects.
These results corroborate our 2016 pilot study (N=185), which showed a 64 percent decrease in opioid consumption among patients using medical cannabis for chronic pain management.
The rationale and effect size are consistent with studies conducted in Canada that similarly gauge substituting cannabis for other medications.
Our study population was 59 percent female with a mean age of 49.8 years (SD±13.8), reflecting the population demographic in which chronic pain is common – older adults and women.
Cannabis as an opioid alternative
The poor performance of many pain medications, including high numbers needed to treat (NNT) and challenging side-effect profiles, have many looking for alternatives that have greater analgesic efficacy.
Additionally, the ongoing opioid crisis has made it more difficult to obtain opioid prescriptions, and the increasing social acceptance of cannabis as a safe, alternative medication may be driving people toward opioid alternatives.
Although our data are observational and retrospective, the pat tern emerging from these and numerous similar studies makes it clear that some individuals derive benefit from cannabis-based medicines—enough so that they discontinue traditional pain medications.
Strategies for effectively substituting cannabis for opioids
Despite this pattern, however, we must proceed cautiously, as other studies report that cannabis use is associated with worse clinical pain symptoms and prescription medication misuse.
Although some may frame these incongruent findings as conflicting, we believe that they instead suggest that there are subsets of individuals for whom cannabis is unhelpful (or even harmful), and others for whom substitution is possible and clinically useful. Thus, the pressing questions moving forward are how and in which clinical populations this substitution can be done most effectively.
Although we did not examine whether participants modified their medication regimen under the guidance of medical professionals, some recent studies provide intriguing hints of how clinicians might help patients effectively substitute cannabis for opioids.
For example, Sagy et al. reported that patients with fibromyalgia (N=367) were guided by a certified nurse through a slow, methodical titration regimen of delta 9-tetrahydrocannabinol (THC) oil and/or cannabis flower.
After six months, participants reported significant improvements in pain and quality of life, as well as decreased opioid and benzodiazepine use.
Similar effects were found in a study examining patients with chronic pain (N=600; unspecified conditions) who were under going an opioid taper.
Participants were given access to sublingual, oral, and/or vaporised cannabis products with appropriate education on dose titration, as well as online psychological sup port tools. Eighty-one percent of participants discontinued or reduced their opioid dose and all but one participant reported satisfaction with sleep, pain control, and quality of life.
Additionally, two recent clinical trials shed light on important mechanisms by which Cannabidiol (CBD) and THC may alleviate opioid withdrawal or reduce opioid consumption.
In the first study, Hurd et al. showed that CBD reduced cue-related anxiety and craving among individuals in recovery from heroin use disorder, suggesting that CBD may assist in quelling symptoms related to opioid addiction or dependence (and perhaps other substance use disorders as well).
In the second study, Cooper et al. found that smoked THC dominant cannabis combined with sub threshold doses of oxycodone provided similar pain relief as a higher dose of oxycodone, providing plausibility that individuals could reduce opioid consumption by adding cannabis into their treatment regimen.
Taken together with the observational studies mentioned above, these findings highlight several important factors for substituting effectively: flexible dosing regimens (both in terms of cannabinoids and administration routes), educational supports for both cannabis titration and pain-related symptoms, and psychological services.
Tips for providing clinician oversight in cannabis treatment
Although federal restrictions present challenging barriers to con ducting rigorous cannabis studies (especially randomised clinical trials), cannabis is becoming increasingly available. States have continued to pass both medical and adult-use cannabis legislation, and hemp-derived CBD products are available in nearly all states.
In this context, patients can and will use cannabis for symptom management. Despite the lack of strong clinical trials that give explicit dosing guidance, clinicians can still provide sound clinical oversight by:
- Developing treatment plans that take into account patient expectations/goals (eg, substitution) and that include symptom tracking;
- Employing harm-reduction strategies (eg, avoid smoking, “start low, go slow”); and
- Ensuring patients know the limits of both the evidence and the regulatory system in place — especially for CBD products, which often are inaccurately labeled and do not undergo stringent safety testing.
In so doing, clinicians can embody the practice of evidence based medicine by synergising the best available scientific evidence with compassionate clinical expertise that accounts for the preferences and rights of patients with whom they are making clinical decisions.
This is not yielding to a health fad, but taking a step toward demystifying cannabis so it can be judiciously used as medicine.
Kevin Boehnke, PhD, is a research investigator in the Department of Anesthesiology and the Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, Michigan.
This article was originally published in the American Journal of Endocannabinoid Medicine (AJEM). Find the original article including reference list here
Fibromyalgia diaries: Travelling as a medical cannabis patient
Medical cannabis patient, Julia Davenport, on the challenges of travelling with a prescription.
While cannabis oil has dramatically improved fibromyalgia patient Julia Davenport’s quality of life, it has brought with it new challenges when it comes to travel, as she explains here.
Chronic pain has a nasty habit of getting in the way of doing the things you love.
My big passion which I share with my husband, and I guess our one extravagance, is jetting off to far flung places.
Over the years, however, fibromyalgia, arthritis and aching joints have conspired to make travelling evermore arduous.
Now in my 70s with various replacement parts, difficult terrain is one of the biggest barriers to exploring new places.
Certainly, my husband’s bucket list destination, the Galapagos Islands, is on my no-fly list. I would have adored to go there at some point, but navigating those volcanic rocks, even with my walking stick, would be a nightmare.
Familiar holiday spots closer to home are also becoming increasingly inaccessible. Every year our extended family visits the same Northumberland cottage, which is at the bottom of a steep bank.
In years gone by, I’d be fine to walk down to it through the working farm in which it stands. Now, because my back and shoulders have deteriorated, I have to drive right to the door.
Finding ways to compensate for the things you can no longer do is a constant theme with chronic pain conditions.
Aside from mobility challenges, another restriction on travel with rheumatological conditions can be the weather, and humidity can play havoc with chronic pain. I’d love to go to Central America, for example, but I just couldn’t tolerate the heat and humidity.
Having said that, although hot dry weather is far better than the cold British winter, the difference is not enough to drag me away from my family at Christmas time.
For all my gripes about life on the road, though, traveling remains my great joy, and discovering medical cannabis and CBD has definitely helped; although it’s not all plain sailing.
Travelling with medical cannabis
In November I’m returning to South Africa, a place I’ve visited a few times and which has a special place in my heart.
On previous visits, because we’ve flown via Dubai, I’ve not taken medical cannabis or CBD with me.
There is no way I’d risk taking cannabis with me to the UAE, where people have apparently been arrested and put in jail for having codeine, never mind anything else, despite having a prescription for it.
They have a ridiculously long list of substances that they deem addictive which you can’t have. There are things you can apply for permission to take, but I just wouldn’t trust that I wasn’t going to get arrested.
When we’ve flown long-haul through Dubai in the past, I would tend to take enough medication just for the journey. I have even flushed pain medication down the toilet on a connecting flight to Dubai just to make sure I’m not in possession on arrival.
I’ve then managed to pick up cannabis products quite easily in certain final destinations.
In South Africa there was a shop similar to a Holland and Barrett which sold CBD products legally. They were able to match the equivalent of what I was already taking to their products.
In Japan, it was also relatively easy to buy CBD over the counter, even with the language barrier.
In the past, the ease at which you can buy CBD has definitely influenced my travel choices. There are lots of countries that I’d give a wide berth to because of their approach to medication, which is often underpinned by false views on addiction.
At the same time, with so many countries opening up to CBD, travelling is getting easier and the main challenge is the routing of flights through the Gulf.
Thankfully on my next trip to South Africa we are travelling direct to Cape Town directly so I can rest easy that I won’t end up behind bars.
Guidance for travelling with medical cannabis
Some countries allow medicinal cannabis and some even recreational cannabis. Some allow CBD but others do not.
Guidance from the Medical Cannabis Clinicians Society recommends that patients always contact the embassy to check the legal situation in the country they are visiting before travelling with medical cannabis.
Some countries require a letter of proof from a clinician, some require a request to be submitted to the embassy requesting to travel, some restrict the amount of medication you are able to travel with, i.e. up to 30 days supply. It is suggested that any guidance is sought and confirmed in writing.
It is advised that travellers keep medication on their person, stored in its original packaging along with a copy of their issued prescription and relevant corresponding paperwork.
You can get an idea of the country’s stance on cannabis initially by searching for “legality of cannabis” on Wikipedia – but always check with the embassy as well.
Fibromyalgia diaries: To vape or not to vape?
Medical cannabis oil has been life-changing for Julia, but she’s still struggling to come to terms with vaping.
Fibromyalgia patient Julia Davenport says cannabis oil has been life-changing for her, but she’s still struggling to get on board with flower.
My perception of cannabis has changed dramatically in the few years since I started taking it as pain relief.
As I mentioned in my last entry, I’m from a generation which, despite living through the enlightened age of the 1960s, grew up believing the plant to be bad.
This created a strong resistance to even trying CBD or medical cannabis when they emerged as possible treatments for pain associated with my fibromyalgia and arthritis.
I’m over that now, and take CBD daily, with a private medical cannabis prescription to use orally whenever I have a flare-up.
One taboo I’m still struggling to get past, however, is the use of vape.
Buried in my kitchen drawer is a dry herb vapouriser, alongside the medical cannabis flower prescribed to me by a pain consultant.
With this, I’m armed and ready with what I understand to be the fastest route for medical cannabis to get into the bloodstream.
But, sadly, although it could have rescued me on several occasions in the year since I bought the device, its box remains sealed.
I’m sure many Cannabis Health readers will be shaking their heads right now. What a travesty that something millions of people with a range of conditions could potentially benefit from is going to waste.
I do truly feel lucky to have a private prescription at a time when countless others are unable to access medical cannabis through cost, red tape or misinformation.
The problem I have is my huge aversion to smoking. Yes vaping isn’t smoking, but the action of ingesting something that looks like smoke into your lungs just doesn’t feel right.
While I’ve never smoked in my life, my father was a heavy smoker who suffered from the lung disease, chronic emphysema. My mother also had coronary artery disease, possibly related to smoking.
For these reasons, I just have a mental block about vaping, despite reading about how effective it can be as a breakthrough remedy.
No doubt many people my age, who grew up with parents who smoked, also feel the same; and perhaps there is some way to go before vape vendors can escape perceived links to smoking.
Maybe more evidence on the impact of vaping on the lungs will help to change this over time – and I’ll eventually make use of my vapouriser.
Meanwhile, in putting my fibromyalgia diary together, I began to think about all the ways cannabis has changed my life. I thought I’d share perhaps the most unusual one – going cold turkey on my teddy bear collection.
With chronic pain conditions, including fibromyalgia, night time can be particularly difficult and insomnia is common. It is a horrible experience to feel utterly drained but be unable to fall asleep, sometimes for days.
Before discovering CBD and medical cannabis I would often find myself wide awake in the middle of the night. It was at these times that my attention drifted on my iPad to eBay.
For some reason, possibly nostalgia, my search for distraction amid the pain and boredom took me to the furry world of vintage teddy bears.
Many nights spent bidding for bears in the blue light led to a considerable collection building up.
Now, my days as an arctophile (yes there is a word for someone who collects or is very fond of teddy bears) are over.
My CBD and medical cannabis regime has significantly cut the number of sleepless nights I experience and, in turn, the volume of new bears taking up space on my shelves.
Next time: Travelling as a medical cannabis patient.
“As a psychiatrist I have been amazed by the power of medical cannabis”
Dr Tahzid Ahsan, a consultant psychiatrist on discovering the benefits of cannabis for mental illness.
Estimated reading time: 6 minutes
For almost 20 years I was shamefully oblivious to the truth, but now I have seen the benefits of medical cannabis in all walks of society, writes Dr Tahzid Ahsan, consultant psychiatrist and prescriber at The Medical Cannabis Clinics.
Professor David Nutt wrote a recent article for the British Medical Journal, entitled; Why doctors have a moral imperative to prescribe medical cannabis
So when did the moral compass change around cannabis and why?
For thousands of years cannabis has helped humankind with discomfort and diseases of the mind, body and spirit, discussed in great detail as a form of medicine in ancient Hindi, Chinese and Arabic manuscripts.
The current stigma arises from a period of civil rights movement in the 1960s US, leading to a direct ban on all psychoactive substances during the ‘flower power ‘era.
The US’s number one ally followed suit, with the UK enforcing the 1971 Drugs misuse act as swathes of ethnic minorities were migrating to the UK, leading many to being incarcerated for cannabis use.
In the 1980s I grew up in an inner city area of a major city, where social and economic deprivation were rife. I recall young black and ethnic minority men being incarcerated by the police due to cannabis use, some were even placed into mental health units under the premise of the 1983 Mental Health law, stating that they were psychotic due to cannabis use.
Despite substantial evidence to suggest that migration and trauma is a factor for someone to develop schizophrenia and psychosis, the abhorrent stigma still remains that cannabis directly causes this.
As a result , rightly or wrongly, the three associations that are currently most attached to cannabis are criminality, race and socioeconomic status, preventing a nascent industry and treatment from getting the exposure that it deserves.
For almost 20 years I was shamefully oblivious to the truth, the veil of ignorance preventing me from seeking further knowledge around a substance that had helped with mind, body and spirit for thousands of years.
As a training day coordinator for my consultant training scheme in 2017, I managed to have an invitation accepted by my ‘hero’ Professor Nutt himself. Witnessed by over 150 psychiatrists, Professor Nutt reflected on the past, present and future of psychiatry, with us. I recall the grumbling tones of protestation from the crowd when cannabis was mentioned as a potential treatment for many mental health conditions in the future.
In 2018, the story of young Alfie whose life was transformed by medical cannabis, led to a dramatic change to the 1971 Drugs Misuse Act, whereby cannabis for medical use was reduced in scheduling meaning it could ‘be prescribed in humans’. This small change in the law has led to a fledgling industry.
I joined The Medical Cannabis Clinics in November 2020, the first medical cannabis clinic to form in the UK. I then became a registered doctor for Project Twenty21, set up by Professor Nutt’s organisation Drug Science. The project made medical cannabis prescriptions more affordable, as well as gathering important real world evidence for research.
Over the past two years I can honestly say I have been truly amazed by the power of medical cannabis.
My shock comes from how medical cannabis can traverse such a huge range of mental illnesses in such a short space of time, with very little side effects noted.
Patients love the fluidity and malleability of medical cannabis, they don’t feel it’s dictating their lives like traditional medications have done. Some have even described cannabis as an accompaniment to their lives like a “long lost friend”, helping them cope from moment to moment, providing them with the necessary headspace to recover, grow and learn.
With one cannabis flower I have treated people with depression, anxiety, autism, ADHD, PTSD, insomnia and more.
I have seen the benefits in people from all walks of British society, from the 70-year-old lady in a local village to an 18-year-old male from south London.
I have heard many stories where people were literally at the end of the tether, having gone through a multitude of medications and therapy, to finally find something that can help them feel ‘normal’ again. They can now live life to the fullest, with a new found confidence in themselves to interact with the world around them in a fruitful manner. When I hear patient’s stories of how they have reconnected with people who they had avoided for many years, it almost brings a tear to my eye.
In my entire 20 years of being in the medical field, I have never once heard an equally glowing review about a particular psychotropic medication, in comparison to medical cannabis.
My whole perception of medical recovery has changed. As clinicians we dictate what the patient should have, and at what time. If they don’t conform, we label them as ‘non-compliant’ (bad patients), despite the side-effects causing more issues for some than the condition itself.
With medical cannabis, patients can choose what strain and how much percentage of THC or CBD they would like, the terpene profiles that suit their goals and needs, adjusted according to how it benefits them. For the first time in their lives patients are enjoying recovering from their mental ailments through the power of medical cannabis.
Unfortunately most in the UK are completely oblivious to the immense benefits of cannabis as described above, still associating cannabis with criminality, race and socio-economic status.
Due to certain elements of the Proceeds of Crime Act 2012, we have been left in a position where the UK is one of the biggest exporters, as well as the biggest importers of medical cannabis. Yet UK patients cannot benefit from locally grown medical cannabis, they can only be prescribed cannabis that has been transported across the world. This has created a bottleneck where patients have been left waiting for weeks due to stock issues.
It’s promising to hear that MPs such as Jeff Smith, who recently motioned the Medical Cannabis Access Bill, are working to try and make quality medical products more easily accessible to patients.
In the west, research and subsequent treatment depends on the gold standard of randomised controlled trials (RCTs). If evidence of treatment has not followed these standard research protocols, the evidence is almost dismissed by clinicians.
As you can imagine it’s easy to do research on a drug where dosages can be changed very easily in a neat incremental manner. But cannabis does not fit into the neat categories within RCTs. The effect of the flower can change according to the strain, terpene profile and cannabinoid content. It requires a different approach and respect when it comes to evidencing benefits of medical cannabis, with more emphasis on qualitative clinical case studies.
At a time of great division nationally after Brexit and ongoing worldwide geopolitical turmoil, medical cannabis could be a unifying force that allows for more compassion and understanding between all of us.
Cannabis, like the notion of ‘faith’, knows no boundaries, colour creed, or religion. I feel truly blessed that I have come across a treatment that I believe will shape the western philosophy of medicine for the foreseeable future.
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