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ECS deficiency – the root cause of ‘hard-to-treat’ conditions?

A deficiency in the endocannabinoid system may play a role in conditions such as fibromyalgia, migraine and IBS

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The ECS regulates a host of different functions in the body and brain.

Could a deficiency of the endocannabinoid system be the root cause of ‘hard-to-treat’ conditions such as fibromyalgia, irritable bowel syndrome (IBS) and migraine? Some experts think so.

In medicine, some conditions are branded as ‘treatment resistant’ – in other words, they are health issues that for decades doctors have struggled to get to the bottom of. Conditions such as fibromyalgia, migraines and IBS are among the syndromes classed as ‘hard-to-treat’.

In a desperate attempt to find a solution that relieves their symptoms, many patients living with these diagnoses have self-prescribed cannabis, often risking legal repercussions to get access to – what to them, has always been a medicine.

It is only in more recent years that scientists have been turning their attention to the medicinal properties of cannabis, as well as the body’s puzzling endocannabinoid system (ECS).

Over the past two decades, the ECS has slowly emerged from relative obscurity to become a more widely known and increasingly researched area of medicine.

Fibromyalgia: A banner advert for the medical cannabis clinic

What is ECS deficiency?

The ECS was initially discovered in the early 1990s by Israeli scientist Raphael Mechoulam, during his research into the effects of the cannabis plant on the brain and body.

What he found was a system built into all animals with nervous and immune systems, which appeared to regulate a host of different functions in the body and brain, from pain and inflammation to body temperature and mood.

Over two decades, leading cannabis expert, Dr Ethan Russo, has built on Mechoulam’s original work. In 2016, he put forward the theory of endocannabinoid deficiency as a cause of certain health conditions, particularly treatment resistant syndromes like fibromyalgia, IBS and migraine.

Dr Russo hypothesised that in some conditions, there are deficiencies in the ECS that causes the system to be under-active, or to not produce enough of the endocannabinoids needed to regulate certain functions in the body and/or brain.

He found that if a patient supplemented their ECS with molecules that emulated the chemicals that transmit information from one nerve or one cell to another – known as phytocannabinoids – then this can help rebalance the ECS and as a result improve their symptoms.

Dr Anthony Ordman, one of the UK’s senior consultants in pain medicine, and an experienced prescriber of medical cannabis, believes the theory carries some significant weight. 

“I find it a very helpful hypothesis, both for helping doctors to understand how to use cannabis medicine, but also to help patients to understand what we’re trying to do,” Dr Ordman told Cannabis Health.

“In other words, they’re not necessarily medicines like morphine that actually do something, rather their purpose is in helping the body rebalance.”

He continued: “Cannabis can reduce long-term stress, which is often present in fibromyalgia patients and it can relax muscle tension and normalise sleep, which is always badly affected in [the condition].

“This concept of rebalancing the body explains how one simple group of chemicals can have so many beneficial effects. It’s not because it’s magic or mystical – it’s because it helps bring the body back to normality.”

Is this why CBD works so well?

The key elements of the ECS that affect people’s health are the endocannabinoids, anandamide and 2-arachidonoylglycerol (2-AG), as well as the relative abundance and state of cannabinoid receptors, CB1 and CB2.

Dr Elisabeth Philipps, a neuroscientist specialising in the ECS, said of the theory: “It is still quite controversial in some ways, because the ECS is not widely understood, but in terms of fibromyalgia, IBS, migraine, what they call the treatment-resistant syndromes, I think an endocannabinoid deficiency is contributing.

“I think that’s why CBD works so well for so many people in so many different conditions. It’s not by chance that somebody might take CBD for pain and somebody might take CBD for sleep. It’s because there are widespread deficiencies.”

She added: “There’s some really good work around how migraine is probably partly to do with endocannabinoid deficiency and our body not producing enough 2-AG or anandamide which the body needs for the ECS to function.”

One of the many areas of ECS research that remains incomplete, is where deficiencies in the system come from and whether certain conditions are caused by specific chemical imbalances.

Dr Elisabeth Philipps

Some theories suggest genetic makeup plays a role in people’s susceptibility to certain conditions, while others look to lifestyle choices as a possible cause.

What is clear, is that the ECS is likely to become central in scientists’ further understanding of these conditions.

“We know that multiple systems are going to be affected in conditions like fibromyalgia, which is why in conventional medicine, it’s so difficult to treat,” Dr Philipps explained.

“What we don’t know at the moment is specifically why there’s a deficiency in any of the systems – the ECS included.

“But what we do know is that by using cannabinoids, it is going to support areas like anxiety, sleep, and pain. For conditions like fibromyalgia, supporting the ECS function is going to be very much part of the picture of providing wellness.”

A holistic approach

Although compounds found in cannabis have been shown to help regulate people’s ECS, Dr Philipps stressed that medical cannabis is just part of the picture.

“We need to be looking at these conditions more holistically,” she said.

“For example, chronic stress down-regulates the ECS. We can see that there are lower levels of endocannabinoids in people who are chronically stressed.

“We can put more cannabinoids into the body, but at the end of the day removing that stress is going to help balance the body more naturally.”

For Dr Philipps, cannabis products should be part of a holistic approach to the ECS, that gets to the “root cause” of the issue. 

By continuing to research the system, scientists should hopefully be able to further understand hard-to-treat conditions and how they can be improved, she said.

“Often, you take a painkiller and it’s a bit like a plaster; you don’t really get into the root cause,” she explained.

“Using CBD or medical cannabis you are getting to the root, because you are treating or supporting the body’s ECS to work more effectively.”

Dr Philipps added: “These conditions are so widespread, from migraine to IBS, hundreds of millions of people who suffer every day don’t necessarily get the answers that they need from a conventional medical approach. 

“If we know more about deficiencies and ECS, we can understand more about how we can support it through medications or supplements.”

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Mental health

Mental health, addiction and medical cannabis – an expert’s insight

We sit down with the recently-appointed medical director of The Medical Cannabis Clinics, Dr Luisa Searle.

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Mental health, addiction and medical cannabis - an expert's insight

The recently-appointed medical director of The Medical Cannabis Clinics, Dr Luisa Searle, shares how her background in psychiatry and addiction is feeding into her new role. 

Dr Luisa Searle has been treating patients with addiction disorders for the last six years, seeing patients struggling with substance misuse and establishing outreach services for young people and the homeless across London. 

Now, she is helping people legally access cannabis, a substance that has historically been demonised as a ‘gateway drug’. 

Feeling burnt out and craving a fresh new challenge, Dr Searle was looking for a change in her career when she crossed paths with The Medical Cannabis Clinics, joining the team as medical director in April this year. 

anxiety: A banner advert for the medical cannabis clinics

“It frustrates me, this division that there seems to be in mental health, whereby if you’ve got a substance misuse issue, you’re not worthy of mental health treatment,” Dr Searle told Cannabis Health. 

“But actually, your mental health is often being self-medicated by substances and whether you agree with that or not, that’s how some people cope.”

Prior to joining TMCC, Dr Searle was unaware that medical cannabis was beginning to be prescribed more widely.

She was coming into the industry with a fresh perspective, and despite her background in addiction medicine, she said she had very little prejudice against cannabis. 

“It didn’t make sense to me to not explore it,” Dr Searle said.

Dr Luisa Searle, medical director at The Medical Cannabis Clinics

A balanced approach

“I’m not here to say it’s a wonder drug. I’m not here to say it doesn’t have its risks or side effects. It’s by no means suitable for everybody, but this idea that it’s a substance of abuse and not even [worth] researching as a potential medicine I think is, unfortunately, based in historical racism and hysteria, which has no place in science as far as I’m concerned.”

But while she was intrigued by this new and emerging field of medicine, due to her past experience, she was determined to take a “balanced approach” to prescribing. 

For Dr Searle, it is imperative that cannabis is seen for what it is. While it has immense potential for managing hard-to-treat conditions and a possible alternative to physically addictive opioids, it is still a substance that can cause dependence. 

“Any substance, legal or illegal, with some psychoactive effect has the potential for abuse, but that’s where I come in as the doctor,” Dr Searle said. 

“If I felt that you needed diazepam, that prescription is entirely under my control. It is down to me to work with patients  to try to prevent [dependency] from happening and to advise and educate them, so that they can make informed decisions about their care.”

Dr Searle is only three months into her role at TMCC but she is already seeing the positive impact that medical cannabis is having on patients. 

People with difficult-to-treat conditions like insomnia and anxiety are seeing improvements in their lives after trying numerous conventional treatments that failed to help. 

Meanwhile, patients who have previously relied on pharmaceuticals like antidepressants and SSRIs  – which can come with severe side effects – were able to “feel themselves” again after reducing their dose of traditional medication in favour of medical cannabis. 

“What’s really been nice is seeing success with people who have tried lots of different conventional treatments and haven’t really gotten anywhere,” Dr Searle said.

“I was talking to a gentleman who had a traumatic brain injury and was getting migraines on a regular basis. He had really struggled with his work and his life. With a small amount of medicinal cannabis flower, he feels much more himself.

“That’s the really nice thing [about] working in this clinic; just seeing that turnaround in people who’ve been quite stuck.”

NHS access

Having worked for the NHS for 15 years, Dr Searle is a firm believer in everyone having access to the healthcare they need. 

Right now, this does not apply to the medical cannabis space. Very few people have been able to access an NHS prescription while private prescriptions can cost hundreds per month. 

“It is a little bit challenging for me that I have to be in a private clinic in order to provide medical cannabis treatment,” Dr Searle said.

“While TMCC has extremely reasonable prices in comparison to other types of private health care, it is still a cost and if you’re on a low income it might as well be a million pounds.”

Dr Searle wants to see medical cannabis being more widely prescribed, but it has to be “sensible” with regulations around who can prescribe and how. 

She continued: “Why shouldn’t it be available on the NHS in the right circumstances? What I don’t want to see is what can potentially happen with opioids – with people becoming dependent on them.

“It’s not a medication for all. There are concerns, particularly among younger people. We’re still not 100 per cent clear as to the risks around potentially life-changing mental health issues and specifically psychosis.”

Importance of eduction

Dr Searle has not encountered huge numbers of cases where recreational users have later developed psychosis, but she has seen enough for it to be a concern. 

“It’s not something that I could just dismiss,” she said.

“When we have young people coming to us, it’s all about education. It’s just like any medication, if you start on antidepressants, you don’t start with a high dose, you start on a low dose and build it up. You check the tolerance and you review the patient regularly to see if there have been any improvements or side effects.”

Dr Searle also points out that studies into psychosis and cannabis use have examined street cannabis rather than medical-grade products prescribed by clinics like TMCC. 

“Street cannabis potentially has incredibly high levels of THC and very low levels of CBD,” she said

The benefits for some patients speak for themselves, but Dr Searle stresses the fact that a medical cannabis prescription is not right for everyone. 

“Whilst I think [medical cannabis] is great and we get lots of positive feedback, we do have some adverse reactions to it where it’s not suitable,” she said.

“People shouldn’t be lulled into a false sense of security that just because your doctor prescribed it and it’s legal for medicinal use it’s not without its risks.”

Dr Searle sees a lot of potential in cannabis as an alternative drug for chronic mental health disorders and pain, even as a possible method for weaning patients off opioids. But she warns that people who are prone to addiction may end up transferring their dependency from one substance to another. 

“If you break your leg, opioids are fantastic for that, but what they’re not so good for is chronic pain,” she said. 

“The withdrawal process from them can be horrendous and there could be a place for cannabis to alleviate some of those withdrawal symptoms.”

But, she added: “I think I would be much more cautious about that, simply because until you’ve dealt with and understood your addiction and those behaviours and those are resolved and you’ve engaged with other ways to cope with your emotional stresses, you may just be switching one addiction for another.”

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Medical cannabis and pregnancy – what you need to know

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Canadian cannabis patients use less opioids and alcohol – study

Just under half of patients say they have reduced their use of other controlled substances. 

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Canadian cannabis patients use less opioids and alcohol - study

Just under half of Canadian medical cannabis patients say the treatment has enabled them to reduce their use of other controlled substances. 

According to new data, nearly one in two Canadian patients authorised to use medical cannabis say they have been able to reduce – or cease entirely – their consumption of other controlled substances, particularly opioids and alcohol.

A team of researchers from Canada and the United States surveyed almost 3,000 Canadian patients enrolled in the nation’s federal medical marijuana programme, which began over two decades ago. 

Medical cannabis has been legal in Canada since 2001, the country legalised the possession and retail sale of adult-use cannabis in 2018.

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In the research, which was published in the Journal of Cannabis Research, investigators reported that 47 per cent of respondents acknowledged substituting cannabis for other controlled substances. 

Of those who said that they used cannabis in place of prescription medications, half acknowledged doing so for opioids – a finding that is consistent with other studies. 

Many respondents also reported using cannabis to reduce their alcohol intake.

However, the study highlighted the need for more open communication between patients and their doctors.

Around one-third of respondents did not inform their primary care providers (PCP) that they were engaging in drug substitution.

Authors concluded: “This study examined patient-provider communication patterns concerning cannabis use and substitution in Canada. 

“Results suggest that patients often substitute cannabis for other medications without PCP guidance. The lack of integration between mainstream healthcare and medical cannabis could likely be improved through increased physician education and clinical experience.

“Future studies should investigate strategies for effectively involving PCPs in patient care around medical cannabis with specific focus on substitution and harm reduction practices.”

Commenting on the findings, NORML’s deputy director Paul Armentano, said: “Cannabis has established efficacy in the treatment of multiple conditions, including chronic pain, and it possesses a safety profile that is either comparable or superior to other controlled substances.

“It is no wonder that those with legal access to it are substituting cannabis in lieu of other, potentially less effective and more harmful substances. As legal access continues to expand, one would expect the cannabis substitution effect to grow even more pronounced in the future.”

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