Medical Cannabis Linked to Rebound Headaches

By Pat Anson, PNN Editor

Medication overuse headache, also known as “rebound” headache, is a common problem for people who frequently use pain medication to relieve headaches and migraine.

According to the American Migraine Foundation, rebound headaches can be triggered by a wide assortment of analgesics, from aspirin and triptans to acetaminophen and opioids. Even caffeine can cause a rebound headache if you consume more than 200mg a day – about two cups of coffee.     

So perhaps it’s not surprising that medical cannabis is also associated with medication overuse headache, according to a preliminary study by researchers at Stanford University School of Medicine.

“Many people with chronic migraine are already self-medicating with cannabis, and there is some evidence that cannabis can help treat other types of chronic pain,” said study author Niushen Zhang, MD, a neurologist who is director of Stanford’s Headache Fellowship Program.

“However, we found that people who were using cannabis had significantly increased odds of also having medication overuse headache, or rebound headache, compared to people who were not using cannabis.”

Zhang and her colleagues looked at the medical records of 368 people who had chronic migraine -- which is 15 or more headache days per month. Less than half were using medical cannabis

Researchers found the cannabis users were six times more likely to have rebound headaches than those who did not use cannabis. People who used cannabis were also more likely to take opioids.  Previous research has found that opioids and cannabis can both influence the part of the brain called the periaqueductal gray, which has been linked to migraine.

Zhang’s study will be presented at the American Academy of Neurology’s annual meeting next month.

Medical cannabis has become a trendy alternative to pharmaceuticals for treating migraine, with research showing that both inhaled and ingested cannabis can reduce migraine pain. 

A recent study of nearly 10,000 people in the U.S. and Canada who used a migraine tracking app found that 82 percent who used cannabis believed it was an effective pain reliever.    

A 2017 study conducted in Israel found that combining THC and CBD in an oral dose was just as effective in treating migraine pain as amitriptyline – a tricyclic antidepressant commonly prescribed for migraine.

And a 2016 study at the University of Colorado found that cannabis significantly reduced the number of migraine headaches. Inhalation appeared to provide the fastest results, while edible cannabis took longer to provide pain relief.

About a billion people worldwide suffer from migraine headaches, which affect three times as many women as men. Over 37 million people in the United States live with migraines, according to the American Migraine Foundation.

Cannabis Reduces Blood Pressure in Older Adults

By Pat Anson, PNN Editor

Medical cannabis is being used to treat dozens of health conditions, from chronic pain, muscle spasms and nausea to hepatitis, HIV and glaucoma.  Now we’re learning that cannabis may also be a useful treatment for high blood pressure.

A small study conducted by researchers at Ben-Gurion University of the Negev (BGU) in Israel found that cannabis significantly reduces systolic and diastolic blood pressure in older adults with hypertension. The study, recently published in the European Journal of Internal Medicine, is believed to be the first to document the cardiovascular benefits of cannabis.

“Older adults are the fastest growing group of medical cannabis users, yet evidence on cardiovascular safety for this population is scarce,” said lead author Dr. Ran Abuhasira of BGU and Soroka University’s Cannabis Clinical Research Institute. "This study is part of our ongoing effort to provide clinical research on the actual physiological effects of cannabis over time."

Twenty-six patients aged 60 and older either smoked cannabis or ingested it through oils, while their blood pressure, heart rate, and body measurements were monitored.  After three months of cannabis therapy, their mean 24-hour systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively. Blood pressure was lowest three hours after ingesting cannabis and at night.

Researchers believe that pain relief, the primary reason most patients use medical cannabis, may have contributed to lowered blood pressure.

Previous studies by BGU researchers found that cannabis significantly reduced pain in older adults living with cancer, Parkinson's disease, post-traumatic stress disorder, ulcerative colitis, Crohn's disease, multiple sclerosis and other chronic conditions. Most patients also said their quality of life improved.

A growing number of seniors are discovering the medical benefits of cannabis. A recent survey of patients at a geriatric clinic in Southern California found that over half were using cannabis on a daily or weekly basis, usually to treat pain, difficulty sleeping, anxiety and depression. Although medical marijuana has been legal in California since 1996, nearly two-thirds of those surveyed said they used cannabis for the first time as older adults.

Are Cannabis Dispensaries Really Associated with Fewer Opioid Overdoses?

By Roger Chriss, PNN Columnist

A new study published in The BMJ claims that U.S. counties with medical and recreational cannabis dispensaries have fewer opioid-related deaths.

Researchers at Yale and University of California at Davis found that an increase of just one or two storefront dispensaries in a county was associated with a 17% reduction in all-opioid mortality rates. Deaths involving illicit fentanyl and other synthetic opioids fell by 21 percent.

Although the researchers cautioned that “the associations documented cannot be assumed to be causal,” cannabis supporters were quick to praise the findings.

“The data to date is consistent and persuasive: For many pain patients, cannabis offers a viable alternative to opioids, potentially improving their quality of life while possessing a superior safety profile,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

While the study findings are interesting, they highlight the importance of considering the complex supply side of legal and illegal drug markets, and how it shapes opioid use and misuse. The study looked at data from over 800 counties with legal dispensaries, and compared them to counts of fatal overdoses between 2015 and 2018.

It turns out many of these counties were on the West Coast, where illicit fentanyl had yet to became as pervasive on the black market as it had in other parts of the country. Since 2018, deaths involving fentanyl have soared on the West Coast. 

“If you were to do the same study with current data, you’d find something different because of the way both opioid deaths and cannabis dispensaries have shifted since then,” Chelsea Shover, PhD, an assistant professor at UCLA School of Medicine told Healthline. 

In general, the opioid overdose crisis has gotten worse in the past couple of years. The CDC recently reported that in the 12 months ending in May 2020, ten western states reported a nearly 100 percent increase in deaths involving illicit fentanyl and other synthetic opioids. The increase was particularly sharp in states that legalized recreational cannabis.  

This is the problem with ecological data and associational findings. If you pick the right time or place, you can get an appealing result. And you may ignore other important issues.  

States that legalized cannabis tend to have better public health and more addiction treatment services. They generally have adopted the Affordable Care Act and Medicaid expansion, and have stronger social safety nets. All of these factors are believed to contribute to rates of substance use disorders and overdose risk.

Ecological data alone never proves anything. It merely suggests associations. If the association holds up over time, then researchers can look into a possible causal relation. If however, the association does not hold up, then claims about causality are pointless.

At this point cannabis does not seem to reliably reduce opioid overdose deaths. Further research will be needed to tease out the effects of cannabis legalization amid all the other factors involved in the overdose crisis.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

Medical Cannabis Needs Better Research

By Roger Chriss, PNN Columnist

Much of the uncertainty and reluctance about using medical cannabis stems from a lack of high-quality research. Instead of randomized controlled trials, surveys and data-mining are commonly seen, leaving clinicians and policymakers with little to work with.

That is the basis for the American Medical Association’s concerns about states legalizing medical cannabis.

“Scientifically valid and well-controlled clinical trials conducted under federal investigational new drug applications are necessary to assess the safety and effectiveness of all new drugs, including potential cannabis products for medical use,” the AMA declared in a policy statement.

Good research would help reduce such concerns. Unfortunately, a lot of recent research involves poor methodology and problematic funding, weakening potentially useful results.

For example, a recent study published in the journal Cureus found that cannabis was a “useful adjunct and substitute for prescription opioids” for chronic pain patients and had the added benefit of improving their physical function and quality of life.

To conduct the study, researchers surveyed 550 patients being treated at three licensed medical cannabis clinics in the northeastern United States, using an anonymous online survey consisting of 11 questions about medication use, pain levels and side effects.

This is very problematic. A convenience sample is a simple method for quickly grabbing data. Its downsides are that it isn't random and is subject to a lot of selection bias. And anonymous surveys are unreliable. As a 2018 Australian study showed, claims of prescription opioid use by people using medical cannabis are often very inaccurate.

Similarly, an observational study at 21 medical clinics in Canada found that the “high rate of cannabis use for chronic pain and the subsequent reductions in opioid use suggest that cannabis may play a harm reduction role in the opioid overdose crisis.”

But the study was sponsored by Tilray, a Canadian cannabis firm that has provided cannabis for clinical trials and is involved in the adult recreational-use market in Canada. Drug studies sponsored by industry need to be viewed with caution, since such studies are known to produce results favorable to the sponsoring organization.

In general, studies that collect data through convenience samples or anonymously via online surveys or apps are not reliable. And studies funded by industry may be biased.

What Happened to Sue Sisley’s Study?

Good studies do get done. However, their results are not always published.

In 2019 Sue Sisley, a psychiatrist at the Scottsdale Research Institute in Phoenix, finished a study on cannabis for post-traumatic stress disorder (PTSD) that took ten years to complete, promising that “the full results of the study, including all the data, will be publicly released."

But Sisley’s research still hasn’t been published. Last year she admitted the study findings may have been compromised by the poor quality of cannabis that the DEA allows for research.

“Most scientists end up with this mishmash of different strains (including stem sticks, leaves, etc.) — all of it seems to get thrown into a grinder in an overzealous effort to standardize the study drug batches for clinical trials," Sisley said.

Research results need to be published even if they are not positive. There is a tendency to promote positive results and hide negative findings. Publication takes a lot of time and effort, and negative results may impede the flow of research dollars.

But if the benefits and risks of medical cannabis are to be better understood, we need all the results. And researchers should get full credit for their work, even if the results aren’t what advocates or enthusiasts were hoping for.

Medical cannabis needs more high-quality research. Surveys of people recruited from a medical cannabis dispensary cannot be generalized to the population at large, and studies sponsored by industry must be treated with caution. Improving medical cannabis research will go a long way toward helping people use medical cannabis safely and effectively.

Roger Chriss suffers from Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

Mild Withdrawal Common Among Pain Patients Who Use Cannabis

By Pat Anson, PNN Editor

About 10 percent of patients who use medical cannabis to relieve chronic pain develop more severe withdrawal symptoms, according to a new study that found most patients have only mild symptoms and remain stable after long-term cannabis use.

Researchers at the University of Michigan Medical School and the VA Ann Arbor Healthcare System followed 527 Michigan residents with chronic pain for two years, asking whether they experienced any of 15 different withdrawal symptoms – such as craving, nausea, irritability and aggression - when they had gone a significant amount of time without using cannabis.

At the start of the study, most had only mild (41%) or moderate (34%) withdrawal symptoms, with 25% of the patients classified as having severe withdrawal.  Researchers say many patients were not even aware they experienced withdrawal, attributing symptoms such as fatigue and poor sleep to their underlying pain conditions, not to any dependence on cannabis.

"Some people report experiencing significant benefits from medical cannabis, but our findings suggest a real need to increase awareness about the signs of withdrawal symptoms developing to decrease the potential downsides of cannabis use, especially among those who experience severe or worsening symptoms over time," says lead author Lara Coughlin, PhD, an addiction psychologist at U-M Medical School.

After one year, about 13% of the patients experienced more withdrawal symptoms, with 8% reporting more severe symptoms after two years. People who were younger, smoked cannabis, used larger doses, and had poor mental health were more likely to have severe symptoms.

However, the vast majority of cannabis users did not experience more withdrawal symptoms, with those who reported mild symptoms likely to stay that way. About 20% of patients reported fewer symptoms after one year and 14% had fewer symptoms after two years. Older age and vaping were associated with lower odds of having severe symptoms.     

“The majority of participants remained in their initial withdrawal class throughout the 2-year study period, with the highest stability among those with mild withdrawal symptoms at baseline. Of those who transitioned to another symptom class, transitioning to milder symptoms was slightly more common than transitioning to more severe symptoms,” researchers reported in the journal Addiction.

“For the majority of patients, the current findings indicate that the severity of withdrawal symptoms are likely to remain stable over time.”

Poor sleep was the most common withdrawal symptom, followed by depressed mood, decreased appetite, craving, restlessness, anxiety and irritability. The study did not assess whether cannabis was effective for pain relief or what form of ingestion worked best.

Cannabis Not Perceived As Risky

Most Americans believe cannabis has less abuse potential than alcohol and many commonly prescribed anti-anxiety and pain medications, according to survey results recently published in the journal Addictive Behaviors.

Researchers at the University of Delaware and Michigan State University surveyed over 1,000 adults in 2019 about their views on cannabis products such as hemp, CBD, THC and marijuana. The vast majority felt cannabis products have a valid medical use and have less abuse potential than hydrocodone, oxycodone, Xanax and Valium.

source: addictive behaviors

“These results suggest that consumers perceive CBD as more like an over-the-counter pain reliever such as Tylenol or Advil and less like prescription opioids,” researchers found. “They perceive CBD and hemp as medicinal and as having little potential for abuse, making them an attractive replacement for addictive pain relievers.”

The researchers acknowledged that there is little clinical evidence to support these views, but blame the lack of studies on the federal government’s classification of marijuana as a Schedule I Controlled Substance, saying it has “severely limited research.”

A longtime critic of federal marijuana policy was not surprised by the survey findings.

“The overwhelmingly majority of Americans have long abandoned the federal government’s ‘Flat Earth’ position that marijuana is highly dangerous substance without any therapeutic efficacy,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

“It is time for Congress to jettison this intellectually dishonest position as well and remove cannabis from the Controlled Substances Act in a manner similar to alcohol — thereby ending the existing state/federal conflict and permitting state governments, not the federal government, to be the primary arbiters of cannabis policy.”

Cannabis Significantly Reduced Rx Opioid Use in Chronic Pain Patients

By Pat Anson, PNN Editor

Nearly half of chronic pain patients using medical cannabis reported significant improvement in their pain levels and most were able to reduce or stop their use of opioid pain medication, according to a large new study.

The findings, recently published in the journal Cureus, involved 550 chronic pain patients being treated at three licensed medical cannabis clinics in the northeastern United States. The study is one of the first to look at patients who were prescribed opioids for at least three months and continued to use opioids after starting cannabis therapy.

“Our results show a remarkable percentage of patients both reporting complete cessation of opioids and decreasing opioid usage by the addition of medical cannabis, with results lasting for over a year for the majority,” wrote lead author Kevin Takakuwa, MD, an emergency medicine physician affiliated with the Society of Cannabis Clinicians.

“We hypothesize these effects may be due to the reported synergistic decrease in pain that has been shown with adding cannabis to opioids. Likely, as a result, the majority expressed not wanting opioids in the future, particularly those in the younger age group.”

Pain patients enrolled in the study initially took a small amount of cannabis orally (a balanced blend of THC and CBD) and titrated to a higher dose until it had an effect.

Almost half (48%) reported a significant decrease in their pain, and most said they had improved quality of life (87%) and better physical function (80%) while using medical cannabis.

Most reported they either stopped using prescription opioids (40%) or reduced their opioid use (45%).  Nearly two thirds said they sustained the change for over a year (65%) and did not want to take opioids again (63%).  

“One reason for our impressive results may be the focused protocol employed by the study sites, which recommends a small amount of oral cannabis taken in conjunction with each opioid medication dose with small increments to titration, in a motivated patient population,” wrote Takakuwa.

“There has never been a randomized controlled human trial examining how to use medical cannabis in combination with opioids and there is no established protocol that exists. Experts disagree on how to manage opioid prescriptions in patients with chronic pain who use cannabis, and many clinicians defer to the patient or dispensary agent on decisions regarding specific cannabis products and dosages.”

But some doctors take another approach and simply get rid of patients after learning they use cannabis. It’s worth noting that nearly one in four patients (24.8%) enrolled in the study reported losing access to prescription medication or medical care as a result of their cannabis use or after testing positive for THC.

The Centers for Disease Control and Prevention specifically recommends that doctors not test for THC or dismiss patients for their cannabis use “because this could constitute patient abandonment and could have adverse consequences for patient safety” by forcing them to live with untreated pain or turn to street drugs.

Can Cannabis Be Used to Treat Opioid Addiction?

By Pat Anson, PNN Editor

Canadian researchers – with funding from U.S. taxpayers – are proposing a novel treatment for opioid use disorder: Cannabis.

In a paper published in the journal Drug and Alcohol Dependence, researchers from the University of British Columbia (UBC) and the BC Centre on Substance Use (BCCSU) say cannabis could help people being treated for opioid addiction by reducing their risk of exposure to illicit fentanyl and other street drugs.

The finding is based on urine drug tests of 819 people being treated for opioid addiction in Vancouver, BC, the first major city in North America to experience an outbreak of fentanyl-related overdoses. Addiction treatment usually involves taking opioid agonist drugs (OATs) such as buprenorphine or methadone.

The researchers found that over half the participants (53%) tested positive for fentanyl, suggesting they were still using street drugs. Those who tested positive for THC -- the psychoactive compound in cannabis -- were about 10 percent less likely to have fentanyl in their urine.

"These new findings suggest that cannabis could have a stabilizing impact for many patients on treatment, while also reducing the risk of overdose," said lead author Eugenia Socías, MD, a clinician scientist at BCCSU. "With overdoses continuing to rise across the country, these findings highlight the urgent need for clinical research to evaluate the therapeutic potential of cannabinoids as adjunctive treatment to OAT to address the escalating opioid overdose epidemic."

Socias and her colleagues say cannabis may play an important role in keeping people in addiction treatment programs. Previous research at BCCSU found that drug users initiating OAT who used cannabis daily were about 21 percent more likely to be retained in treatment after six months than non-cannabis users. People who stay in treatment face much lower risks of dying from an overdose, acquiring HIV or suffering other harms of drug use.

‘Gateway Drug’

The research at UBC and BCCSU was funded, in part, by grants from the U.S. National Institute on Drug Abuse, which is part of the National Institutes of Health (NIH).

The NIH has taken a dim view of cannabis in the past, calling marijuana a “gateway drug” for some users, particularly adolescents. A 2015 study funded by NIH found that nearly a third of those who use marijuana develop some degree of marijuana use disorder.

“Whether smoking or otherwise consuming marijuana has therapeutic benefits that outweigh its health risks is still an open question that science has not resolved,” said Nora Volkow, MD, Director of the National Institute on Drug Abuse.

Public health officials in British Columbia have proposed some controversial solutions to the opioid crisis, including decriminalization of all illicit drugs. A treatment center in Vancouver currently provides diacetylmorphine -- prescription heroin – to drug users to keep them from using street heroin that is often laced with fentanyl, a synthethic opioid that is 50 to 100 times more potent than morphine.

The Canadian Institutes of Health Research recently approved funding for a pilot study in Vancouver to evaluate cannabis as an adjunct therapy to OAT.

"Scientists are only just beginning to understand the role cannabis might play in supporting people's well-being, particularly those who use other substances," said co-author M-J Milloy, PhD, the Canopy Growth professor of cannabis science at UBC. "This study will help us understand if and how cannabis might have a role in addressing the overdose crisis."

FTC Warns CBD Companies About False Health Claims

By Pat Anson, PNN Editor

The U.S. Federal Trade Commission is once again going after companies that make unsubstantiated claims about the health benefits of cannabidiol (CBD) products. The crackdown, called “Operation CBDeceit,” is part of the agency’s ongoing effort to protect consumers from misleading advertising.

The FTC announced that six sellers of CBD oils, topical creams, gummies, lozenges and other products have signed administrative settlements agreeing not to make any further deceptive claims that CBD can treat pain, migraines, arthritis, cancer, heart disease and other health conditions.

“These CBD sellers lacked the scientific proof to back up their extreme claims. In fact, they often didn’t have any proof at all. But that didn’t stop them from saying these benefits were clinically proven. In truth, CBD is not a magical cure-all and there is no competent and reliable scientific evidence for these kinds of over-the-top health claims,” said Andrew Smith, Director of the FTC Bureau of Consumer Protection.

The FTC complaint against Utah-based Bionatrol Health alleged the company claimed its CBD products treat pain better than prescription medications like OxyContin. The company also allegedly deceived customers who ordered one bottle of its CBD oil by changing the order to five bottles without their consent.

The proposed settlement requires Bionatrol to pay $20,000 to the FTC and to notify customers about the FTC order. Similar settlements were reached with the other five companies.

This isn’t the first time the FTC and other federal agencies have gone after sellers of CBD, kratom and other dietary settlements for making unsubstantiated health claims.

The enforcement actions are sporadic and usually only target small companies. Sometimes a warning letter is as far as it goes and the company makes only a minor change in its marketing claims.

FTC IMAGE

In March 2019, for example, the FTC and Food and Drug Administration sent a warning letter to Nutra Pure, telling the company its hemp and CBD oils were unapproved drugs under federal law and “may not be legally introduced or delivered for introduction into interstate commerce.”

Nearly two years later, the company is still selling hemp and CBD oils, and has a disclaimer on its CBDPure website stating that its products “are not intended to diagnose, prevent, treat, or cure any disease.”

But when this reporter posed as a customer in an online chat with “Catherine,” a CBDPure representative, we were assured that CBD can treat pain and other health conditions.  

Customer: “Hi I'm wondering if you can recommend a CBD product for arthritis pain.”

Catherine: “Our oils are 300, 600 or 1000 mg CBD in full spectrum hemp oil. People with a mild condition or just looking to improve health start with the 300mg or 600mg. People with more severe or chronic conditions typically purchase the 1000 mg CBDPure hemp oil or 750 mg CBDPure soft gel.” 

Customer: “Will they help with pain and other health conditions?” 

Catherine: “Yes. There are numerous studies showing CBD has the ability to provide therapeutic benefits in the treatment of various conditions, including chronic pain, arthritis, anxiety/depression, nausea, epilepsy, insomnia and sleep issues, fibromyalgia, glaucoma and many other ailments.” 

Customer: “That's interesting. I have a friend with fibromyalgia. Is there something that can help her?” 

Catherine: “Yes. Same deal. Ideally, you start off with a lower mg dose and increase the amount you take weekly until you find what works for your body chemistry.” 

Customer: “And it'll eventually make the pain go away once you find the right dose?” 

Catherine: “Yes. It really depends on how your body tolerates and adapts to these dietary supplements.”

FTC officials say false claims about the therapeutic benefits of CBD and other supplements create a “real potential for serious harm to consumers health and safety.” But in a briefing with reporters announcing the six settlements reached in Operation CBDeceit, they acknowledged their investigation did not find any evidence about customers being harmed by the companies’ products.

“We’re not here saying CBD products are dangerous or that CBD products can’t offer benefits. Just that if you’re going to tout health benefits of your products, those claims have to be truthful and they have to be substantiated by the science,” said Smith.

Daily Drop of CBD Oil Reduces Migraine Headaches

By Pat Anson, PNN Editor

A CBD oil formulated for migraine sufferers significantly reduces the number of migraine headaches, according to a survey conducted by Axon Relief, a Utah-based company that makes a line of therapeutic CBD products.

“Our goal was to put out a CBD oil that is specific for people with migraine and to get feedback from them. There is a lot of anecdotal evidence that it works, but we haven’t seen any clinical data really behind it. And so this is kind of a first effort of ours to get some directional data on how effective this is,” says Ben Rollins, founder of Axon Relief.

Axon’s CBD Oil is made from pure hemp seed oil and has about 30mg of CBD per dose, a stronger than average dosage of cannabidiol. It contains no extra flavors, colors or THC (tetrahydrocannabinol), the psychoactive ingredient in cannabis, and is tested by a third-party lab.

The company asked new users of its CBD oil to take the Headache Impact Test (Hit-6™) both before and after a 30-day trial period. The questionnaire asks participants about the frequency and severity of their migraines, and how it impacts their daily lives.

Of the 105 customers who participated in the survey, 86 percent said a daily dose of the CBD oil reduced the impact of their headaches. On average, they also had nearly four fewer headache days per month.

The number of participants with chronic migraine – daily headaches – fell from 15 at the start of the study to 10 after the trial period, a 33% decline.

AXON RELIEF IMAGE

“Since the '90s I've been on constant high doses of carbamazepine and gabapentin. The periodic pain breakthroughs were only controlled by hydrocodone,” one user said. “What a change CBD Oil has made: no more carbamazepine or hydrocodone, and only half the gabapentin -- and far better pain control.”

Another participant said the CBD oil “significantly helped with my chronic migraines. If taken at onset, I can rely on it to take the edge off relatively quickly."

Previous studies have found that inhaled and ingested cannabis help reduce migraine pain.  A recent study of nearly 10,000 people in the U.S. and Canada who used a migraine tracking app found that 82 percent who used cannabis believed it was an effective pain reliever.    

A 2017 study conducted in Israel found that combining THC and CBD in a 200mg oral dose reduced pain by 55 percent in a small group of migraine sufferers.

And a 2016 study at the University of Colorado found that inhaled and ingested cannabis significantly reduced the number of migraine headaches. Inhalation appeared to provide the fastest results, while edible cannabis took longer to provide pain relief.

Axon Relief will soon be introducing an extra strength version of its CBD oil, which will contain about 100mg of CBD per dose. The company is also releasing a new dietary supplement in capsule form that combines CBD with magnesium, CoQ10 and riboflavin – ingredients recommended by the Migraine Trust. 

Caution Recommended on Cannabis Use Before Surgery

By Roger Chriss, PNN Columnist

The U.S. House of Representatives voted last week for the first time to legalize marijuana at the federal level. While passage by the Senate appears unlikely, the historic House vote on the MORE Act shows how much public attitudes about marijuana have changed.

A recent Gallup poll found that 68 percent of the country now favors having legal access to marijuana. Last month voters in four states approved recreational cannabis measures, raising to 15 the number of states where cannabis is completely legal. Thirty-six states have approved it for medical use.

As cannabis use becomes more accepted and widespread, healthcare providers need to take cannabis into consideration when treating patients, especially those undergoing surgery.

The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) recently convened a panel of 17 experts to develop new guidelines on the care of cannabis-consuming surgery patients. The result is a set of recommendations that include cannabis weaning before surgery and close monitoring during surgery, particularly for heavy cannabis users.

Because of the potential for cannabis to interfere with anesthesia, the guidelines recommend that patients who use a cannabis product more than 2 or 3 times per day should be considered for tapering or cessation several days before surgery. That includes patients who use more than 1.5 grams per day of smoked cannabis, more than 300 mg per day of CBD oil, or more than 20 mg per day of THC oil. Cannabis users may also need additional medication for postoperative nausea and vomiting.

There is only limited research on how cannabis interacts with analgesics and other medications. But the few studies that have been done suggest caution is warranted.

A 2006 study done in Germany looked at patients after surgery. None of the patients was able to achieve sufficient pain relief at any dose of Cannador, a cannabis plant extract. Several experienced significant side effects, including sedation and nausea. And the study had to be halted because of a severe adverse event in one patient.

A recent study at the University of Michigan looked at cannabis use and surgical outcomes in 1,335 adults undergoing elective surgery. About half reported using cannabis medically, recreationally or both. The results are concerning.

"On the day of surgery, cannabis users reported worse pain, more centralized pain symptoms, greater functional impairment, higher fatigue, greater sleep disturbances and more symptoms of anxiety and depression versus non-cannabis users,” the researchers said.

Medication use, including opioids and benzodiazepines, was also higher in the cannabis group. The study authors concluded that "cannabis users have higher clinical pain, poorer scores on quality of life indicators, and higher opioid use before and after surgery."

Another recent study at the University of Colorado Hospital was smaller and more specific, looking at 118 patients who had surgery for a broken leg. About one-fourth of the patients reported prior cannabis use. Although cannabis use was not associated with a higher dose of the anesthetic propofol during surgery, it was associated with more post-operative pain. Cannabis users also required significantly more pain medication than the control group.

Lead study author Ian Holmen, MD, told Practical Pain Management that it was important for clinicians to ask patients about their cannabis use before any surgical procedures.

“A provider just needs to know if the patient uses cannabis or not. It doesn’t matter if it’s a daily situation, just so [providers] are aware that the post-operative and possibly interoperative period are going to appear different in a patient who’s using cannabis than one who is not,” Holmen said.

Further study is needed to better understand how cannabis use affects surgical outcomes and how the effects may change at various doses of cannabis products. But the concerns of the Perioperative Pain and Addiction Interdisciplinary Network appear well-founded. Guidelines for the perioperative management of cannabis use are a necessary and useful step forward as cannabis use becomes more common.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research. 

12 Holiday Gifts on Life With Chronic Pain

By Pat Anson, PNN Editor

If you live with chronic pain or illness and want to have a friend or family member get a better understanding of what you're going through -- here are 12 books and videos that would make great gifts over the holidays. Or you can always “gift” one to yourself.

Click on the cover to see price and ordering information. PNN receives a small amount of the proceeds -- at no additional cost to you -- for orders placed through Amazon. As an Amazon Associate, we earn from qualifying purchases. 

Finding a New Normal: Living Your Best Life with Chronic Illness by Suzan Jackson

For nearly 20 years, Suzan Jackson has lived with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) — a condition she shares with two of her sons. In this book, Jackson shares what she and her family have learned about living well with chronic illness and finding a “new normal” through strong relationships, healthy emotions and finding joy in everyday life. The emphasis is on living life, not just enduring it.

War on Us by Colleen Cowles

Lawyer Colleen Cowles looks at how the war on drugs and myths about addiction have created a dysfunctional drug policy that prosecutes doctors for treating pain and stigmatizes patients for seeking relief. The U.S. has spent over a trillion dollars fighting the war and has little to show for it except some of the highest rates of addiction, overdose and incarceration anywhere in the developed world.

Ketamine Infusions: A Patient’s Guide by Berkley Jones

Berkley Jones looks at the increasing use of ketamine, a non-opioid analgesic, in treating chronic pain, depression, post-traumatic stress disorder and anxiety. This book is a useful guide if you are considering ketamine infusions and want to know how to select a provider, what to expect during infusions and possible side effects. Although primarily used to treat depression, some pain patients say ketamine is effective in treating neuropathy and CRPS.

Bitten: The Secret History of Lyme Disease and Biological Weapons by Kris Newby

Author Kris Newby began looking into the origins of Lyme disease after she was bitten by a tick and became seriously ill. Her research led her to a secret U.S. government program during the Cold War that used insects as biological weapons to spread disease. Newby believes the Lyme outbreak that began 50 years ago and has infected millions of Americans may have been the result of a military experiment gone wrong.

Vagina Problems: Endometriosis, Painful Sex and Other Taboo Topics by Lara Parker

A memoir by Lara Parker that explores — with unflinching honesty — her battle with endometriosis, a chronic vaginal condition that makes daily life difficult and sex painful. As a teenager, doctors initially dismissed Parker’s pain as “bad period cramps” and suggested her pain was psychological. She nearly checked herself into a mental institution before finally getting a proper diagnosis.

A Quick Guide to CBD by Dr. Julie Moltke

CBD won’t cure you of chronic pain, but Dr. Julie Moltke says cannabidiol can reduce pain, inflammation, anxiety and insomnia — and help make life more livable. This handbook is intended for beginners who want to learn how and when to take CBD, and are puzzled by all the hype surrounding vapes, oils, gummies and edibles on the market.

Pain Warriors by Tina Petrova

A documentary produced by patient advocate Tina Petrova that examines the poor treatment and medical neglect faced by millions of pain sufferers in North America. The film is dedicated to Sherri Little, a chronic pain patient who committed suicide after one last attempt to get effective treatment. Available on DVD or for streaming on Amazon Prime.

Together: The Healing Power of Human Connection by Dr. Vivek Murthy

This timely book by former U.S. Surgeon General Dr. Vivek Murthy looks at the importance of human connections and how loneliness affects our health and society at large. To combat loneliness, Murthy recommends spending at least 15 minutes each day connecting with people we care about and to give them our undivided attention.

Bottle of Lies: The Inside Story of the Generic Drug Boom by Katherine Eban

Wonder why that generic drug you take doesn’t seem to work? About 90% of pharmaceutical drugs are generic and most are manufactured overseas. While generics are promoted as cheaper alternatives to brand name drugs, journalist Katherine Eban found the generic drug industry rampant with greed, fraud and falsified manufacturing data — resulting in many patients consuming drugs that are ineffective or have dangerous side effects.

In Pain: A Bioethicist’s Personal Struggle with Opioids by Travis Rieder, PhD

Travis Rieder is a professor of bioethics at Johns Hopkins University who severely injured his foot in a motorcycle accident and became dependent on opioids while recovering from surgery. In this book, he shares his frustration with the healthcare system and how it often abandons patients to pain, addiction or both. Rieder serves on a CDC advisory panel that is helping the agency prepare an update of its controversial 2016 opioid guideline.

The Chronic Pain Management Sourcebook by David Drum

A comprehensive guide about chronic pain by medical journalist David Drum, who summarizes the many causes, types and treatments of pain. Drum also has tips on managing stress, anxiety, lack of sleep and depression. The book is easy to understand and would be a useful resource for family members, friends and caretakers who want to understand and help someone living with chronic pain.

A Little Book of Self Care: Trigger Points by Amanda Oswald

This well-illustrated book provides 40 simple, step-by-step exercises you can use to manage back pain, migraine and other painful conditions. Author Amanda Oswald explains how “trigger points” — small knots of muscles and connective tissue — can be relieved through self-massage and the “power of touch” without visiting a chiropractor or physical therapist.

These and other books and videos about living with chronic pain and illness can be found in PNN’s Suggested Reading section.

Study Shows Cannabis Oil Improves Fibromyalgia Symptoms

By Pat Anson, PNN Editor

A small placebo-controlled trial shows that daily doses of cannabis oil rich in THC (tetrahydrocannabinol) significantly improves pain, fatigue and quality of life in people with fibromyalgia.

The study findings, recently published in the journal Pain Medicine, involved 17 women with fibromyalgia living in Florianopolis, Brazil. Participants were given drops of cannabis oil or a placebo for eight weeks, starting with an initial dose of one drop a day orally and then titrating to an average of 3-4 drops a day.

The cannabis oil used in the study contained 1.22 mg of THC and 0.02 mg of CBD (cannabidiol) per drop. THC is the psychoactive ingredient in marijuana.

The women self-reported their symptoms on a questionnaire every 10 days. Few changes were noted in the placebo group, but the women receiving cannabis oil reported significant improvement on a wide range of symptoms, including pain, depression, anxiety and fatigue. They were also more likely to “feel good” and not miss work compared to the placebo group.

“To our knowledge, this is the first randomized controlled trial to demonstrate the benefit of cannabis oil -- a THC-rich whole plant extract -- on symptoms and on quality of life of people with fibromyalgia,” researchers said. “During the intervention, the impact of the intervention on quality of life in the cannabis group participants was evident, resulting in reports of well-being and more energy for activities of daily living. Pain attacks were also reduced, albeit subjectively, in frequency and intensity.”

The researchers concluded that cannabinoids can be a low-cost and well-tolerated therapy for fibromyalgia patients, and recommended that it be included as an herbal medicine option in Brazil’s public health system.

“The demonstration of safety and efficacy in this gold-standard model is significant. Millions of Americans suffer with FM (fibromyalgia) – a condition that tends to be poorly controlled by standard medicines. These clinical findings indicate that for many of these patients, plant-derived cannabis preparations may be a safe and effective alternative,” said Paul Armentano, Deputy Director of NORML, a pro-marijuana advocacy group.

A major weakness of the Brazilian study is its small size. Participants also continued to self-medicate with analgesics and anti-inflammatory medications during the study, which could have affected the findings.

A larger 2019 study in Israel also found that cannabis reduces pain and improves quality of life for fibromyalgia patients. The cannabis used in that study was ingested by tincture, oil or vaporizer.

Growing Number of Seniors Discovering Medical Benefits of Cannabis

By Pat Anson, PNN Editor

A new survey shows that medical marijuana is increasingly being used by California seniors to treat pain, insomnia, depression and other conditions associated with old age. Many began using cannabis for the first time as older adults.

Researchers at the University of California at San Diego surveyed 568 seniors at a geriatric clinic in southern California. All were at least 65 years of age, and most were older than 75.

Fifteen percent of the seniors said they have used cannabis products within the past three years, with the method of consumption evenly split between lotions (35%), tinctures (35%) and smoking (30%). Over three‐quarters reported cannabis “somewhat” or “extremely” helpful in managing their symptoms, with few adverse effects.

Although medical marijuana has been legal in California since 1996, sixty-one percent of respondents said they used cannabis for the first time as older adults. Recreational use in California was legalized in 2016.

“Most older adults in the sample initiated cannabis use after the age of 60 years and used it primarily for medical purposes to treat pain, sleep disturbance, anxiety, and/or depression. Cannabis use by older adults is likely to increase due to medical need, favorable legalization, and attitudes,” researchers reported in the Journal of the American Geriatric Society.

Over half of respondents (53%) reported using cannabis on a daily or weekly basis. The majority (78%) used cannabis for medical purposes only, with the most common conditions being pain/arthritis (73%), sleep disturbance (29%), anxiety (24%), and depression (17%).

“It is not surprising that a rising percentage of seniors consider cannabis to be a viable therapeutic option in their later years. Many seniors struggle with pain, anxiety, restless sleep, and other conditions for which cannabis products may help mitigate,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

“Moreover, many seniors are well aware of the litany of serious adverse side-effects associated with available prescription drugs, like opioids or sleep aids, and they perceive medical cannabis to be a practical and potentially safer alternative.”

Most respondents said their family and friends knew of their cannabis use, but less than half (41%) reported their healthcare provider was aware.

Previous studies have found that cannabis is growing in popularity among older adults, primarily due to changes in public attitudes.

Nationwide survey findings recently published in the Annals of Internal Medicine found that about 5% of adults aged 55 and older said they'd used marijuana or hashish in the previous month. Use was almost twice as high among men, with 6.7% reporting cannabis use compared to 3.5% of women.

Although interest in medical marijuana is growing, there is limited research in the U.S. on its effectiveness in treating pain and other symptoms, especially among seniors.

A large study in Israeli found medical marijuana can significantly reduce chronic pain in elderly patients without adverse effects. Many patients were also able stop or reduce their use of opioid medication.    

Nearly 60 percent who originally reported "bad" or "very bad" quality of life said their lives had improved to "good" or "very good." And over 70 percent reported moderate to significant improvement in their symptoms. About one in four Israeli adults use cannabis, one of the highest rates in the world.

Study Finds Cannabis Does Not Reduce Opioid Abuse

By Pat Anson, PNN Editor

It’s a common belief that cannabis may reduce the use of opioids and may even help solve the opioid crisis. But a new study by researchers at Columbia University Mailman School of Public Health found that people with substance abuse problems are just as likely to use heroin or to misuse prescription opioids on days when they consume cannabis.

The study, published in the journal Addiction, is believed to be one the first to test whether adults with substance abuse problems are substituting opioids with cannabis. Researchers followed 211 adults in the New York City area for 90 days, asking if they had used cannabis, heroin, or misused prescription opioids.

Participants were mostly male, unemployed, unmarried, and had a high prevalence of substance misuse and pain. “Misuse” of prescription opioids was defined as taking more pain medication than prescribed or without a prescription.

On average, participants reported they used cannabis on 15% of days without opioids, opioids were used on 15% of days without cannabis, and both cannabis and opioids were used on 7% of days. On days that participants used cannabis, the odds of using opioids nearly doubled. The findings were consistent whether participants were experiencing pain or not.

"Our results suggest that cannabis seldom serves as a substitute for non-medical opioids among opioid-using adults, even among those who report experiencing moderate or more severe pain," said Deborah Hasin, PhD, professor of epidemiology at Columbia Mailman School. "In other words, our study suggests that cannabis is not an effective way to limit non-medical opioid use."

Cannabis Users Need More Anesthesia

Another recent study found that cannabis may actually raise pain levels for patients recovering from surgery. In an analysis of 118 patients who had surgery for a broken leg at a Colorado hospital, researchers found that cannabis users needed more anesthesia during surgery than non-users. They were also more likely to have post-operative pain and use higher doses of opioid pain medication while hospitalized.

The findings, presented at the annual meeting of the American Society of Anesthesiologists, adds to the growing body of research suggesting that patients who use cannabis have higher anesthesia needs and more surgery-related pain.

"There is some evidence that cannabis may be beneficial for chronic and nerve pain. However, early research suggests that this is not the case for acute pain such as for surgery of a broken leg," said lead author Ian Holmen, MD, an anesthesiology resident at the University of Colorado Hospital in Aurora, where the study was conducted.

"We now understand patients who chronically use opioids prior to surgery often have exaggerated pain responses and need increased pain medication after surgery because they have an increased tolerance. We speculate that cannabis use may cause a similar effect, but we need more research to determine if this is the case."

Holmen and his colleagues found that cannabis users had higher pain scores while recovering from surgery and received 58% more opioids per day while hospitalized. They also needed about a third more anesthesia. The amount of anesthesia during surgery is typically based on observations of a patient’s involuntary body movements, increased heart rate, high blood pressure or increased rate of breathing, which are signs the patient may be experiencing more pain.

Researchers did not include in the study patients who suffered from chronic pain or those who had previously been prescribed opioids.

"This study shows that it is important for patients to tell their physician anesthesiologist if they have used cannabis products prior to surgery to ensure they receive the best anesthesia and pain control possible, including the use of non-opioid alternatives," said Holmen. "It also confirms that more research is needed to understand how cannabis impacts pain."

A 2019 study of patients who had colonoscopies found that regular marijuana users required three times the amount of a common sedative, propofol, as did nonusers.

Cannabis-Based Drugs Risky for Older Patients with COPD

By Pat Anson, PNN Editor

While many senior citizens are discovering the benefits of medical cannabis in relieving pain and other health problems, a large new study suggests caution is warranted for those with chronic obstructive pulmonary disease (COPD).

Researchers at St. Michael's Hospital in Toronto say older adults with COPD who take prescription drugs made with synthetic cannabinoids were 64% more likely to die. The odds are even worse for elderly patients with COPD who take high-dose cannabinoids for the first time. New users had a 178% higher risk of being hospitalized for COPD or pneumonia and a 231% increased risk of death.

"Cannabinoid drugs are being increasingly used by older adults with COPD, so it is important for patients and physicians to have a clear understanding of the side-effect profile of these drugs," says lead author Nicholas Vozoris, MD, a respiratory specialist at St. Michael's and assistant professor at the University of Toronto.

"Our study results do not mean that cannabinoid drugs should be never used among older adults with COPD. Rather, our findings should be incorporated by patients and physicians into prescribing decision-making. Our results also highlight the importance of favouring lower over higher cannabinoid doses, when these drugs actually do need to be used."

The study analyzed the health data of over 4,000 older adults diagnosed with COPD who took either nabilone or dronabinol, two medications made with synthetic cannabinoids that are used to treat nausea, vomiting and loss of appetite.

The findings, published in the journal Thorax, suggest that nabilone and dronabinol may cause sedation and suppress breathing in patients whose health is already compromised by COPD, a progressive lung disease that causes difficulty breathing and chronic coughing.

"Older adults with COPD represent a group that would likely be more susceptible to cannabinoid-related respiratory side-effects, since older adults less efficiently break down drugs and hence, drug effects can linger in the body for longer,” said Vozoris.

“Cannabinoids may not be any safer to use among older adults with COPD than opioids, which are also associated with a heightened risk of respiratory- related morbidity and mortality. While further research is needed to confirm the safety profile of cannabinoid drugs among older adults with COPD, our findings should be taken into consideration in prescribing decision making in this population.”

Cannabis and Menopause

While high doses of cannabinoids may not be appropriate for older patients with COPD, many middle-aged women are using cannabis to treat symptoms of menopause.

According to a small study being presented at the annual meeting of The North American Menopause Society, over one in four women have either used or are currently using cannabis to manage menopause symptoms.

The study involved 232 female military veterans (average age of 56) living in Northern California. Over half reported hot flashes and night sweats regularly. Twenty-seven percent said they had used marijuana to help battle menopause symptoms, while another 10% said they were interested in trying cannabis.

“While the therapeutic use of cannabis by veterans is not altogether uncommon, this study is among the first to highlight veterans’ use of marijuana for this particular condition. Given cannabis’ relatively high rate of use among the women in this cohort, scientists and others would be well-advised to further explore its safety, efficacy, and prevalence among women experiencing menopause,” said Paul Armentano, Deputy Director of NORML, a marijuana advocacy group.

A 2018 survey of over 2,700 elderly patients in Israel found that medical marijuana significantly reduced their chronic pain without adverse effects. Nearly one in five patients stopped using opioid medication or reduced their dose.