Medical Cannabis Provides Only Minor Relief for Chronic Pain

By Pat Anson, PNN Editor

An international team of researchers has concluded that medical cannabis and cannabinoids do not provide relief to most people with chronic pain, but are of some benefit to others.

The findings, based on a limited review of 32 medical cannabis studies, were published in the journal BMJ. They are the third set of international guidelines released this year to discourage the use of cannabis as an analgesic because clinical evidence is lacking.

“We are hopeful that patients and physicians will find our guideline helpful, and take away that while medical cannabis will not be effective for most people living with chronic pain, it may provide important benefits for a minority of patients,” said lead author Jason Busse, associate director of McMaster University’s Medicinal Cannabis Research Center in Ontario, Canada.

“For example, we found that 10% more patients that used medical cannabis vs. placebo in trials reported an important improvement in pain relief. This means that only one patient of every 10 treated with medical cannabis experienced this improvement.”

Busse and his colleagues said medical cannabis might provide a “small increase” in pain relief, sleep quality and physical function, with a “small to very small increase” in side effects such as dizziness, nausea and cognitive impairment.

It’s important to note that the panel’s recommendations do not apply patients in palliative care or to smoked or vaporized cannabis. The research team, which included a diverse group of physicians, academics and patient representatives, could not find a good quality clinical study that explored the use of inhaled cannabis.

“We hope that such trials will be forthcoming, as cross-sectional data has found many (perhaps the majority of) people living with chronic pain who use cannabis therapeutically use dried flower products that are typically inhaled or vaporized,” Busse told PNN in an email.

“The most robust evidence base is probably for use of cannabidiol (CBD) to help manage certain forms of pediatric epilepsy; however, most patients use cannabis to manage chronic pain and there are important evidence gaps that urgently need to be addressed so that patients can make fully-informed decisions.”

Due to the limited research on inhaled cannabis, the guideline’s recommendations only cover cannabis products such as edibles, sprays, oils and tinctures, which are usually low in tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis that makes people high.

The panel recommended that non-inhaled cannabis or CBD only be used on a trial basis by patients when “standard care” for pain management is not sufficient. The recommendation applies to adults and children with moderate to severe chronic pain caused by cancer, neuropathy, nociceptive pain or nociplastic pain. The latter two categories cover conditions such as osteoarthritis and fibromyalgia.

“Our weak recommendation in favour of a trial of medical cannabis or cannabinoids reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and a willingness to accept a very small to modest risk of mostly self limited and transient harms,” researchers said.

“The panel, including patient partners, believes that there is great variability in how much reduction in pain severity, improvement in physical functioning, or sleep quality each patient would consider important. Patients who place a high value in improving these symptoms by any amount are more likely to pursue a trial of medical cannabis or cannabinoids.”

The researchers recommend that patients start with a low-dose CBD product, and gradually increase the dose and THC level depending on how the patient responds.

Two medical guidelines released earlier this year also take a dim view of cannabis as a pain reliever. The Australian and New Zealand College of Anaesthetists (ANZCA) urged doctors not to prescribe medical cannabis for patients with chronic pain unless they are enrolled in a clinical trial.

The International Association for the Study of Pain also said it could not endorse the use of cannabinoids to treat pain because there was not enough evidence on the safety and efficacy of CBD.

Study Finds Marijuana Reduces Pain, but Worsens Self-Care

By Pat Anson, PNN Editor

The 1998 comedy “The Big Lebowski” has a cult-like status as a stoner film, largely because of the way Jeff Bridges portrays a weed-smoking slacker who has no job, can’t pay the rent and spends half the movie in a bathroom robe. The Dude abides life at his own pace.

A new study may have inadvertently reinforced some of that stoner stigma, finding that marijuana use reduces pain but significantly worsens patient “self-care” – a broad category that includes behavior such as motivation, physical activity and appearance.

The study involved 181 pain patients enrolled in Pennsylvania’s medical marijuana program, who used marijuana for eight weeks and regularly completed surveys on its effects.

The study findings, recently published in the journal Medical Cannabis and Cannabinoids, showed that participants reported significant improvement in their pain and anxiety, and a small improvement in quality of life. But there was a caveat.

“One sees that the improvements to the pain and anxiety dimensions are tempered by a decline in the area of self-care. This is important because the side effect profile of cannabis may be diminishing the improvement in (quality of life),” wrote lead author Andrew Peterson, PharmD, University of the Sciences in Philadelphia. “A review of the literature found no other study connecting the use of marijuana with declines in self-care in pain patients using MM (medical marijuana).”

The study did not look at the doses used by participants, but since all products in Pennsylvania’s medical marijuana program contain some level of tetrahydrocannabinol (THC) – the psychoactive substance in marijuana – researchers believe there might be a connection. They said further studies were needed to see if there’s a relationship between THC, self-care and quality of life.

“There are many sources describing the negative consequences of marijuana,” Peterson wrote. “Given that our study found a decline in self-care among pain patients using MM (medical marijuana), it would be of interest to learn what aspects of self-care change when using MM for pain.”

According to the National Institute on Drug Abuse, some of the negative consequences of marijuana use include changes in mood, difficulty with thinking and problem-solving, impaired memory and an altered sense of time.  

CBD Reduced Burnout and Depression in Healthcare Workers

By Pat Anson, PNN Editor

After a year and a half of social distancing, masks and isolation, are you feeling emotionally burned out from the pandemic?

If so, you’re not alone. A recent survey of over 1,000 workers found that over half reported they were fatigued, depressed and had trouble concentrating.  Another study in the UK found that healthcare providers and other essential workers were particularly at risk of depression due to the stress of COVID-19.

With that in mind, researchers at the University of São Paulo in Brazil recently conducted a study to see if daily doses of cannabidiol (CBD) could relieve emotional exhaustion and burnout symptoms in a cohort of 120 frontline healthcare professionals.

Half of the study’s participants received 300mgs of CBD oil daily for four weeks. The other half did not receive CBD. All participants were evaluated weekly by a psychiatrist and encouraged to exercise.

The research findings, published in JAMA Psychiatry, found that participants who received CBD treatment had a significant reduction in emotional exhaustion and burnout compared to those who did not. CBD consumption was also associated with less anxiety and depression, but had no impact on post-traumatic stress syndrome (PTSD).

Five participants in the CBD group dropped out of the trial after suffering from serious adverse events, mostly elevated liver enzymes. Those cases resolved after CBD of discontinued.

“This randomized clinical trial found that the efficacy and safety of daily treatment with CBD, 300 mg, for 4 weeks combined with standard care was superior to standard care alone for reducing the symptoms of emotional exhaustion, anxiety, and depression among frontline health care professionals working with patients with COVID-19,” researchers reported.

“Burnout among health care workers is an important issue for health care systems, with a direct impact on quality of care. No pharmacological treatment is currently available for the prevention or treatment of burnout symptoms and emotional exhaustion among frontline health care professionals working with patients with COVID-19… Therefore, the results of the present study could have a relevant impact on the mental health of health care staff worldwide.”

The researchers said more placebo-controlled trials were needed to assess whether CBD could be used more broadly as a mental health treatment.

Previous studies have also found that medical cannabis reduced symptoms of depression. A 2020 study conducted in New Zealand found that people consuming up to 300mg daily in CBD oil reported significant improvement in their pain, mobility, anxiety and depression. Some also said they slept better and their appetite improved.

Another 2020 study found that 95% people who smoked or inhaled cannabis through a vaporizer reported a decline in depression within 2 hours. Cannabis with high levels of tetrahydrocannabinol (THC) was particularly effective in reducing depression.

My Migraine Journey: From Electrodes to Cannabis

By Gabriella Kelly-Davies, PNN Columnist

The room swirled as my eyes fluttered open, and I could feel something tight around my neck. It felt like a vice, making it difficult to swallow. The antiseptic smell was familiar, but I couldn’t quite place it. Struggling to focus my eyes, I heard a voice I knew well — it was Ben, a doctor at the hospital where I worked as a physiotherapist.

“How do you feel?” Ben said, shining a bright torch into my eyes.

“Where am I?”

“You’re in emergency. An ambulance brought you here. You were lying on the side of the road, unconscious.”

Ben told me the ambulance officers had received reports of cyclists being pushed off their bikes at the quieter end of the beach. They assumed that’s what had happened to me.

That day, my twenty-fourth birthday, heralded the onset of a life of migraine attacks.

Gabriella Kelly-Davies

During the 1990s, I regularly traveled around Australia for work while studying business at night. In the plane as I read my textbooks, a pain like an electric shock would shoot up the back of my neck and head.

It lasted for several minutes, then a deep ache started in the base of my skull. The pain eventually spread upwards, fanning out until it covered the entire back of my head and temples.

All too soon, the pain I experienced while flying became more regular and was most severe after sailing and playing my piano or cello. Cycling and tennis also triggered it.

In 1996, I started a job in Parliament House, Canberra as a policy adviser to a senior politician. Mid-morning, I would feel shooting pains running up the back of my head, accompanied by waves of intense nausea. Soon afterwards, a deep ache in the base of my skull started, quickly spreading up over my head and into my temples. My eyes felt gritty, as if they were full of sand, and I yearned for them to explode to release the mounting pressure inside them.

Often when the pain was at its worst, I couldn’t think of the words I wanted to say, infuriating some colleagues. Sometimes I couldn’t string two words together coherently. My mouth refused to form the words I wanted to say, as if the messages weren’t getting through from my brain to the muscles in my face.

The Merry-Go-Round

Returning to Sydney in 1999, I despaired of ever being free of pain and nausea. I consulted an endless round of specialists and health professionals, but none of them helped much. I felt overwhelmed by head and neck pain and a general sense of ever-increasing pressure inside my head and eyes. I fantasized about boring a hole through the base of my skull with an electric drill to release the tension.

Between 2000 and 2005, I progressively stopped doing all the things I most loved because they triggered migraine attacks. My goal became getting through a day of work, returning home and lying in a dark room with a series of ice packs under my neck.

Anxiety about being stigmatized and the intolerance I perceived in some colleagues at work prevented me from admitting I was in pain. Instead, I worked like a Trojan to ensure I maintained a high level of performance and no one could accuse me of using pain as an excuse to under-perform.  

While on the endless merry-go-round of seeking solutions, I ended up at the Michael J. Cousins Pain Management and Research Centre in Sydney. Dr. Cousins and a team of health professionals assessed me. They diagnosed occipital neuralgia, a form of headache that can activate migraine attacks. I had chronic pain, a malfunction in the way the nervous system processes pain signals.

The team suggested an experimental treatment. It involved implanting tiny electrodes into the back of my head and neck to block the pain signals from traveling along the nerves in my head. I agreed to the surgery and afterwards; I had fewer migraine attacks than previously. I even had a few completely pain-free days.

One year later, I felt something sharp sticking out from the base of my skull. My pain specialist discovered an electrode wire protruding through the skin. Tests revealed the electrodes were infected, so they were removed. Afterwards, migraine attacks returned in full force.

Three months later, new electrodes were implanted, but they didn’t work as well, possibly because scar tissue blocked transmission of the electric current. Still, overall I was better than before the initial surgery. I worked full time and sang in a choir at Sydney Opera House.

Disappointingly, disaster struck in 2008. A superbug infected the electrodes, forcing my doctor to remove them. Once the infection cleared and the electrodes were re-implanted, they were only partially successful, and my life returned to its pre-electrode state.

Multidisciplinary Pain Management

A significant turning point occurred in 2009 when I participated in a three-week multidisciplinary pain management program. Each day, a team of pain specialists gave lectures on topics such as chronic pain and how it differs from acute pain. The physiotherapists started us on a carefully graded exercise program, and a psychologist taught us cognitive behavioural therapy techniques to help us change the way we thought about and dealt with pain. Surprisingly, the exercises didn’t cause a flare-up and at last I felt as if I was making progress.

The pain management program taught me to stop catastrophizing and to believe I had the power to change how I reacted to pain. For years, I practiced the stretches and strengthening exercises every night after work. I also applied the psychological techniques, and they became central to my daily routine.

Twelve years later, I continue to live with migraine. I’ve tried several migraine preventatives, but none helped. Eight months ago, I started taking medicinal cannabis and it has significantly reduced the frequency and severity of migraine attacks.

Over the years I’ve learned to reduce the impact of migraine on my life by using techniques such as mindfulness meditation and carefully paced exercise that turn down the volume of pain signals racing through my malfunctioning nervous system.

Chronic pain is complex and difficult to treat but it is possible to live well with pain. I encourage you to do a multidisciplinary pain management program and continue your search for approaches that reduce the impact of pain on your life.  

Gabriella Kelly-Davies is a biographer and studied biography writing at the University of Oxford, Australian National University and Sydney University. She recently authored “Breaking Through the Pain Barrier,” a biography of trailblazing Australian pain specialist Dr. Michael Cousins. Gabriella is President of Life Stories Australia Association and founder of Share your life story.

Terpenes Make Cannabis More Effective as Pain Reliever

By Pat Anson, PNN Editor

A new study may help explain what makes cannabis effective as a pain reliever. It’s not just cannabinoids like cannabidiol (CBD) or tetrahydrocannabinol (THC), but terpenes -- the aromatic compounds that give cannabis its distinctive “skunky” smell. The finding could lead to new ways to boost the potency of cannabis, opioids and other pain-relieving drugs without increasing the dosage.

In experiments on laboratory rodents, scientists at the University of Arizona Health Sciences found that Cannabis terpenes, when used alone, mimic the effects of cannabinoids, including a reduction in pain sensation. When terpenes were combined with a synthetic cannabinoid, the pain-relieving effects were amplified – an “entourage effect” – that reduced pain levels without an increase in euphoria and other side effects.

"A lot of people are taking cannabis and cannabinoids for pain," said lead researcher John Streicher, PhD, a member of the UArizona Health Sciences Comprehensive Pain and Addiction Center and associate professor of pharmacology at the College of Medicine-Tucson.

"We're interested in the concept of the entourage effect, with the idea being that maybe we can boost the modest pain-relieving efficacy of THC and not boost the psychoactive side effects, so you could have a better therapeutic."

Terpenes are found in many plants and are the main component in essential oils. The terpene linalool gives lavender its distinctive floral scent, while citrus trees get their smell from the terpene limonene. Plants create terpenes to lure pollinators, such as birds and insects, and to protect themselves from predators.

Streicher and his colleagues focused on four Cannabis terpenes: alpha-humulene, geraniol, linalool and beta-pinene. They evaluated each terpene alone and in combination with a synthetic cannabinoid that stimulates the body's natural cannabinoid receptors.

In laboratory experiments, researchers found that all four terpenes activated a cannabinoid receptor in the brain, just like THC. The behavioral studies in mice also revealed the terpenes lowered pain sensitivity, reduced pain sensation, lowered body temperature, and reduced movement and catalepsy, a freezing behavior related to the psychoactive effects of cannabinoids.

When terpenes were combined with the synthetic cannabinoid, researchers saw a greater reduction in pain sensation -- demonstrating a terpene/cannabinoid interaction in controlling pain.

"It was unexpected, in a way," said Streicher. "It was our initial hypothesis, but we didn't necessarily expect terpenes, these simple compounds that are found in multiple plants, to produce cannabinoid-like effects."

The study findings were recently published in the journal Scientific Reports. Streicher and his research team still need to confirm if terpenes have an entourage effect when combined with THC and other naturally occurring cannabinoids. Their long-term goal is to develop a dose-reduction strategy that uses terpenes in combination with cannabinoids or opioids to achieve the same levels of pain relief with fewer side effects.

Although the therapeutic benefits of terpenes are not well understood, some cannabis companies are already incorporating them into their products. Lemon Kush, for example, is a hybrid marijuana strain that contains limonene, while the hybrid Blue Dream has a terpene found in blueberries. Terpenes are also being added to chocolate, beverages and many other consumer products.  

Fibromyalgia Patients Substituting CBD for Pain Medication

By Pat Anson, PNN Editor

With opioid medication increasingly harder to obtain, many people with chronic pain are turning to cannabis-based products for pain relief.  A new survey of fibromyalgia patients suggests that cannabidiol (CBD) works well not only as an alternative to opioids, but for many other pain medications.

Researchers at Michigan Medicine surveyed 878 people with fibromyalgia who were currently using a CBD product and found that 72% of them had substituted CBD for a conventional pain medication.

Over half (59%) reduced or stopped taking non-steroidal anti-inflammatory drugs (NSAIDs), while 53% used CBD as a substitute for opioids, gabapentinoids (35%) or benzodiazepines (23%), an anti-anxiety medication that was once commonly prescribed for pain.

"I was not expecting that level of substitution," said Kevin Boehnke, PhD, a research investigator in the Department of Anesthesiology and the Chronic Pain and Fatigue Research Center at Michigan Medicine.

Fibromyalgia is a poorly understood disorder characterized by widespread body pain, fatigue, poor sleep, anxiety and depression. Standard treatments for fibromyalgia such as gabapentinoids often prove to be ineffective or have unwelcome side effects.

"Fibromyalgia is not easy to treat, often involving several medications with significant side effects and modest benefits," said Boehnke. "Further, many alternative therapies, like acupuncture and massage, are not covered by insurance."

CBD is one of the chemical compounds found in cannabis, but it doesn’t have the same intoxicating effect as tetrahydrocannabinol (THC), the psychoactive ingredient in marijuana.  Some cannabis products contain a combination of THC and CBD, while others just have CBD.

Survey participants who used CBD products containing THC were more likely to report symptom relief and to use them as substitutes for pain medication. This suggests that THC may enhance the therapeutic benefits of CBD.

A recent Israeli study found that people with fibromyalgia who took daily doses of cannabis oil rich in THC had significantly less pain and fatigue.

Another recent study in Israel found that cannabis products – both with and without THC – reduced pain and depression in fibromyalgia patients. Like the findings of the Michigan study, about one out of five patients either stopped taking or reduced their use of opioids and benzodiazepines.

"People are using CBD, substituting it for medication and doing so saying it’s less harmful and more effective,” said Boehnke. “If people can find the same relief without THC's side effects, CBD may represent a useful as a harm reduction strategy."

The Michigan Medicine study was recently published in The Journal of Pain.

Does Cannabis Increase Risk of Suicide?

By Roger Chriss, PNN Columnist

A new National Institute of Health study confirms a long-standing association between cannabis use and suicidality in younger adults.

NIH researchers looked at data from over 280,000 people aged 18 to 34 who participated in the National Survey of Drug Use and Health from 2008 to 2019. Their findings, published in JAMA Open Network, concluded that cannabis increased the risk of suicidal thoughts (ideation), planning and attempts by young adults.

“While we cannot establish that cannabis use caused the increased suicidality we observed in this study, these associations warrant further research, especially given the great burden of suicide on young adults,” Nora Volkow, MD, director of the National Institute on Drug Abuse, said in a statement.

Cannabis use is rising fast in the United States. Use more than doubled from 22 million people in 2008 to 45 million in 2019, and regular use tripled to nearly 10 million people by the end of the study. The increased use of cannabis coincided with a spike in suicides among young adults, which rose by 52% for women and 45% for men from 2008 to 2019.

NIH researchers found that daily cannabis use and a history of a major depressive episode (MDE) increased the risk of suicide, particularly for women. The prevalence of a suicide plan in the past year was 52% higher for women with MDE than for men with MDE.

But even when a young adult was not depressed, suicide ideation rose in tandem with the frequency of their cannabis use. Seven percent of those who used cannabis occasionally had suicidal thoughts, a number that rose to 9% for people who use cannabis daily and to 14% for people with cannabis use disorder.

The NIH study supports prior findings. Stanford researchers recently reported that in states that legalized recreational marijuana there was a 46% increase in self-harm injuries among 21- to 39-year-old men.

A 2020 study in the Journal of Addiction Nursing and a 2019 study in JAMA Psychiatry also found a strong association between cannabis and suicidality.

But the relationship is complex. The 2020 study looked at recreational cannabis use, while the 2019 study examined adolescent use. The new NIH study looked at national survey data over a period that started well before adult-use legalization in Colorado and Washington. It makes no distinction between medical and recreational cannabis, a distinction that could be important.

Explanations for the suicide association also vary, such as the higher potency of cannabis and increased availability of cannabis products. But these trends vary by state and over time, so more granular analysis is needed in order to tease out relationships among these factors.

More important, it is not clear at this point if cannabis use is simply associated with an underlying trend, exacerbating a growing problem, or is itself an independent risk factor. Sorting this out will be extremely difficult, because cannabis use does not occur in a vacuum and cannabis itself is a delivery system for a slew of cannabinoids whose effects and interactions are not fully understood.

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 No Help to Lobsters

By Pat Anson, PNN Editor

Do lobsters feel pain when they’re boiled alive?

Seafood lovers, cooks, academics, animal rights activists and even governments have debated that question for years, with the general consensus being that they do. Lobsters, crabs and other crustaceans will often writhe in pain and try to escape when dropped into a pot of scalding hot water. The practice is considered so cruel that Switzerland and New Zealand made it illegal to boil a live lobster.

Some cooks try to ease the lobsters’ pain by stunning them with a jolt of electricity or putting them on ice to dull their senses before cooking them.  In 2018, a restaurant owner in Maine even blew marijuana smoke on a lobster named Roscoe, who reportedly grew so mellow he never wielded his claws as weapons again while in captivity.

We’ll never know the long-term effect of getting a lobster stoned because Roscoe was returned to the ocean as a thank you for his service. Good for him.

Which brings us to a bizarre study recently completed by scientists at the University of California San Diego and the Scripps Research Institute, who decided to replicate the Roscoe experiment in a lab.

"The 2018 minor media storm about a restaurant owner proposing to expose lobsters to cannabis smoke really was the starting point. There were several testable claims made and I realized we could test those claims. So we did," lead author Michael Taffe, PhD, an adjunct professor at Scripps Research told IFLScience.

Taffe and his colleagues purchased ten Maine lobsters at a local supermarket, fed them a last meal of frozen krill and fish flakes, and placed them in an aerated vapor chamber.

For the next 30 to 60 minutes, the lobsters were exposed to vapor rich in tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis.

Afterwards, some of the lobsters were “rapidly euthanized” with a kitchen shear and dissected, while others were immersed in hot water to see how they’d react.

bioRxiv

Detectable levels of THC were found in the muscles and organs of the euthanized lobsters, so from that standpoint the experiment was a success. But the THC apparently had little effect on the remaining live lobsters, who displayed “distinct motor responses” and other signs of pain when put in hot water.   

"The effect of vapor THC on this nociceptive (pain) behavior was very minimal. Statistically supported in one case, but of very small magnitude," said Taffe.

We’ll leave it to readers to decide whether a study like this is humane, worthwhile or even makes sense. But it is worth noting that taxpayers helped pay for it.

The lobster cannabis study was supported by grants from the U.S. Public Health Service. Researchers were careful to note that federal funding was not directly used to purchase the lobsters. That money came from La Jolla Alcohol Research, a private company that is developing vapor inhalation technologies.  According to GovTribe, La Jolla Alcohol Research has received about $3 million in federal funding in recent years, most of it coming from the National Institute on Drug Abuse.

Cannabis Poisoning Calls Rise, Particularly for Children

By Pat Anson, PNN Editor

A new analysis of calls to U.S. poison control centers suggests that more regulation is needed of cannabis products to protect consumers – and children in particular — from adverse health consequences.

Researchers found a significant increase in cannabis-related calls to poison centers from 2017 to 2019, about half of them from a healthcare facility.

Most of the 28,630 calls involved someone ingesting cannabis flower or buds, but a growing number involved manufactured cannabis products such as edibles, vaporized liquids and concentrates. About a third of the calls were considered serious.

Cannabis-Related Calls to U.S. Poison Control Centers

JAMA NETWORK OPEN

Most of the calls about manufactured cannabis products involved underage children. Twenty-seven percent involved children under the age of 10 and about a third (34.5%) involved youths between 10 and 20 years of age. Edibles were involved in about two-thirds of those calls.

“Children may be at particular risk for exposure to edible products, such as cookies or candy,” wrote lead author Julia Dilley, PhD, Oregon Health Authority, in JAMA Network Open.

“Although we did not see more serious health outcomes for manufactured product exposures compared with plant products overall, most cannabis plant exposures involved polysubstance use, whereas most cases for manufactured products were for those products alone, suggesting that exposure to manufactured products alone may be relatively more likely to generate adverse events.”

Dilley and her colleagues say cannabis products are riskier for children because they may not know they are consuming THC (tetrahydrocannabinol), the psychoactive ingredient in cannabis. Even when they are labeled, research has found that the amount of THC in cannabis products is often inaccurate.

The study did not distinguish between medical and recreational cannabis. Interestingly, the rate of calls to poison centers from states where cannabis is legal was slightly higher than those where cannabis is still illegal, suggesting that legalization does not increase the level of safety.  

“Market factors may drive the industry to continue developing novel products, which could present additional health risks. Applying regulatory controls to market-driven innovations in potency and additives is key. Novice cannabis users are often advised to ‘start low, go slow’; this guidance may be equally applicable to regulating new retail cannabis markets and products,” researchers said.

Some cannabis companies are intentionally marketing their products as candy and snacks to make them more attractive to children. The Food & Wine website reports the Wrigley Company recently filed three lawsuits against cannabis manufacturers, alleging they produced THC-spiked products that resemble Wrigley candies such as Skittles, Life Savers and Starbursts   

“We take great pride in making fun treats that parents can trust giving to their children and children can enjoy safely," a Wrigley spokesperson told Reuters. "We are deeply disturbed to see our trademarked brands being used illegally to sell THC-infused products."

One cannabis company, THC Living, recently took a “snortable” cannabis candy off the market after complaints on social media. According to Leafly, the packaging and marketing of “Cannabis Bumps” were designed to make the powdered candy look like cocaine. Each package contained a hefty dose of 600mg of THC.    

Don’t Worry Be Happy: Why People Turned to Cannabis During the Pandemic

By Pat Anson, PNN Editor

Demand for medical cannabis rose significantly in the U.S. during the pandemic, according to a new study that found many Americans turned to cannabis to relieve stress and make them feel happy.

The study was conducted by Veriheal, a telemedicine company that helps connect patients with licensed marijuana doctors and dispensaries.

In reviewing a database of over 125,000 Veriheal patients from January 2020 to March 2021, researchers found that applications for medical cannabis cards spiked during waves of Covid-19 infections, and as social unrest grew over the presidential election and the murder of George Floyd.

"Medical cannabis has traditionally been viewed as an alternative treatment for relieving physical pain and chronic ailments," said Maha Haq, CEO of Cultivating Research Education and Advocacy Group (CREA), a research firm that studies psychoactive drugs like cannabis and psychedelics.  

"That most people are actually looking to the plant to ease psychological stressors, often related to external social upheaval, is an incredibly important discovery that helps medical professionals better understand evolving consumer relationships with cannabis, and from there, improve the quality of their treatment and related mental healthcare programs." 

Asked what was the primary effect they wanted to get from medical cannabis, nearly half of patients (46%) picked “Happy” and less than a third (29%) said pain relief. Other patients said they used cannabis to help them relax, sleep, feel mellow or more focused.

The chart below shows that sign-ups and appointments for cannabis consultations rose sharply during stressful periods; when there were spikes in COVID-19 infections, last summer’s Black Lives Matter protests, and the insurrection at the U.S. Capitol in January 2021.

SOURCE: VeRIHEAL

Researchers say the findings indicate that new cannabis consumers – at least during the pandemic -- were more likely to use cannabis to improve their mental and emotional health, as opposed to treating pain and other physical symptoms.  

“We found that people are seeking psychological relief in response to exogenous shocks including COVID-19 and beyond. Periods of social unrest, such as the Black Lives Matter protests and 2020 elections, can be seen as spikes in medical cannabis interest within our datasets," said Haq.

Positive Views About CBD Products

Most pain patients have favorable views about medical cannabis, according to a second, smaller survey of people being treated at pain management clinics in southern California. The findings were recently published in the Journal of Pain Research.

Researchers recruited 253 patients to participate in the survey, most of whom were on Medicaid or Medicare and had low incomes. Nearly two thirds (62%) said they had tried a CBD product in different formulations, including those containing THC.

Most CBD users said it significantly reduced their pain (59%) and allowed them to reduce or stop their use of pain medication (68%), including opioids (54%).  

CBD was particularly effective for those suffering from back pain (67%) and nerve pain (47%), and less effective for patients with fibromyalgia (21%) and migraine (33%).  

“While the familiarity with dosing was mixed and participants used a wide variety of products including products containing THC, they report that these products have helped them with many different pain-involving and neurological conditions,” wrote lead author Jan Schilling, MD, Scientific Director of Vitamed Research. “This cohort also reported that products both with and without THC have helped them to reduce overall pain medication and more specifically opioid medication.”

Most respondents believed that CBD was a good treatment option, not harmful and not addictive. About half said they would be more comfortable if their physician prescribed CBD products.

Most Older Adults Don’t Tell Doctors About Their Cannabis Use

By Pat Anson, PNN Editor

A growing number of older adults have discovered the medical benefits of cannabis – everything from pain relief to lower blood pressure. But a new study found that most older Americans aren’t telling their doctors about their cannabis use.

In an analysis of over 17,000 Americans aged 50 and older who participated in the 2018 and 2019 National Surveys on Drug Use and Health, researchers at the University of Texas at Austin found that nearly nine percent had used cannabis in the past year. Of those, less than 40% had discussed their cannabis use with a healthcare provider.

Researchers say that’s an alarming figure because the cannabis users were significantly more likely to have substance abuse and mental health problems than nonusers.  

“Only a minority of older cannabis users discussed their drug use with a healthcare professional, although medical users were more likely than nonmedical users to have done so,” said lead author Namkee Choi, PhD, Professor of Gerontology at the University of Texas at Austin.

“Given little difference in cannabis and other substance use/use disorders between nonmedical and medical users, older cannabis users, regardless of use reasons, should consult healthcare professionals about their use, and healthcare professionals should screen for cannabis and other substance use as part of routine care.”

Compared to recreational users, medical users consumed cannabis more frequently, with nearly 40% using it everyday or a few times each week. Surprisingly, less than 20% of medical users bought their cannabis from a dispensary; most obtained it from friends, family or strangers. About 95% of medical users said obtaining cannabis was fairly easy or very easy.

“The finding that a significant proportion of medical and nonmedical users obtained cannabis via private/informal sources indicates that they are likely to use cannabis and cannabis products with unknown tetrahydrocannabinol (THC) potency,” said Choi. “Given the increase in THC potency, healthcare professionals should educate older cannabis users, especially high-frequency users, on potential safety issues and adverse health effects of cannabis and cannabis products obtained from unregulated sources.”

The study findings were published in The American Journal of Drug and Alcohol Abuse.

A 2018 survey by the American Association of Retired Persons (AARP) found that most older Americans think marijuana is effective for pain relief, anxiety and nausea. Seventy percent of those surveyed say they would consider asking their healthcare provider about medical marijuana if they had a serious condition that they thought might respond to it.

A recent study published in the journal Cannabis and Cannabinoid Research found that older adults are more likely to purchase sublingual formulations of cannabis, such as edibles and tinctures, as well as products low in THC and high in CBD.

Urine Tests Show Medical Cannabis Often Mislabeled

By Pat Anson, PNN Editor

Pick up almost any canned or packaged food in a grocery store and you’ll see a lengthy list of its ingredients, right down to the amount of sodium, fat, vitamins and calories in each serving.

That kind of attention to detail – and truth in advertising -- continues to elude the cannabis industry, according to a new study that found the amount of THC and CBD listed on many medical cannabis products to be wildly inaccurate.

Researchers at Massachusetts General Hospital didn’t test the products themselves, but instead analyzed urine samples from nearly 100 patients who frequently used medical cannabis to treat their pain, anxiety, depression or insomnia. Vaping was the most common form of administration, but patients also smoked or ingested cannabis products purchased at Boston-area dispensaries.   

Laboratory testing showed no CBD metabolites in about a third of the urine samples from patients who said they used cannabis products that were mostly CBD or had equal parts THC and CBD. THC was detected in nearly 80% of those samples, including ones from patients who thought they were only ingesting CBD.

The distinction is important because THC (tetrahydrocannabinol) is the psychoactive ingredient in cannabis that can make users high, while CBD (cannabidiol) is the chemical compound believed to have health benefits.

"People are buying products they think are THC-free but in fact contain a significant amount of THC," says lead author Jodi Gilman, PhD, an investigator in the Center for Addiction Medicine in Massachusetts General’s Department of Psychiatry. "One patient reported that she took a product she thought only contained CBD, and then when driving home that day she felt intoxicated, disoriented and very scared."

About 20% of patients who used a vaporizer had no detectable levels of either THC or CBD in their urine. Researchers think that’s because some vaping devices may not heat cannabis products sufficiently for patients to inhale the active ingredients. THC was more likely to be found in patients who smoked cannabis or ingested it orally.

"A lot of questions about the content of the products and their effects remain," says Gilman. "Patients need more information about what's in these products and what effects they can expect."

The study findings, published in JAMA Network Open, are the latest to show that the actual ingredients in cannabis products vary considerably from their labels. Although 36 states and Washington DC have legalized medical cannabis, there is little consistency in labeling, regulating or testing medical cannabis, as there is for food, supplements and pharmaceutical drugs.

A 2015 study of cannabis edibles sold in California and Washington found that only 17% were labeled accurately. Over half had significantly less CBD than labeled and some had negligible amounts of THC.   

A recent study conducted by the Food and Drug Administration of 147 hemp and cannabis products found that less than half contained CBD within 20% of their label declarations.   

Harvard Study Finds Cannabis Effective for Chronic Pain

By Pat Anson, PNN Editor

Long-term use of medical cannabis may be an effective treatment for chronic pain, according to a small study by researchers at Harvard Medical School and McLean Hospital in Boston.

Thirty-seven patients suffering from arthritis, joint pain, neuropathy and other chronic pain conditions were evaluated over a six-month period while ingesting cannabis products through smoking, vaporizing, edibles, oils and other methods. All of the patients were cannabis “naive” — meaning they had never used cannabis before or had abstained from use for at least a year prior to the study.

After six months of daily treatment with cannabis, patients reported significant improvements in their pain, sleep, mood, anxiety and quality of life. Their use of opioid pain medication declined by an average of 13% and 23% after 3 and 6 months of treatment, respectively, although not to a degree that was considered significant.

A control group of 9 pain patients that did not use cannabis did not have a similar pattern of improvement in pain or other symptoms. 

“This naturalistic study of medical cannabis (MC) patients with chronic pain provides preliminary evidence that ‘real world’ MC treatment may be a viable alternative or adjunctive treatment for a least some individuals with chronic pain,” wrote lead author Staci Gruber, PhD, Associate Professor of Psychiatry at Harvard Medical School. 

“As results also revealed that individual cannabinoids appear to exert unique effects on pain and comorbid symptoms, more research is needed to potentially optimize cannabinoid-based treatments for pain.”

Gruber and her colleagues say increased exposure to tetrahydrocannabinol (THC), the psychoactive ingredient in cannabis, appeared to be closely related to improvements in pain, while increased CBD exposure was related to improvements in mood, but not pain. Many patients reduced their use of THC as the study progressed.

“Interestingly, we have found that many patients aim to achieve symptom alleviation without experiencing the intoxicating effects of THC. Therefore, it is likely that patients are able to achieve adequate pain relief using lower doses of THC over time than initially utilized,” said Gruber, who heads the Marijuana Investigations for Neuroscientific Discovery (MIND) program at McLean Hospital.

Researchers say additional studies are needed to explore how THC and CBD modulate pain and other symptoms. Their findings are published in the journal Experimental and Clinical Psychopharmacology.  

While the findings are intriguing, the small number of patients involved in this and most other cannabis studies makes it hard to draw firm conclusions.  

Last month two professional pain societies – the International Association for the Study of Pain (IASP) and the Australian and New Zealand College of Anaesthetists -- released statements saying they could not endorse the use of cannabis to treat pain because there are no large, high-quality and unbiased clinical trials of cannabis as an analgesic.

Cannabis Users Deserve Better Research

By Roger Chriss, PNN Columnist

This has been a challenging month for supporters of medical cannabis, with two professional pain societies – the Australian and New Zealand College of Anaesthetists and the International Association for the Study of Pain (IASP) both releasing statements saying they do not endorse the use of cannabis to treat pain.

IASP’s position statement came after a two-and-a-half-year review of cannabis studies by researchers at the University of Bath's Centre for Pain Research, who found little evidence to support the use of cannabis for pain control.

“Cannabis seems to attract strong opinions. If ever a field needed evidence and a rigorous scientific opinion it is this one. For many this will be an unpopular conclusion, but we need to face up to the fact that the evidence is simply lacking. Science is not about popularity but keeping people safe from false claims,” said Professor Christopher Eccleston, Director of the Centre for Pain Research

Eccleston and his colleagues published their findings in a series of 13 articles in IASP’s journal PAIN. They found that many cannabis studies had too few participants, tested a single-dose exposure in a laboratory, or the trials only lasted a couple of weeks. Such work can justify further research, but not the clinical use of a drug by patients, which requires long-term studies of safety and efficacy.

"Cannabis, cannabinoids, and cannabis-based medicines are becoming an increasingly popular alternative to manage pain. However, our review shows that there is limited evidence to support or refute their use for the management of any pain condition. The studies we found were poor quality and the evidence was of very low-certainty," said Dr. Emma Fisher of the University of Bath.

Although cannabis has been used for thousands of years for pain and other conditions, there are few good quality studies to support its use, as anesthesiologist Abdul-Ghalliq Lalkhen, MD, notes in his new book, “An Anatomy of Pain.”

“There have so far been only twelve randomized controlled trials on cannabis in the past five years, and most of these studies have indicated that cannabinoids are not effective in the management of neuropathic pain," wrote Lalkhen.

Even when cannabis studies are conducted, they often have disappointing results. Zynerba Pharmaceuticals had high hopes for developing CBD drugs and a transdermal CBD skin patch, but quietly dropped them after disappointing clinical trials.

“Zynerba’s drugs have struggled mightily in the clinic, missing key endpoints and sometimes failing to show dose-dependent responses. Plans for an epilepsy and osteoarthritis drug fell away with clinical failures in 2017. A year later, so did a patch that was meant to deliver their THC through the skin,” Jason Mast reported in Endpoints News.

The lack of good evidence was noted by the Food and Drug Administration when it recently warned two companies illegally marketing over-the-counter CBD products for pain relief:

“It’s important that consumers understand that the FDA has only approved one drug containing CBD as an ingredient. These other, unapproved, CBD products may have dangerous health impacts and side effects. We remain focused on exploring potential pathways for CBD products to be lawfully marketed while also educating the public about these outstanding questions of CBD’s safety,” said FDA Principal Deputy Commissioner Amy Abernethy, MD.

Even when high-quality, placebo controlled trials are conducted, they often fail to replicate the results of lower-quality studies. For instance, cannabis is often touted for post-traumatic stress disorder (PTSD). But a recent clinical trial of cannabis for PTSD found it worked no better than a placebo.

“No active treatment statistically outperformed placebo in this brief, preliminary trial. Additional well-controlled and adequately powered studies with cannabis suitable for FDA drug development are needed to determine whether smoked cannabis improves symptoms of PTSD,” researchers concluded.

The American Medical Association takes a similar view. “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 said.

Cannabis users deserve high-quality research. And the medical community deserves respect for not endorsing cannabis before the evidence base is well established. Arguing over low-quality studies does not have the persuasive power of a high-quality clinical trial.

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.

Doctors Advised Not To Prescribe Cannabis for Chronic Pain

By Pat Anson, PNN Editors

Pain management experts around the world are becoming more vocal about the growing use of medical marijuana as a treatment for chronic pain, saying there is little evidence to support the use of cannabis as an analgesic.

Today the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists (ANZCA) released new guidance urging doctors not to prescribe medical cannabis for patients with chronic, non-cancer pain unless they are enrolled in a clinical trial.

“Until there are results from high-quality, unbiased clinical trials which establish the effectiveness and safety of medicinal cannabis in treating chronic pain, the Faculty of Pain Medicine does not believe cannabinoid products should be prescribed,” Mick Vagg, MD, Dean of the Faculty of Pain Medicine, said in a statement.  

“We want to highlight to healthcare providers that currently available medical cannabis products are not even close at this stage to showing that they deserve a place in the management of the complex patients who suffer from ongoing pain. We believe clinicians will welcome this clear guidance.”

ANZCA is a professional society for nearly 8,000 anesthesiologists and pain management specialists in Australia and New Zealand, and sets standards for pain medicine in both countries.

Australia and New Zealand have some of the highest rates of cannabis consumption in the world. But New Zealand only allows medical cannabis for terminally ill patients, while Australia requires a prescription for cannabis that is often difficult to obtain.

About one if five Australians live with chronic pain.   

“Medical cannabis products are not even close at this stage to showing that they deserve a place in the management of the complex patients who suffer from ongoing pain.”

— Dr. Mick Vagg

“By far the most common reason for the use of medicinal cannabis in this country is chronic pain − however there is a critical lack of evidence that it provides a consistent benefit for any type of chronic non-cancer pain, especially compared to the treatments we already strive to provide in pain clinics,” Vagg said.

“The research available is either unsupportive of using cannabinoid products in chronic non-cancer pain or is of such low quality that no valid scientific conclusion can be drawn. Cannabidiol-only formulations have never been the subject of a published randomised controlled trial for chronic pain treatment, yet they are the most commonly prescribed type of cannabis product.”

Vagg also said research is lacking in how cannabinoids react with pharmaceutical drugs, particularly in relation to their sedative and psychiatric side effects.

‘Hypothesis’ of Analgesia

ANZCA’s new guidance came just days after the International Association for the Study of Pain (IASP) released a position statement saying it could not endorse the use of cannabinoids to treat pain. IASP said there were preliminary studies supporting the “hypothesis of cannabinoid analgesia,” but not enough to overcome the lack of evidence on the safety and efficacy of cannabinoids.

“While IASP cannot endorse the general use of cannabinoids for treatment of pain at this time, we do not wish to dismiss the lived experiences of people with pain who have found benefit from their use,” said Andrew Rice, MD, chair of IASP’s Presidential Task Force on Cannabis and Cannabinoid Analgesia.

“This is not a door closing on the topic, but rather a call for more rigorous and robust research to better understand any potential benefits and harms related to the possible use of medical cannabis, cannabis-based medicines and synthetic cannabinoids for pain relief, and to ensure the safety of patients and the public through regulatory standards and safeguards.”

Rice said IASP was concerned that laws allowing the use of medical marijuana were being adopted without the same rigor and regulatory procedures that are followed for pharmaceutical products. Patients who self-treat their pain with cannabis are also at risk, according to Rice, because their doctors often don’t know about their cannabis use.  

“IASP is also calling for the delivery of a comprehensive research agenda. Priorities include identifying patients with pain who may receive the most benefit from cannabis or cannabinoids, and who may be at risk of the most harm,” said former IASP president Lars Arendt-Nielsen, MD, who co-chaired the Cannabis Task Force.

Supporters of medical cannabis dispute the contention that there is inadequate evidence about the use of cannabis for pain.

“These recommendations are political, not scientific. Several peer-reviewed trials have concluded that inhaled cannabis is safe and effective for treating various types of pain, in particular neuropathic pain,” Paul Armentano, Deputy Director of NORML, said in an email to PNN.

Armentano cited a 2017 study from the U.S. National Academy of Sciences, which found “conclusive or substantial evidence” that cannabis is an effective treatment for chronic pain.

“In the real world, the therapeutic use of cannabis is rising among chronic pain patients, many of whom are substituting it in place of opioids. In jurisdictions where cannabis is legally available, chronic pain is the most qualifying condition among medical cannabis patients enrolled in state-specific access programs. To willfully ignore these data is indicative that political considerations, rather than scientific considerations, influenced this group’s decision,” Armentano said.