Medical Marijuana

September 12, 2011 Written by JP       [Font too small?]

The July-August edition of the Journal of the American Board of Family Medicine addresses one of the more contentious medical, political and societal issues of our time: medical marijuana. The review provides a balanced perspective about the pros and cons of cannabis use in modern medicine. It not only describes scientific evidence pertaining to legal and illegal cannabis, but also points out issues that require more clarification and future study including: the addictive potential of the “drug”, optimal delivery methods and quality control issues involving natural and synthetic contaminants. My own investigation into the medicinal use of marijuana uncovered some promising and troubling findings.

On the positive side, two trials from 2010 and 2011 demonstrated encouraging results in the management of chronic pain related conditions such as fibromyalgia and postsurgical neuropathic pain. However, other recent cannabis studies point to a lack of success in the treatment of diabetic neuropathy and a decline in cognitive performance in multiple sclerosis patients that use “inhaled or ingested street cannabis”. This new data is unlikely to sway stalwart opinions about medical marijuana one way or the other. But, I hope it will add some scientific weight to the discussion.

Note: Please check out the “Comments & Updates” section of this blog – at the bottom of the page. You can find the latest research about this topic there!

To learn more about the studies referenced in today’s column, please click on the following links:

Study 1 - Cannabis and Its Derivatives: Review of Medical Use (link)

Study 2 - Cannabis Use in Patients with Fibromyalgia: Effect On (link)

Study 3 - Smoked Cannabis for Chronic Neuropathic Pain (link)

Study 4 - Effects of Cannabis on Cognitive Function in Patients (link)

Study 5 - Randomized Placebo-Controlled Double-Blind Clinical (link)

Medical Cannabis May Improve Quality of Life in Fibromyalgia Patients

Source: PLoS One. 2011; 6(4): e18440. (link)

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Posted in Alternative Therapies, Memory, Mental Health

18 Comments & Updates to “Medical Marijuana”

  1. anne h Says:

    WOW!
    They use alot of Marinol here in Hospice work…

  2. JP Says:

    Thanks, Anne!

    In the Los Angeles area, there are medical marijuana dispensaries all over the place. A few years back I visited one (out curiosity) and I was looked at with great suspicion. They probably thought I was a narc! :)

    Be well!

    JP

  3. Eric Says:

    Heard a lot about Marijuana. It has both positive and negative side too.

  4. liverock Says:

    JP

    You should have got a script from Doctor FeelGood and tried a sample,all in the cause of scientific research of course!

  5. JP Says:

    This would be the place to get one, Liverock. They’re all over the place around these parts. :)

    Be well!

    JP

  6. Thom Milson Says:

    I couldn’t help but notice the quoted “inhaled or ingested street cannabis”. I’m fully pro medical marijuana, but here in the U.K where it is not legal, many people buy complete rubbish because they have to buy it illegally. Most young people don’t think or know that there are different types with different health benefits and just want to use it to get stupidly blazed, this all feeds through to politicians etc and makes the whole situation worse.
    I’m pretty sure that the negative effects are also nowhere near as bad as other drugs we are commonly pescribed, such as antibiotics which damage the liver (or even accepted legal drugs such as alcohol).
    I’ve seen so many positive effects in my mother who suffers from M.E it’s amazing. Why can’t we move forward?

  7. JP Says:

    Hi, Thom.

    I hope we will move forward. Solid research is a key component in the process. Thankfully, new studies are slowly trickling in. An example: this study investigating the effects of cannabis in patients with Crohn’s disease – please download the PDF for the full text:

    http://www.ima.org.il/imaj/dynamic/web/ArtFromPubmed.asp?year=2011&month=08&page=455

    Be well!

    JP

  8. JP Says:

    Updated 1/12/16:

    http://onlinelibrary.wiley.com/doi/10.1002/phar.1673/full

    Pharmacotherapy. 2016 Jan 9.

    Effects of Medical Marijuana on Migraine Headache Frequency in an Adult Population.

    STUDY OBJECTIVE: No clinical trials are currently available that demonstrate the effects of marijuana on patients with migraine headache; however, the potential effects of cannabinoids on serotonin in the central nervous system indicate that marijuana may be a therapeutic alternative. Thus, the objective of this study was to describe the effects of medical marijuana on the monthly frequency of migraine headache.

    DESIGN: Retrospective chart review.

    SETTING: Two medical marijuana specialty clinics in Colorado.

    PATIENTS: One hundred twenty-one adults with the primary diagnosis of migraine headache who were recommended migraine treatment or prophylaxis with medical marijuana by a physician, between January 2010 and September 2014, and had at least one follow-up visit.

    MEASUREMENTS AND RESULTS: The primary outcome was number of migraine headaches per month with medical marijuana use. Secondary outcomes were the type and dose of medical marijuana used, previous and adjunctive migraine therapies, and patient-reported effects. Migraine headache frequency decreased from 10.4 to 4.6 headaches per month (p<0.0001) with the use of medical marijuana. Most patients used more than one form of marijuana and used it daily for prevention of migraine headache. Positive effects were reported in 48 patients (39.7%), with the most common effects reported being prevention of migraine headache with decreased frequency of migraine headache (24 patients [19.8%]) and aborted migraine headache (14 patients [11.6%]). Inhaled forms of marijuana were commonly used for acute migraine treatment and were reported to abort migraine headache. Negative effects were reported in 14 patients (11.6%); the most common effects were somnolence (2 patients [1.7%]) and difficulty controlling the effects of marijuana related to timing and intensity of the dose (2 patients [1.7%]), which were experienced only in patients using edible marijuana. Edible marijuana was also reported to cause more negative effects compared with other forms.

    CONCLUSION: The frequency of migraine headache was decreased with medical marijuana use. Prospective studies should be conducted to explore a cause-and-effect relationship and the use of different strains, formulations, and doses of marijuana to better understand the effects of medical marijuana on migraine headache treatment and prophylaxis.

    Be well!

    JP

  9. JP Says:

    Updated 1/13/16:

    http://content.iospress.com/articles/journal-of-alzheimers-disease/jad150915

    J Alzheimers Dis. 2016 Jan 12.

    Safety and Efficacy of Medical Cannabis Oil for Behavioral and Psychological Symptoms of Dementia: An-Open Label, Add-On, Pilot Study.

    BACKGROUND: Tetrahydrocannabinol (THC) is a potential treatment for Alzheimer’s disease (AD).

    OBJECTIVE: To measure efficacy and safety of medical cannabis oil (MCO) containing THC as an add-on to pharmacotherapy, in relieving behavioral and psychological symptoms of dementia (BPSD).

    METHODS: Eleven AD patients were recruited to an open label, 4 weeks, prospective trial.

    RESULTS: Ten patients completed the trial. Significant reduction in CGI severity score (6.5 to 5.7; p <  0.01) and NPI score were recorded (44.4 to 12.8; p <  0.01). NPI domains of significant decrease were: Delusions, agitation/aggression, irritability, apathy, and sleep and caregiver distress.

    CONCLUSION: Adding MCO to AD patients’ pharmacotherapy is safe and a promising treatment option.

    Be well!

    JP

  10. JP Says:

    Updated 02/07/17:

    http://ascopubs.org/doi/abs/10.1200/jco.2015.33.29_suppl.198?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&

    J Clin Oncol. 2015 Oct 10;33(29_suppl):198.

    Use of medical cannabis to reduce pain and improve quality of life in cancer patients.

    198 Background: Early attention to pain and symptoms in those with cancer improves both quality of life and survival. Opioid medications are the mainstay treatment of cancer-related pain. Cannabinoids are increasingly used as adjunctive treatments for cancer pain, but clinical evidence supporting their use as an “opioid sparing agent” or to improve quality of life is as yet unknown. Our study sought to determine if the addition of cannabinoids (medical cannabis) resulted in the reduction of the average opioid dose required for pain control, and improve self-reported quality of life indices.

    METHODS: A retrospective chart review of cancer patients followed in our CCMB Pain and Symptom Clinic was conducted.

    INCLUSION CRITERIA: age over 18 years and formal enrollment in Health Canada’s Marihuana for Medical Purposes (MMPR) program (n = 24). Average dose of opioids were calculated in milligrams of morphine equivalent (ME) per day at the last documented visit prior to enrolment in the MMPR and then at the subsequent clinic visit. Averages of self-reported ESAS scores (pain, tiredness, drowsiness, nausea, appetite, depression, anxiety, sense of wellbeing) were calculated for the same visits. Statistical analysis using the paired student’s t-test compared means and determined the significance of any changes.

    RESULTS: Following enrolment in the MMPR, the average opioid dose decreased by 70.375mg of MEs (p = 0.29). Self-reported ratings (10-point Likert scale) in pain (0.75, p = 0.23), tiredness (0.58, p = 0.21), drowsiness (1.125, p = 0.04), nausea (1.125, p = 0.04), appetite (1.42, p = 0.04), depression (1.29, p = 0.02) and anxiety (1.58, p = 0.004) improved after enrolment. Sense of wellbeing ratings did not change.

    CONCLUSIONS: Patients with cancer pain benefited from the addition of cannabinoids. The average opioid dose decreased following access to medical cannabis. Self-reported ratings of several quality of life indicators showed statistically significant improvement. Our study shows a signal that cannabinoids may reduce cancer patients’ reliance on opioids to control pain. Further prospective controlled studies are needed to further elucidate the role of cannabinoids in the treatment of cancer pain.

    Be well!

    JP

  11. JP Says:

    Updated 06/30/17:

    http://www.europeanneuropsychopharmacology.com/article/S0924-977X(17)30237-7/abstract

    Eur Neuropsychopharmacol. 2017 May 30.

    Cannabinoids in attention-deficit/hyperactivity disorder: A randomised-controlled trial.

    Adults with ADHD describe self-medicating with cannabis, with some reporting a preference for cannabis over ADHD medications. A small number of psychiatrists in the US prescribe cannabis medication for ADHD, despite there being no evidence from randomised controlled studies. The EMA-C trial (Experimental Medicine in ADHD-Cannabinoids) was a pilot randomised placebo-controlled experimental study of a cannabinoid medication, Sativex Oromucosal Spray, in 30 adults with ADHD. The primary outcome was cognitive performance and activity level using the QbTest. Secondary outcomes included ADHD and emotional lability (EL) symptoms. From 17.07.14 to 18.06.15, 30 participants were randomly assigned to the active (n=15) or placebo (n=15) group. For the primary outcome, no significant difference was found in the ITT analysis although the overall pattern of scores was such that the active group usually had scores that were better than the placebo group (Est=-0.17, 95%CI-0.40 to 0.07, p=0.16, n=15/11 active/placebo). For secondary outcomes Sativex was associated with a nominally significant improvement in hyperactivity/impulsivity (p=0.03) and a cognitive measure of inhibition (p=0.05), and a trend towards improvement for inattention (p=0.10) and EL (p=0.11). Per-protocol effects were higher. Results did not meet significance following adjustment for multiple testing. One serious (muscular seizures/spasms) and three mild adverse events occurred in the active group and one serious (cardiovascular problems) adverse event in the placebo group. Adults with ADHD may represent a subgroup of individuals who experience a reduction of symptoms and no cognitive impairments following cannabinoid use. While not definitive, this study provides preliminary evidence supporting the self-medication theory of cannabis use in ADHD and the need for further studies of the endocannabinoid system in ADHD.

    Be well!

    JP

  12. JP Says:

    Updated 03/15/18:

    https://www.ncbi.nlm.nih.gov/pubmed/29538683

    Inflamm Bowel Dis. 2018 Mar 10.

    A Randomized, Double-blind, Placebo-controlled, Parallel-group, Pilot Study of Cannabidiol-rich Botanical Extract in the Symptomatic Treatment of Ulcerative Colitis.

    Background: Cannabidiol (CBD) exhibits anti-inflammatory properties that could improve disease activity in inflammatory bowel disease. This proof-of-concept study assessed efficacy, safety and tolerability of CBD-rich botanical extract in ulcerative colitis (UC) patients.

    Methods: Patients aged 18 years or older, with left-sided or extensive UC, Mayo scores of 4-10 (endoscopy scores ≥1), and on stable 5-aminosalicylic acid dosing, were randomized to 10-weeks’ CBD-rich botanical extract or placebo capsules. The primary endpoint was the percentage of patients in remission after treatment. Statistical testing was 2-sided, using a 10% significance level.

    Results: Patients were less tolerant of CBD-rich botanical extract compared with placebo, taking on average one-third fewer capsules, and having more compliance-related protocol deviations (principally insufficient exposure), prompting identification of a per protocol (PP) analysis set. The primary endpoint was negative; end of treatment remission rates were similar for CBD-rich botanical extract (28%) and placebo (26%). However, PP analysis of total and partial Mayo scores favoured CBD-rich botanical extract (P = 0.068 and P = 0.038, respectively). Additionally, PP analyses of the more subjective physician’s global assessment of illness severity, subject global impression of change, and patient-reported quality-of-life outcomes were improved for patients taking CBD-rich botanical extract (P = 0.069, P = 0.003, and P = 0.065, respectively). Adverse events (AEs) were predominantly mild/moderate with many in the CBD-rich botanical extract group potentially attributable to the ∆9-tetrahydrocannabinol content. A greater proportion of gastrointestinal-related AEs, indicative of UC worsening, was seen on placebo.

    Conclusion: Although the primary endpoint was not reached, several signals suggest CBD-rich botanical extract may be beneficial for symptomatic treatment of UC.

    Be well!

    JP

  13. JP Says:

    Updated 04/21/18:

    https://www.ncbi.nlm.nih.gov/pubmed/29674967

    Front Pharmacol. 2018 Apr 5;9:315.

    No Acute Effects of Cannabidiol on the Sleep-Wake Cycle of Healthy Subjects: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study.

    Cannabidiol (CBD) is a component of Cannabis sativa that has a broad spectrum of potential therapeutic effects in neuropsychiatric and other disorders. However, few studies have investigated the possible interference of CBD on the sleep-wake cycle. The aim of the present study was to evaluate the effect of a clinically anxiolytic dose of CBD on the sleep-wake cycle of healthy subjects in a crossover, double-blind design. Twenty-seven healthy volunteers that fulfilled the eligibility criteria were selected and allocated to receive either CBD (300 mg) or placebo in the first night in a double-blind randomized design (one volunteer withdrew from the study). In the second night, the same procedure was performed using the substance that had not been administered in the previous occasion. CBD or placebo were administered 30 min before the start of polysomnography recordings that lasted 8 h. Cognitive and subjective measures were performed immediately after polysomnography to assess possible residual effects of CBD. The drug did not induce any significant effect (p > 0.05). Different from anxiolytic and antidepressant drugs such as benzodiazepines and selective serotonin reuptake inhibitors, acute administration of an anxiolytic dose of CBD does not seem to interfere with the sleep cycle of healthy volunteers. The present findings support the proposal that CBD do not alter normal sleep architecture. Future studies should address the effects of CBD on the sleep-wake cycle of patient populations as well as in clinical trials with larger samples and chronic use of different doses of CBD. Such studies are desirable and opportune.

    Be well!

    JP

  14. JP Says:

    Updated 04/21/18:

    https://www.ncbi.nlm.nih.gov/pubmed/29674131

    Brain Dev. 2018 Apr 16.

    Efficacy of CBD-enriched medical cannabis for treatment of refractory epilepsy in children and adolescents – An observational, longitudinal study.

    The objective of this observational study was to evaluate the efficacy of medical cannabis for the treatment of refractory epilepsy. Fifty-seven patients (age 1-20 years) with epilepsy of various etiologies were treated with Cannabis oil extract (CBD/THC ratio of 20:1) for at least 3 months (Median follow up time-18 months). Forty-Six Patients were included in the efficacy analysis. Average CBD dose was11.4 mg/kg/d. Twenty-six patients (56%) had ≤50% reduction in mean monthly seizure frequency. There was no statistically significant difference in response rate among various epilepsy etiologies, and cannabis strain used. Younger age at treatment onset (<10 years) and higher CBD dose (>11 mg/kg/d) were associated with better response to treatment. Adverse reactions were reported in 46% of patients and were the main reason for treatment cessation. Our results suggest that adding CBD-enriched cannabis extract to the treatment regimen of patients with refractory epilepsy may result in a significant reduction in seizure frequency according to parental reports. Randomized controlled trials are necessary to assess its true efficacy.

    Be well!

    JP

  15. JP Says:

    Updated 07/07/18:

    http://www.clinicaterapeutica.it/ojs/index.php/ClinicaTerapeutica/article/view/183/91

    Clin Ter. 2017 May-Jun;168(3):e102-e107.

    Medical Cannabis in Patients with Chronic Pain: Effect on Pain Relief, Pain Disability, and Psychological aspects. A Prospective Non randomized Single Arm Clinical Trial.

    BACKGROUND: There is an increasing interest in the medical use of cannabis, particularly in the treatment of chronic pain.

    OBJECTIVES: The aim is to evaluate the effects of cannabis use and the associated benefits reported by patients with various chronic pain diagnoses.

    MATERIAL AND METHODS: A total of 338 patients with different chro- nic pain conditions were treated with a Cannabis Flos 19% decoction for 12 months, in addition to their pharmacological therapy. Baseline levels for pain medications, pain intensity, pain disability, anxiety and depression were recorded at 1, 3, 6 and 12 months.

    RESULTS: Pain intensity records a statistically significant reduction from Baseline to 12 months follow up (X² 61.375; P<0,001); the im- provements from Baseline to 12 months follow up are also recorded in pain disability (X² 39.423; P<0,001) and in anxiety and depression symptoms (X²30.362; P<0,001; X²27.786; P<0,001).

    CONCLUSIONS: Our study suggest that Cannabis therapy, as an adjun- ct a traditional analgesic therapy, can be an efficacious tool to make more effective the management of chronic pain and its consequences on functional and psychological dimension. Further randomized, controlled trials are needed to confirm our conclusions.

    Be well!

    JP

  16. JP Says:

    Updated 08/18/18:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6074811/

    J Pain Res. 2018 Jul 31;11:1411-1419.

    Personal experience and attitudes of pain medicine specialists in Israel regarding the medical use of cannabis for chronic pain.

    Introduction: The scientific study of the role of cannabis in pain medicine still lags far behind the growing use driven by public approval. Accumulated clinical experience is therefore an important source of knowledge. However, no study to date has targeted physicians who actually use cannabis in their daily practice.

    Methods: Registered, active, board-certified pain specialists in Israel (n=79) were asked to complete a Web-based survey. The survey was developed using the Qualtrics Online Survey Software. Questions were formulated as multiple-choice questions, and these addressed three areas of interest: 1) doctors’ personal experience; 2) the role of cannabis in pain medicine; and 3) cannabis medicalization and legalization.

    Results: Sixty-four percent of all practicing pain specialists in Israel responded. Almost all prescribe cannabis. Among them, 63% find cannabis moderately to highly effective, 56% have encountered mild or no side effects, and only 5% perceive it as significantly harmful. Common indications are neuropathic pain (65%), oncological pain (50%), arthralgias (25%), and any intractable pain (29%). Leading contraindications are schizophrenia (76%), pregnancy/breastfeeding (65%), and age <18 years (59%). Only 12% rated cannabis as more hazardous than opiates. On a personal note, 45% prefer cannabis for themselves or a family member. Lastly, 54% would like to see cannabis legalized in Israel.

    Conclusion: In this survey, pain clinicians experienced in prescribing cannabis over prolonged periods view it as an effective and relatively safe treatment for chronic pain, based on their own experience. Their responses suggest a possible change of paradigm from using cannabis as the last resort.

    Be well!

    JP

  17. JP Says:

    Updated 10/03/18:

    https://link.springer.com/article/10.1007%2Fs00520-018-4154-9

    Support Care Cancer. 2018 Sep;26(9):3029-3038.

    The effect of nabilone on appetite, nutritional status, and quality of life in lung cancer patients: a randomized, double-blind clinical trial.

    BACKGROUND: Over one half of the patients diagnosed with advanced lung cancer experience anorexia. In addition to its high incidence, cancer-induced anorexia promotes the development of the anorexia-cachexia syndrome, which is related to poor clinical outcomes. Recently, drugs derived from cannabinoids, such as Nabilone, have been recognized for their appetite improvement properties; however, clinical trials to support their use in cancer patients are necessary.

    METHODS: This is a randomized, double-blind, placebo-controlled clinical trial to assess the effect of Nabilone vs. placebo on the appetite, nutritional status, and quality of life in patients diagnosed with advanced Non-small cell lung cancer (NSCLC) (NCT02802540).

    RESULTS: A total of 65 patients from the outpatient clinic at the National Institute of Cancer (INCan) were assessed for eligibility and 47 were randomized to receive Nabilone (0.5 mg/2 weeks followed by 1.0 mg/6 weeks) or placebo. After 8 weeks of treatment, patients who received Nabilone increased their caloric intake (342-kcal) and had a significantly higher intake of carbohydrates (64 g) compared to patients receiving placebo (p = 0.040). Quality of life also showed significant improvements in patients in the experimental arm of the trial, particularly in role functioning (p = 0.030), emotional functioning (p = 0.018), social functioning (p = 0.036), pain (p = 0.06), and insomnia (p = 0.020). No significant change in these scales was seen in the control group.

    CONCLUSION: Nabilone is an adequate and safe therapeutic option to aid in the treatment of patients diagnosed with anorexia. Larger trials are necessary in order to draw robust conclusions in regard to its efficacy in lung cancer patients.

    Be well!

    JP

  18. JP Says:

    Updated 10/05/18:

    https://www.epilepsybehavior.com/article/S1525-5050(18)30483-9/fulltext

    Epilepsy Behav. 2018 Oct 1;88:162-171.

    Abuse potential assessment of cannabidiol (CBD) in recreational polydrug users: A randomized, double-blind, controlled trial.

    RATIONALE: Treatment with a highly purified oral solution of cannabidiol (CBD), derived from the plant Cannabis sativa L., demonstrated some evidence of central nervous system (CNS)-related adverse events in patients enrolled in phase 3 trials for treatment of childhood-onset epilepsy. Cannabidiol was categorized as a Schedule 1 substance by the United States Drug Enforcement Administration; therefore, it was important to test CBD for human abuse potential.

    METHODS: This was a single-dose, randomized, double-blind, double-dummy, placebo- and active-controlled crossover trial. The abuse potential of single oral doses of plant-derived pharmaceutical formulations of highly purified CBD (Epidiolex®; 750 mg, 1500 mg, and 4500 mg) was compared with that of single oral doses of alprazolam (2 mg), dronabinol (10 mg and 30 mg), and placebo in healthy recreational polydrug users. The primary endpoint to assess abuse potential was the maximum effect (Emax) on Drug-Liking visual analog scale (VAS). Other measurements included Emax on Overall Drug-Liking VAS, Take Drug Again VAS, positive and negative effects, other subjective effects, and Drug Similarity VAS. Cognitive and psychomotor functions were assessed using the Divided Attention Test, the Hopkins Verbal Learning Test-Revised, and the Digit-Symbol Substitution Task. Pharmacokinetic parameters were determined for CBD and its major metabolites. Standard safety measures and adverse events were assessed.

    PRINCIPAL RESULTS: Of 95 eligible subjects, 43 qualified for the treatment phase, received at least 1 dose of investigational medicinal product, and were included in safety assessments; 35 subjects were included in the pharmacodynamic analysis. Subjects receiving alprazolam and dronabinol had significantly higher Drug-Liking Emax (P < 0.0001) compared with those receiving placebo, confirming study validity. Compared with placebo, Drug-Liking was not significantly different for subjects taking 750-mg CBD (P = 0.51). Drug-Liking Emax values for 1500-mg and 4500-mg CBD were significantly different from placebo (P = 0.04 and 0.002, respectively); however, the mean differences were 18-point differences between positive controls and placebo. Alprazolam and dronabinol had significantly higher Drug-Liking, Overall-Liking, and Take Drug Again VAS Emax values compared with all doses of CBD (P ≤ 0.004). In contrast to alprazolam, CBD administration had no observable effect on cognitive/psychomotor tests. Pharmacokinetic parameters for CBD in this trial were consistent with previous studies. The majority of adverse events reported during the trial were of mild or moderate severity; no serious adverse events or deaths were reported.

    CONCLUSION: Administration of a therapeutic dose of CBD (750 mg) showed significantly low abuse potential in a highly sensitive population of polydrug users. Although high and supratherapeutic doses of CBD (1500 mg and 4500 mg, respectively) had detectable subjective effects compared with placebo; the effects were significantly lower than those observed with alprazolam and dronabinol.

    Be well!

    JP

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