Medical Marijuana: Why It’s Different

November 11, 2015May 10, 2016 / Thomas Cohn, MD

Recently, one of the two suppliers of medical marijuana to patients in Minnesota offered a tour of their facility to a small group of leading pain physicians. The business is fascinating and a completely different model from anywhere else in the country. In the rest of America, marijuana for medical purposes is not highly regulated, and is sold by minimally regulated distributors selling whatever types of marijuana they feel might be useful. Needless to say, it is basically the same marijuana that is being sold for recreational purposes to get high.

Minnesota has taken a very different approach to the legalization of marijuana. First, the legislature has recognized that there may be some legitimate medicinal value to marijuana, and that for certain conditions it may be helpful. The legislature also felt recreational marijuana had a spectrum of problems and wanted to avoid adding to the problems of abused substances. Therefore, in Minnesota, only medical marijuana is available, and it is tightly regulated.

There are only two producers of medical marijuana currently allowed in Minnesota. These producers can provide only to patients that have been certified with certain conditions approved to receive such medication. The patient receives extracts from the marijuana plant to ingest as a pill, concentrated liquid, or to inhale as a vapor. It is not available for smoking or as an additive in food. The formulation received by the patient is determined by a pharmacist, and adjusted as well as titrated to help with a patient’s particular symptoms. The pharmacist also will evaluate the effectiveness of the treatment every time the patient is seen, and information for the State is being kept on the treatment, its effectiveness, and what is being given to the patient.

Medical Vs. Recreational Marijuana in Minnesota

Medical marijuana is usually very different than the marijuana found on the street. For most medical conditions, the cannabinoids of interest are the “CBDs” and not THC, the part that gets one “high.” From research done around the world, plants with different amounts of CBD to THC are being grown to produce the desired amounts of these compounds to be used in the medications. Unfortunately at this time, isolating specific CBDs known to exist has not yet been the focus of manufacturing. The medications manufactured currently just have specific amounts and ratios of CBD and THC.

The producer that I visited was extremely interesting. The growing of the plants is very high tech. From the plants used to the growing conditions, all aspects are tightly controlled. After the plants are harvested, the components are isolated and carefully extracted and made into the medicines for each particular individual.

Not all patients who have been qualified by a physician will be accepted by the medical marijuana distributors. Further, since all medical marijuana is considered experimental, none of the cost of treatment is covered by insurance. Doctor visits regarding certification, follow up visits, and all drug and pharmacy costs are cash only and no credit cards are accepted. Medication costs are also fairly expensive since they are made at a custom pharmacy with strict quality controls for safety and purity.

Medical marijuana is truly a product currently for those who have failed conventional treatment. The treatment is only now for certain conditions. If qualified, it may or may not work for any individual. The cost is quite expensive, not supported by insurance, and is cash only. The benefit is medical marijuana is designed as another medication tool to help control symptoms of certain conditions. It is consistent and manufactured like most other drugs to be pure and safe. It is not designed for recreational use and getting high.

Intractable Pain and Medical Marijuana

November 9, 2015 / Thomas Cohn, MD

Medical marijuana for intractable pain is now on the agenda for Minnesota. The commissioner for the Department of Health is now evaluating whether to add intractable pain as a condition that will be included in its medical marijuana program. The commissioner received recommendations against adding pain from the medical advisory committee. There will be a public hearing this week and comments can be sent directly to the Department of Health, at health.cannabis@state.mn.us.

In Minnesota, intractable pain would most likely be handled differently than any other diagnosis for medical marijuana. Already, the medical panel has advised that it be restricted to people over the age of 21. Further, they want to make sure that anyone prescribed is not pregnant and that conventional treatments for pain have already failed.

What is Intractable Pain?

In Minnesota, intractable chronic pain is a legal definition set up by the legislature in the 1990’s. It means pain caused by some medical condition that is unresponsive to normal medical care including medication, physical therapy, and other management. If a patient has intractable pain, then they qualify for the use of opioid medication for management of symptoms. One other component of chronic intractable pain is that it must be certified by two different physicians. Unless new legislation is passed, chronic intractable pain would need to be certified by two physicians, not just one provider in order to qualify for the medical marijuana program.

Over the next month the Minnesota Health Commissioner is going to make a decision on adding intractable pain as a condition for medical marijuana, and it will affect both patients and healthcare providers. If you want to have input on the decision, now is the time. Past history has shown that the most vocal and persuasive voices will influence the decision on what diagnoses are on the list to receive medical marijuana. Mothers with children that had severe seizures were the main force that started the legalization in Minnesota. Patients and medical providers will be the force that determines if intractable pain is added to Minnesota’s list of conditions that are accepted for medical marijuana.

New Findings on Medical Marijuana For Chronic Pain

October 9, 2015 / Thomas Cohn, MD

New research out of Canada suggests that medical marijuana may help people with chronic pain control serious side effects, but it may lead to an increase in minor side effects.

Lead researcher Dr. Mark Ware said medical marijuana appears to be a relatively safe option.

“In terms of a side effect profile, we felt the drug had a reasonably good safety profile, if you compare those effects to other medications,” said Dr. Ware, director of clinical research at McGill University Health Center in Montreal.

Medical Marijuana Study

For their study, researchers tracked 215 patients with chronic pain who used medical marijuana. Participants were studied for one year, and they were compared to a control group of 216 individuals who did not use medical or recreational marijuana. Individuals in the medical marijuana group were given leaf marijuana containing 12.5 percent THC, and they were allowed to smoke it, eat it or vaporize the substance.

At the conclusion of the study, researchers uncovered:

Those who used medical marijuana to ease their chronic pain did not have an increased risk of serious side effects, compared to those who didn’t use pot.

Medical marijuana users were more likely to experience minor side effects, like headaches, nausea, sleepiness and dizziness. They saw a 73 percent increase in less-serious side effects.

Researchers suggest medical marijuana users saw some pain relief through the use of the drug, and they also had better moods and reported a higher quality of life.

Dr. Ware said the study was the first and largest in terms of the long-term safety of medical marijuana, and it could help people who are deciding whether or not to try medical marijuana for their chronic pain.

“This is a paper they should bring to the attention of their physician or health care provider,” Ware said. “Anybody who is interested in using cannabis to treat pain should know this information, as it can influence the decision-making process considerably.”

Dr. Ware also said patients who have never tried marijuana my have a different experience when first getting used to medical pot

“For somebody reading this who’s never tried it, the effects they experience might be different,” Ware said.

Chronic Pain Patients May Soon Be Eligible For Medical Marijuana in Minnesota

September 11, 2015September 11, 2015 / Thomas Cohn, MD

Minnesota officials are considering adding chronic pain to the list of approved conditions for the state’s medical marijuana program.

Meetings about adding intractable pain to the list of approved conditions for medical marijuana began two weeks ago, but so far officials aren’t any closer to a decision. Should state officials add chronic pain to the approved list, chronic pain sufferers would be able to begin purchasing medical marijuana next summer.

Officials are a little leery about adding the chronic condition to the list for a few reasons:

How many would apply? – State officials say they are unsure how many chronic pain sufferers would apply for medical marijuana, and they don’t know if their suppliers would be able to meet the increased demand. Early estimates said it could eventually triple or quadruple the 5,000 patients they currently expect to apply.

Defining chronic pain – Many people deal with pain, but how would chronic pain be defined under the program? One insider suggested that chronic pain would be defined as pain for which “no relief or cure of the cause of the pain is possible,” though the definition could be open to interpretation.

How will doctors respond? – According to the advisory panel tasked with deciding on whether or not chronic pain will be added to the list of approved conditions, some doctors and clinics are leery about sending their patients to buy medical marijuana. There are so many compounds in marijuana, and we don’t have extensive knowledge of how all those compounds will interact with different types of chronic pain.

Decision Time

According to reports, the decision to add chronic pain to the list of approved conditions falls with Department of Health Commissioner Ed Ehlinger and his advisory panel. The panel is comprised of medical professionals and health experts who will help Ehlinger make a decision by the end of the year.

Additionally, the Minnesota legislature can expand Ehlinger’s decision should they feel it’s too strict, or they can place more restrictions on the program should they feel it’s too interpretive.

Related source: Star-Tribune

Minnesota on the Eve of Medical Marijuana

June 29, 2015 / Thomas Cohn, MD

Recently there have been excellent reviews on the state of the science of medical marijuana. Minnesota is about to start its program, but only a handful of people have been approved for the program and there are not many providers interested in participating. So why is medical marijuana off to such a slow start in Minnesota?

Medical cannabis is a complex subject, after attending many lectures on the subject, and reviewing significant amounts of literature, the one main conclusion is that the science behind cannabinoids is only in its infancy. For the average reader, the Time Magazine May 14, 2015 and the National Geographic July, 2015 issues have good information. At a higher level for medical science, the June 23/30, 2015 issue of the Journal of the American Medical Association has more data.

US Lags Behind

The United States has not been a leader in the study of marijuana. Since marijuana has been labeled a Schedule 1 compound by the DEA, its scientific analysis in the U.S. has been extremely limited. Some of the best research initially has come out of Israel where many of the cannabinoid compounds have been isolated, and in Spain where some of the cancer research and other studies have been done. The most recent issue of JAMA has reviewed a large number of medical studies with regards to a variety of conditions. For the scientist, it is clear there is a significant shortage of information supporting claims of effectiveness of the compounds for most conditions. Most information is based on a very limited numbers of study participants. Comparing the information to almost all other drugs on the market, these studies would barely qualify for drug approval.

The quality of studies for marijuana and chronic pain has been especially limited. The studies researched include neuropathic pain and cancer pain. Most of the studies just looked at a numeric pain scale to measure success and did not quantify any other objective measure like functional ability. The outcome was a modest improvement in reported pain level, but deeper evaluation did not show any changes in quality of life measures when compared to placebo or standard treatments.

After reading multiple articles on cannabinoids and pain, one clear message is present. First, there are a number of different cannabinoid compounds, probably well over a hundred. Second, the chemistry is poorly understood and the effectiveness to treat a variety of medical conditions is limited. Medicine has become a very science driven field. Physicians are constantly under fire to provide care that is safe and effective. The current status for medical marijuana is truly still in the research phase. We won’t be able to fully embrace medical marijuana as a viable option until we know more about all of its compounds.