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.

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.

Medical Marijuana: A Growing Acceptance

February 11, 2015 / Thomas Cohn, MD

The world’s view on marijuana appears to be rapidly changing. Marijuana was thought of as solely a recreational drug only a few years ago. It was basically slid into a role as something to use only to escape the world and get high. It has been classified by the DEA as drug in Schedule 1, with no medical value. It was put into the same category as heroin and LSD. More recently, medical professionals have been starting to recognize the research on cannaboids and the beneficial compounds marijuana holds. The public perception of marijuana is starting turn in its favor.

Last week there were three main events that advanced the growing acceptance of the medicinal value of marijuana. The first was that the American Academy of Pediatrics (AAP) came out in favor of re-classifying marijuana to a Schedule 2 drug, just like other narcotics like morphine or Percocet. This would change the federal status from being illegal on all fronts to being considered a drug, and thus legal to study and to be prescribed for certain medical conditions. Currently, with its Schedule 1 status, doing adequate medical research is extremely difficult, stifling the development of medical knowledge and its usage. Preliminary research does show medical value of various cannaboids for seizures, nausea, cancer and pain. However, which cannaboids of the about 100 known compounds work best with the least amount of risks is poorly understood. Furthermore, we do not know if it is a combination of compounds or if a specific delivery mechanism is necessary.

The new US Surgeon General, Dr. Vivek Murthy, M.D. has also joined the chorus. This week he indicated that he supported reclassifying marijuana to Schedule 2 drug. He also reported that cannaboids did have medical value in certain conditions. Again, the reclassification would allow widespread research and development of cannaboids for their medicinal value.

Marijuana in Minnesota

In Minnesota, medical marijuana appears to be slowly moving forward. The growers of marijuana have been selected and several locations for dispensaries have been chosen. It still will be limited in use, and it will not be available for the use in pain management, at least in the early stages. The state will investigate marijuana’s potential benefits for chronic pain suffers during the first year medicinal marijuana is available. Furthermore, several Indian tribes are considering whether they will make medical marijuana legal and available on their reservations. The rules that apply on Indian reservations will be up to the individual tribes since they act as sovereign nations with their own laws.

The value of cannaboids to treat many conditions appears to be more positive, and the research is catching up. Changes in the legal drug status hopefully will become reality soon, and the knowledge of how to use these compounds as medicine will become more solid. For now, it is still illegal to use marijuana, and most physicians, due to legal constraints and lack of definite knowledge of risks, do not actively recommend its use.

Study: Medical Marijuana Leads to Fewer Overdose Deaths

August 26, 2014February 17, 2016 / Thomas Cohn, MD

A new study published in the Journal of the American Medical Association found that states that have legalized medical marijuana report significantly fewer overdose deaths than states that haven’t legalized medical cannabis.

The Study

For their study, researchers analyzed mortality data and medical marijuana adoption across the US between 1999 and 2010. Only 13 states adopted medical marijuana by the end of data collection, but the results were fascinating.

“We found that there was about a 25% lower rate of prescription painkiller overdose deaths on average after implementation of a medical marijuana law,” said lead author Dr. Marcus Bachhuber.

Looking solely at 2010, Bachhuber said states with medical marijuana laws experienced about 1,700 fewer deaths than what would have been expected based on numbers prior to medical marijuana legislation. Bachhuber said medical marijuana can be a viable option for individuals suffering from certain chronic pain conditions.

“It can be challenging for people to control chronic pain, so I think the more potions we have, the better,” he said. “But I think it’s important, of course, to weigh the risks and benefits of medical marijuana.”

As I mentioned in previous blog posts, the issue I have with marijuana is that it contains so many compounds that haven’t been sufficiently studied. I’m all for conducting more research on medical marijuana, but I don’t think the results of this study mean every state should immediately legalize medical marijuana.

It’s certainly an eye-opening study and raises many good points, but one of the main objectives of any good pain doctor is to control for as many variables as possible. That’s much harder to do with marijuana. You don’t know how the compounds in that specific plant are going to react with that specific person.

The American Academy of Pain Medicine echoed similar sentiments when discussing the recent findings.

“AAPM believes that we need to do research on cannabinoids to determine its safety and efficacy,” said Dr. Lynn Webster, former AAPM president. “The problem with medical marijuana is that we never know using marijuana what chemicals are being ingested. That makes it really unpredictable, but the use of cannabinoids may well have a place in the treatment of pain and other diseases. The AAPM believes that the DEA should reschedule cannabinoids from Schedule I to Schedule II so that it will make it easier for research to be conducted.”

There will almost certainly be more research on medical marijuana in the near future, but until more is known, it can’t be viewed as a perfect solution.

Related source: CNN.com