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Medical Marijuana and CBD: Miracles or Menace? (Part 1)

I recently underwent orthopedic surgery from an injury sustained in my teenage years as a cheerleader. After years of discomfort, limping, limited range of motion, and several scopes I finally succumbed to the inevitable and had a partial knee replacement. I am very thankful for modern technology and medical interventions and treatments that make this possible but was quickly reminded of how much I appreciate crutches, the polar ice machine, and pain medication.

As a healthcare provider, I am acutely aware of the significant benefits that pain medications provide but also keenly understand that if these medications are used inappropriately, they can lead to catastrophic damage in one’s life; physically, mentally, emotionally, socially, and spiritually. As a patient, it is sometimes difficult to find a balance between using enough medication to alleviate the pain so physical therapy exercises can be done in order to get back to “normal” life versus using too much. One thing is for sure, if medications are used inappropriately, your life may never be “normal” again.

* It is important to note that neither medical marijuana nor CBD oil is indicated for this type of post-operative pain. This will be explained as you continue reading.

With so many people in this world suffering from physical discomforts, emotional pain, chronic insomnia, or personal dissatisfaction, it is no wonder that substances have been used to ease multiple kinds of pain. One particular substance, marijuana, has been considered illegal until recently. Few topics bring up stronger emotions than medical marijuana. It captures the attention of all; not only doctors and lawyers, researchers and scientists, public officials, and policymakers, but even the general population.

Many people have questions about marijuana and a couple of particular substances extracted from the plant, namely cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC). The purpose of this article is to briefly discuss some of the similarities and differences, indications for use, legality, and identify safety precautions by using any of these substances. Part I will talk about medical marijuana while part II will review CBD. THC has specific and limited medical indications and not the focus of these articles. 

A BRIEF HISTORY

Variations of the cannabis plant have been around for thousands of years, with evidence of its existence found in a small village in China, dating back to approximately 8000 BCE. The Chinese emperor, Shen Nung, in 2737 BCE described the powerful impact it had on treating patients that were described to have inflammatory disorders (rheumatism, gout, and malaria). The psychoactive response was noted, but at the time it was felt that the benefits outweighed the risks. This ancient medicine gradually spread to India, Africa, and then Europe. In fact, during Colonial times in the United States, hemp was a major commercial crop in the South. It was mainly a source of fiber used for textiles at the time. It wasn’t until 1890, that cotton became the major cash crop of the South.

By 1850, the United States Pharmacopeia described the practice of using marijuana for labor pains, nausea, and rheumatism. Again, the intoxicating effects of the plant were noted among patients and caught the eye of the U.S. Federal Bureau of Narcotics in the 1930s. At that time, the addictive potential of marijuana frightened the government and parents alike. Marijuana became symbolically associated with those who rebelled against authority in the 1950’s and just 20 years later, was classified (alongside heroin and LSD) as a Schedule I drug, having no medicinal use and the highest potential for abuse.

With this colorful history and longevity of marijuana, it’s easy to see why medical marijuana in the 21st century creates all sorts of questions. Is it safe? Is it addictive? How do we keep it out of the hands of teenagers? Has it been proven to be effective? What conditions can it treat? In what form and what dose?
Here are some main points to help improve understanding of medical marijuana, CBD, and what THC is.

MEDICAL MARIJUANA

What is it?

Traditionally, marijuana is smoked via hand-rolled cigarettes or pipes, can be vaped, or eaten in cookies or tea. Some users smoke or eat the concentrated resins or extracts, which contain higher amounts of marijuana’s active ingredients.

Marijuana contains more than 400 distinct chemicals that bind to various receptors throughout the body generating a multitude of effects. Marijuana has a combination of properties that decreases anxiety, produces a mild sedative effect, creates an expansion of consciousness, decreases the perception of pain, stimulates appetite, and creates a desire for more of the drug. Even though it is used to achieve feelings of happiness and relaxation, it may also cause anxiety or paranoia, forgetfulness, depression, scattered thought processes, and distortions in time.
We have abundant research analyzing the components of tobacco smoke but minimal data on the composition of marijuana smoke. We know that tobacco smoke contains more than 4,000 chemicals, with at least 50 of these compounds known to cause cancer. Smoking marijuana generates more than 2,000 compounds. It’s logical that the smoke components between the two will have many similarities, but are likely to have some striking differences. Until more research is done, it should be assumed that smoking marijuana increases the risk of developing multiple types of cancer.

Medical marijuana means different things in different states. In Utah, a summary of the current status of medical marijuana (or medical cannabis program) can be found at https://health.utah.gov/wp-content/uploads/MedCanFactSheet4-8-19.pdf

The medical cannabis program should be operational by March of 2020. It requires individuals seeking this treatment to apply for a medical cannabis card with their qualified medical provider (QMP) in the office through an electronic verification system. Qualified medical providers must complete certain education requirements in order to be allowed to prescribe medical cannabis. Providers are limited as to the number of patients they can have in the medical cannabis program and this form of treatment is only approved for specific conditions. Prescriptions must be filled at a central state pharmacy or a retail pharmacy that has applied for this privilege (the number of pharmacies allowed to apply is currently seven). Only certain dosages and devices will be available. Smoking and edibles are prohibited. The law limits who is allowed to possess or purchase medical cannabis (based on proximity to the pharmacy) and allows for a specific amount to be dispensed at one time.

What is it used for?

Since marijuana appears to impact almost every body system, it is used for a variety of conditions. It is typically used to help control chronic pain (although it is not strong enough for severe pain, ie: pain associated with kidney stones or post-operative). Marijuana appears to ease episodes of nerve pain associated with multiple sclerosis (MS), lessen tremors in Parkinson’s disease and may have potential benefits with people suffering from fibromyalgia, endometriosis, and interstitial cystitis. It has been used to manage nausea, weight loss, PTSD, glaucoma, irritable bowel syndrome, Crohn’s disease and wasting syndrome associated with HIV. Marketing claims in advertisements and on labels regarding its effectiveness should be viewed cautiously. Evidence of marijuana’s effectiveness in all these applications is waning.

Is it legal?

Medical marijuana is now legal in more than half the states throughout the country and in Washington DC. It is still illegal from the federal government’s perspective.
It is important to note that compliance with the Utah Medical Cannabis Act may not protect patients from liability for violations under federal law or the laws of other states.

Is it safe?

Probably, as it has been used for thousands of years, but it also obviously has some side effects and downfalls that need to be understood. It does affect the perception of space and time. It causes a decline in cognition, a delayed response time, impairs memory, and the ability to plan, focus, and carry out multiple tasks. Marijuana negatively affects coordination, judgment, and reaction time. The exact form and dose that should be used and for what condition is still not clearly understood. When looking at the addictive and overdose potential compared to narcotics, it is safer than opiates.

Summary

Medical marijuana does have therapeutic benefits and may carry less risk than traditional medications currently used. Inherently, it has some negative effects also, and the risks and benefits will need to be discussed on an individual basis with your healthcare provider. It will be legal to use in Utah, when specific conditions are met by the Spring of 2020, but is still considered illegal by the federal government. There is still a lack of rigorous scientific testing and research is ongoing.
Look for part II next week, to learn how CBD is related to marijuana and how it is used.

The National Academies of Sciences, Engineering, and Medicine has released a review of the evidence for the use of medical cannabis. You can download a FREE copy at
https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state

Resources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569602/

https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476

https://www.health.harvard.edu/blog/medical-marijuana-2018011513085

Gillespie, B. (2019) Marijuana: Ancient Medicine, the Devil’s Playground, or Medical Miracle? Elite Healthcare Nursing Continuing Education, 50-62.

A Cautionary Tale

I am going to tell you about a patient of mine named Steve. That is not his real name but this is his real story. Steve was in a car accident at age 16. He did not break any bones but he did get bad whiplash. He was seen in the emergency room and treated for his problems. The doctor in the emergency room gave him a prescription for hydrocodone to help with his pain. Hydrocodone is a strong narcotic pain medication and goes by brand names such as Vicodin, Lortab, and Norco. The healing process from the car accident was slow. He did physical therapy. He saw chiropractors. He had good days and bad days. His pain was real. The narcotic pain medicine did help his pain so his doctor continued to give him refills as he worked through the healing process. However, as time passed his doctor eventually told him he needed to stop taking the strong pain medicine because of the concern over addiction potential. But his pain remained significant and he was too scared to stop them. Steve was afraid his pain would be unbearable without them.

When I met Steve he was 34 years old. He had struggled with chronic pain since he was 16. He came into the urgent care complaining of back pain. He told me he had been helping some friends move and he had thrown his back out. I did my evaluation, diagnosed him with muscle spasm, and recommended treatment including rest, ice, Tylenol, and ibuprofen. I also gave him a handout with stretches he could do at home to help his back recover. He asked me if he could have something stronger for the pain. At that point, he told me that only Percocet (oxycodone, another narcotic pain medicine) worked for his pain.

As I had never met Steve before and he was asking me for a very strong pain prescription, I went online and pulled his narcotic prescription report. His report showed he had filled over 50 prescriptions for narcotics in the past year. They had been prescribed by many different doctors and were filled at many different pharmacies. The average narcotic prescription was written for 20 pills. Altogether he had received over 1000 narcotic pills during that time. His most recent prescription for Percocet had been filled just 3 days previously.

At that moment, it was clear Steve had a serious narcotic prescription problem. I showed him his prescription record. He seemed frustrated. He then told me his story beginning with a car accident at age 16. While dealing with the recovery of his back injury he graduated high school and started working. He got married. He had 3 kids. But the pain persisted. And the need for narcotic pain prescriptions persisted as well.

Slowly his life became more and more consumed by trying to get pain pills. He would constantly be thinking about how he would be able to get his next pain prescription. He went through all the doctors in his town until none of them would see him anymore. He got a reputation in the local emergency room as a “drug seeker” and they stopped treating him with narcotic pain pills. He was having to travel further and further to get pain medicine. He missed a lot of work. He lost several jobs over this. His wife supported him financially until she realized he wasn’t looking for jobs anymore – he was spending all his time going around the state looking for pain medicine. She tried to get him help when she realized what was going on. But he grew tired of feeling judged. They got a divorce.

At the point I met Steve he was single, on disability, not involved with his kids at all, and exceptionally angry. He felt no one believed his pain was real. He begged me for narcotic pain medicine. I offered him other solutions which he declined. He left, quite upset. I have never seen him since. 

Steve’s life was ruled by narcotic pain medicine. Steve’s life was destroyed by narcotic pain medicine. His experience should be a cautionary tale for all of us but unfortunately, his story is not unique. The narcotic (also called opioid) epidemic is ravaging our nation and Utah has not been spared. In fact, in Utah, one person dies nearly every day from an opioid overdose. Utah also has the 7th highest drug overdose rate in the nation. Clearly, we are not “safe” in Utah.

What can we do? What can you do? How can you protect yourself and your family from this scourge? Start by educating yourself about the problem. Go to the website www.opidemic.org. They give detailed information on this epidemic and how to address it.

Never starting down the path of using narcotics is the first step. This year Utah and other states passed strict laws limiting and monitoring how physicians prescribe opioids. Physicians are strongly encouraged to avoid prescribing narcotics for things like lacerations, broken bones and even after surgery. You may find your doctor offering you other pain control options aside from narcotics. Heed that counsel.

If you already take narcotic pain medicines or if you have an accident and your doctor offers you a narcotic prescription to help with pain, I encourage you to ask your doctor what other options for pain control might be available to you. There may be safer alternatives for you to consider. 

Remember Steve. Remember that his problems starting out innocently at 16 years of age after his car accident. If his doctors had offered him other pain options at the beginning or if his parents had known to ask questions about the narcotic pain prescriptions, then his life of opioid addiction would have been entirely avoided. We don’t want anyone to end up like Steve. Help yourself and help protect your family.

I have other patients who have struggled with opioid addiction but have decided to act to not let it rule their lives. I have patients who have gotten off narcotics and have been able to take back control of their lives. They feel better. They have more energy. They can think more clearly. They can experience joy again. And they urge me, beg me, to never prescribe them or anyone else a narcotic prescription ever again. They tell me it is worth it to put up with some extra pain right now, and maybe even a few sleepless nights because of bad pain, rather than to start down a path that can lead to opioid addiction. And I believe them.

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