Nancy A. Melville

May 17, 2016

AUSTIN, Texas — With growing public support and promising, but inconclusive, signs of therapeutic benefits in the use of herbal cannabis, medical marijuana laws are marching full steam ahead across the United States, prompting the American Pain Society (APS) to issue a white paper to assist in cannabis-related clinical issues that pain physicians are increasingly facing.

"Cannabis is here, there's no question about it, and most of us as clinicians who treat pain will see patients who are either using it under certification or illicitly," coauthor Seddon R. Savage, MD, told Medscape Medical News here at the APS 35th Annual Scientific Meeting. "So we thought clinical guidance and recommendations on research that is needed would be important."

Medical marijuana laws are currently in place in 24 states and the District of Columbia. With legislation underway in numerous other states to decriminalize medical marijuana, clinicians are under more pressure than ever to address patients' use of cannabis.

The white paper, published online in the Journal of Pain, represents a consensus document compiled by authors with diverse perspectives and opinions, said Dr Savage, from Silver Hill Hospital Chronic Pain and Recovery Center and the Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire.

"The authors of the paper span the spectrum from legalization advocates to those who do not even support certification for medical marijuana, so this forced us to really have a balanced look at our clinical experiences," she said.

"We looked at the evidence that is available on the use of clinical cannabis and extrapolated to some degree on management strategies from our experiences with the prescribing of controlled substances."

The paper's key clinical recommendations include the following:

  • Be aware of federal laws and current enforcement: "We suggest if you are going to certify or follow individuals using medical cannabis that you be aware of federal laws, how the laws work and how the laws may change over time," Dr Savage said.

  • Likewise, be aware of and work within state laws.

  • Be guided by evidence, not commercial messaging: "This is an important one -- we need to get our information from science and not from people who are marketing their products," Dr Savage said.

  • Advise patients on cannabis strains and extracts compared to cannabinoid medications as possible. "There's not a lot to guide us, but if, for example, someone has an addiction or high anxiety, you might start with something with higher cannabidiol," which, unlike delta-9-tetrahydrocannabinol (THC), does not appear to produce euphoria.

  • Advise patients on routes of administration as possible.

Dr Savage suggested that patients using clinical herbal cannabis should be managed with a paradigm similar to that for opioids, including establishing clear goals of treatment; screening for risk for misuse, addiction, and diversion; counseling on individualized risks and benefits; and considering a written understanding and agreement.

The strongest evidence in terms of the therapeutic benefits from herbal cannabis, specifically cannabinoids, suggests analgesic effects, with a lengthy list of other possible benefits, including anticonvulsant activity, relief of anxiety and post-traumatic stress disorder, migraine relief, and inflammatory bowel disease.

"The problem is that most of the benefits are simply not well studied, with the exception of FDA [US Food and Drug Administration] indications for antiemetic and antinausea properties associated with chemotherapy and for wasting associated with HIV," Dr Savage said.

Many tout herbal cannabis as a much-needed alternative to opioids, with very low or no potential for overdose and relatively low rates of addiction. One recent study in JAMA Internal Medicine in fact showed lower rates of opioid overdose mortality rates in states with laws allowing the use of medical marijuana.

The arguments opposing the clinical use of herbal cannabis are equally compelling, however: Proper dosing is uncertain; with no federal oversight of purity or content, levels of active ingredients may not be known; and there is the concern that increased clinical availability of herbal cannabis can lead to increased misuse and associated harm.

Various notable potential serious adverse effects have been reported, including a risk for tachycardia and orthostatic hypotension, and Dr Savage added that numerous case series in the literature describe people having myocardial infarction within an hour of using marijuana.

One issue that has consensus from both sides, however, is the need for more evidence, and the paper also detailed recommendations along those lines, including the following:

  • Increase federal funding for pain-related cannabis research.

  • Increase research aimed at herbal cannabis and cannabinoids, including broadening pain conditions being studied and supporting larger-scale, phase 3 clinical trials.

  • Ease regulatory restrictions impeding cannabis research, including considering rescheduling it from a schedule 1 drug.

  • Improve access to high-quality cannabis for research with diverse strains and derivatives with varying cannabinoid content ratios.

  • Encourage states to collect individual- and population-level data to advance the understanding of individual health outcomes and public health effects of cannabis availability.

Dr Savage emphasized the importance of this last recommendation of collecting data.

"I know of no states that are collecting individual-level health data on people who are using it, including information such as how it is working, are they having any unexpected complications, have they been able to change any other medications they're using?" Dr Savage said.

"Imagine if we had a registry that actually collected health data on these things," she added. "We could learn a lot very quickly to study public health impacts on this."

The authors lastly emphasized that without quality control of cannabis production and dispensing, medicinal benefits are highly compromised.

"If patients can legally use cannabis as a therapeutic modality, sources of high-quality medicinal grade cannabis with strict quality control and known constituents will be required," the authors write.

"Avenues will need to be opened to allow the cannabis to be dispensed through pharmacists who acquire medicinal grades of cannabis from sources with adequate quality control. Until that happens, the line between medicinal cannabis and recreational cannabis will continue to be blurred."

Dr Savage has disclosed no relevant financial relationships. The disclosures of other authors are detailed on the online published version of the paper.

American Pain Society (APS) 35th Annual Scientific Meeting. Presented May 13, 2016.

J Pain. Published online March 4, 2016. Abstract

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