Medical

Medical marijuana shows early promise to lessen opioid use and potential abuse, suggests a systematic review of published studies being presented at the ANESTHESIOLOGY® 2019 annual meeting. However, much more rigorous scientific research must be done to determine if there truly are pain relief benefits to medical marijuana that can ease chronic pain and outweigh potential risks.

Israel’s medical cannabis patients are making another step in their battle against the country’s new regulation, which came into full effect in early September. Intended to help standardize the industry by requiring more stringent quality control and adding pharmacies as middlemen between growers and patients, the reform has so far resulted in market shortages and hiked prices. Now patients are demanding that pharmacies hand all their unstandardized supply back to the growers.

Before the reform, patients with a medical cannabis license paid a fixed sum of NIS 370 (approximately $105) a month regardless of the amount they were prescribed. Now, pharmacies charge NIS 180 (approximately $51) per 10 grams, meaning anyone buying over 20 grams is paying more than they did before the reform. Additionally, the Ministry of Health has forced growers to hand over all product that does not meet the new quality standard, to accustom patients to the new procedure.

Israel’s medical cannabis patients have petitioned Israel’s Supreme Court some months ago to put a stop to the new regulations. The court has ordered the ministry of health to extend all pre-reform patient licenses until March 2020, enabling those patients to continue buying cannabis products according to the old pricing and standard. Last week, Israeli nonprofit the Medical Cannabis Association sent a letter to all growers, stating that despite the court order some growers have refused to comply and supply product according to the old prices. In the letter, the association threatened to appeal the court to hold violating growers in contempt.

Now, the association is taking its battle to the pharmacies. On Friday, the association sent a letter to umbrella organization the Pharmaceutical Association of Israel, stating that according to the court ruling they must either return all non-standardized cannabis product to the growers or sell it according to the old prices. Pharmacists must comply with the court order, which “supersedes any administrative directive to the contrary,” the letter said.

David Papo, chairman of the Pharmaceutical Association of Israel, told Calcalist that the pharmacists are but the messengers. It is the growers who are deliberately creating shortages and hiking prices, he said, and the pharmacists are forced to sell according to the prices imposed by the growers.

The pharmacists put the blame for the shortages on the growers when the latter did not hand over their non-standardized supply, and now when the supply has been handed over, they still blame the growers, Dana Bar-On, the founder and CEO of the Medical Cannabis Association, told Calcalist. But the growers are not the only ones at fault for the shortages and the exorbitant prices, Bar-On said. “These are non-standardized products that still fall under the old regulation that are now sold in pharmacies,” she said. “The absurdity eclipses all logic.”

Though no grower has agreed to go on record, several growers who talked to Calcalist on condition of anonymity described their situation as being between a rock and a hard place. They comply with the regulator and the law, they said, but the regulator has “seized” all cannabis products and handed them to the pharmacies, even the non-standardized product that the Supreme Court has ordered could still be supplied outside of pharmacies. It is the health ministry in its role as the regulator that must solve the situation, they said.

The medical marijuana program in Illinois is seeing record growth since changes in the law greatly expanded the program and made it easier for patients to participate.

More than 87,000 patients have qualified for the program since stores opened in November 2015 — including a spike of almost 37,000 in the fiscal year ending June 30, a 93% increase, according to state records. The surge of new patients exceeds the number signed up in any previous fiscal year, based on the latest annual report on medical cannabis by the Illinois Department of Public Health.

The number of patients has continued to climb, according to the state’s monthly reports, since the state dropped requirements for patient fingerprints and criminal background checks in 2018, and added 11 new qualifying illnesses in August including common conditions such as chronic pain, migraines and arthritis.

Retail sales exceeded $22 million in September alone, almost evenly split between cannabis flower and concentrates and infused products.

The annual state report, which includes data through June, sheds further light on the growth and demographics of the medical cannabis industry.

Since becoming legal as a qualifying condition for medical marijuana in 2016, post-traumatic stress syndrome has become by far the most common condition cited by patients.

More than 8,600 patients were certified by doctors as having PTSD, followed by severe fibromyalgia, spinal cord disease, and cancer as the most common conditions.

The two most popular conditions act as umbrella terms for a variety of conditions, patients and industry experts said. PTSD serves as a catchall for mental health conditions that are not on the list of qualifying conditions, such as anxiety or depression, while fibromyalgia can act as a stand-in for chronic pain, which was not previously a qualifying condition.

Jim Champion, of Somonauk, is an Army veteran with multiple sclerosis who led the fight for medical marijuana in Illinois. (Jose M. Osorio / Chicago Tribune)

Army veteran Jim Champion has multiple conditions that qualify for medical marijuana, including multiple sclerosis and osteoarthritis, but some days, he said, his fibromyalgia is worst of all.

“It is awful,” he said. “It sends sharp pains through my neck and shoulders. Sometimes I just want to chop off my arms it hurts so bad. It can be completely debilitating.”

The one thing that helps, he said, are medical marijuana edibles. “That fixes me right up, more than any of the pills the Veterans Administration used to give me,” he said.

A study published in June in the Journal of Clinical Medicine found that cannabis was a safe and effective treatment for more than half of the 367 patients treated.

Jim and his wife, Sandy, were instrumental advocates in getting Illinois’ medical cannabis law passed, and in expanding access to it. Jim was a member of the state’s Medical Cannabis Advisory Board until it was disbanded as part of a political deal to add post-traumatic stress disorder as a qualifying condition in 2016.

People with medical conditions like fibromyalgia, a disorder known for widespread pain, fatigue and mood effects, share information, and that can lead more patients to come forward seeking help, Dr. Leslie Mendoza Temple said. Patients are required to get a doctor’s certification that they have a qualifying condition, and doctors must document any health problem cited, said Mendoza Temple, medical director of integrative medicine for NorthShore University Healthcare, who has certified some 400 patients.

“I’m getting more and more interest,” she said. “It’s bringing out people looking for relief.”

Cannabis doesn’t work for all patients, and some take too much and have bad experiences, as with any drug, she said. Now that chronic pain is a qualifying condition, she said, people may no longer need to cite fibromyalgia.

In addition to the existing medical marijuana program, the new Opioid Alternative Pilot Program, which started early this year, allows patients to obtain medical marijuana in place of prescription painkillers. It has registered an additional 2,200 new patients — most of them for joint, back or neck pain — with another 1,000 awaiting physician certification, the state report found.

The number of patients seeking to replace opioids is relatively small in part, industry members said, because physician certification of patients lasts only 90 days, compared with regular patient certifications of one to three years.

Also this year, the state began issuing provisional access registration cards to let patients and their caregivers buy medical cannabis while their applications are being processed.

In August 2019, the state added 11 new qualifying conditions, including chronic pain, migraines, anorexia nervosa and autism, but the report only covered the state’s fiscal year through June 30, so did not include those conditions.

Patient consultant Mickey Nulf hands product to client Michelle Farina at Columbia Care medical cannabis dispensary in Chicago in June 2019. (Chris Sweda / Chicago Tribune)

Since sales began in November 2015, the medical cannabis program in Illinois has had about $200 million in wholesale sales, and $364 million in retail sales — a markup of about 76%, which has increased with greater demand this year.

About 4,500 physicians certified patients for medical cannabis in the most recent fiscal year. Most certified fewer than 25 patients, but 58 physicians certified more than 100 patients each. One unidentified physician submitted certifications for patients to substitute cannabis for opioids more than 1,000 times.

Most of the patients — 55% — were 50 years old or older. The number of patients was distributed fairly evenly across all age ranges, though those under 30 made up only 11 percent of patients. The number of men and women was split almost evenly, with slightly more women participating.

Geographically, not surprisingly, Cook County, the state’s most populous county, had the most patients by far with 17,587, followed by the collar counties and Winnebago County, where Rockford is located. One-third of the counties had 60 patients or fewer.

Of 21 licensed operating cultivation centers and 55 licensed medical cannabis dispensaries in Illinois, the most popular by far was the Clinic Mundelein, with 2,550 patients, followed by Dispensary 33 in Chicago’s Uptown neighborhood, EarthMed in Addison, 3C Compassionate Care Center in Naperville, and Moca Modern Cannabis in Chicago’s Logan Square —all in or near relatively affluent areas.

Linda Marsicano, a spokeswoman for Green Thumb Industries, which operates the Clinic Mundelein and 3C, credited their patient care specialists for providing personalized service and public education.

Six months after Gov. Brian Kemp signed a law allowing companies to grow and sell medical marijuana in Georgia for the first time, the program remains stalled because he and other top politicians still haven’t appointed members of a commission to oversee the expansion. 

Aides to Kemp, Lt. Gov. Geoff Duncan and House Speaker David Ralston haven’t said why there’s no members yet for the Georgia Access to Medical Cannabis Commission. But until they do, the expansion is effectively sidelined. 

The legislation, House Bill 324, gave the seven-member commission vast oversight over the state’s medical marijuana operation, including picking which businesses can grow the plant and developing the licensing requirements that retailers must meet to sell it.

It’s a cornerstone of legislation that creates a new but limited marijuana industry in Georgia. The legislation was celebrated as a milestone for patients who were previously allowed to use the drug — but had to violate state and federal laws to purchase it.

One potential cause for the lag time is that the commission is essentially a startup, unlike other boards and agencies with built-in procedures and existing members. State officials say they’ve been inundated with applications — more than 50 candidates have surfaced for the spots.

The law also sets strict requirements for appointments, including a rule that commission members must not have any ownership stake or other financial interest in a cannabis oil firm during their term — and five years after it ends.

Still, the delay is a setback for patients and their families who celebrated the law’s passage with hopes it would provide much-needed treatment for severe seizures, terminal cancers, Parkinson’s disease and other illnesses. 

“It’s extremely frustrating for medically fragile patients to finally get a bill passed that allows the distribution of medical cannabis oil, and then still be waiting on Governor Kemp to establish the commission,” said Blaine Cloud, whose daughter Alaina suffers from a severe form of epilepsy that could be treated by the drug. 

“Registered patients and many others continue to suffer every day – and will continue to suffer since it will take time to get companies licensed once the commission is finally established.”

It’s estimated that over 1 billion individuals worldwide suffer from the debilitating pain of migraines. And now new research shows that CBD may help.

There is nothing quite like a migraine. The American Migraine Foundation (AMF) estimates that over 1 billion individuals worldwide suffer from the debilitating pain of migraines. With 1 in 5 women, 1 in 16 men, and 1 in 11 children all dealing with the life-changing effects of migraines, it’s no wonder CBD and marijuana are often brought up as a means of therapy.

Dr. Stephen Silberstein, director of the Headache Center at Jefferson University Hospital in Philadelphia, recently published a piece with the AMF that showcased the benefits and risks of CBD and THC for those that experience migraines. He states, “If you have a lot of neck pain or soreness, it is perfectly reasonable to use CBD oil. It may even prevent nausea and vomiting,” symptoms often associated with a severe migraine episode. 

Dr. Silberstein also notes that while CBD and medical marijuana is not yet legal in all states, patients should consult their doctor and research where their CBD is made to ensure it’s labeled correctly. 

Do studies exist to showcase other benefits that CBD offers those that have migraines?  

A study from the University of Colorado, published in the journal Pharmacotherapy, showed that the frequency of migraines in patients who used cannabis dropped from 10.4 per month to 4.6 — a number that’s both statistically and clinically significant. Additionally, secondary findings showed that different cannabis delivery routes had different strengths: Smoked marijuana, which hits the bloodstream almost instantly, was best for treating acute migraines. On the other hand, edibles, which take much longer to metabolize, helped prevent headaches.

The Association of Migraine Disorders shared a first-hand account of Michelle Tracy, who explained her fear and hesitation to try CBD and marijuana to combat migraines. Her compelling story serves as a reminder that often, when patients are told, “there’s nothing else that can be done,” it can cause debilitating stress and confusion. Travis closes her story with, “I remain optimistic that there is even more help to be found as more research is conducted, and as marijuana becomes even more socially acceptable.” 

While CBD offers therapy above and beyond prescriptions, Mayo Clinic cites that patients need to be aware of risks as well. “Though it’s often well-tolerated, CBD can cause side effects, such as dry mouth, diarrhea, reduced appetite, drowsiness, and fatigue.” For those that spend days in the dark, it may be time to bring up CBD to their health care team to investigate if it’s a viable solution to their migraines.