CMSC: Medical Marijuana, Part 1
Medical Marijuana - it’s a topic almost everyone wants to learn more about, and sessions on this topic were filled with health care providers at the recent annual meeting of the Consortium for MS Centers. Alan Bowling, MD, Colorado Neurological Institute, led the multiple sessions on integrative care, which included much information and discussion about cannabis, the formal name for marijuana.
Dr. Bowling has a longstanding interest in integrative care, which he says "refers to conventional medicine along with unconventional medicine as appropriate, and lifestyle medicines.” When CMSC first began their annual meetings 20 years ago, Dr. Bowling had a session on integrative care, and he said 4 people attended and noted the two of them left early. It is now the longest running symposium of CMSC, and the education committee saw a need to provide a comprehensive course on cannabis this year.
Cannabis has been used for millennia
To begin, Dr. Bowling says it’s important to understand cannabis as a medicinal plant “has a long history of use for spasticity and nerve related pain relief, dating back 4,000 years to Ancient Greece. Most recently with the loosening of laws in the US, we now have medical marijuana legally in 44 states.”
There are two primary parts to cannabis – tetrahydrocannabinol (THC) and Cannabidiol (CBD). THC is the element in marijuana that will give the user a high feeling, while CBD in non-psychoactive. CBD is used in the research grade cannabis. In all, said Dr. Bowling, there are over 100 different cannabinoids in cannabis, making it a complex herbal product to study.
“We have quite good evidence from formalized trials – there have been 19 randomized controlled trials with research grade cannabis, with the general sense that pain and spasticity is improved,” said Dr. Bowling. He notes that multiple sclerosis is the second greatest studied medical use of marijuana, just behind cancer studies for nausea.
Educating health care providers
Prescribing medical cannabis has several complications, according to Dr. Bowling. “Many health professionals have little or no training in this area and many people with MS have trouble accessing objective information.” He bases much of his information on the large collection of publications on the safety of cannabis for a wide range of medical conditions.
Dr.. Bowling says part of his presentation is to assist health professionals to understand more about the possible side effects of cannabis use, which may include “addiction, worsening of depression, anxiety, increased suicidality, psychosis, an association with testicular cancer, respiratory issues, heart attack … these are all side effects demonstrated (in studies) through statistical associations
“Starting with the basics – what we take for granted with medications is prescribing information,” said Dr. Bowling. He says there is a need to “develop that information for cannabis and then provide that in a way so health professionals and people with MS can engage in evidence based conversation. This would be information about the content of the cannabis as well as dosing instructions. For now, there is now requirement for this information, even in states with medical marijuana programs.
He expressed concern that “people who work at dispensaries usually have no medical or scientific training but yet they are making very specific recommendations about health products. There needs to be prescribing information - detailed information developed for cannabis and then provide that in a way health professionals and people with MS can engage in evidence based conversation.
50 states of medical marijuana laws
States with medical marijuana laws lack the infrastructure to oversee their programs, according to Dr. Bowling. Unlike drugs, which are covered through the federal government and the Food and Drug Administration (FDA), the medical inspection process for metal and pesticides (found to be in the 80-85% of the products tested) in cannabis falls on each state. The states do not have the personnel, budget or knowledge as to how to conduct these tests, said Dr. Bowling, noting that labeling on products in dispensaries is often found to be incorrect as for the strain, or the levels of THC, the active ingredient in cannabis that helps with pain and spasticity.
Dr. Bowling also notes that the “microbiome of the cannabis plant presents problems - a healthy cannabis plant has fungus growing on both the exterior and interior; that fungus may be fine for the plant but it can be harmful for humans, especially if they are immuno-suppressed like some of our MS patients are.”
Dr. Bowling has his MS clinic in Colorado, a state where both medical and recreational marijuana can be purchased. He openly talks with all of his patients about their experiences and says “my patients report the same as in clinical trials - sense of improvement for muscle stiffness, pain, and spasticity is the benefit reported most often.”
He further talked about the inability for the person with MS to get research grade cannabis, that is grown without pesticide, and has followed rigorous methods of how it is grown and monitored for THC levels. “The challenge is you can't buy (research grade cannabis products) at US dispensaries, and no product in the US dispensaries has been tested for effectiveness for MS or any other medical condition. The labels aren’t necessarily what’s in the product.”
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