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Etiologic and Therapeutic Considerations
By the year 2016, the medical marijuana industry will gross approximately 5 billion dollars annually. Legislation is rapidly changing in the United States and Canada. The trend is one of legalization and standardization of medicinal strains of Cannabis indica, Cannabis sativa, and hybrid combinations.1 Inevitably, patients will look to their naturopathic physician as a source of information.
Patients with debilitating and often chronic pain cost the healthcare system in the United States more than 100 billion dollars annually. An individual with neuropathy uses 3 times more healthcare dollars than a healthy, matched control.2,3 Pharmaceutical interventions range from gabapentin to antidepressants with unpredictable analgesic effects. Undesirable side effects from medications are commonplace. Irretraceable pain leads patients to seek unconventional solutions. It is estimated that 10-15% of the population with non-cancer pain uses cannabis for pain relief.4
The first positive study examining cannabis and pain was published in 1899 in the British Journal of Medicine.5 In the late 1990s, there was a resurgence of research interest in the medical uses of marijuana. In 1999, the Institute of Medicine formally acknowledged the potential medicinal value of Cannabis species, including the treatment of neuropathic pain.
Peripheral nervous system cannabinoid receptors, CB1 and CB2, exert analgesic effects when stimulated by exogenous delta-9-tetrahydrocannabinol (THC) or endogenous cannabinoids, like anadamide.6,7 Peripheral stimulation of CB1 and CB2 receptors induces the release of norepinephrine and activation of andrenoreceptors. This cascade elicits an anti-nociceptive effect.8 Cannabinoid receptor activation has some effects on glutamine and GABA release, again inducing an anti-nociceptive effect. The exact mechanism of action has not been determined.9 In the brain, THC has an affinity for CB1 receptors in the amygdala and primary cingulate cortex. It is postulated that cannabis has the ability to alter how the body perceives pain, in addition to peripheral anti-nociception.10
Statistically significant neuropathic pain relief is considered to be a 30% reduction in self-reported pain intensity, based on a standardized 11-point rating scale.11 Two placebo-controlled, double-blinded, crossover studies investigating smoked marijuana and HIV-related sensory neuropathy found reductions in pain between 30% and 46%. Secondary improvements in mood, sleep, physical disability, and quality of life were all reported. Adverse effects were self-limiting and usually consisted of headaches, dry eyes, respiratory irritation, and feeling “high.” Pain relief is not dependent on the patient feeling the euphoric effect of the drug. Significant pain relief was achieved with THC blood levels less than half of what would be consumed recreationally. Subjects were able to remain on opiates and other pain medications without interactions.12,13,14 Studies investigating spinal cord injury neuropathies showed greater pain relief using cannabis than gabapentin or opiates. A synergistic effect between cannabis and other analgesics has been noted.15,16
Patients utilizing cannabis for pain relief do not necessarily want the euphoric high for which cannabis is so well known. Evidence suggests that marijuana strains with a high ratio of cannabidol (CBD) to THC can attenuate some of the negative psychotropic effects. Cannabis indica species tend to contain more CBD than do Cannabis sativa species.17 Anecdotally, Cannabis indica has a greater sedative effect, while Cannabis sativa is considered to be more stimulating. Citicoline is a nootropic supplement and is an intermediate to phosphatidylcholine. Preliminary research suggests citicoline affects the dopaminergic reward pathway in the brain and can help reduce the psychotropic effects of marijuana and reduce intake and cravings, if desired.18
Cannabis vaporization is a less-toxic alternative to smoking. Vaporization heats the plant until a THC vapor is formed without combustion. Tar and irritating respiratory toxins are not released. At low doses, vaporized cannabis can significantly reduce neuropathic pain.19
Marijuana compassion centers provide medical-grade cannabis to patients in a secure environment. Compassion centers operate from a “harm reduction” perspective. The location is secure, the cannabis is grown in climate-controlled environments, with periodic genetic testing conducted to ensure strain accuracy. Marijuana bred for recreational use tends to have a high THC to CBD ratio for a euphoric effect, with THC concentrations reaching upwards of 13% – significantly more THC than strains from even 10 years ago.20 Compassion centers stock cannabis with THC:CBD ratios closer to 1:1 for people who are trying to avoid feeling intoxicated. Learning about the various strains of Cannabis indica, Cannabis sativa, and hybrids is encouraged among patrons. According to the director at the Toronto Compassion Centre, edible forms, as well as glycerin and alcohol extracts of cannabis, are available and increasingly popular. Anecdotally, oral ingestion is also considered more effective for physical pain. A referral to a compassion center is required from a licensed medical or naturopathic doctor.
The individual clinician may never choose to recommend cannabis to his or her patients. Nevertheless, any naturopathic doctor in clinical practice can expect to eventually have a patient ask about medical marijuana, particularly when dealing with a patient population in chronic pain. Being prepared to field controversial, politically charged questions is necessary for clinical proficiency.
Lydia Thurton, ND, graduated from the Canadian College of Naturopathic Medicine in 2010. Lydia maintains a general family practice in the Greater Toronto area and is also the naturopathic physician for the HIV/AIDS Committee of Durham Region. Her special area of focus is on African-Canadian, and Caribbean patient populations and she is a regular contributor to the Toronto Caribbean News. In the summer of 2014, Lydia will be joining an integrative pain management team. She can be reached at [email protected].
References
Etiologic and Therapeutic Considerations
By the year 2016, the medical marijuana industry will gross approximately 5 billion dollars annually. Legislation is rapidly changing in the United States and Canada. The trend is one of legalization and standardization of medicinal strains of Cannabis indica, Cannabis sativa, and hybrid combinations.1 Inevitably, patients will look to their naturopathic physician as a source of information.
Patients with debilitating and often chronic pain cost the healthcare system in the United States more than 100 billion dollars annually. An individual with neuropathy uses 3 times more healthcare dollars than a healthy, matched control.2,3 Pharmaceutical interventions range from gabapentin to antidepressants with unpredictable analgesic effects. Undesirable side effects from medications are commonplace. Irretraceable pain leads patients to seek unconventional solutions. It is estimated that 10-15% of the population with non-cancer pain uses cannabis for pain relief.4
The first positive study examining cannabis and pain was published in 1899 in the British Journal of Medicine.5 In the late 1990s, there was a resurgence of research interest in the medical uses of marijuana. In 1999, the Institute of Medicine formally acknowledged the potential medicinal value of Cannabis species, including the treatment of neuropathic pain.
Peripheral nervous system cannabinoid receptors, CB1 and CB2, exert analgesic effects when stimulated by exogenous delta-9-tetrahydrocannabinol (THC) or endogenous cannabinoids, like anadamide.6,7 Peripheral stimulation of CB1 and CB2 receptors induces the release of norepinephrine and activation of andrenoreceptors. This cascade elicits an anti-nociceptive effect.8 Cannabinoid receptor activation has some effects on glutamine and GABA release, again inducing an anti-nociceptive effect. The exact mechanism of action has not been determined.9 In the brain, THC has an affinity for CB1 receptors in the amygdala and primary cingulate cortex. It is postulated that cannabis has the ability to alter how the body perceives pain, in addition to peripheral anti-nociception.10
Statistically significant neuropathic pain relief is considered to be a 30% reduction in self-reported pain intensity, based on a standardized 11-point rating scale.11 Two placebo-controlled, double-blinded, crossover studies investigating smoked marijuana and HIV-related sensory neuropathy found reductions in pain between 30% and 46%. Secondary improvements in mood, sleep, physical disability, and quality of life were all reported. Adverse effects were self-limiting and usually consisted of headaches, dry eyes, respiratory irritation, and feeling “high.” Pain relief is not dependent on the patient feeling the euphoric effect of the drug. Significant pain relief was achieved with THC blood levels less than half of what would be consumed recreationally. Subjects were able to remain on opiates and other pain medications without interactions.12,13,14 Studies investigating spinal cord injury neuropathies showed greater pain relief using cannabis than gabapentin or opiates. A synergistic effect between cannabis and other analgesics has been noted.15,16
Patients utilizing cannabis for pain relief do not necessarily want the euphoric high for which cannabis is so well known. Evidence suggests that marijuana strains with a high ratio of cannabidol (CBD) to THC can attenuate some of the negative psychotropic effects. Cannabis indica species tend to contain more CBD than do Cannabis sativa species.17 Anecdotally, Cannabis indica has a greater sedative effect, while Cannabis sativa is considered to be more stimulating. Citicoline is a nootropic supplement and is an intermediate to phosphatidylcholine. Preliminary research suggests citicoline affects the dopaminergic reward pathway in the brain and can help reduce the psychotropic effects of marijuana and reduce intake and cravings, if desired.18
Cannabis vaporization is a less-toxic alternative to smoking. Vaporization heats the plant until a THC vapor is formed without combustion. Tar and irritating respiratory toxins are not released. At low doses, vaporized cannabis can significantly reduce neuropathic pain.19
Marijuana compassion centers provide medical-grade cannabis to patients in a secure environment. Compassion centers operate from a “harm reduction” perspective. The location is secure, the cannabis is grown in climate-controlled environments, with periodic genetic testing conducted to ensure strain accuracy. Marijuana bred for recreational use tends to have a high THC to CBD ratio for a euphoric effect, with THC concentrations reaching upwards of 13% – significantly more THC than strains from even 10 years ago.20 Compassion centers stock cannabis with THC:CBD ratios closer to 1:1 for people who are trying to avoid feeling intoxicated. Learning about the various strains of Cannabis indica, Cannabis sativa, and hybrids is encouraged among patrons. According to the director at the Toronto Compassion Centre, edible forms, as well as glycerin and alcohol extracts of cannabis, are available and increasingly popular. Anecdotally, oral ingestion is also considered more effective for physical pain. A referral to a compassion center is required from a licensed medical or naturopathic doctor.
The individual clinician may never choose to recommend cannabis to his or her patients. Nevertheless, any naturopathic doctor in clinical practice can expect to eventually have a patient ask about medical marijuana, particularly when dealing with a patient population in chronic pain. Being prepared to field controversial, politically charged questions is necessary for clinical proficiency.
Lydia Thurton, ND, graduated from the Canadian College of Naturopathic Medicine in 2010. Lydia maintains a general family practice in the Greater Toronto area and is also the naturopathic physician for the HIV/AIDS Committee of Durham Region. Her special area of focus is on African-Canadian, and Caribbean patient populations and she is a regular contributor to the Toronto Caribbean News. In the summer of 2014, Lydia will be joining an integrative pain management team. She can be reached at [email protected].
References
It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using ‘Content here, content here’, making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for ‘lorem ipsum’ will uncover many web sites still in their infancy.
It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using ‘Content here, content here’, making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for ‘lorem ipsum’ will uncover many web sites still in their infancy.
The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using ‘Content here, content here’, making
The point of using Lorem Ipsum is that it has a more-or-less normal distribution of letters, as opposed to using ‘Content here, content here’, making it look like readable English. Many desktop publishing packages and web page editors now use Lorem Ipsum as their default model text, and a search for ‘lorem ipsum’ will uncover many web sites still in their infancy.
It is a long established fact that a reader will be distracted by the readable content of a page when looking at its layout. The point of using Lorem Ipsum is that it has a more-or-less normal distribution
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