Marijuana for Chronic Pain — Yes or No?
Cronic pain can be a monstrous burden to bear, especially if it’s causing an individual debilitating symptoms and affecting their daily lives to a large extent. While each individual finds a different treatment that works for them, there are hundreds of chronic pain sufferers who swear by marijuana to relieve their pain. According to a Times of India report, the Indian hemp drug commission appointed in 1893, hailed cannabis for the ‘mild euphoria’ and ‘pleasant relaxation’ caused by it. It is said that by the early ’80s, American society was struggling with drug problems and in 1985, the Rajiv Gandhi government buckled under the pressure and enacted a law called the Narcotic Drugs & Psychotropic Substances (NDPS) Act which prohibits a person to produce/manufacture/cultivate, possess, sell, purchase, transport, store, and/or consume any narcotic drug or psychotropic substance. In August 2015, AIIMS-Bhubaneswar and Medical Cannabis Foundation of India hosted a Seminar on Chronic Pain in which the use of cannabis to treat chronic and cancer pain was discussed. There are a few movements and petitions filed by people across the country to legalise the drug. Bangalore-based musician Viki Vaurora has even started a campaign called Great Legalisation Movement to legalise marijuana.
According to a US report, as of March 2015, 23 states and the District of Columbia had medical marijuana laws in place. The use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence. Six trials that included 325 patients examined chronic pain, 6 trials that included 396 patients investigated neuropathic pain, and 12 trials that included 1600 patients focused on multiple sclerosis. Several of these trials had positive results, suggesting that marijuana or cannabinoids may be efficacious for these indications. Clinical trials also report that vaporized cannabis is effective at mitigating pain. 2013 FDA-approved trial assessing the impact of vaporized cannabis on neuropathic pain reported that even low doses of THC (1.29 percent) provided statistically significant 30 percent reductions in pain intensity when compared to placebo. While a plethora of patients have found relief through cannabis, there has been a lot of debate about the use, efficacy and adverse effects of marijuana. We talk to experts from the medical field who share their views on the subject.
Dr. Deepak Sharan,Consultant in Orthopaedics, Rehabilitation, Ergonomics, Occupational Safety and Health RECOUP Neuromusculoskeletal Rehabilitation Centre, Bangalore
I have never had to prescribe medical marijuana for chronic pain and I do not support its use because of an adverse risk vs. benefit ratio. The risk of adverse effects, drug interactions, addiction and abuse far outweighs the transient pain relief obtained by it . The use of medical marijuana for treatment of chronic pain is popular only in countries where interdisciplinary rehabilitation focusing on non-pharmacological methods are either not available due to lack of professional expertise, not encouraged by insurers due to perceived high costs, or by patients looking for a passive quick fix without having to take the trouble of budging out of their houses to seek long-term rehabilitation.
My philosophy is that individuals can fully recover from chronic pain, even from an advanced stage, through intensive, physician-directed, interdisciplinary, multimodal, protocol based rehabilitation. According to our published research, the factors that determine recovery from chronic pain are as follows:
- Expert assessment and monitoring of rehabilitation by a physician skilled in manual musculoskeletal medicine.
- Protocol based, intensive, inter-disciplinary rehabilitation including skilled manual therapy, body awareness and psychological approaches.
- Identification and correction of all identified predisposing factors, e.g., posture, habitual deep muscle tension, pain related fear, kinesiophobia, breathing pattern disorders, nutrition, hypermobility, medical and psychological co-morbidities.
- Individuals take responsibility for making changes in their approach to work and other activities.
Dr. Janet McKenzie, ND, Summit Natural Health Centre, Ontario
Any medication with hallucinogenic properties is automatically viewed as a substance that should be banned, regardless of its medicinal potential. Because of this history, substances such as marijuana, which has a record of medicinal use spanning 5 millennia, face extreme scrutiny when proposed for modern medicinal usage. No one medication will work equally well for all people and this is particularly true of painkillers because people experience pain so differently. For these reasons (among others), people living with chronic pain need access to a broad range of medications. I think it is appropriate to include marijuana-derived substances, such as cannabidiol or CBD , in this range. Since the first principle of medical practice is to do no harm, there is a need to proceed cautiously. Whether marijuana is being used medicinally in its whole plant form or as a single ingredient extract, society and health practitioners have a dual obligation to ensure the safety of those who are treated with prescribed marijuana. Fulfilling these obligations will require controls over access to medical marijuana and/or its extracts but should not prohibit access. Beyond the questions of whether and how to make medical cannabis and its extracts available to people with chronic pain looms the larger question of how best to treat chronic pain. In an aging society, chronic pain will constitute an epidemic of its own, and we need to equip ourselves to deal with it more effectively. Cannabis should be part of the tool kit. Better education and support on the use of medical marijuana and drug-free alternatives for managing chronic pain are essential tools that will be needed by the general practitioners who are at the frontline in responding to a chronic pain epidemic.
We also need to stop losing painkilling tools such as opiates to the cycle of demonization and prohibition by ensuring prescription standards are rational, clear and properly regulated. The opiates historically used to manage pain reduce it effectively, but have many side effects and a high potential for addiction. We are now witnessing what appears to be an epidemic of addiction to prescribed opiate painkillers, and this has led to controversy and confusion around how best to treat chronic pain. An article written by Lecia Bushak describes the history of medical cannabis but also makes note of societal tendencies to prohibit and demonize the use of medications that were previously accepted. These instances are markedly similar; medications with the potential to be habit-forming are over-prescribed and an addiction “epidemic” results. Instead of addressing the issue of ineffective controls, the powers outlaw the use of the drugs.
Dr Sunil Kumar Aggarwal,Board Certified Physician in Hospice and Palliative Medicine and Physical Medicine and Rehabilitation, Washington, USA. Honorary Trustee, Medical Cannabis Foundation of India.
The use of medical marijuana to treat chronic conditions is an acceptable, very promising and successful therapy. Cannabis can help in the treatment of chronic pain by reducing reliance on other pharmaceutical pain medicines and ultimately, help in rehabilitating injuries that might have been sustained. Many chronic pain patients like to distance themselves from the pain so that it is not as overwhelming and they can continue to function and carry on normal activities. Cannabis is known for pain relieving properties and for millennia, has been described in ancient Chinese and Ayurveda.
In chronic pain indication, a lot of pain is related to neuropathic pain or nerve injuries and many randomised control trials have been done to show the efficacy of Cannabis for treating this kind of pain. Evidence also exists in rheumatology and inflammatory conditions, cancer-related pain, visceral pain and myofascial pain. In USA where they have legalised the use of Cannabis in some states, there has been reduction in the mortality related to the use the opioids which are also used for pain. However, in India, there is a lack of supply of opioids for pain relief so having cannabis available in addition to having more supply of Indian opioids would be helpful for pain management.
In the Indian context, there was a survey that was published in 2014 with 5000 and more respondents in 8 cities. The estimated incidence rate of chronic pain in the population was 13% and pain in the knees, legs and joints was found to be most prevalent. This lead to inability to exercise, maintain relationships or maintain an independent lifestyle. As for the legality and use of medical marijuana in India, the NDPS Act which is the central government law regarding narcotic drugs and psychotropic substances does empower state governments to lay rules for cultivation of cannabis and to allow such cultivation in the respective States for medical and scientific purposes. However, no state government has made rules to license cannabis cultivation.For example, in the state of Orissa, there is a rule that allows doctors and medical professionals to possess Ganja as well as possess medicines containing Ganja.
Dr. Palanisamy Vijayanand,Consultant in Pain Medicine, Sri Ramakrishna Hospital, Coimbatore.
The legality of cannabis here is confusing — each state has its own rules . While cultivation is legal in Uttarakhand, consumption is legal in Odisha and Gujarat, banned in Assam, and possible with a license in Maharashtra. There are states that have banned its sale, while some have restricted it to be sold by authorised dealers.
An estimated 3.2% of our population uses cannabis (NDPS act allows consumption of bhang) and the numbers could be much higher when occasional (ab)users are included. Compared with nicotine and alcohol that are legal, cannabis carries a much lesser potential for abuse and social fracas. Yet, legalizing it without conditions is fraught with danger, mainly adulteration, leading to deaths. A quality control regime on the other hand, would open the door for the pharmaceutical industry to make a killing out of ancient cultural norms.
The Medical Complexities
Opioids remain the ‘gold standard’ for managing pain, but cannabis still has a long way to go to prove its efficacy. It might turn out to be a wonder drug, but till then, the tall claims in Indian media that it cures diabetes and reduces oxygen requirements in lung diseases are just that. For a drug that has been in use since antiquity, indigenous forms of medicine such as Ayurveda have a much stronger claim to cannabis than modern medicine. Medical cannabis would involve prescribing specific extracts such as cannabidiol, which would be of disadvantage to the practitioners of indigenous medicine. A distinction between natural and synthetic cannabis would be required, with clear guidelines on who could prescribe what.
The Phobia
Few within the Indian medical community have voiced their opinion on medical cannabis. Is it because of lack of scientific evidence? Possible. But, they might be scared, worried and have little knowledge of the regulations — mirroring their standpoint vis-a-vis opioids.‘Opiophobia’ now represents the fears government agencies knocking on the door, addiction and deaths — among physicians who prescribe opioids. It has precluded them from prescribing opioids to desperate pain sufferers, especially at end-of-life, egged on, in addition, by its poor availability due to arcane Indian laws. Cannabis, too, could go the same way.
Liberalising and making the drugs under the purview of NDPS act to be readily available for medical use, without the necessary checks and balances, is fraught with danger. Half a million people in USA have died in the past fifteen years due to prescription opioids overdose, and close to 100 Americans die every day — a result of the collaborative effort between physicians, advocacy groups and the pharmaceutical industry. Indian physicians, too, are not entirely incorruptible — a skeptic would think. Some medical cannabis users could turn difficult by utilising the services of multiple prescribers (known as doctor shopping) to obtain cannabis from multiple sources, to either overdose themselves or sell it in the streets for a higher price (drug diversion).
The government, if convinced about the medicinal value of cannabis should make it an Essential Psychotropic Drug within the NDPS act, and encourage an affordable generic version. There should be rigorous clinical trials to prove its effectiveness, educating and licensing the physicians to prescribe cannabis judiciously as well as monitor for dependence and addiction, monitoring prescriptions with a centralised database to prevent misuse and abuse, ensuring an uninterrupted supply and fine-tuning the regulations based on societal requirements. The western nations are in a hurry to replace their opioid epidemic with a cannabis epidemic. India need not be.
For more updates subscribe to :
