Therapeutic Benefits of Cannabis: A Patient Survey

Charles W Webb, MD and Sandra M Webb, RN, BSN

Abstract

Introduction

Research into the therapeutic benefits of cannabis has been severely limited by the federal Schedule I classification, which essentially prohibits any ability to acquire or to provide cannabis for studies investigating possible therapeutic effects. Limited studies have been done in Canada and in Europe, as well as several in California.

Hawai‘i is one of twenty states (plus the District of Columbia) which allow certifications for use of medical cannabis. The authors have been certifying patients for use of medical cannabis in Hawai‘i for more than four years. In an attempt to discover the perceived benefits and adverse effects of medical cannabis, we conducted a survey of medical cannabis patients.

Methods

Results

The overall response rate was 94%. The mean age was 49.3 years and the median age was 51. No data was collected on sex or race/ethnicity. Almost all respondents (97%) used medical cannabis primarily for relief of chronic pain.

Average reported pain relief from medical cannabis was substantial. Average pre-treatment pain on a zero to ten scale was 7.8, whereas average post-treatment pain was 2.8, giving a reported average improvement of 5 points. This translates to a 64% average relative decrease in pain.

Other reported therapeutic benefits included relief from stress/anxiety (50% of respondents), relief of insomnia (45%), improved appetite (12%), decreased nausea (10%), increased focus/concentration (9%), and relief from depression (7%). Several patients wrote notes (see below) relating that cannabis helped them to decrease or discontinue medications for pain, anxiety, and insomnia. Other reported benefits did not extend to 5% or more of respondents.

Six patients (6%) wrote brief notes relating how cannabis helped them to decrease or to discontinue other medications. Comments included the following: “Medical cannabis replaced my need for oxycodone. Now I don’t need them at all.” “I do not need Xanax anymore.” “In the last two years I have been able to drop meds for anxiety, sleep, and depression.” “I’ve cut back 18 pills on my morphine dosage.”

A majority (71%) reported no adverse effects, while 6% reported a cough and/or throat irritation and 5% reported a fear of arrest. All other adverse effects were less than 5%. No serious adverse effects were reported.

Discussion

According to the Institute of Medicine, chronic pain afflicts 116 million Americans and costs the nation over $600 billion every year in medical treatment and lost productivity.1 Chronic pain is a devastating disease that frequently leads to major depression and even suicide.2 Unfortunately, the therapeutic options for chronic pain are limited and extremely risky.

Spurred by efforts to encourage physicians to become more pro-active in treating chronic pain, US prescription opioids (synthetic derivatives of opium) have increased ten-fold since 1990.3 By 2009 prescription opioids were responsible for almost half a million emergency department visits per year.4 In 2010 prescription opioid overdoses were responsible for well over 16,000 deaths.5 A 2010 article in theNew England Journal of Medicine addressing this problem is aptly titled “A Flood of Opioids, a Rising Tide of Deaths.”3 Drugs such as OxyContinR are so dangerous that the manufacturer’s boxed warning states that “respiratory depression, including fatal cases, may occur with use of OxyContin, even when the drug has been used as recommended and not misused or abused.”6 Clearly safer analgesics are needed.

The Hippocratic Oath reminds to “first, do no harm.” It cannot be over-emphasized that there has never been a death from overdose attributed to cannabis.7 In fact, no deaths whatsoever have been attributed to the direct effects of cannabis.7 Cannabis has a safety record that is vastly superior to all other pain medications.

Many physicians worry that cannabis smoke might be as dangerous as cigarette smoke; however, epidemiologic studies have found no increase in oropharyngeal or pulmonary malignancies attributable to marijuana.8–10 Still, since smoke is something best avoided, medical cannabis patients are encouraged to use smokeless vaporizers which can be purchased on-line or at local “smoke-shops.” In states that (unlike Hawai‘i) allow cannabis dispensaries, patients can purchase “vapor pens,” analogous to e-cigarettes and fully labeled regarding doses of THC and other relevant cannabinoids.

Tests have proven that smoke-free vaporizers deliver THC as well or even more efficiently than smoking, and that most patients prefer vaporizers over smoking.11 Like smoking, vaporizers allow patients to slowly titrate their medicine just to effect, analogous to IV patient-controlled analgesia (PCA) that has been so successful in hospital-based pain control. This avoids the unwanted psychoactive side-effects often associated with oral medication such as prescription MarinolR (100% THC in oil) capsules which tend to be slowly and erratically absorbed and are often either ineffectually weak or overpoweringly strong.12,13 Because inhaled cannabis is rapid, reliable, and titratable, most patients strongly prefer inhaled cannabis over MarinolR capsules.14

While the relative safety of cannabis as medication is easily established, the degree of efficacy is still being established. The reported pain relief by patients in this survey is enormous. One reason for this is that patients were already self-selected for success: they had already tried cannabis and found that it worked for them. For this sample, the benefits of cannabis outweighed any negative effects. The study design may therefore lend itself to over-estimating the benefits and under-estimating the negative side-effects if extrapolated to the general population.

Another reason that the reported pain relief is so significant is that cannabis has been proven effective for many forms of recalcitrant chronic pain. A University of Toronto systematic review of randomized controlled trials (RCT’s) examining cannabinoids in the treatment of chronic pain found that fifteen of eighteen trials demonstrated significant analgesic effect of cannabinoids and that there were no serious adverse effects.15

While opioids are generally considered to have little benefit in chronic neuropathic pain, several RCT’s have shown that cannabinoids can relieve general neuropathic pain,16 as well as neuropathic pain associated with HIV and with multiple sclerosis (MS). 17,18 One study found that cannabis had continuing efficacy at the same dose for at least two years.19

Even low dose inhaled cannabis has been proven to reduce neuropathic pain. In a randomized, double-blind, placebo-controlled crossover trial involving patients with refractory neuropathic pain, Ware, et al, found that therapeutic blood levels of THC (mean 45 ng/ml achieved by a single inhalation three times a day) were much lower than those necessary to produce a cannabis euphoria or “high”(> 100 ng/ml).19

Cannabis is relatively non-addicting, and patients who stop using it (eg, while traveling) report no withdrawal symptoms. One author (Webb C.) worked for 26 years in a high volume emergency department where he never witnessed a single visit for cannabis withdrawal symptoms, whereas dramatic symptoms from alcohol, benzodiazepine, and/or opioid withdrawal were a daily occurrence.

The Hawai‘i Medical Association recommends that Medical Cannabis be re-scheduled to a status that is either equal to or less restrictive than the Schedule III status of synthetic THC (MarinolR), so as to reduce barriers to needed research and to humanely increase availability of cannabinoid medications to patients who may benefit.”20

Medical cannabis remains controversial mainly because the federal government refuses to recognize cannabis as an accepted medication. To this we would echo the words of Melanie Thernstrom in her excellent book The Pain Chronicles,2 “How could treating pain be controversial?” one might ask, “ Why wouldn’t it be treated? Who are the opponents of relief?”

Conclusions

Cannabis is an extremely safe and effective medication for many patients with chronic pain. In stark contrast to opioids and other available pain medications, cannabis is relatively non-addicting and has the best safety record of any known pain medication (no deaths attributed to overdose or direct effects of medication). Adverse reactions are mild and can be avoided by titration of dosage using smokeless vaporizers.

More research needs to be pursued to discover degrees of efficacy in other areas of promise such as in treating anxiety, depression, bipolar disorder, autism, nausea, vomiting, muscle spasms, seizures, and many neurologic disorders. Patients deserve to have cannabis released from its current federal prohibition so that scientific research can proceed and so that physicians can prescribe cannabis with the same freedom accorded any other safe and effective medications.

Authors’ Biography

Conflict of Interest

None of the authors identify a conflict of interest.

References