Published: LifeLines for Health, vol. 7 (Spring 2016)

By Dr Dustin Sulak D.O. 

Chronic pain and opiate addiction have ruined countless lives and changed the landscape of medicine.

Some patients feel let down by the medical system when they are denied effective treatment for chronic pain. Others feel injured by medical providers who have started them on opiate medications that have led to addiction and ruined their lives. Healthcare providers feel frustrated that they cannot do more to safely help patients with chronic pain, guilty for providing effective short-term treatments with harmful long-
term effects, and depleted of compassion for patients who need help.

Luckily, there is another solution that is safe, effective, and sustainable. Plus, patients can grow their own. The vast majority of medical cannabis patients use this herbal medicine to treat chronic pain.

The providers at my medical practice are amazed by the results of medical cannabis in the treatment of chronic pain. Patient after patient tells a similar story, and it goes something like this: “I cut my opiate usage drastically, I’m sleeping better, feeling happy, and enjoying my life more, all with less side effects.”

We find that whenever we see a patient who has been using opiates to treat chronic pain, after starting medical cannabis the opiate dosage decreases by at least 50% in the first week. It’s often more like a 60-80% reduction. Many patients go on to completely discontinue opiate medications over the next several months. They often reduce or discontinue other pain medications as well, including anti-depressants and anti-seizure drugs.

Scientific research tells the same story. A review article published in Life Sciences (2004) concludes, “The administration of low doses THC in conjunction with low doses of morphine seems to be an alternative regimen that reduces the need to escalate opioid dose while increasing opioid potency.” An animal study found that adding a small amount of THC increased the effectiveness of morphine by four to twelve times.

And while cannabinoids, like THC, can work together with opioids to increase potency in the pain centers of the brain, there isn’t a significant effect on the brainstem, the area responsible for decreased heart rate, slower breathing, and ultimately death in the case of an opiate overdose. This means that using cannabis with opioids is safer than using opioids alone.

Patients are starting to figure this out. A study published in the Harm Reduction Journal (2009) looked at 350 medical cannabis users, and found that 65% of them were using cannabis as a substitute for prescription drugs, 40% were using it as a substitute for alcohol, and 26% were using it as a substitute for illicit drugs. Three of the subjects used cannabis to help them quit smoking tobacco. The most common reasons for the substitution were less adverse side effects, better symptom management, and less withdrawal.

So while we all were told that cannabis is dangerous because it is a “gateway drug,” scientists are now calling it an, “exit drug” within the framework of harm reduction. The goal is to substitute a safer drug for one that’s more dangerous in patients who are unable to achieve total abstinence.

And cannabis is certainly safer than most of our current options for treating chronic pain. In 1999, the Institute of Medicine published a report that stated, “Except for the harms associated with smoking, the adverse effects of cannabis use are within the range tolerated for other medications,” and “there is no conclusive evidence that marijuana causes cancer in humans.”

Unlike opiate medications, cannabis can remain effective at a low dose for years or decades. While opiates can numb the pain and disconnect the mind from the body, increasing risk for inappropriate activity and re-injury, cannabis often does the opposite. Patients report that after using cannabis, the pain is still there but is less intense, less bothersome, and they no longer have to dwell on it. They often feel more connected to their bodies because they no longer have to retreat from the pain. Patients feel able to reclaim their lives from the constant focus on pain.

Cannabis does not have to be smoked, as many patients are using tinctures (liquid extracts) and vaporizers (smoke-free inhalation). Certified patients are able to grow their own or purchase the medicine from caregivers or dispensaries.

Choosing the Right Medicine Strains

There are hundreds of varieties (i.e. strains, cultivars) of medical cannabis, each with different medicinal effects. The unique properties of each strain arise from their synergy of the cannabinoids, terpenes, and other compounds. Finding the right medicine will likely require trying out a number of varieties, but the following guidelines can help direct your search. Most patients eventually find 2-3 different strains that work well for different purposes, such as one for daytime and one for sleep.

Medical marijuana strains fall into a few major categories: indica, sativa, hybrid indica/sativa, and high-CBD. While these terms are not scientifically accurate, they are widely used in the cannabis world. Furthermore, cannabis by one name from one producer may be vastly different than cannabis by the same name from a different producer. The best way to identify a strain that works or doesn’t work for you is to have it laboratory tested for cannabinoid and terpene content, and to remember the appearance and aroma infusing fresh buds.

CANNABIS SATIVA strains are tall plants with narrow leaves and buds often having a spicy or flowery fragrance. These varieties are generally more mentally stimulating,
more energetic and euphoric. They tend to help more with nausea and other abdominal complaints, appetite stimulation, headaches, depression and fatigue. Although side effects are uncommon and usually mild, sativa strains are more likely to cause or worsen anxiety or paranoia.

CANNABIS INDICA strains are shorter and bushier plants and often having sour or fruity fragrance. Indica varieties are typically relaxing and sedating. They tend to help more with pain, anxiety, muscle spasms, and insomnia.

HYBRID INDICA/SATIVA strains are very common, and have been bred to achieve specific qualities. Many hybrid strains are able to produce effects that provide the best of both worlds.

CBD-RICH strains have specifically been bred to produce high levels of cannabidiol (CBD). CBD has several
exciting medicinal properties, including anti-anxiety, anti-inflammatory, anti-tumor, anti-seizure, and pain relief. Strains with high levels of CBD have decreased our negligible psychoactivity, making them desirable forpatients who want the medical benefits without getting “high” or impaired. This can be ideal for patients who need to drive, work, etc.

We recommend you consult with an experienced healthcare provider to receive personalized recommendations on cannabis strains and cannabinoid ratios/dosages for your condition. If you cannot find an expert, you can network with other cannabis-using patients that have similar conditions and find out which strains work the best for them, but remember, unless you purchase from the same producer, you may end up with totally different product.

Cannabis does not have to be smoked.

The beneficial compounds in cannabis can be administered by inhaling smoke or vapors, ingesting cannabis added to food or drink, swallowing capsules, taking liquid extracts such as tinctures or oils absorbed through the mouth or swallowed, or applying cannabis lotions, salves or patches to the skin. Each delivery method will have a different medicinal effect, even when using the same strain of cannabis. There is no “best” delivery method – each has it’s benefits, drawbacks, and clinical utility in certain situations.

INHALATION: ONSET 1-5 MINUTES, DURATION 1-6 HOURS

Inhalation of cannabis has several advantages, including fast onset, ease in consuming the correct dosage, and convenience. It’s an ideal delivery for patients with nausea, vomiting, or other conditions that make swallowing difficult. Due to the rapid onset of inhaled cannabis, it’s easiest for users to judge their response and know how much the cannabis is helping and whether or not they need more. On the other hand, inhaled cannabis is more likely to cause cardiovascular side effects, has a shorter duration than other methods, and may have a higher abuse potential.

Smoking is perhaps the most traditional method of cannabis use, and while it works well for many patients,
it has some disadvantages. The heat and smoke irritate the respiratory tract and lungs and could potentially worsen conditions such as asthma and COPD. While the smoke itself contains carcinogenic (cancer-causing) substances, long term heavy marijuana smokers do not have an increased risk of lung cancer, likely due to the anti-cancer properties of cannabis offsetting the carcinogens in the smoke.

Herbal vaporizers are very popular with many medical marijuana patients, and are widely considered to be the healthiest way to inhale cannabis. Studies have shown vaporizers reduce the amount of harmful substances created compared to burning and smoking. The vaporizer heats the herb to a specific temperature between 300 and 400 degrees Fahrenheit, releasing the medicinal substances into a vapor without the plant material burning. The vapor produced is warm and non- irritating. It contains the smell and flavor of the cannabis but feels as if you are breathing air.

A wide variety of vaporizers can be found on the market today, and many require some practice before achieving optimal use. When a patient uses a vaporizer it may take a little longer for the therapeutic effects of the cannabis to be felt compared to smoking. Many novices make the initial mistake of taking too many puffs in their first use, thinking they are not getting the medicine because it does not feel like smoke in their lungs. You can avoid this mistake by following our Introduction to Cannabis and Cannabis Sensitization programs.

TOPICAL (EXTERNAL USE ON SKIN): ONSET AND DURATION VARIABLE

Cannabis or its oil-based extracts can be added to balms, lotions, salves, patches, and linaments. Many of these preparations can be made at home and applied topically to help alleviate pain, muscle spasms, inflammation, itching, and various skin conditions, including eczema. Topical use of cannabis typically does not produce psychoactive effects if used in small amounts and in small areas. Using large amounts over significant areas of the body can cause psychoactive effects. Topicals labeled “transdermals” are designed for better absorption and will have a full body effect. The efficacy of a topical preparation may depend on its potency, but many patients have found they can use flower/bud trimmings or leaves to produce an effective topical medicine.

LIQUID CANNABIS EXTRACTS: ONSET 10-45 MINUTES, DURATION 2-8 HOURS

A tincture is a liquid extraction of cannabis, often in a solution of alcohol. Sometimes the word tincture
is erroneously used to describe oil infusions, which can be used in a similar manner. Liquid extracts can be absorbed directly through the mucous membrane in the mouth for faster onset, or they can be swallowed.

This is one of the most versatile delivery methods and works well for most patients. They are convenient, discreet (minimal odor), and easy to dose correctly. The onset and duration are intermediate compared to ingestion or inhalation. Liquid medicines do have some challenges: active constituents can settle to the bottom of the bottle, the effects are variable if held in the mouth vs swallowed, alcohol tinctures can irritate the mouth and may be inappropriate for people with a history of alcohol abuse, and the taste can be bitter or spicy.

To use a liquid cannabis extract, a specific number of drops or milliliters can be placed under the tongue and
held for 1-2 minutes before swallowing. Brushing one’s teeth first can increase blood flow in the mouth and speed the onset. Because each batch of liquid medicine may have a different potency, be sure to look at laboratory testing results, or if unavailable, start each new batch with a few drops and increase slowly. When using an alcohol based tincture, add the liquid to a small amount of warm or hot water first – this will evaporate some of the alcohol and dilute the rest, preventing irritation to your mouth.

INGESTION: ONSET WITHIN 1-2 HOURS, DURATION 4-12 HOURS

Cannabis can be added to a wide range of capsules, foods, and beverages. When cannabis is swallowed, it is absorbed through the GI tract and then metabolized in the liver (known as first-pass metabolism), which changes the cannabinoids into a form with longer duration of action and somewhat different medical properties. Many users report ingestion produces a stronger psychoactive effect, while others report less psychoactivity, and most find that ingestion produces somewhat different therapeutic effects. Many patients find that once they know their optimal dose, ingestion is a superior delivery method due to convenience, long duration, and preferred effects. Ingestion can be complicated by erratic absorption from one day to the next – absorption may depend on other foods consumed, sleep, stress, and other factors that affect the motility of the gastrointestinal tract. Also, cannabis edibles may not have a homogenous distribution of cannabinoids throughout the entire product – one half of the cookie may be more potent than the other half.

It is often difficult to achieve the correct dosage when consuming cannabis edibles, mostly because it takes so long for the patient to know if he or she has taken
too little or too much. For these reasons, we emphasize caution when eating cannabis; it is a good idea to start with a very small amount, wait 2-3 hours, then repeat the dose if needed. While it is not dangerous to overdose on edible cannabis, the effects can be quite unpleasant, sometimes aggravating the symptoms a patient wishes to improve. Since so many patients make dosage mistakes with cannabis-infused foods and have unpleasant experiences, we recommend keeping novice cannabis users avoid edibles and use cannabis in the form of a medicine, not a food.

Please note that while raw cannabinoids have non- psychoactive therapeutic properties, the effects commonly associated with cannabis are due to cannabinoids that have been heated (decarboxylated). Before being consumed, cannabis must be heated to convert the cannabinoids into their active form.

RECTAL (Variable onset and duration)

Cannabis suppositories can be useful for treating conditions in the pelvis and low back, and in patients who are unable or prefer not to inhale or swallow cannabis. Some patients report that rectal administration is less-psychoactive than eating, which may be due to the avoidance of first-pass liver metabolism. The little research on rectal cannabis absorption shows wide variability in absorption, and the composition of the suppository can make a significant difference.

RAW CANNABIS PREPARATIONS (ONSET 2-45 MINUTES, DURATION 2-8 HOURS)

Almost all of the research on the therapeutic properties of cannabinoids has examined the compounds after they have been exposed to heat, an activation process known as decarboxylation. A small body of literature has shown that raw cannabinoids possess anti-inflammatory and anti- nausea properties at surprisingly low doses in rodents. Patients have reported that raw cannabinoids are also effective for treating pain and seizures.

Raw cannabis is non-psychoactive and has a higher content of terpenes, the substances that produce the aroma, which also have a broad range of therapeutic effects. While very large doses can cause some digestive upset, few other side effects have been reported from raw cannabis. Fresh raw cannabis flowers can be eaten directly (chewing for a few minutes can speed onset), prepared into an oil, or brewed into tea (boil 1g cannabis in 1 L of water for 15 minutes). This recipe of cannabis tea produces a beverage with 90% raw cannabinoids and 10% decarboxylated, and quickly loses its potency over the course of a week, even when stored in the refrigerator.

About Dr Sulak: Dr Dustin Sulak, D.O. is
a renowned integrative medicine physician based in Maine, whose practice balances the principles of osteopathy, mind-body medicine and medical cannabis. Regarded as an expert on medical cannabis nationally, Dr. Sulak educates medical providers and patients on its clinical use, while continuing to explore the therapeutic potential of this ancient yet emerging medicine. He received undergraduate degrees in nutrition science and biology from Indiana University, a doctorate of osteopathy from the Arizona College of Osteopathic Medicine, and completed an internship at Maine- Dartmouth Family Medicine Residency.

Material for this article was originally posted on www.Healer.com written by Dr. Dustin Sulak and may be viewed here http://healer.com/

Resources

Brenneisen, R., et al. “The effect of orally and rectally administered delta 9-tetrahydrocannabinol on spasticity: a pilot study with 2 patients.” International journal of clinical pharmacology and therapeutics 34.10 (1996): 446-452.

Earleywine, Mitch, and Sara Smucker Barnwell. “Decreased respiratory symptoms in cannabis users who vaporize.” Harm Reduct J 4.11 (2007).
Elsohly, Mahmoud A., et al. “Rectal bioavailability of delta- 9-tetrahydrocannabinol from various esters.” Pharmacology Biochemistry and Behavior 40.3 (1991): 497-502.

Gieringer, Dale, Joseph St. Laurent, and Scott Goodrich. “Cannabis vaporizer combines efficient delivery of THC with effective suppression of pyrolytic compounds.” Journal of Cannabis Therapeutics 4.1 (2004): 7-27.

Grotenhermen, Franjo. “Pharmacokinetics and pharmacodynamics of cannabinoids.” Clinical pharmacokinetics 42.4 (2003): 327-360.

Hart, Carl L., et al. “Comparison of smoked marijuana and oral Δ9-tetrahydrocannabinol in humans.”Psychopharmacology 164.4 (2002): 407-415.

Hazekamp, Arno, et al. “Cannabis tea revisited: A systematic evaluation of the cannabinoid composition of cannabis tea.” Journal of ethnopharmacology 113.1 (2007): 85-90.

Rock, E. M., et al. “Tetrahydrocannabinolic acid reduces nausea‐induced conditioned gaping in rats and vomiting in Suncus murinus.” British journal of pharmacology 170.3 (2013): 641-648.

Verhoeckx, Kitty CM, et al. “Unheated Cannabis sativa extracts and its major compound THC-acid have potential immuno- modulating properties not mediated by CB 1 and CB 2 receptor coupled pathways.”International immunopharmacology 6.4 (2006): 656-665.