Medical Cannabis
FEATURE
Part Two in a Series
Jeffrey Tucker
DC, DACRB
Medical Cannabis Conversation
Can chronic pain patients eliminate opiates with the use of medical cannabis? Some say yes! I don’t have experience with the opioidcannabis switch out, but almost 1.9 million North Americans utilize legal cannabis to treat conditions such as chronic pain, polymorphic seizures, cancer-related side effects, etc. (Arcview Market Research). I practice in Los Angeles, California, which is the largest cannabis market in the United States, so I have experience working with acuteand chronic-pain patients and the use of medical cannabis. Surprisingly, in my practice, seniors are the fastest growing demographic using medical cannabis. The impact medical marijuana will have on the pain crisis is still unknown, but I think it’s a safe option and one we, as a profession, need to explore. Cannabis won’t cause respiratory arrest or cause your heart to stop like opioids. I am a chiropractic rehab practitioner and medical cannabis fits in well with my holistic practice.
More than two-thirds of Americans now live in jurisdictions that have legalized either the medical or adult use of marijuana (Arcview Market Research). States with legalized medical cannabis have a decreased amount of deaths due to overdosing on opioid painkillers. In the Journal of the American Association for the Advancement of Science (November 2017), a study found that the annual rate of deaths due to overdose on opioid painkillers was nearly 25% lower in states that permitted medical marijuana, and that the effect had
‘ ‘ With chronic pain patients, if you can get them from a 5 or 6/10 to a 4/10, that’s a big improvement. 5 J
grown stronger in the five years after states approved medical marijuana.
As much as I want patients to be pain-free, in some cases this is just not possible to achieve. However, medical cannabis is one more treatment option that I can offer to try to help patients become more comfortable. A pain score (on a l-to-10 scale) above 5/10 makes it difficult for patients to focus. So if I can get a patient to a 2 or 3,1 know patients will work, function, and continue life a little easier. With chronic pain patients, if you can get them from a 5 or 6/10 to a 4/10, that’s a big improvement.
Cannabis Selection
The forms of cannabis available to patients are edible, topical, tincture, and vape. Once patients have decided to try cannabis, we can help them decide the right kind of cannabis. The best selection of medical cannabis products can be obtained in what are called “collective shops.” These are stores that have all of the cannabis products for sale with knowledgeable representatives.
Chiropractors can carry tinctures, patches, and creams in our offices and sell them to patients. Personally, I am not interested in carrying vapes and edibles in my office.
The biggest difference between medical cannabis versus commercial marijuana is not the strains. In fact, the strains are similar, but we need consistent dosing with medical cannabis. To be used as a medicine, we need to know what is in it and how well it’s absorbed. Another question to ask is, “How much of the different cannabinoids are you getting?” Current cannabis product formulations are topicals (sometimes poorly absorbed), orals (sometimes poorly absorbed), inhaled vape liquid, and smoked (carcinogens). As health-conscious practitioners, I feel that we should seek the therapeutic benefits of cannabis without the negative health effects of smoking.
We have all heard stories of people eating a brownie or cookie baked with marijuana in it (an edible) and having a problem getting “high” or “wasted” an hour or two later. These edibles contained the main psychoactive cannabinoid in marijuana, tetrahydrocannabinol (THC). The euphoric effects of THC are caused by its activation of CB1 receptors. Like any other cookie or brownie, it tastes so good people keep eating the stuff. It takes at least an hour to feel the effects after ingesting it, and it may take even longer. People assume after a half-hour
that it isn’t working, so they just eat some more. Then they eat too much and it becomes hard to function. When you eat an edible, it lasts six to eight hours. That’s a long time to deal with psychoactive effects. Depending on the dose, you can feel the effects or you can “really feel” the effects.
By consumption, THC cannabis-infused solid edibles dominate while liquid edibles are expected to grow in popularity. Edibles with CBD and without THC, or CBD with THC, are available in different flavors, strengths, and designs, including sweet and sour gummies, honey sticks, chocolates, drinkable shots, cake pops, and a whole lot more. Keep in mind that edible products can be high in carbohydrates (sugar), just like any candy or confectionary. It is a little scary and yet comical to me that people who enjoy candy can receive the effects of CBD too. I don’t think we, as a profession, are ready to work with edibles yet, but forms such as tinctures, tablets, and transdermal patches are a good option to recommend along with a cream to patients.
• Vaporizing is steamed distillation and refers to the flower’s oils
• Tincture (liquids) — last four to six hours
• Tablets or capsules — last about six to eight hours, like edibles
• Transdermal patches last about 10 to 12 hours
CBD - THC
Cannabis is a complex plant. Because it has been illegal, very little research has been done on it, but the more research that is done, the more medicinal properties are found. CBD is one of more than 80 different active cannabinoid chemicals identified. Both CBD and THC are compounds within plants of the genus Cannabis, which includes both hemp and marijuana. Each strain is a particular strain of the cannabis plant. The main strains are Cannabis sativa and Cannabis indica. The C. sativa strains are the primary psychoactive cannabinoids in cannabis. Tetrahydrocannabinol (THC) is the most psychoactive component. Hemp-derived CBD does not cause the “high” commonly associated with marijuana. CBD oil derived from marijuana contains THC, which will get people “high” or “stoned” when they smoke it.
The medical excitement in our field alone is that cannabis is being used as an anti-inflammatory and pain reliever. Research is being done for anti-cancer properties and other common conditions, but a downside of THC is that it can increase anxiety and paranoia. That’s what you find in the high C. sativa strains on the street. Please understand that THC has a tendency to increase anxiety. With chronicpain patients, they are already feeling anxious. Often, they don’t sleep well and this increases anxiety, which further increases pain. However, CBD hemp or cannabis can break that cycle because the marijuana strain C. indica is more relaxing and can reduce anxiety. When you reduce anxiety, there’s an increase in better quality sleep and a reduction in pain. Inhaling the hybrids (50/50) of C. sativa/indica are worth a trial for pain relief. I do feel that inhaling is not good for the lungs, so if you have preexisting lung issues (inflammation), then we can’t recommend inhaling. However, if you have a healthy respiratory tract and you want to keep it healthy, we can recommend the vaporizers because the big advantage there is no smoke. A disposable, ready-to-use vaping pen can be good for up to 200 puffs. Vapor is “no smoke.” It’s the equivalent of a miniature oven, and the ideal temperature setting on a vaporizer is —375 degrees. You are cooking the plant, and when you inhale, you don’t see anything. You are vaporizing the resin, but you don’t ignite it. If you don’t want to inhale, then you have lots of other options.
Terpenes
Terpenes are naturally occurring organic compounds found mainly in plant life including cannabis, conifer trees, aromatic flowers, herbs, and fruits. Some insects even produce terpenoids, such as termites and some butterflies. Terpenes are considered the most important aspect of any plant’s essential oils and contribute to the scent, flavor, and color of the plant. Terpenes are chief components in essential oils, aromatherapy, and perfumery. This is old “folk medicine” but new information for many in alternative medicine. We have all seen the boom in essential oils in the past five years. Terpenes associated with cannabis are at their strongest before a marijuana plant is
cut, harvested, dried, and cured. These steps all diminish the power of the terpenes in terms of flavor, aroma, and effect. When consumed, through either inhalation or ingestion, they interact with the cannabinoid receptors in your brain, just like THC or CBD does. Terpenes alone won’t get you high, but they can assist the cannabinoids to help increase the effects of cannabis.
Tinctures
Tinctures were common in the US in the late 1800s and early 1930s for treating arthritis and migraines. Sir William Osier from Johns Hopkins Hospital was quoted in 1895 as saying our most effective remedy for migraine headaches is cannabis. That was before oxycodone and Vicodin.
Transdermal Patches
There are transdermal patches that you can put on your wrist or ankle where the skin is thin (areas where veins are close to the surface). Patches can last about 10 to 12 hours. The advantage of a patch is that you can peel it off and then the effects stop. If you took it off before the dose is finished, you can put it back on another time.
Topicals
A CBD-formulated topical cream is good for sore muscles and areas where there is pain. Derived from raw hemp oil and other combinations of natural ingredients, this remains my first choice for patients along with tinctures.
You could start your morning breakfast with hemp cereal and sweeten your morning hot beverage with a CBD-iniused honey stick (10 mg CBD per stick). Your lunch could include CBD infused gummies; an afternoon snack of a 2 oz 30 mg CBD red or blue color cake pop; happy hour could be a 2 fl oz single-shot, easy-to-drink 20 mg CBD berry or grape flavor. You get the picture. Be mindful of what your patients really need and help them understand the proper uses of this natural remedy. I remember years ago when I started trials of large fish oil dosages (omega-3 s) on my chronic pain patients, and those that really saturated their bodies with it for months seemed to reach a new plateau of improvement. The same thing happens with patients who have a low vitamin D level. I get them up to higher than normal levels, and they describe improvement here and there. I feel the same thing happens with cannabis.
Be careful and stay within your state’s laws.
References:
1. https://www.arcviewmarketresea.rch. com/
2. National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press.
3. CannaBizLLC.net
Dr. Jeffrey Tucker practices in West Los Angeles, California. He is the current secretary treasurer of the AC A Rehab Council. His website is www.DrJeffreyTucker.com.
