Medical experts say that cannabis-based medication including medications containing THC should be prescribed instead of opioids.
Elderly people who suffer with chronic pain conditions such as back and joint injuries, should be prescribed cannabis instead of conventional painkillers, doctors have said. Recent polls suggest that over 75% of people over the age of 55 would consider taking it.
Doctors have advised that cannabis-based medicines that contain THC which is the cannabinoid that is renowned for creating the infamous high, should be used in place of opioid medications.
Draft guidance that was published last month by the National Institute for Health and Care Excellence (“NICE”) recommended that prescription guidelines for patients with chronic pain will soon move away from drugs like paracetamol, aspirin, ibuprofen and opioid medications such as codeine, tramadol and morphine.
The NICE guidance suggests that over one million chronic pain patients in the UK should be prescribed a specific exercise programme or acupuncture instead of opioids medications or OTC painkillers.
Doctors have suggested that patients with back pain could see a benefit from using cannabis oil which was legalised for certain conditions in November 2018. While medical cannabis and cannabis oil is not widely available on the NHS, some private clinics are licensed to prescribe medical cannabis once other medication has failed to work.
A recent poll by Open Cannabis had results that suggested that over 75% of people over the age of 55 would seriously consider using cannabis medication if it was offered to them. This compared to 66% of the population as a whole. Open Cannabis is a campaign to widen access to cannabis medicines in the UK. Open Cannabis is working to share accurate information and data about cannabis medications with both the public and healthcare professionals, to initiate debate about the positive impact cannabis medicines could have on people’s lives. Open Cannabis also want to focus on educating UK patients about cannabis-based medicines and the options that are available to them.
Prescriptions could keep patients from resorting to the black market
Making medical cannabis more widely available could prevent patients from accessing cannabis on the black market through illegal transactions with potentially dangerous drug dealers. Dr. Steve Hajioff, a former chair of the British Medical Association said that cannabis should be made available legally using prescriptions to prevent patients resorting to the black market for drugs to provide pain relief.
Dr. Steve Hajioff stated that cannabis-based medicines can fill the void in helping patients suffering from chronic pain and gradually replace opioids prescribed for pain-management and non-steroidal anti-inflammatory drugs.
Patients who may benefit the most from medical cannabis need to be aware of the legal routes through which they can access cannabis-based medications in the UK. There is no definitive data on how many people are using cannabis illegally for pain relief. However, the Centre for Medicinal Cannabis carried out research in collaboration with You Gov which conducted a survey of 10,602 adults. This survey found that over 1.4 million people which is 2.8% of the British population, are currently using cannabis illicitly to treat chronic health conditions such as chronic pain, anxiety, insomnia and depression.
This statistic illustrates that people are feeling the benefits of cannabis even when it is not prescribed in a form that is not of a medical standard. The quality of medical cannabis that chronic pain sufferers could receive once they have a prescription would likely be far greater than that of cannabis sold on the street. Illegal cannabis is often sprayed with various chemicals and the user has no idea where the product has come from. Sales of this scale on the black market also leads to widespread gang violence, as there is a fight for market share of the black market.
Cannabis was legalised for medicinal purposes in November 2018 following a ground-breaking campaign to allow access to cannabis prescriptions for children with treatment-resistant epilepsy, who used cannabis oil to manage their seizures.
It is now legal to be prescribed medicine containing THC, the chemical compound in the cannabis plant that induces the high that recreational users seek. This is banned for recreational use in the UK at the moment and is only legal when prescribed by a doctor. CBD has also been proven to have many positive benefits for chronic pain issues, anxiety, insomnia and depression and is legal to be sold in the UK. CBD has no psychoactive effects and works in a similar manner to THC to reduce inflammation and interact with the endocannabinoid system.
Since the change in the law in November 2018, very few medical cannabis prescriptions have been issued on the NHS. This results from NICE guidelines that suggested that doctors should be wary about providing cannabis oil to patients before full medical trials have taken place. There have yet to be any randomised controlled trials in the UK investigating the benefits and side effects of medical cannabis. However, there are developments in this fast moving and nascent industry, and there is hope that a randomised controlled trial can be initiated in 2021.
The NHS have stated that a much larger trial over an extended period of time is required to prove to the government that medical cannabis is safe and effective. Once this is proven it should then be made available through the NHS for a wider group of people.
The Reduced Stigma of Cannabis
For years cannabis has been associated with violence and illegal activity and has not been viewed as a medication. However, these perceptions are gradually changing with older adults taking a different view on cannabis and opening their minds to the prospective benefits. A study undertaken recently in the United States discovered that cannabis use among adults defined as ‘older’ meaning over 65, has been steadily increasing. This study found that cannabis use within this demographic has risen from 2.4% to 4.8% from 2015 to 2018.
There are several factors that contribute to this change in perception of cannabis and the increased use within the elderly population. One key factor is that the stigma surrounding cannabis is slowly evaporating and it is being recognised as a socially acceptable pass time and a genuine medication for certain ailments. Cannabis within pop culture is now integrated casually into TV shows and music, whereas in the past it was often presented as a nefarious activity and those partaking were acting in a rebellious manner.
More research needs to be carried out in the UK before the NHS will even consider prescribing cannabis on a large scale. It is up to pioneers within the medical, cannabis and pharmaceutical industries to make this happen and it will require contributions from a wide range of people to provide definitive evidence of the efficacy and safety of medical cannabis. The public’s perception of cannabis is vital to achieve this too. Public support will be required to pressure the government into acting and assisting doctors to enable them to prescribe cannabis medicines to patients whose daily lives could be dramatically improved.
What is Medical Cannabis?
Medical cannabis uses the cannabis plant or specific cannabinoids found within the cannabis plant to treat diseases or conditions. The cannabis plant contains more than 100 different chemicals known as cannabinoids; each one has a varying effect. Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the two cannabinoids that have been researched the most. THC & CBD are typically the two cannabinoids that administered within medications.
Research is being conducted to see if cannabis-based medicines could be used to treat an array of diseases such as:
- Appetite issues
- Crohn’s disease
- Immune diseases such as HIV/AIDS and Multiple Sclerosis (MS)
- Mental health conditions like posttraumatic stress disorder (PTSD)
- Rheumatoid arthritis
The greatest amount of evidence for the therapeutic effects of cannabis-based medicines are its ability to reduce chronic pain, nausea and vomiting due to chemotherapy and spasticity caused by Multiple Sclerosis.
How Does Cannabis Produce Its Effect on the Human Body?
THC exerts all of its known effects on the central nervous system through interactions with the CB1 cannabinoid receptor. Research into cannabinoid mechanisms has been allowed by the availability of specific antagonists acting at CB1 receptors.
THC’s chemical structure is comparable to the chemical found in the brain named anandamide. The similarity in the chemical structure between the two allows the body to recognise THC, this then causes an alteration in normal brain communication.
Endogenous cannabinoids such as anandamide function as neurotransmitters as they send chemical messages between neurons throughout the central nervous system. Anandamide affects the areas of the brain that influence thought, memory, pleasure, coordination, movement and the perception of time.
Due to the similarity in the chemical structure, THC can attach to molecules named cannabinoid receptors on neurons within these areas of the brain and then activate them. This disrupts various mental and physical functions causing the aforementioned functions such as thought and movement to be affected. The neural communication network that these cannabinoid neurotransmitters exist within is called the endocannabinoid system. The endocannabinoid system is integral to the functioning of the central nervous system and interfering with the endocannabinoid system can have profound effects.
THC can manipulate the functioning of the hippocampus and orbitofrontal cortex.
The effects that cannabis can have on the central nervous system include the disruption of psychomotor behaviour, stimulation of appetite, antinociceptive actions – most importantly against pain of neuropathic origin. While there are signs of mental impairment within long-term cannabis users there is little evidence to suggest that the effects are irreversible.
How does Cannabis relieve different types of pain?
There are three different types of pain.
- Nociceptive pain
- Neuropathic pain
- Central pain – there is still much debate into this kind of pain, Fibromyalgia is a common example of Central pain
Pain is caused by the coordinated activation of brain cells. Specific brain regions lead to the sensation of pain and the strength of pain signals can be modulated. There are examples of people having a physical injury, i.e. nociceptive pain, but feel pain free. There are also examples of there being an absence of physical injury, but the individual is in a great deal of pain, this is central pain.
Nociceptive pain, also referred to as inflammatory pain, is the result of tissue damage. Subjectively, it can be described as aching, throbbing or a sharp pain that is the result of physical damage. If you’re injured, the damaged tissues recruit immune cells to repair the damage to your body. The recruited cells then release proteins and chemicals that activate receptors on nerves which then travel to the spinal cord and then onto the brain, thus causing the sensation of pain.
Nociceptive pain can be reduced by decreasing the pain signals at the area of injury by blocking the inflammatory process and the signals that are sent. An alternative manner in which to dampen the pain is to limit their effects as the pain signals travel up the spinal cord to the brain. Cannabis can be used to optimise both of these processes to decrease pain.
Both THC & CBD can reduce pain at the site of an injury, THC & CBD also both have anti-inflammatory effects. THC’s anti-inflammatory effects are driven by the activation of CB2 receptors on immune cells that dampen the body’s pain inducing reaction to an injury. CBD reduces inflammation through blocking inflammatory mediators and changing the activation of macrophage repair cells to the anti-inflammatory type from the pro-inflammatory type.
THC can directly activate CB1 receptors which modulates pain at the level of the spinal cord, this indirectly increases the opioid receptor activation. CBD increases the level of anandamide, which operates in the same way as THC to activate CB1 receptors. CBD also enhances the activity of the receptors for GABA which is a primary inhibitory neurotransmitter. This inhibitory effect can dampen the pain signals as they travel to the brain.
CBD can also improve your mood by activating serotonin receptors which has both stress reducing and anxiety reducing effects. Those who suffer from chronic pain conditions are more likely to suffer from depression or anxiety, meaning that CBD can be a valuable edition when fighting a chronic condition.
When you are in a positive frame of mind your focus on pain is likely to decline and it can be a powerful tool to fight pain. However, as time passes is can become near impossible to achieve these positive feelings.
Neuropathic pain arises from damage to the central nervous system. Neuropathic pain affects between 7-10% of the population and can result from an injury. Multiple Sclerosis is when the insulation of nerve cells is broken down that causes neuropathic pain. Other instances of diseases that inflict neuropathic pain are HIV, AIDS, diabetes, shingles and Parkinson’s diseases. Chemotherapy can also cause neuropathic pain due to its destructive effects on cells in the body.
In a similar manner to treating nociceptive pain, over activation of the CB1 receptors caused by taking THC can lead to the pain having a weaker effect and therefore effecting the sufferer to a lesser extent. Balanced cannabis prescriptions would be more efficacious over a longer period as the effect of the pain would continually decrease over time.
Neuropathic pain is extremely difficult to treat as it doesn’t result from inflammation that can be treated by non-steroidal anti-inflammatory drugs. Whether the pain is caused by chemotherapy, amputation or a disease, cannabis could be an effective treatment for neuropathic pain. Medical cannabis is a promising treatment option as its benefits have been observed in cancer and non-cancer instances of neuropathic pain in both rodent and human clinical studies.
Central pain refers to a type of pain that arises from dysfunction to the nervous system. Often pain arises in the absence of any demonstrable cause, this means that it can be particularly difficult to treat. Fibromyalgia is an instance of central pain that arises from dysfunction in the way pain signals make their way to the brain. The origin of fibromyalgia is largely unknown, and the specific cause of fibromyalgia is yet to be determined. The symptoms of fibromyalgia are often inconsistent from patient to patient.
There have yet to be extensive studies investigating the benefits of cannabis in treating central pain. However, the benefits of treating fibromyalgia with cannabis has been established. In a study of 26 fibromyalgia sufferers, every participant reported an improvement in their condition from cannabis use and half of the participants stopped taking all other medication they were using prior to the trial. This study suggests that medical cannabis may provide essential pain relief for those with fibromyalgia and other central pain conditions where the origin of the pain cannot be established.
High THC products may be an effective pain reliever, but they may not be an optimal pain relief strategy. A balanced THC:CBD ration or CBD rich products may provide a better long term treatment option for chronic pain conditions. This is primarily down to the side-effects of THC.
How does Medical Cannabis help?
Cannabinoids which are the active chemicals within medical cannabis are similar to the chemicals in the body that modulate appetite, memory, pain and movement.
Medical cannabis has received a lot of press over the last few years due to its positive effects on helping children with epilepsy control their seizures. Epidyolex was fast tracked to ensure it was available on the NHS as of the 6th of January 2020 for the thousands of people who could be prescribed the drug to treat their epilepsy. Clinical trials researching the effects of Epidyolex showed that the treatment could reduce the number of seizures by up to 40% in children with epilepsy when used in combination with Clobazam.
Another instance of a cannabis-based medicine being approved is Sativex which can be used to treat Multiple Sclerosis. However, Sativex has only been approved for a limited number of patients because of the high cost of the medication.
Chronic pain is the issue that medical cannabis could be prescribed to the largest number of patients for. While medical cannabis is not strong enough to manage severe pain such as post-surgical pain or a broken bone. While more definitive evidence is needed in the form of a randomised clinical trial, initial evidence suggests that medical cannabis is effective for treating chronic pain conditions that plague millions of people in the UK. Chronic pain is likely to affect everyone’s lives as they age, whether it is a family member or a direct experience. Nerve pain is another instance of where medical cannabis could be effective. There are very few options at the moment, and the existing options such as Neurotin and Lyrica are highly sedating, meaning that they are not easily incorporated into daily life. One of the key benefits of cannabis which has been disclosed by patients and via anecdotal stories, is that using cannabis to manage pain allows the sufferer to resume activities that they had to stop due to pain without feeling disengaged.
Cannabis is also a muscle relaxant and people swear by its ability to lessen the tremors in Parkinson’s disease.
Discussing Cannabis with your Doctor
Many people find themselves in a position where they wish to learn more about the prospective benefits of using cannabis to treat the condition from which they are suffering from. There is a distinct lack of education concerning cannabis and its therapeutic effects within both the medical community and the general population. Educating General Practitioners and Medical staff within the NHS and Private Medical sector is imperative if cannabis is ever going to be widely available as a medication. The medical community has been dismissive of cannabis in general for many years, however as the evidence proving its efficacy and safety improves and increases it becomes more difficult to dispute the therapeutic benefits of cannabis. Many patients that use illicitly sourced cannabis to treat issues such as pain and anxiety feel that they cannot discuss the positive impact cannabis has out of fear of being reprimanded or scolded by their doctor.
Rigorous studies are needed before doctors will embrace medical cannabis. The risks and side effects of using cannabis regularly over an extended period of time also need to be assessed and proven.
As with any medication it is always crucial to discuss the side effects of any medication you are prescribed with your doctor. If the cannabis-based medicine that’s prescribed contains THC it may cause psychoactive effects. Diarrhoea and decreased appetite may also be experienced.
The Future of Medical Cannabis in the UK
Despite the legalisation of medical cannabis in 2018, it is still extremely difficult for a patient to obtain a medical cannabis prescription in the UK. All treatment options have to have been expended and the patient’s GP has to be receptive to allowing them to be prescribed cannabis. Medical cannabis is currently only available on the NHS for children and adults with rare, severe forms of epilepsy. It is also available for cancer patients experiencing severe vomiting and nausea due to chemotherapy and to people diagnosed with Multiple Sclerosis.
To receive a medical cannabis prescription in the UK, a patient has to actively seek it and then visit a private clinic at their own expense. Medical cannabis is not covered by medical insurance so both the cost of the consultation and the medication itself must be paid for by the patient.
The patient must first have an eligibility consultation with a medical cannabis clinic to assess whether they are eligible for a prescription. The limited evidence to date and the fact that cannabis-based medicines are unlicensed, prescribing cannabis-based medicines is restricted to clinicians listed on the Specialist Register of the General Medical Council. A GP can make a referral to a specialist doctor once their patient has reached the appropriate point in the treatment pathway. This means that the patient has to visit a specialist at their own expense.
The cost of the eligibility consultation, then the appointment with a specialist and finally the medication itself is likely to cost the patient in the region of £500. The cost of a month’s supply of a medical cannabis prescription is approximately £250.
This is simply unaffordable to the vast amount of the population, especially for those who suffer with chronic pain as their condition can often mean they are unemployed.
Allowing bulk imports of cannabis into the UK was a positive step in reducing the cost of medical cannabis for the patient.
Ultimately, randomised clinical trials need to be conducted to prove the efficacy and the safety of cannabis-based medicines. Providing this evidence is the only way in which the NHS will subsidise medical cannabis to either make it available on the NHS or more affordable via a private clinic.
It is likely that the participants in a randomised controlled trial will have to pay for the cost of the medication if a trial is to materialise. Otherwise it will be too big an expense for any pharmaceutical or cannabis company to risk initiating a trial. This would mean that there would be no consultation costs which could make the medication more affordable and allow participants to pay around £200 per month for their cannabis-based medicine. The trial would require thousands of participants and would need to last for several years. If a randomised controlled trial like this is successfully undertaken, it could lead to medical cannabis being available on the NHS.
Pain management is the largest treatment area that cannabis could address. A trial into the efficacy of medical cannabis to treat chronic pain could revolutionise the treatment options available to chronic pain sufferers. It could present an option with limited long-term side effects that enables normal life to continue and ensure that their condition is not debilitating.
Cannabis has the potential to be used to create medications that improve millions of people’s lives, enhance chronic pain sufferers’ daily lives and allow people to stay in employment for longer. More research must be carried out, but cannabis seems to have the potential to truly help people individually and society as a whole.