Finding Your North Star: A Cannabis Alternative in Pain Management in Canada

Cannabis as the Go-To Therapeutic: One Family’s Personal Journey of Discovery

One Nurse's Battle with the Stigma Against Medical Cannabis Use and Chronic Pain

The Pain Dilemma: Cannabis Versus Medicine?

Navigating Turbulent Seas: A Navy Veteran's Personal Story About Medical Marijuana

Articles

View our interactive March/April 2021 digital edition

March/April 2021 Digital Edition

! We are excited to be bringing you four digital editions this year. This issue is focused on chronic pain.

First, we gain valuable insights from Dr. Julia Hildebrand, Dr. Peter Blecher, Starseed Medicinal, Medical Cannabis Canada, and WeedMD in which they share their experiences with medical cannabis patients in Canada, both specifically related to chronic pain and medical cannabis use for other reasons. It’s interesting to note that even though cannabis is fully legalized in Canada, many patients still opt in to be registered on the medical side.

Our patient perspective comes from Brendan McKernan and his father Richard, who both had personal experience with medical cannabis and chronic pain that led to some amazing breakthroughs. The McKernan family has worked in the life sciences field for decades, with Richard forming several companies over the years and his sons following suit. When Richard was diagnosed with latestage cancer, the family turned to science to see what could be done to ease his pain. The answer came from cannabis and learning about the endocannabinoid system and how various tinctures and cannabinoids interact with it. This family’s story of personal strife leading to forming a company and medical cannabis conference that can help others is truly inspiring.

Eloise Theisen, a geriatric nurse practitioner and current president of the American Cannabis Nurses Association, witnessed patients suffering firsthand during her early work as an oncology nurse. As her patients started expressing more interest in medical cannabis to alleviate the pain associated with their cancer treatments, Theisen decided to dive in and learn as much as she could to help advise her patients. Now, as a nurse practitioner, Theisen has her own practice, advises patients on Leaf411, and is passionate about seeing other healthcare professionals learn more about this medicine.

On the research side, we spoke with Kevin Boehnke, PhD, a research investigator at the Chronic Pain Institute Research Center in the anesthesiology department at the University of Michigan. Boehnke discussed his research efforts to address questions such as what health conditions are patients using cannabis for, which dosage formats are they using, and does it help chronic pain. Boehnke’s previous research was based on cross-sectional studies, but he recently received funding from the NIH to better understand how CBD and THC interact with different types of chronic pain as well as with sleep in the context of chronic pain. Boehnke's goal in this new study is to figure out how CBD and THC act together or separate so that they can then translate that information back to the patient.

Stanley Atkins II is a veteran patient turned advocate, out of necessity, and here he shares his incredible journey to help reform cannabis policies in his home state of Georgia. Atkins is another great example of how personal experience with medical cannabis shaped his future and led him down a road to help others gain the access to this medicine that he so desperately needed.

Finally, we hear directly from a patient caregiver—Jessica Mandile—on how medical cannabis turned her husband’s quality of life around dramatically.

As our cover implies, the question we’re posing in this issue is if medical cannabis is a new frontier in alternative medicine. For centuries, patients have sought alternative options when faced with a condition that traditional medicine did not alleviate. Chronic pain is one of the most common ailments people face, often arising as a side effect from other illnesses—as we can see in this issue with several stories of patients dealing with cancer and chemotherapy. With medical cannabis becoming more mainstream, now is the time to really look into this as an alternative option. It’s not a cure-all, but if medical cannabis has the potential to help people with specific problems—such as chronic pain—that is something the medical community and general public should be aware of.

On April 27th, we will be hosting a 90-minute e-symposium featuring a presentation from Eloise Theisen and a patient-focused panel discussion with Stanley Atkins II, Brendan McKernan, and Otha Smith III. Please join us for this free event and pose your questions directly to the people involved in the field and experiencing the benefits of medical cannabis: 

Enjoy this issue and I hope to see you on April 27th!

Welcome to the second edition of Cannabis Patient Care! We are excited to be bringing you four digital editions this year. This issue is focused on chronic pain.

Cannabis and Chronic Pain: A New Frontier?

If you asked Georges Theriault what pain feels like, he’d tell you about a day he sat alone in his garage. Unable to walk, barely able to stand, he recalls the moment he realized he had become a shell of his former self.

“When you’re sick, you can’t believe what your life has become,” said Theriault, a 63-year-old Canadian Forces and Royal Canadian Mounted Police (RCMP) veteran, who was diagnosed with diabetes in 2012.

Before his diagnosis, Theriault rarely sat still for long. He qualified for pre-Olympic boxing, ran sled dogs in Alaska, worked as a ski patroller in Europe and, before retirement, led an executive security firm protecting top Canadian politicos. After retiring and relocating from Ontario to New Brunswick, his health quickly and steadily declined; before long, the effects of the illness required the replacement of one hip and both knees.

After three surgeries and four years of physiotherapy and conventional opioid-based narcotics, as well as naproxen, Theriault still hadn’t recovered. “At the very end, I was in the hospital for eight days and the doctor looked at me and said, ‘I can’t do anything else for you,’” he shared.

Theriault’s story is all-too-common in Dr. Julie Hildebrand’s practice. In her 30 years of biomedical research and patient experience, she has met many patients like him, caught in a pain management symptom-prescription loop.

“As physicians, we do not like to start treatment for pain with narcotics, though it is, unfortunately, where many patients end up,” Hildebrand said. “We usually start small—with anti-inflammatories and massage—and augment progressively if symptoms do not abate. But once a patient starts with opiates, treatment can spiral as the body develops a tolerance—after that, there is very little left in terms of conventional treatment. Cannabis has given some of my patients new hope, however.”

Hildebrand is a New Brunswick-based physician published in papers and publications on cannabis medicine as a new therapy, effects of opioid addiction, methadone treatment, analysis, and mental health. She works closely with Starseed Medicinal, the medical division of Canadian licensed cannabis producer WeedMD Inc., to provide cannabis counseling and treatment options for patients in the country’s Atlantic-area provinces.

A general practitioner, Hildebrand began prescribing cannabis to patients in 2014. She became interested in learning more—a lot more—about cannabis medicine after seeing significant improvement in patients suffering from chronic pain. Over the following seven years, Hildebrand became the Atlantic region’s foremost expert physician prescribing medical cannabis.

Theriault, a 40-year military and RCMP veteran, had never tried cannabis in any form before. Through a series of referrals, he connected with Dr. Hildebrand, who prescribed the drug in an oil format, high in both tetrahydrocannabinol (THC) and cannabidiol (CBD). Within a year, he had transitioned off all narcotics for cannabis, and today, he says he is pain-free.

“The (hospital’s) doctor couldn’t believe it. I can ride my motorcycle, I can walk. I went from using a walker to having a new life,” said Theriault.

Like Theriault, many of Hildebrand’s patients find cannabis as a third or fourth-line treatment option for conditions, ranging from post-traumatic stress disorder (PTSD) to fibromyalgia. And like Theriault, who is now a medical patient of a local New Brunswick-based licensed producer, most have gone down traditional pharmacological treatment paths with little success and turned to cannabis when all else failed.

“Patients would come to me and say ‘cannabis works.’ I wasn’t comfortable with the idea of patients buying it on the street, so I started to study the phenomenon from a clinical perspective, travelled and met experts, and read all I could that was available to offer treatment and counseling. I was quickly overwhelmed with both the demand and the impact of this medicine. It opened up a new era of treatment for me,” said Hildebrand. “As a physician, it is gratifying to see results after so many failed attempts.”

Canada’s medical cannabis landscape has grown exponentially in recent years. Regulation was established by the country’s national health authority, Health Canada, in 2001. The change stemmed from a decision by The Ontario Court of Appeal, which ruled prohibition unconstitutional, as it didn’t allow exemption for medical use. The country’s initial legislation allowed for approved patients to grow their own plants, or to acquire their medicine from a designated grower.

Legislation was modernized in 2014 to allow patients to purchase products directly from a licensed commercial producer such as WeedMD, which received its initial licensing in 2016.

Medical authorization from a licensed health care practitioner is required for Canadian patients to purchase medical cannabis, many of whom say they use it to treat a variety of ailments, from chronic pain to PTSD. Once authorized, patients may register with a licensed producer of their choice and buy direct. According to Hildebrand, the average amount generally prescribed is 2 grams per day, though her patients often experiment with dosage under her supervision until the optimal dose is found.

“The efficacy of cannabis medicine is still being studied and while the endocannabinoid system isn’t taught in medical school anywhere near as extensively as it should be, we are seeing the results for ourselves in our clinics,” said Hildebrand.

In 2018, cannabis was legalized for both medical and recreational adult-use under a combined legislation, The Cannabis Act, replacing the medical cannabis framework legalized in 2001. Under the legislation, adults are permitted to purchase cannabis at licensed retail locations (subject to laws on possession limits and consumption), though provisions around access, taxation, and possession exist for medical patients.

“Despite cannabis’ recreational legal status, many patients opt to remain registered in the medical system,” said Dr. Peter Blecher, Starseed Medicinal’s Chief Medical Officer who helped set up the Starseed Medical platform and benefits reimbursement structure back in 2014.

Medical producers can guarantee access to medical-grade cannabis products such as high-CBD flowers, gel caps, oils, and sprays formulated for precise, metered dosing; and patients can receive one-to-one specialized care from select producers who offer such support. Additionally, medical cannabis is considered a medical expense and can be claimed on an individual tax return, provided it has been authorized by a healthcare professional and is purchased directly from a licensed producer.

“While many producers turned their attention to the recreational market, we doubled-down on our efforts to care for patients,” Blecher said. “We began working with a growing number of practitioners and enhanced our patient program with simple onboarding, education, and a pharmacy approach to ordering and fulfillment. We wanted to make sure no patients were left behind.”

Emerging research continues to validate patients reported success with cannabis, and it is being shown to be an effective treatment for many who suffer from pain. Dr. Blecher has spent more than 15 years working in the field of chronic pain management, treating complex pain through a combination of interventional, pharmacotherapeutic, as well as guided mindfulness and self-management approaches. In the 2000s, he was witness to the rampant over-prescribing of opioids for chronic pain, and consequent issues of addiction, distress, and societal costs this left in its wake. His personal observations and subsequent investigations into the science of cannabinoids led him to become an ardent advocate for the use of cannabis as an opioid displacement strategy. He developed his proprietary TOP-CART program (Tapering of Opioid Prescribing with Cannabis As Replacement Therapy), and ultimately assembled and trained the team of medical experts that came to be North Star Wellness, and recently started working with Hildebrand to expand care into Atlantic Canada.

 (1) that followed 1000 patients using cannabis for chronic pain found that, among those who remained on medical cannabis for six months, pain intensity and pain-related interference scores were reduced.

In addition to her practice, Hildebrand is the medical director of the Methadone Maintenance Therapy Program at Saint Joseph’s Hospital in Saint John, New Brunswick. She often observes comorbidity of anxiety disorders and opioid addiction in methadone patients.

“Anxiety and pain are mechanistic,” she said. “I wondered, what if we try to treat both the pain and anxiety with cannabis? I noticed the people who were using cannabis on the side were doing better. They were sticking to their methadone treatment better than those who weren’t. Now what if those patients who had been originally prescribed opiates for pain chose cannabis instead? Because we’re complex beings, it’s rare someone only suffers from pain. The beauty of cannabis is that it can address many health problems at one time.”

 study, the proportion of studied individuals who reported using opioids decreased by half. Furthermore, in a 

 (2), 72% of medical cannabis patients revealed that cannabis decreased their reliance on traditional medication. According to the survey, 1 in 4 reported decreased reliance on opioid pain relievers, but 36% of these patients reported that barriers to accessing cannabis led them to return to those medications.

The results point to a greater need than ever for patient access and physician support for cannabis as an opioid exit therapy, explained Max Monahan-Ellison, a medical cannabis consultant and board member with Medical Cannabis Canada.

“Survey research indicates a good portion of patients are treating for chronic pain, and observational studies have highlighted that cannabis can be an effective option to help reduce opioid dependency,” said Monahan-Ellison. “The challenge is that cannabis is still primarily seen as a second or third-line treatment option by prescribers.”

He added that for insurance providers, most of whom don’t recognize medical cannabis, this treatment option is something of a regulatory oddity. In Canada, medications approved for specific indications are issued a drug identification number (DIN). Excluding pharmacological cannabinoid drugs such as Sativex and Nabilone, cannabis in any format has not received a DIN from the regulator.

Without a DIN—and despite necessary medical authorization—cannabis generally isn’t considered or regulated as a traditional pharmaceutical medicine, nor is it covered by any public health drug plans. Yet, many carriers including Sun Life, Canada Life, Green Shield, and Medavie Blue Cross cover medical cannabis as an insured drug, with limitations.

“The key point here is that despite the fact that carriers have created coverage options, there has been low uptake from employers and other payors to include cannabis on their formularies because cannabis has to be added as a paid benefit,” said Blecher.

Often, standard extended benefits will cover the drug when prescribed to treat specific conditions, such as epilepsy and multiple sclerosis, that have a greater body of clinical evidence for cannabis efficacy. However, those policies tend to exclude the majority of the patient population and businesses typically have to buy into them as part of their benefits packages.

Many of the plans seen today resulted from external pressure and demand from plan sponsors (employers, union groups, and so forth) looking for medical cannabis options, Monahan-Ellison explained, adding he has heard from the insurance sector that uptake of these programs is low.

“Insurers develop benefits offerings based on the needs of customers, the employers who purchase group plans for their staff—and they emphasize that if the demand isn’t there, the benefits won’t be there either,” he said.

“At the same time, as plans expand their coverage to other indications, they will be relevant to a broader group of employees. Continued research is essential for building the case for private insurers to expand covered indications and public payors to consider reimbursing the treatment option. It will take a coordinated effort of government, industry, and advocacy groups to push forward change in this category and expand access,” said Monahan-Ellison.

WeedMD includes cannabis coverage as a drug benefit in its employee insurance plan, should an employee use cannabis for medical purposes. The company built its Starseed medical platform to bridge the gap between patients and insurers through a "virtual pharmacy" model. 

Today, the company is Canada’s leading licensed producer in the paid benefits arena. In addition to its work with four of Canada’s major insurers, its offering has been embraced by union groups, who offer reimbursement for Starseed Medicinal cannabis products to qualifying members. The company holds a partnership with Labourers’ International Union of North America (LiUNA) the largest construction union in Canada with a number of Ontario-based locals signed. In January 2021, the company signed its sixth LiUNA local and first in Manitoba, to the Starseed medical program.

“We wanted to build a program that, for the first time, could really bring insurers and employers together to provide insured patients with an alternative to other covered drugs, like opiods and benzodiazepines,” Blecher said. “We know all the too well the stories about the ripple effect of opiate drugs and addiction. While those pain medications are relatively inexpensive to pay for up front, the percentage of patients who develop dependency, in turn, run into a host of other issues: a decline in job productivity, more time off the job, slower return-to-work, mental health and addiction issues, and new expenses such as dental care or long-term methadone treatment, all of which cost insurers far more in the long run.”

Starseed works directly with insurers on their patients’ behalf to ensure medication is paid for in the background as patients focus on their treatment. The only other group that receives a comparable level of coverage are Canada’s veterans. In fact, many licensed producers work with veteran groups to provide advocacy and education to those with medical cannabis coverage, reimbursed by Veterans Affairs Canada. 

While national registered patient counts dipped following legalization, data shows patient counts are once again rising steadily. Today, according to Health Canada, roughly 375,000 patients are registered with federally licensed producers, while 43,000 are registered for personal or designated production.

Canada’s cannabis industry has grown exponentially in recent years. Pre-recreational legalization on October 17, 2018, 125 producers were licensed. Today, more than 570 producers are licensed for various activities, including cultivation, processing, sale, research, and testing.

In Hildebrand’s practice, the rates of new patients signing up for medical cannabis—particularly seniors between the ages of 70 and 90—are on the rise. Cannabis is talked about in retirement-age communities as a safer treatment option, and pain sufferers are interested in trying it more than ever, she explained.

“Considering cannabis is legal for purchase in-store, now when a patient reaches out, I know they are serious,” said Hildebrand. “They need professional advice on how to consume, how often, and whether there are any contraindications—you can’t get that at a recreational shop. It is vital that practitioners are ready and able to support them, but there are still many barriers to access.”

Though cannabis is legal in Canada, many physicians are still reluctant to prescribe because they are not sure about dosing and which formats to prescribe—they simply don’t know enough about it, Hildebrand noted. Most patients find her by referral, or through their own research after their requests for medical cannabis are rejected by their own physician.

“It happens a lot. I often hear that physicians are only willing to try medical cannabis after all else has failed. My message to other doctors is that we don’t have to wait until all other avenues have been explored, especially opiates,” she said. “In medicine, we learn a great deal from books, black and white. But when we get in front of patients, most conditions often fall in a grey zone. Though sticking to outlined criterions are important and useful, the really good doctors also follow their intuition and are willing to think outside the box.”

 suggests that in some provinces, fewer cannabis prescriptions are being issued. Between September 2019 and March 2020, Alberta, Newfoundland, and Ontario saw fewer healthcare practitioners associated with registrations, leading to the assumption that many people could be self-medicating by accessing cannabis through other means.

 reported that 14% of Canadians aged 16 and older indicated they used cannabis for medical purposes. The report found that just over 20% of medical cannabis patients access treatment with a medical document, which means the rest are purchasing their medicines from either the recreational or the illicit market.

In addition, Medical Cannabis Canada’s 2020 survey found that among medical cannabis patients, 50% reported that it’s hard to find a healthcare practitioner to speak with about obtaining a medical document and 83% reported that the stigma about medical cannabis use exists among medical professionals.

The optics of cannabis use—smoking, rolling, pipes, and bongs—and antiquated, prohibition-era ideas about the drug contribute to its limited acceptance in the medical profession, Hildebrand explained. The plant’s legal status in much of the world and consistency through batches has made clinical research challenging, and the availability of verifiable data hasn’t kept pace with patient demand.

“Dealing with pain or struggling with a chronic health condition can be very isolating. Worrying about securing medication and paying out-of-pocket only adds to the stress of illness, and can compound symptoms,” Blecher said. “In many cases, cost is the single-largest barrier for patients, and the reason why they revert back to cheaper, covered, and often more dangerous and addictive medications.”

But many producers are providing ample support for their patients—both insured and uninsured. In the case of Starseed, it offers compassionate pricing for low-income patients, first responders, veterans, and seniors, including full, complimentary access to virtual medical consultations with it suite
of professionals.

Blecher added: “The cost of cannabis has long been a huge barrier for patients, as it isn’t regarded in the same way that traditional pharma is—there is no government reimbursement, with the exception of veteran coverage, so it’s up to private insurers, employers, union groups, and licensed producers to step up and affirm their core commitment to patient care.”

Hildebrand confirms many of her patients reporting the greatest improvements are those who are supported, monitored, and following a thoughtful treatment plan designed for the individual—not only the disease or condition.

“Medicine is both an art and a science. Many doctors forget about the art and the intuition in our practice—balancing both and really caring for our patients gives them the best chance at recovery.”

As for Theriault, nowadays when in his garage, he is definitely not sitting around anymore. Instead, he is grabbing a shovel to clear snow, or gathering landscape tools to prune hedges, or mowing the lawn—returning to a life full of simple moments that remind him that life is indeed back to normal.

H. Meng, M.G. Page, P. Ajrawat, A. Deshpande, B. Samman, M. Dominicis, K.S Ladha, J. Fiorellino, A. Huang, Y. Kotteeswaran, A. McClaren-Blades, L.P. Kotra, and H. Clarke, 

. doi: 10.1007/s12630-020-01903-1 (2021) 

https://pubmed.ncbi.nlm.nih.gov/33469735./

Dr. Julie Hildebrand, Dr. Peter Blecher, and a medical cannabis patient share their insight into medical cannabis as a treatment for pain management in Canada through the help of WeedMD and others.

More and more research in treating previously untreatable diseases and conditions is accelerating, in part because of new discoveries within certain plants such as cannabis, but also because of a general surge in life sciences research and discoveries.

A unique motivating factor happened in early 2020. It was in February that life sciences researchers were handed a significant challenge to find a vaccine for a deadly novel virus. In record time, British researchers found the first successful treatment for COVID-19: a cheap steroid dexamethasone. That treatment has been credited with saving 650,000 lives across the world, according to an article in 

 (1), and came about because of genetic sequencing.

Today, genetic sequencing is being prioritized in laboratories across the world to track both variants and reinfections—a process that is spreading to other medical research as a result of the research into treatment for the virus. Even the cannabis genome has been sequenced.

In the cannabis world, new discoveries about what can and will soon be treated are also coming fast and furious. Cannabis has been proven effective for treating chronic pain, multiple sclerosis, epilepsy, and a host of other human maladies (2).

But what has really caught the attention of the medical community is the potential for cannabis to treat cancer. Ongoing studies are focusing on how cannabis can actually shrink tumors. It can be used successfully for treating the nausea that usually accompanies chemotherapy, and the anxiety of going through that process.

For example, recommended drugs to treat prostate cancer include abiraterone, an androgen biosynthesis inhibitor that works by decreasing the amount of certain hormones in the body (3). It comes with a long list of side effects, including confusion, vomiting, yellowing of the skin or eyes, swelling of the hands and feet, blood in the urine, and more.

Another drug is nilutamide, used after prostate surgery to stop the growth and spread of cancer cells. It can cause life-threatening lung disease (4).

Life sciences researchers following the “first, do no harm” creed of medicine are always in search of a way to avoid devastating side effects that could actually complicate cancer treatment by creating other health issues for the patient. That’s where cannabis comes in.

The McKernan family—brothers Brian, Brendan, and Kevin; sister Dr. Melissa McKernan-Pulliam (an electrophysiologist); and their parents Richard and Virginia—are life sciences explorers.

The brothers and their father helped build three major companies: Packard Bioscience, a scientific instrumentation company run by Richard, an electrical engineer who had designed avionics for military jets; Agencourt Bioscience, one of the largest commercial genomic services company in the US; and Agencourt Personal Genomics, which developed the SOLiD Next Generation Sequencing Platform that reduced the cost of genome sequencing by a factor of 100,000.

All three were acquired by major life science companies—Packard Biosciences was acquired by PerkinElmer in 2001, Agencourt Bioscience was acquired by Beckman Coulter, Inc. in 2005, and Agencourt Personal Genomics was acquired by Applied Biosystems in 2006.

Kevin McKernan stayed with Applied Biosystems after it acquired Agencourt Personal Genomics, working on worldwide sequencing development with another one of that company’s acquisitions, Ion Torrent.

Meanwhile, Brendan and older brother Brian formed Courtagen Life Science in 2010 to move genome sequencing into the clinic to help kids with epilepsy, autism, and mitochondrial disease. “We started seeing an overlap with the cannabis field because a number of doctors and physicians began asking about alternative therapies to help those kids,” said Brendan.

Kevin left Ion Torrent and formed Medicinal Genomics Corporation (MGC) in 2011, which was acquired by Brendan and Brian's company Courtagen Life Sciences in 2012 (5), and began working on sequencing the first cannabis genome after he was approached by a friend, who had lost multiple siblings to cancer at a relatively young age. Kevin began to explore genetic mutations and the potential treatment impacts of cannabis use. Beyond its commonly known ability to reduce nausea for chemotherapy patients, he uncovered significant evidence, born from scientists around the globe, exploring cannabis’ ability to reduce cancer cell proliferation and promote cell destruction. Now all three brothers were working at the same company. “Kevin was one of the first to sequence the cannabis genome, and he made it public for the world to use so we could start understanding and building a foundation for the cannabis plant,” said Brendan.

The brothers brought their father in as chairman of the board. After the legalization of medicinal cannabis in Massachusetts in 2016, MGC gained significant momentum to develop pioneering technology for growers that strengthens cannabis safety standards and increases productivity. But in 2017, all drivers of success for the brothers came to a grinding halt. Their dad, Richard, was diagnosed with stage four prostate cancer. The brothers then decided that it was time to reassess what they were doing, and potentially ramp up their work on using cannabis as a treatment option.

The devastating news of their father’s diagnosis caused a moment of reflection for the family, which actually accelerated their work. They took their father’s prostate genome and discovered a specific gene mutation that researchers said showed promise with various cannabinoids. “He had an mTOR and a BRAF mutation (6). These called for AKT inhibitors (which can reduce cancer cell growth), but there were none that had gone through the Food and Drug Administration,” said Brendan.

But there was a problem. Most of those AKT inhibitors were still in phase B clinical trials where researchers were working on the therapeutic efficacy of the inhibitors. “But if you happen to Google AKT 1 inhibitors in cannabinoids, you’ll find a bunch of scientific literature on its anti-neoplastic activity for the different cancer cell lines,” Brendan explained. “We eventually showed this data to my dad, who was very conservative. He didn’t really want to go on cannabis, he didn’t even drink alcohol. But after he looked at all the clinical literature, he agreed to try cannabis to help with his condition.”

Their father’s situation was turning dire. He lost about 50 pounds and was wasting away. “His cancer spread to his whole bone structure and he had tremendous pain and nausea,” Brendan said.

But the day he was given cannabis, he ate like a king. “His nausea went away. His bone pain went away. He had a nice, rosy feeling for the first time in a very long time,” Brendan commented.

He was kept on that cannabis-based therapy. The types of cannabinoids and different terpenes were adjusted.

Kevin made sure to test the purity of the cannabis before giving it to his father, eventually getting his company to invest in Pathoseek (7), a microbial detection system designed for testing cannabis flower, extracts, and infused products. He also worked on sequencing the genetics of cannabis strains to make sure they were getting the right compounds they wanted to use, and built the first public database called Kannapedia (8) that catalogs with genetic certainty the origins of thousands of cannabis strains and their relationships to other identified strains.

Eventually, a cocktail for their father’s therapy was found—a mixture of several cannabinoids: cannabigerol (CBG), cannabidiolic acid (CBDA), tetrahydrocannabinolic acid (THCA), tetrahydrocannabinol (THC), and cannabidiol (CBD). “We had a couple of different terpenes in there that had promise for prostate cancer,” Brendan said. “But it took us a good year to experiment with that.”

“We sought advice from leading experts in the field including Dr. Raphael Mechoulam, Dr. Bonni Goldstein, Dr. Dustin Sulak, Dr. Debra Kimless, and Mara Gordon. We experimented on everything from vaping to edibles to oils, and it turns out that we ended up using a combination of those things,” Brendan said. “The oils were great once we found the right combination, they would stay in his system for five or six hours before he would need his next dose.”

Their success in treating their father’s prostate cancer really turned heads. “The doctors at Dana-Farber/Brigham and Women’s Cancer Center in Boston were blown away that someone who had stage IV cancer was lasting this long and had no bone pain unless he was off of cannabinoids,” Brendan said. “That was absolutely amazing.”

When it came to allowing cannabis therapy, that hospital was the exception rather than the rule. Other medical systems in the Boston area were adamantly against it, Brendan explained, recalling how their father had to be rushed to an emergency room on occasion during the course of his illness. “He happened to end up at one particular hospital that became aware he was using cannabis,” he said. “They actually threatened to throw us out of the hospital and charge us for all of the bills as opposed to sending it to the health care insurance. They refused to allow us to give him cannabis at the hospital.”

He argued that their father was experiencing tremendous nausea when he was not taking cannabis. “Our family said ‘You guys have tried all the antiemetic drugs (anti-nausea drugs) that you have in stock and my father continues to throw up. He’s now throwing up all of his medication—the heart medication, and all the pain medication you’re putting him on. He cannot get comfortable. When we put him on cannabis, all that goes away, and you can continue treating him.’”

Fortunately, Brendan said, they had a wonderful nurse who helped. “She said ‘I know a lot of patients have gone to cannabis. I’ve seen how it can help patients. I’m going to walk out of this room, and you should probably do what you need to do to help your father. And don’t tell us anything’.”

Their father’s skepticism about cannabis changed as he went through the process, Brendan explained, so much so that he fundamentally believed at the end of his life that politicians opposing this drug should go to jail for holding these compounds back from patients. “My father just saw how beneficial they were to his own life. And for us to see the impact that cannabinoids had on my father’s life, and the fact that we, as a family, had the opportunity to spend four decent years with him before the last couple of months of his life where things really deteriorated.”

Richard lost his battle with prostate cancer on May 3, 2019 (9).

The Healthcare Promise of Genome Sequencing

The key to finding help for their father began with genome sequencing, a process that can identify the deoxyribonucleic acid (DNA) fingerprint of a germ, and is part of a broader movement in healthcare to do precision medicine (10).

What is genome sequencing and how does it work?

According to the National Human Genome Research Institute (11), a genome is an organism’s complete set of DNA, a chemical compound that contains the genetic instructions needed to develop and direct the activities of every organism. DNA molecules are made of two twisting, paired strands. Each strand is made of four chemical units, called nucleotide bases. The bases are adenine (A), thymine (T), guanine (G), and cytosine (C).

Bases on opposite strands pair specifically; an A always pairs with a T, and a C always with a G.

The human genome contains approximately 3 billion of these base pairs, which reside in the 23 pairs of chromosomes within the nucleus of all cells.

Each chromosome contains hundreds to thousands of genes, which carry the instructions for making proteins. Each of the estimated 30,000 genes in the human genome makes an average of three proteins.

“There’s a variety of different ways to sequence individuals,” Brendan said. “If you happen to go to a hospital for a seizure disorder, they might run a genetic test on you, which is a very targeted panel of maybe 100–400 different genes. There’s certain mutations that pre-dispose an individual to various types of seizure disorders.”

“If you happen to have something like my father’s BRAF mutation, we know those happen to have clinical literature supporting the use of AKT 1 inhibitors.

“But if you don’t know what’s wrong with a person, you may sequence their entire genome and look at all the genes associated with the body and then use an informatics platform to help interpret that data to see if you can associate clinical symptoms with various genetic mutations, and see if you can find the targeted therapy,” he said.

In 2012, Brendan had his own genome sequenced by Kevin to try to get at the root of an issue he was having with his heart—atrial fibrillation. He said that he went through a lot of traditional medicines at first, such as calcium channel blockers and beta blockers. “But I was falling asleep at work,” he said. “I was cloudy. My blood pressure was dropping dramatically along with my heart rate. I went back to the doctor and said: ‘Look, I can’t take these prescribed medicines anymore because I can’t operate or live my life.’”

The sequencing revealed a series of calcium channel mutations. Those mutations are believed to be causing Brendan’s arrhythmias due to calcium leaks. After extensive research, Kevin found a series of studies related to CBD’s roll in buffering calcium levels in the mitochondria, posing the question: Is it plausible to say that perhaps compounds in the cannabis plant may help improve his condition? “Some doctors thought it was worth a try and they thought it was relatively low risk,” he said. “I went on to cannabinoids and lo and behold, my rhythm disorders, for the most part, went away.” 

Brendan was quick to point out that his case is just one example and a lot of research has to be done to prove that this is not a private mutation relative to the rest of the population. It has to be studied. "Hundreds to thousands of different genetic defects can likely all share the common phenotype of arrhythmias. My experience does not support the use of CBD for any arrhythmia. My successful treatment is likely specific to my private case of calcium channel mutations and caution is advised extending this treatment to any person with the relatively vague descriptor of having 'arrhythmias,'" he explained. "The other plausible scenario is that certain cannabinoids also help regulate stress levels in the body and stress is known to trigger for arrhythmias as are things like caffeine and alcohol. I have removed virtually all those other components to my diet as well. I haven't been back to the hospital since.".

Brendan explained that he takes a combination much like his father was on: typically CBD, CBDA, CBG, and on occasion, THC as well. "It's probably closer to a four to one ratio of the non-psychoactive components to the psychoactive component," he added.

"I have also lived with chronic pain as long as I can remember. I, for the most part, have pain every day. It's a mixture of very sharp stabbing pains in my back to numbness and pins and needles in my leg. And occasionally the leg feels like it's filling up with hot water. That's the typical feeling I had for many years," said Brendan. "The cannabis has dramatically dulled that pain. Some days I don't have pain at all, which amazes me because I went for decades having pain on a daily basis. On average, it doesn't eliminate all of the pain all of the time. But it's gotten to the point where I can live my life and I'm not thinking about the pain all the time."

Perhaps even more astounding is that Brendan has completely come off all pharmaceutical drugs. "I have eliminated 100% of all other pharmaceuticals," he said. "Cannabinoids are the only things I take outside of vitamins and supplements, and that's it."

These personal experiences with medical cannabis became an “ah-ha” moment for the brothers. Brendan explained that he and his brother Kevin want to enable the industry to better understand the genetics of the plant and its impact on human health.

There’s a lot more work to do to sequence and annotate the plant, interpret all the genes, and put that into a meaningful clinical context to better help patients, Brendan said. “But the industry is moving in that direction.”

In 2017, Kevin participated in one of the first studies (12) on rare genetic variants in core endocannabinoid system genes that was identified in 6032 patients with a broad spectrum of neurological disorders.

The McKernan family’s unique story about their father, and Brendan’s experience with treating his own issues, resonates throughout the medical cannabis community. The brothers had unique tools available to them that not only led to advanced diagnosis and therapeutics, but served as a framework for further research.

“When we see a problem in our family, at least we sequence our genome to see what we could find,” Brendan said. “What do the genes tell us and where does that send us? One could call it a rabbit hole of digging into all the research to figure out if there is data to support a hypothesis about particular compounds that may help with a specific condition. Our experience solidified our belief that we need to drive science and medicine in this field to help a lot more patients.”

As a result of that desire, the leadership team at MGC founded the CannMed Conference Series, whose mission is to bring together the world’s leading cannabis experts to share their findings and latest research. In late 2015, MGC partnered with Dr. Raphael Mechoulam and hosted the inaugural CannMed Conference at Boston’s Harvard Medical School in April 2016. The CannMed Cannabis Conference now gathers the brightest minds in the cannabis industry worldwide to help further cannabis research, advance breeding techniques, and discuss advances in laboratory safety. In just two years, the conference size outgrew the venue at Harvard University, and moved to the West coast where they will host the fifth annual gathering at the Pasadena Convention Center in September 2021. This year, CannMed will include an 8-hour Medical Practicum, where attendees can learn the practical guidelines of cannabinoid therapeutics and research, from medical leaders in the industry (13).

Brendan believes that regulations need to change to keep the cannabis industry moving forward in the right direction. "It needs to start, unfortunately, with the federal government changing its position, especially since they have, in fact, patents and approved drugs that are based off of cannabinoids even though it’s still a Schedule 1 drug. It just doesn’t make any sense now,” he said.

In looking back on the experience with his father, and all that the family went through fighting against the stigma of the plant while employing a deeper understanding of both the cannabis and human genome, Brendan struck a note of hope going forward. “It’s an intriguing field,” he said. “Ten years ago, I would never have thought or told people I would be in the cannabis space. Now I can’t envision being in any other industry because I think our particular sector, with the 900-plus compounds in the plant, is going to, over time, develop the biggest pharmaceutical library our healthcare system has seen in decades.

“There’s so many active compounds in this plant. Once we unravel them and figure out what conditions they can be applied to, I think you’re going to see improvements for diseases associated with the central nervous system, safer alternatives for chronic pain and certainly palliative benefits for those dealing with cancer.”

There are cannabis doctors and scientists who are exploring the potential of cannabis being used in cancer treatment, such as Dr. Bonni Goldstein, Dr. Dustin Sulak, and Dr. Ethan Russo (14), all of whom are presenting at the 2021 CannMed Conference September 29-October 1, 2021 (15). 

Brendan noted that this conference was just one of many ways in which scientists and researchers are coming together to study cannabis and how it can help treat various human conditions. “We’re just standing on other people’s shoulders and trying to carry that torch forward to educate the world and make a difference,” he said.

https://www.economist.com/britain/2021/02/27/how-british-science-came-to-the-rescue

https://www.ncbi.nlm.nih.gov/books/NBK425767/

https://medlineplus.gov/druginfo/meds/a611046.html

https://medlineplus.gov/druginfo/meds/a697044.html

https://www.genomeweb.com/molecular-diagnostics/courtagen-closes-genetic-testing-business-citing-regulatory-reimbursement#.YEqnHRiZPBI

https://academic.oup.com/jcem/article/97/7/E1139/2833320

https://www.medicinalgenomics.com/pathoseek-id/

https://www.courant.com/obituaries/hc-obituary-richard-t-mckernan-20190529-story.html

https://www.cdc.gov/genomics/about/precision_med.htm

https://www.genome.gov/human-genome-project/Completion-FAQ

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5690672/

http://cannmedevents.com/practicum/#speakers

Brendan McKernan and his father Richard found their way to medical cannabis almost as a last resort, but the plant became a turning point in their lives and careers that led to them down a road to help others.

An interview with Eloise Theisen, a board certified Adult Geriatric Nurse Practitioner who specializes in cannabis therapy and the president of the American Cannabis Nurses Association.

Chronic pain has been described as an “unpleasant sense of discomfort” (1), which may persist or continue to progress over an extended period of time. In the case of acute pain, it arises rather quickly as a result of a bodily response to an injury and is often treatable. With chronic pain, the discomfort is typically resistant to medical treatments. Medical conditions such as fibromyalgia, cancer, shingles, arthritis, diabetes, previous injuries, and so forth are among the many ailments that can be connected to chronic pain. Environmental or psychological factors have also been found to aggravate and worsen chronic pain.

Eloise Theisen, an Adult Geriatric Primary Care Board-certified nurse practitioner, who has been in the nursing field for more than 21 years is now using her medical expertise to assist patients in using medical cannabis to treat their chronic pain. Aside from Theisen’s medical experience she is also the Chief Nursing Officer at Leaf411, which is a free cannabis hotline for anyone who wants to call and discuss their cannabis use or inquire about cannabis use with a nurse (2). Theisen is also the president of the American Cannabis Nurses Association (3). Originally, Theisen began her impressive nursing career in oncology. In this department, it was quite common to see patients experiencing chronic pain issues from the illness or cancer treatments. When she first began seeing patients using cannabis, she didn't have much of a curiosity to explore it further. However, seven years ago she saw an increase in patients interested in using the medicinal plant as part of their cancer care treatment plan and decided to use the knowledge she gained from her personal experience with cannabis to help patients. Thus began her journey into the medical cannabis landscape.

"It became really clear to me that most healthcare professionals did not have good knowledge of cannabis and how to help patients access it safely and effectively," said Theisen. "Because of my personal experience, I decided to create a practice designed to help patients navigate cannabis as a medicine.”

Cancer patients suffer from treatment side effects such as chemotherapy-induced peripheral neuropathy or severe bone pain related to their cancer diagnosis. Through the help of the internet, patients were doing their own research to find alternatives to alleviate or manage their symptoms. Theisen mentioned that patients were also turning to her for guidance. “I started to really help these patients answer questions, help them determine how to find a safe product," she said. "This was prior to legalization in California. We didn’t have good regulations in place around testing.”

Before the legalization of cannabis in California, there weren’t quality control (QC) or quality assurance (QA) regulation standards to ensure that customers were being offered a safe product. “Products could be sold to patients and they could have high levels of molds or bacteria in them,” said Theisen.

Conventional treatment options have started to lose some of their appeal to those suffering from chronic pain conditions. More and more patients have been seeking out medical cannabis to treat their conditions rather than use traditional methods. Over the past seven years, Theisen has witnessed a lot of chronic pain patients who were on treatment plans containing medications such as opioids to manage their pain, become ineffective or have extreme side effects that greatly diminish their quality of life. Cancer patients were being told to reduce their opioid prescriptions due to the growing epidemic of overdoses and addiction. With these reductions, patients weren’t being offered any alternatives to help ease their discomfort. Being in pain, this was spurring the uptake in patients looking into medical cannabis as a treatment option. “When my patients come to me for cannabis, for chronic pain, many of them are looking to also reduce their pharmaceutical intake," Theisen explained. "I see them improving their symptom management and also reducing their overall pharmaceutical burden.”

By helping patients switch over to the medicinal plant, Theisen was seeing their quality of life and medical conditions improve.

Medical Cannabis Challenges: Stigma, Dosing, and More

Due to the stigma surrounding cannabis, there are still patients who are hesitant to try it. Often, these kinds of patients have gone through conventional treatment plans and are at their last resort for seeking relief. Theisen said that there is still a part of them that carries the stigma of pot heads or stoners. “Most of my patients are older adults, so their average age is around 76. They were the generation that really did tell their kids to say no to drugs. They generally had harsh consequences if they found their kids were consuming drugs, particularly marijuana. They really struggle with allowing themselves to try it because they feel guilty about all these years that they demonized cannabis and now they’re trying to come to it for their own condition management, symptom management," said Theisen. "It’s often their grandkids that are trying to encourage them to use it, to look at it differently. It can definitely inhibit their ability to really explore the plant. That stigma can carry over in ways. For example, they may try it and they don’t get results right away. They just say, see, I knew it and then they give up.”

For new patients, Theisen goes through their health history and inquires if they’ve used cannabis in the past such as in high school or college and if so how they reacted to the plant, negatively or positively. Particularly, most negative experiences she heard were from edibles containing tetrahydrocannabinol (THC). Most patients who come to Theisen though, haven’t tried cannabis prior to seeing her. Occasionally, there are also patients who come in and are reluctant to use cannabis due to little information on medication reactions with the plant. When this situation occurs, Theisen describes the experiences she has had with the more than 6500 patients she has treated. She also monitors her patients regularly and follows them along their medical cannabis journey. By providing that extra layer of calm, this helps give her patients a little bit more confidence in their treatment plan. “There are times though where people are taking certain things and I’m like we have to limit your use because there is a potential for drug-drug interaction," said Theisen. "One example is immunotherapy and THC. In the cancer population, we do have patients who want to use high doses of cannabinoids to treat their cancer. Again, this is sort of the internet’s version of what cures cancer. We do have some animal data to demonstrate that the cannabinoids can play a role in cancer treatment. But there’s been some small studies demonstrating that if you’re using high amounts of THC with immunotherapy, that it can decrease your response rate to that immunotherapy treatment.”

She also mentioned that using these products didn’t affect the overall survival rate, but that there are times when the amount or dosage could have an affect on their other treatments. It is very important to educate patients on the proper dosing of cannabis so they can better understand that the plant also has bidirectional effects. Theisen explained that by starting patients out on a lower dose and slowly increasing that dose, it helps avoid negative side effects and also aids in them finding their therapeutic window so that they are not over-consuming and are getting the best benefit with the least amount of side effects.

As we age, our ability to process medications decreases by around 30%. This may begin happening in our 40s and 50s. Theisen started recognizing that standard dosages being provided in dispensaries were inappropriate for her most common clientele­—the older adult. “I really started to look into reducing those. Again, there is no real standard out there for cannabis dosing. The studies that we have with some dosing comes from either Sativex—that one-to-one tincture out of the United Kingdom—or Dronabinol, which is a synthetic THC, Food and Drug Administration (FDA) approved medication," she said.

Theisen explained that her dosing recommendations have changed over time. "I’ve evolved with THC and cannabidiol (CBD). I’ve gathered information around gender differences. There are definitely different protocols based on your gender and your age," she said. "We’ve also been really fortunate to have an evolution of cannabinoids available to us like cannabigerol (CBG), delta-8-THC, tetrahydrocannabinolic acid (THCA), and cannabidiolic acid (CBDA). The more information that comes out, the more the dosing regimen evolves and changes.”

Lack of Support from Medical Professionals and Insurances

With the legalization of cannabis growing in the United States, you would think that medical professionals would become more open to prescribing medical cannabis to their patients. Theisen has been witnessing a shift in the healthcare field, but still sees a majority of healthcare professionals as not being fully on board with the medicinal plant. They will often mention that there’s not enough research to support this method for treatment. Theisen believes that there is still a lot of fear and stigma among healthcare professionals because of its Schedule 1 ruling and status (4). “Often I hear from other healthcare professionals that they don’t want to discuss it or even learn about it because of that schedule and status. It does prohibit them from exploring it. I’ve seen more nurses and nurse practitioners’ sort of lead the change and get educated, which is not surprising,” Theisen said. Nurses have a boots on the ground mindset and are usually with patients the most. Physicians typically say that if they want to use cannabis that is fine, but that they cannot prescribe it which leaves patients without the proper resources to safely and effectively access this plant medicine.

When patients come to Theisen for their chronic pain, they already have it in their minds as to what type of regimen they want and that usually involves CBD. They do not want to smoke it and they do not want to get high from it. What Theisen and other medical professionals have found is that THC may also play a vital role in their treatment. “We find that a lot of the research that does come out around Sativex for chronic pain does demonstrate that THC is a very important part of that regimen also, especially if they’re coming off some of their opioids or other pain medications, the THC can really help with the withdrawals," said Theisen. "Their protocol might change from the time they begin to the time that they come off their medications. If that’s their choice. It evolves during that. I think cannabis is best when it is personalized. We can certainly have best practices around it, such as stating which is the right cannabinoid for a certain condition and a good starting dose. But the more we personalize it, the better outcome we’ll see.”

In order for a patient to begin their medical cannabis journey, Theisen is very thorough on going through their health history to see what they have tried in the past, what worked, what didn’t work, what helped their condition, what made their condition worse, medications they may currently be taking, and so much more. Drinking alcohol, water intake, and diet are also factors that play a role in regulating your endocannabinoid system (ECS), which is important to detail because the ECS is where cannabinoid receptors are located and play a role in how the body processes the cannabinoids found in cannabis (5). Theisen also likes to have this information aside from the benefit of the ECS, because as great as cannabis can be, it isn’t a silver bullet or cure-all treatment. There are often multiple factors needed to help manage chronic pain.

Unfortunately, insurance companies and the government do not offer financial assistance plans or discounts to medical cannabis users because of its scheduling. For patients who are beginning to research their treatment options with Theisen, all hope is not lost. Her patients are able to get reimbursed for their visits if they have a health savings account (HSA). This may be an option a patient can use with other healthcare professionals involved with cannabis. Theisen remained hopeful that this may be an area in the healthcare industry that changes in the future. For a patient to have everything be out of pocket, it definitely puts a financial strain on them. Cannabis has a stigma around it, which makes insurance companies uncomfortable to cover it. Theisen stated that it should be a patients choice to use their coverage for what they feel is best for their chronic pain, whether that is medical cannabis or opioids. Insurance companies still view the medicinal plant as a drug of abuse, though this plant has various therapeutic properties and should be viewed as a means to provide a patient with a higher quality of life.

Cannabis Resources for Patients and Healthcare Professionals

Aside from meeting with chronic pain patients, Theisen is also the cofounder and chief executive officer (CEO) of Radicle Health (6), which is an education and training company that she cofounded with Timothy Byars. Radicle’s mission is to educate healthcare professionals on the benefits of medical cannabis for various health conditions. Theisen explained that the lack of education out there is by far one of the biggest gaps in the industry at this moment. Without the education, consumers also aren’t educated. There is a lot of misinformation spreading as well. Radicle uses evidence-based research and compiles it into different levels of education that can be purchased by a healthcare professional or the consumer but is geared more heavily in the science category. Theisen mentioned that their goal is to standardize education and training so that patients, consumers, healthcare professionals, and the general public as well as policy holders are all provided with the same information to try and bring change to the stigma and increase safe access. The Radicle Health Clinician Network is Theisen’s practice with Dr. David Ferrera located in California. This is where she sees patients who are solely looking to use cannabis as a treatment, helping them to develop a treatment plan that is focused towards cannabinoid therapies, and work in collaboration with other healthcare professionals to reach their goals. Referrals are not required to meet with Theisen because all fees are out of pocket.

Theisen is also president of the American Cannabis Nurses Association (ACNA) which celebrated their 10-year anniversary last year. The mission of the ACNA is to advance excellence in cannabis nursing practice through advocacy, collaboration, education, research, and policy development. In the last year and her first year as president, Theisen worked on increasing some of the committee work that the organization was lacking. They had an education and research committee as well as a communications committee, but there was no diversity equity and inclusion committee. Theisen felt this was an important piece to the organization and has begun assessing the institution and work towards being an anti-racist organization. “We’re also looking at policy, government affairs, and how can we increase advocacy for nurses. Give them the tools that they need to be advocates at the local, state, and national levels,” said Theisen.

Another aspect Theisen is working towards is credentialing. In many nursing specialties, you can become credentialed. An example of this would be for an oncology nurse, where you can be oncology certified. Although this is a big goal to achieve, ACNA is in the beginning stages of this plan and will continue to push forward. Theisen mentioned that with these credentials, it may help legitimize the work that nurses are doing in the space and help advance their goals of education and dispelling cannabis myths so that misinformation becomes less and less for consumers and other healthcare professionals.

Pain Free with CBD: Everything You Need to Know to Safely and Effectively Use Cannabidiol

, with Alice O’Leary Randall who was the main author (7). In this book, Randall and Theisen educate patients on using CBD to treat medical conditions. One of the topics covered is drug-to-drug interactions, which serves as a reference guide to patients. Often, Theisen is asked about interactions with medications and cannabis. Not much is known due to lack of research as there aren’t large studies performed on drug-to-drug interactions. This does not mean that there is no help in sight. Clinical decisions can be made such as whether a patient needs to be monitored or how unlikely it is that they will experience an interaction. Theisen expanded on this in her reference guide. “That was something that we were really proud to offer so that patients had that reference and at least could bring that to their healthcare professional and say, I’m taking CBD and it looks like I might need you to monitor me a little bit closer," she said. "It helps them open up that conversation with their practitioner. Even if that practitioner doesn’t know, at least we are providing help, trying to help start that conversation, to reduce harm if there is going to be a potential interaction.”

Over the next few years Theisen hopes to see the federal decriminalization of cannabis. She believes that decriminalization at the federal level is what is necessary for increased access and acceptance within the medical community. “I would like to see more healthcare professionals become educated on this because their patients are using it. It’s our job to keep them safe. I would like us to help with dispelling the misinformation and working together as an industry. I do still think we’re a little bit divided as an industry in terms of working together to make sure that we’re providing safe access and reducing harm for patients," she said. "I recognize that healthcare professionals for decades have been missing from the cannabis industry and the work is primarily done by other advocates and educators. I’d love to see us come together more for the common good and common goal.”

Although there is a cloudy haze surrounding cannabis, the cannabis industry is gaining respect for the plant's medicinal properties. If given the chance, cannabis can serve as a treatment plan for a plethora of health conditions and help many patients live a better quality of life so that there is less reliance on prescription medications.

https://www.medicinenet.com/chronic_pain/definition.htm

https://www.healthline.com/health/endocannabinoid-system#how-it-works

Pain-Free with CBD: Everything You Need to Know to Safely and Effectively Use Cannabidiol

 (Rockridge Press, Emeryville, California, 2019).

Eloise Theisen, a board certified Adult Geriatric Nurse Practitioner who specializes in cannabis therapy, shares her unique insight from helping patients.

One Nurse’s Battle with the Stigma Against Medical Cannabis Use and Chronic Pain

As thousands of patients across the country try to manage their chronic pain with myriad medications, they are also juggling side effects, possible toxicity and sometimes even overdose, opioid addiction, and an overall quality of life issue.

According to the Centers for Disease Control (CDC), from 1999–2019, nearly 450,000 people died from overdoses involving opioids, including prescription and illicit opioids. Perhaps even more alarming is that opioids were involved in nearly 47,000 deaths in 2018, almost six times the number of opioid-involved overdose deaths in 1999. And the rate of addiction and overdoses due to opioids continues to rise and devastate families, communities, and patients with chronic conditions (1). As researchers from Oregon Health & Science University, Portland, said, “Unless the nation develops an increased tolerance to chronic pain, reduction in opioid prescribing leaves a vacuum that will be filled with
other therapies” (2).

As such, researchers, scientists, and other interested parties have been investigating cannabis’ role in chronic pain. Kevin Boehnke, PhD, a research investigator at the Chronic Pain Institute Research Center in the anesthesiology department at the University of Michigan took an interest in cannabis research as a side project during his PhD, and then switched his energy to cannabis full time in 2017 when he began a research fellowship at the Chronic Pain and Fatigue Research Center. Boehnke has been tackling questions such as what health conditions are patients using cannabis for, which dosage formats are they using, are patients reducing their use of opioids, and does it help chronic pain. We recently discussed some of the research surrounding those questions with Boehnke and the impact his research might have on the broader medical cannabis community.

Chronic Pain, Opioid Reduction, and Cannabis

Boehnke started his PhD career in public health studying water quality and the transmission of bacteria in water. Although this sounds like a far stretch from his future work with cannabis, he said it got him thinking at the population level and about harm reduction. And after hearing a talk about cannabis, he was curious why the talk only focused on the negative and not on the therapeutic effects of cannabis.

In 2013, Boehnke and Dan Clauw, MD, director of the Chronic Pain and Fatigue Research Center at the University of Michigan—along with the help of a local dispensary—administered a survey. The survey revealed that many medicinal cannabis patients were reducing their opioid use after they started using cannabis. Not only did these findings start Boehnke’s quest to find out more about people using medical cannabis and chronic pain, it also changed his perception of medical cannabis. “Cannabis is a very versatile medicine,” he said. “People use it for sleep, they use it for pain, and they use it for managing mood, all of which interface with chronic pain.”

In 2013, Boehnke and two other investigative researchers from the University of Michigan, Ann Arbor, conducted a retrospective cross-sectional survey that evaluated the use of medical cannabis and decreased opiate medication in 185 patients with chronic pain. The data collection went from 2013–2015, and results were published in 2016 (3). Among the study participants who utilized a medical cannabis dispensary in Michigan from November 2013 to February 2015, medical cannabis use was associated with a 64% decrease in opioid use (n=118), a decreased number and side effects of medications, and an improved quality of life (45%).

Although the study design is limited due to its cross-sectional setup, Boehnke explained that for patients to say that, on average, they had a 64% reduction in opioid use is pretty large. “When we think about how many lives are impacted by the opioid crisis, one way to target that and reduce people’s use of opioids is to either not prescribe them in the first place or offer a safer alternative—something that allows them to effectively lower their dose, so they can lower their risk of overdose or toxicity," Boehnke said.

Boehnke conducted a second, larger survey in 2019 (N = 1321) (4). This study revealed patients’ reasoning for substituting with cannabis. Approximately 80% reported substituting cannabis for traditional pain medications (53% for opioids, 22% for benzodiazepines), citing fewer side effects and better symptom management as their rationale for doing so. The study also found that medical-only users were older, less likely to drink alcohol, and more likely to be currently taking opioids than users with a combined recreational and medical history.

“If patients report that cannabis is more effective, they tolerate it better, and it has a favorable safety profile compared to their other medications, then that's a win from a treatment standpoint,” said Boehnke. “These results, combined with many other studies showing the same, validated that this is a place we should be focusing our energies. The question becomes: How do we do this more effectively and help physicians, patients, and ideally scientists continue to engage with the space?”

Cannabis Use-Frequency and Clinical Outcomes

When you talk about cannabis as a therapeutic remedy, it’s difficult not to mention dosing (how much is too much?), dosing formats (edibles versus smoking), the side effects of “getting high,” the safety of smoking and vaping, and, of course, its efficacy in abating pain and other symptoms.

, Boehnke and five other researchers conducted a cross-sectional study that observed whether daily cannabis-use frequency was associated with pain severity and interference, quality of life measures relevant to pain, for example, anxiety and depressive symptoms, and cannabis-use preferences (5). According to the paper, “Heavy medical-only use participant consumption patterns showed greater preference for smoking, vaporizing, and high tetrahydrocannabinol (THC) products. In contrast, light medical-only use participants had greater preference for tinctures and high cannabidiol (CBD) products.”

Their findings suggest “that lower daily cannabis-use frequency is associated with a better clinical profile as well as safer use behaviors, e.g., preference for CBD and non-inhalation administration routes. These trends highlight the need for developing cannabis-use guidelines for clinicians to better protect patients using cannabis.”

But Boehnke warns that due to the study design, selection bias, and focus on chronic pain, these findings have limitations. “This was not a longitudinal study; it was a single snapshot in time, a cross-sectional study,” Boehnke stressed. “We don’t know if those use behaviors led to worse clinical outcomes, but what we can say is the people who were using cannabis more frequently seemed to have a more impacted clinical profile at the time the study was conducted. It’s possible they were overusing cannabis and that overuse—especially because they were more likely to smoke or vape than use tinctures or topicals—negatively impacted them. It’s [also] possible they were not having as effective pain management or perhaps worsening their symptoms.”

He also said it’s possible these folks were the ones with worse clinical symptoms initially, and as a result, they had a more impacted profile even after using cannabis. “It’s one of those studies that has interesting findings, but contextualizing it is really important,” he said. “From a harm-reduction perspective, there’s a lot of concern about smoking as a primary way of ingesting cannabis. So, if you can use these non-inhalation routes and obtain a similar effect, that's a useful strategy for reducing harm.”

Another concern is using high amounts of cannabis daily via smoking or vaping—the issue is that the effects don’t last long, so patients are often smoking multiple times a day, resulting in "quick spikes and tapers of the THC high. With frequent use, this may contribute to dependence or abuse-like behaviors," Boehnke said. In contrast, “folks in the less frequent-use category were more likely to use CBD-dominant products, which, from a harm-reduction perspective, is also quite interesting and important, because CBD doesn’t have the kind of addiction and abuse potential as THC,” he explained.

His hope is that this study can help stimulate conversations with their patients and be able to offer tips and advice on safer practices. Something like, “Let’s come up with a treatment plan, and in X number of weeks, I’ll follow up to see how it’s going”—as they would with any medication. Boehnke said he feels “all too often what happens is physicians don’t want to talk about it. They refer their patients to addiction services, and sometimes they won’t keep seeing them as long as they’re using cannabis. Some institutions have so-called no-pee, no-pill policies—if a patient tests positive on a drug test, then they can’t get some of their medication.”

Qualifying Conditions of Medical Cannabis Patients

Kevin Boehnke, PhD, a research investigator at the Chronic Pain Institute Research Center in the anesthesiology department at the University of Michigan, discusses his research efforts to address questions such as what health conditions are patients using cannabis for, which dosage formats are they using, and does it help chronic pain.


March/April 2021