Cannabis Patient Care - March/April 2021

Cannabis Patient Care - March/April 2021

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27 march/april 2021 | cannabis patient care research focus 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 cat- egory 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 saf- er 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 So, what medical conditions are patients using cannabis for? In an effort to answer this question, Boehnke and a team of three analyzed state registry data to provide nationwide estimates characterizing the qualifying conditions for which patients are licensed to use cannabis medically. (6) "We wanted to get a big-picture understanding of what peo- ple were using cannabis for nationwide," Boehnke said. "We went to all the states' website that had legal medical cannabis and collected their publicly available reports. If they weren't available, we emailed the offices to collect any kind of data they had, and we put it all together and plotted the data over time and looked at trends in those data." Their findings revealed that chronic pain was the most com- mon qualifying condition reported by medical cannabis pa- tients (64.5% in 2016). And of all patient-reported qualifying conditions in 2016, 84.6% had either substantial or conclusive evidence of therapeutic efficacy. "Lots of people use cannabis for chronic pain, muscle spasms or spasticity, multiple sclerosis, and chemother- apy-associated nausea and vomiting," Boehnke said. "The big takeaway is a growing number of people are using cannabis, and the reasons they're using it actually align with what we know from the evidence." But, what Boehnke pointed out is there are many other con- ditions available under state law with little or no evidence that cannabis is actually helpful for treating. "It's really im- portant to be judicious and thoughtful about how we're con- sidering cannabis to medicine," he warned. "So, it can be used appropriately instead of being thrown against every symptom that somebody has, even if it might not be helpful and in fact, might be keeping them away from a treatment that is helpful." Cannabis as Medicine? One of the fascinating and interesting things about these studies, according to Boehnke, is you get to learn a lot about people. "It's difficult to do a lot of experimental work giving people cannabis, especially if you want to give them a product similar to what you might get in a dispensary," he said. "A lot of what I work with is people's subjective responses and reports about using cannabis, which tells you a lot about the use experience and the culture. Working with the folks at the dispensaries also gave me a cool and unique lens into that aspect as well. "These studies have changed my ideas about medical can- nabis," he said. "In some ways, they've helped contribute to my understanding of what we think of as medicine, as well as how cannabis fits into healthcare." Boehnke also pointed out that for too long people have been saying that cannabis is one of two things—it's either panacea or poison. He believes both of those have been shown to be false, adding that we should find a way to be thoughtful and judicious about taking the middle path be- tween them. "We can do that with science. I think we can do that also by addressing the massive cultural and societal wrongs that have been done with cannabis criminalization," he said. "Because if we just move into treating cannabis as a medicine without acknowledging the massive amounts of pain and suffering inflicted by criminalization, I think we're not do- ing our duty." Boehnke shared a plea to physicians and healthcare profes- sionals. "Many healthcare professionals worry that we don't know what we're doing because cannabis is so different. But every time a patient starts a new medication, you're embark- ing on an N=1 experiment. The patient may respond positively or they might not. But you figure that out together using joint decision making and through trying to address that individu- al's personal needs and preferences," he said. "I believe think- ing about cannabis in that context can be very instructive and useful." Future Research Boehnke and his colleagues recently received funding from the National Institutes of Health (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. Boehn- ke's goal is to figure out how CBD and THC act together or separate so that they can then translate that information back to the patient. "From there, we hope to be able to say if you have these types of symptoms, perhaps you should be using CBD, THC, a combination, or whatever the case may be," he said.

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