Cannabis Patient Care - March/April 2021

Cannabis Patient Care - March/April 2021

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26 cannabis patient care | vol. 2 no. 1 cannapatientcare.com research focus 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 cu- rious 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 dispensar y—ad- ministered a sur vey. The sur vey revealed that many medic- inal cannabis patients were reducing their opioid use after they star ted using cannabis. Not only did these findings star t Boehnke's quest to find out more about people using med- ical cannabis and chronic pain, it also changed his percep- tion of medical cannabis. "Cannabis is a ver y versatile med- icine," 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 ret- rospective cross-sectional survey that evaluated the use of medical cannabis and decreased opiate medication in 185 pa- tients 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 can- nabis 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-sec- tional 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 ef- fectively lower their dose, so they can lower their risk of over- dose or toxicity," Boehnke said. Boehnke conducted a second, larger sur vey in 2019 (N = 1321) (4). This study revealed patients' reasoning for substi- tuting with cannabis. Approximately 80% repor ted substitut- ing cannabis for traditional pain medications (53% for opi- oids, 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 old- er, less likely to drink alcohol, and more likely to be currently taking opioids than users with a combined recreational and medical histor y. "If patients report that cannabis is more effective, they tol- erate 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 be- comes: How do we do this more effectively and help physi- cians, 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 effi- cacy in abating pain and other symptoms. In a recent paper published in the Journal of Pain, Boehnke and five other researchers conducted a cross-sec- tional study that obser ved whether daily cannabis-use fre- quency was associated with pain severity and interference, quality of life measures relevant to pain, for example, anxi- ety and depressive symptoms, and cannabis-use preferenc- es (5). According to the paper, "Heav y medical-only use par- ticipant consumption patterns showed greater preference for smoking, vaporizing, and high tetrahydrocannabinol (THC) products. In contrast, light medical-only use par ticipants had greater preference for tinctures and high cannabidiol (CBD) products." Their findings suggest "that lower daily cannabis-use fre- quency is associated with a better clinical profile as well as safer use behaviors, e.g., preference for CBD and non-inhala- tion 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 limita- tions. "This was not a longitudinal study; it was a single snap- shot in time, a cross-sectional study," Boehnke stressed. "We don't know if those use behaviors led to worse clinical out- comes, but what we can say is the people who were using can- nabis more frequently seemed to have a more impacted clin- ical profile at the time the study was conducted. It's possible they were overusing cannabis and that overuse—especial- ly 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 prof ile even after using cannabis. "It's one of those studies that has interesting f indings, but contextu- alizing it is really impor tant," he said. "From a harm-reduc- tion perspective, there's a lot of concern about smoking as a primar y way of ingesting cannabis. So, if you can use these non-inhalation routes and obtain a similar ef fect, that's a useful strateg y for reducing harm."

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