It is with great regret and a heavy heart that we must announce the suspension of a large part of our services for financial reasons.

As of Monday, September 5th, we must unfortunately suspend initial appointments for all new patients. We must also suspend our training activities for health professionals and patients. Therefore, all announced fall events are cancelled. We will however continue to ensure the renewal of medical cannabis authorizations for existing patients.

We want to assure you that we will be here for our current patients. Our phones and emails will be open, however, we will have fewer staff to support them. Your doctors are here to provide continued care. Follow-up appointments will be a little different, but we are fighting to bring back our full level of care.

Here are ways that you can help:

• Make a contribution to our cause

• Share our campaign with your friends and family, or share on social media

• Continue with us – Moving to the recreational cannabis stream hurts our cause

• Send us a testimonial that you would be willing to share in our public campaigns – Rest assured, we won’t disclose any identifying information. 

•  Be patient with us during this difficult time, we will need more time to return your calls and your emails, we’re here for you but we are under-resourced

You might be wondering how this happened- Santé Cannabis has been a mainstay of medical cannabis access in Quebec since 2014. 

We’ve been struggling with the same question. Medical cannabis is not a priority for our government, for our healthcare industry, and we’ve tried everything we can to maintain our service, but we’re at our breaking point.

We’ve been slammed by the COVID-19 pandemic and increasing costs. And we now operate in the shadow of a recreational cannabis market entirely disconnected from its roots in medicine and patient advocacy. We now lack the resources required to continue providing our essential medical service. The RAMQ billings and educational grants we receive do not cover the costs of the care that we provide, and we must restructure in order to survive. We also receive no additional public funding in a province that profited $65 Million from recreational cannabis sales last year.

To date, none of these public funds are earmarked for medical cannabis research or improving medical cannabis access in Quebec. Many people will wonder, why do we still need medical cannabis clinics now that cannabis is sold legally?

There are many, many reasons:

• Patients using cannabis for medical purposes require care and education that cannot be provided by cannabis store clerks
• Physicians, nurse practitioners and pharmacists identify potential risk factors and drug interactions that require monitoring
• Vulnerable populations require personalized professional support to ensure they use cannabis safely and appropriately
• Cannabis purchased on the recreational market cannot be declared as a medical expense on income tax
• Medical cannabis authorizations provide protection to individuals who depend on it to work, to live and to care for their families
• Children and young persons can only access cannabis for medical purposes, and require personalized professional support
• Some patients receive reimbursement for their medical cannabis purchases, such as through Veterans Affairs Canada, CSST, SAAQ, and health insurance spending accounts. 
• Patients who grow their own cannabis require medical authorization, especially in Quebec where home cultivation is otherwise prohibited
• Specific Higher potency products for medical use are not available at the SQDC and can only be accessed via medical authorization

Once more, here are the ways you can help:

We are about to launch a media campaign to let the public know of this situation. We’ve protected our patients from these financial difficulties until now and avoided voicing them publicly. We are now at a point where we can no longer stay silent. As patients, you can help shed light on the importance of patient access to reliable information, educated medical evaluations and proper follow-ups. If any of the reasons for medical cannabis clinics to exist apply to you and you want to share your experience, send us your testimonial at info@santecannabis.ca.

We have also launched a donation campaign that we invite you to share with your connexions. We believe in our mission. We hope this situation is temporary, and thank you for your patience and support.

– Dr. Dworkind

Donate here

*Please note that this blog dates back to 2022. We restarted initial appointments for new patients in November 2022 and are still taking new patients.

No one said recovering would be easy; they said it would be worth it.  

Whilst sitting here wondering how I am going to take nearly 12 years of chronic health struggles and formulate it into a short blog post, I reflect on a 16-year-old: scared, confused, immature and unprepared adolescent. I bring myself back to the day I got the call from the Montreal Children’s Hospital Gastroenterology (GI) department to give me my first appointment, initiating the testing process for inflammatory bowel disease. It seems like so long ago, yet it’s still so fresh in my memory.  

As a medical cannabis patient and medical cannabis clinic employee, I hope my story can help anyone to see a glimmer of light at the end of even the darkest of tunnels. I currently see my daily fight to maintain balance and good health as a blessing and a strength, but as a teenager just starting to experience life, it felt like an absolute curse and weakness.  

The summer I turned 16, I went to see my gynecologist for my usual 6-month follow-up. Even though I was on birth control, I was constantly spotting between periods. Given my family history of Inflammatory Bowel Disease and Irritable Bowel Syndrome, and an additional concern of constant diarrhea for the last 3 months, worry grew that I may be battling an autoimmune disease. My doctor put in a request for me to be seen by the Montreal children’s hospital’s GI department, where I was diagnosed with Crohn’s disease.  

Within a month of my diagnosis and commencing treatments, I experienced an adverse reaction to the medication my doctors had prescribed to control my disease. It left me with pancreatitis – this was the beginning of my living nightmare.  

Due to ongoing complications, I was hospitalized for months at a time, and I was given opioids to control my pain, benzodiazepines for anxiety, and corticosteroids for the inflammation my disease caused. As time passed each hospitalization got longer and my time at home in between got shorter.  

Over time, I started to notice a shift in my moods. I thought I was only mildly depressed because of the cards I had just been dealt. I figured it was normal considering everything I had gone through in a short amount of time. I was watching my adolescence being ripped away from me. I began to feel like a prisoner in my own body. I went from being an outgoing and sociable teenager to being a reserved and isolated young adult. I was terrified.   

Shortly after being told that my pain from multiple flare-ups left me with chronic nerve damage to my intestines and pancreas, I began to realize that the pain I had was both physical and psychological, which in turn brought on severe anxiety. I started to seek unhealthy coping mechanisms.  

Subconsciously, I turned to opioids that doctors prescribed for my physical pain to alleviate my mental pain as well. I did not want to feel anything, I wanted to be numb. From that point on, there was not a day that went by that I did not misuse morphine, Dilaudid, codeine, fentanyl, or Ativan to escape the fact I was chronically ill and depressed.   

I was being followed in cognitive behavioural therapy and talk therapy for 6 months after my Crohn’s diagnosis. I learned I could tell my therapist whatever she wanted to hear just so my specialists would be happy and leave me be. After each session, I would go home and drown my feelings in whatever opioid I had at my disposal.   

Sleeping and avoiding reality became easier than dealing with my issues.  I had lost everything dear to me: school, friends, romantic partners, self-confidence, and, most of all, self-worth. I was doing absolutely nothing to help myself. I had secretly set a goal to do everything in my power not to see my 25th birthday. At this point, I was chronically depressed and had become a danger to myself.   

My cannabis journey began roughly 2 months later. I went into the ER as usually, thinking I was having another flare-up, but the nausea, vomiting, irritability, cold sweats and increased pain that I was experiencing was not disease related; it was withdrawal. I was hospitalized again, but this time was different. The chronic pain doctors and my care team agreed that I was physically dependent on Dilaudid. They proposed a 20-day in –hospital detox. At 17, I felt like I was being treated like a severe drug addict – little did I know, that was exactly the road I was heading down.  

My older brother came to visit me one day and was appalled with the approach the hospital was taking. Yes, on the one hand, they were doing right by getting me off the opioid causing more harm than good; but on the other hand, I had nothing in the short-term to control the constant pain that I was in. He decided to bring me outside and shared a joint with me. After smoking, my pain diminished, and I was able to finally eat something without vomiting. Since I was a minor my doctors were legally unable to recommend me using cannabis, but if it meant that I would use less opioids, they were not completely opposed to it. The doctors found less habit-forming derivatives of opioids for me to use during pain flare-ups; but with the help of cannabis, I did not need to use as large of doses as I used to.   

After my bowel resection at 20 years old, I recall that my family doctor noticed I was very depressed and needed help. He referred me to the best psychiatrist I’ve ever met. For the first time since getting diagnosed, I felt like I could make considerable progress. I felt like I could open up and be vulnerable with this doctor. I felt like finally someone other than my gastroenterologist genuinely believed in me and did not think I was just a drug seeker, that there was more to my substance abuse than the desire to get high. Despite that, it still took me 6 months to actually let her into some of the deepest, darkest parts of me.     

During one of my countless hospitalizations, I was assigned to the family medicine unit. Dr. Jean Zigby was following me. He was aware that I was trying to reduce my intake of opioids and substitute them with cannabis, but I had no guidance, little cannabis knowledge, nor did I have a clue what was in the cannabis I was consuming. Dr. Zigby changed all that and at 22, I was introduced to Santé Cannabis  

From there, I was blessed with a structured, positive, and organized care team. Confidently, I was able to find healthy approaches to put into practice and regain some balance in my life. I was able to gradually reduce my opioid use for anything other than pain management during my Crohn’s flare-ups. I no longer needed my benzodiazepines, not even for severe anxiety attacks. I was finally taking care of myself, and things began to look up for me. The one thing I did not expect was for the “rollercoaster” I called my life to sporadically have such horrific lows.     

After 7 years of being sick, I had hit rock bottom, attempted to overdose, and to commit suicide multiple times. It took me countless hospitalizations, substance abuse issues and 6 different mental health professionals for me to take my mental and physical health disorders seriously. I had a romantic partner at the time who gave me an ultimatum: it was drugs or her – and clearly, I chose her. I have been on a constant journey of recovery since.   

Due to a long-term use of steroids, I was diagnosed at 23 with ankylosing spondylitis in my sacroiliac joint, as well as rheumatoid arthritis. I was constantly waking up with swollen joints and pain in my lower back, hands, and knees. After being in constant pain for months, I had gone to the emergency room where they had done scans and blood tests. And sure enough, I had a new chronic autoimmune disease that I needed to deal with.  

I was already sober and well into recovery at this point. My medical cannabis care team and I had found a proper THC-rich cannabis regime for my neuropathic pain. Unfortunately, following my care team’s suggestion to add a CBD oil regime to control my ongoing inflammation was too costly for me, as I did not have an income at the time. I had no choice but to start methotrexate, which is a disease-modifying anti-rheumatic drug (and a cancer treatment at higher doses) with debilitating side effects. However, I was able to control my arthritis with it, to a point where I could keep a steady employment.  

Eventually, I was able to afford CBD oil, which in turn helped control the inflammation caused by arthritis. It almost seemed too good to be true, but following a strict ratio of THC:CBD, ALL my chronic health conditions were now under control. I was able to stop 98% of the medications I was prescribed.   

However, with my life headed in the right direction, a part of me still felt unhappy. There was still that little voice in my head, determined to think that I was going to fail, reminding me about the promise I made to myself that I would not see my 25th birthday. I hated the person I saw in the mirror daily. The only emotion I was able to feel was self-hatred. I overthought everything and anything, and I developed chronic social anxiety – I could no longer be in large groups or crowds of people.  

Instead of using drugs, I was now using romantic relationships and close friends to fill the empty hole deep within where self-love used to lie. I simply transferred addictions. I had not completely dealt with my trauma of the last 9 years. I was barely functioning. I hurt people and got hurt. I always had a superhero complex, but by the time I was 24, it was out of control. I thought I could deal with my “baggage” once a week in therapy without applying therapy tools to my daily life. My days revolved around my career and my partner; I was living and breathing for two things and none of them was me. I ended up burning myself out and nearly relapsing.  

I was a week away from the 2-year mark of my sobriety, 4 months away from my 25th birthday and I was once again ready to end it all. I had to take a sick leave from work and broke up with my then-partner when everything was getting hard. I had a plan to end my misery and give up on myself. The day I planned it, to overdose and close my eyes for good, somehow, with my hand full of pills, reality hit me. I realized how far I had come and could see my worth for the very first time in my life. Instead of relapsing and giving up, I decided it was time to go to rehab.  

I finally focused on myself and was able to get back to work. I took therapy seriously and was able to find new ways to appreciate the life I fought so hard for. I surrounded myself with positive and supportive people. I got through the darkness and celebrated my 25th birthday in June 2019.   

By sharing my story, I wanted to show you that anything is possible with a positive support system, a proper care team, and an individualized treatment plan. You can be dealt the worst cards imaginable, but it is the approach you choose to take that can lead to success or failure. I ventured down both roads and believe me when I say: once you learn to love yourself and embrace everything about yourself, you can overcome any obstacle.   

I found the positive before it was too late. I found my purpose and found my place in the world. No matter how dark the road gets for me, I can always manage to find a way to bring a glimmer of hope to the obstacle I am facing. I grew tired of letting my illnesses, my disorders and my struggles define my life, and learned to live with them.  

When I concentrated on caring for myself and dealing with my trauma, I could prevail through the darkness. I could not find the light in my darkness, so I became the light.  

Author: Rebecca Fogel, Patient Care Coordinator, Santé Cannabis   

Rebecca Fogel has worn many hats for Santé Cannabis since October 2017. She works as a Medical Office Assistant, Patient care coordinator and Patient advocate. She leads patient events and support groups, is passionate about public speaking, and is dedicated to providing medical cannabis patients a place to speak freely and to be heard. 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

(Rosa) lives in a retirement home. She seemed earnest about having dominion over her “secret”. On that day, she had maintenance workers attending her floor and an orderly was due to help her get dressed. She withholds her cannabis bottles from prying eyes, only to be laid open to view behind an old Brillo soap box.  

She says she would be represented dramatically by other dwellers as ‘’a habitual user of drugs ” if they knew. Her peers are still very observant of the common perceptions and other existing states. She has learned the intimacy of the daily in-and-out of caregivers and so, she dispenses her CBD oil in due course.   

Half a year later, I sensed she became more defiant, a contemporary moving ahead against the waves of the current stream. She explained. She made a definitive undertaking, testing the water so to speak. During an afternoon tea, she quoted to her fellow guests a news coverage about the benefits of medical cannabis. The feedback hit a schism, as expected. Personal opinions and so-called ‘’common sense “ dinged off each other like kids to broccoli. But amidst all that dissonance, (Rosa) was reassured that those who were in goodwill were assertive about appealing for medical cannabis. She felt not alone. Although encouraged, she isn’t ready to display her CBD bottles openly just yet.  

Little steps toward changing public perception. One (Rosa) at a time. 

Author: Pheng Lim, LPN 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

If you imagine someone smoking a joint, you’re not wrong, but that’s not the only method of administration, nor the most recommended. 

In the early years of medical cannabis legalization, patients mostly smoked their medical cannabis, as it was the only legal option at the time. Since then, other methods of administration (and associated medical formulations) gained recognition and wider acceptance both from patients and prescribers.  

Administration of cannabinoid-based medicines can go through several routes: inhaled (in the lungs), oral (swallowed), oromucosal (through the mouth’s mucosa), transdermal (through the skin), ocular, rectal, etc. 

If you want to learn how that works and debunk some myths, tag along in this dive into medical cannabis administration. 

CLEARING THE SMOKE ON INHALED ADMINISTRATION 

Cannabinoid inhalation produces a fast onset of effects, which can begin within seconds after inhalation; effects peak within 3 to 15 min (depending on authors) and last approximately 2 to 4 hours. [1-3]  

 With this method of administration, the body absorbs a high proportion of active cannabinoids that can then exert their effects on their site of action. This high bioavailability ranges from 10 to 35%, and sometimes up to 56%. The inhalation method (smoked vs. vapourized) and technique influence bioavailability, where technique may vary on depth of inhalation, puff duration, and breath hold. [1, 2, 4, 5]  

 Prescribers often consider smoking cannabis as an inadequate method to administer a medication due to the harmful combustion by-products. [6-8] Vapourization appears as a safer, smokeless administration method producing much less harmful by-products than smoking; [3, 9, 10] the latter is possibly less efficient since it could destroy from 30% to 50% of its cannabinoid content. [6] Vapourization also minimizes throat and lung irritation and can lead to higher cannabinoid blood concentrations as compared to smoking. [3, 6, 11]   

BUT WHAT’S VAPOURIZATION? 

Cannabis vapourization consists in creating a vapour with cannabinoids (and other desirable elements like terpenes) without burning the plant material. 

The current terms used to describe vapourization overlap and makes it somewhat complicated. Two types of vapourization exist: 

• dried cannabis vapourization,  
• and cannabis extracts/concentrate vapourization (also called “vaping”, or “dabbing” in the case of concentrates). 

ARE ALL VAPOURIZERS THE SAME?  

Each vapourization method requires a specific type of vapourizer device, which is not necessarily compatible with the other vapourization type. However, those devices fit under the generic name “vapourizer”. 

• Dried cannabis vapourizers, also called “dry-herb vapourizer”, use a lower heat (170 to 230˚C) than the one created by burning and smoking cannabis (500-600˚C), and thus creates less harmful by-products. [3, 6] 

• Cannabis extract vapourizers, also called vape pens or e-cigarettes, are portable electronic devices that require cartridges (or vape cartridge, vape carts, refill pods, etc.).  
• Cannabis concentrate vapourizers can be 2 things: either a “dabbing rig”, a specialized water filtration device with a heating element, [12] or a compact electronic device (also called dab pen, wax pen) with a small oven to heat concentrates. Depending on the device, cannabis extracts or concentrate vapourizers can operate at higher temperatures (up to around 500˚C). Since concentrates contain very little to no vegetal matter apart from cannabinoids and terpenes, it’s hypothesized that their vapourization at higher temperatures cause less harmful by-products than dried cannabis combustion. 

 Cannabis concentrates come in a wide selection, such as rosin, live resin, shatter, full-melt hashish, etc.  

 Some prescribers prefer recommending dried cannabis vapourization over vaping, as Health Canada approved some dried cannabis vapourizers as Class II medical devices (like the Volcano Medic and other devices from the brand Storz & Bickel). [13] Veterans Affairs and some private insurances may reimburse such medical devices. 

 Vaping of unregulated cannabis products also caused worry in 2019, when Health Canada issued a warning concerning potential pulmonary illness associated with vapourization products (with cartridges). [14] Vitamin E acetate, an additive present in illegal THC vaping products, is strongly associated with e-cigarette (or vaping) associated lung injury. [15] Health Canada strictly regulates the manufacturing of medical cannabis vaping products and prohibits potentially harmful solvents. 

 Note that in Quebec, it is illegal to smoke or vapourize cannabis in a public place without a prescription, whether indoor or outdoor. [16] 

For several patients, smoking or vapourizing cannabis is not the best option. The second most common administration is through the oral route (ingested). 

ORAL ADMINISTRATION  

Compared to inhaled administration, which acts fast and for a relatively short period, oral administration takes a while to produce effects and they last longer. Ingested (swallowed) cannabinoid products take effect after a delay of 1 to 3 hours, and the effects last for about 6 to 8 hours, or longer depending on dose, fasted state, and other individual factors. [3] 

The different times of action between inhaled and oral administration are explained by the distinct absorption speeds. Where inhaled cannabinoids go into the lungs and quickly reach blood circulation, ingested cannabinoids get absorbed in the intestine and metabolized (transformed) by the liver, only then reaching blood circulation. This absorption is slow and variable; the bioavailability ranges from as low as 6% and up to 30%. [5, 17]  

 *A note that the liver converts THC (specifically, delta-9-THC) into an active and potent metabolite (11-Hydroxy-THC), [18, 19] which can contribute to heightened side effects.  

 Some absorption factors we can’t control, like individual rates of metabolism (some being much faster than others) and sex-related absorption differences; a factor we can control is food intake. [5, 20] Cannabinoids have a high affinity with lipids (fats), and studies found that the absorption of THC and CBD increases (up to 5-fold for CBD) when taken with a high-fat meal. [20, 21] 

Oral administration includes several medical cannabis products:  

• Oils, made of cannabis extracts and diluted with a carrier oil, 
• Capsules, containing a precise dose of cannabis extract diluted with a carrier oil, 
• Oral sprays, that deliver tiny drops of cannabis oil, 
• Lozenges, sublingual strips, and edibles. 

“Edibles” refers to food and beverages that contain cannabis and/or cannabis extracts. While edibles make an appealing administration method for recreational purposes, not all prescribers agree that edibles are an adequate dosing method for medical purposes. Advocates argue that a wider selection of ingested product ameliorate patient access and can better meet their individual needs. 

COMPLEMENTARY METHODS 

As discussed in our Chronic pain post series, both oral and inhaled administration can serve in some treatment plans: 

• Oral administration can serve when a treatment requires day-long pain relief, for example, because of its long-lasting effects [3] and the accurate dosing of ingested products. [22] Administration frequency then varies according to pain frequency, from once daily to two or three times a day. [22] 

• Inhalation administration can be helpful to quickly relieve breakthrough pain, [9, 10] with its onset of effects within minutes of inhalation[1-3]. Administration frequency is usually as needed.  

However, in some cases a fast onset of effect is needed, but administration through the lungs won’t do because of a medical condition (like chronic obstructive pulmonary disease); in other cases, spot application could be a more direct method of administration, compared to the oral administration that produces effects on the whole body. In such cases, other methods of administration can prove useful. 

Stay tuned for Part 2 of this blog post, where we’ll go over oromucosal sprays, topicals, suppositories, and more! 

 Author: Charlotte Bastin  

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

YOU ARE A PATIENT OR JUST WANT TO KNOW MORE ABOUT SANTÉ CANNABIS?  

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YOU ARE A HEALTHCARE PROFESSIONAL AND YOU FOUND VALUABLE INFORMATION IN THIS BLOG POST? 

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REFERENCES: 

1. Sharma, P., P. Murthy, and M.M.S. Bharath, Chemistry, Metabolism, and Toxicology of Cannabis: Clinical Implications. Iranian Journal of Psychiatry, 2012. 7(4): p. 149-156.
2. Grotenhermen, F., Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical pharmacokinetics, 2003. 42(4): p. 327–360.
3. MacCallum, C.A. and E.B. Russo, Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 2018. 49: p. 12-19.
4. Vučković, S., et al., Cannabinoids and Pain: New Insights From Old Molecules. Frontiers in Pharmacology, 2018. 9: p. 1259.
5. Bruni, N., et al., Cannabinoid Delivery Systems for Pain and Inflammation Treatment. Molecules : A Journal of Synthetic Chemistry and Natural Product Chemistry, 2018. 23(10).
6. Pomahacova, B., F. Van der Kooy, and R. Verpoorte, Cannabis smoke condensate III: the cannabinoid content of vaporised Cannabis sativa. Inhal Toxicol, 2009. 21(13): p. 1108-12.
7. Notcutt, W.G., Clinical Use of Cannabinoids for Symptom Control in Multiple Sclerosis. Neurotherapeutics, 2015. 12(4): p. 769-777.
8. Zajicek, J., et al., Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial. The Lancet, 2003. 362(9395): p. 1517-1526.
9. Bhaskar, A., et al., Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. Journal of Cannabis Research, 2021. 3(1): p. 22.
10. MacCallum, C.A., L.A. Lo, and M. Boivin, “Is medical cannabis safe for my patients?” A practical review of cannabis safety considerations. European Journal of Internal Medicine, 2021.
11. Spindle, T.R., et al., Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Network Open, 2018. 1(7): p. e184841-e184841.
12. Hädener, M., et al., A preliminary investigation of lung availability of cannabinoids by smoking marijuana or dabbing BHO and decarboxylation rate of THC- and CBD-acids. Forensic Sci Int, 2019. 295: p. 207-212.
13. Health Canada and Government of Canada, Medical Devices Active Licence Listing. 2019.
14. Health Canada and Government of Canada, Information Update – Health Canada warns of potential risk of pulmonary illness associated with vaping products. 2019.
15. Public Health Agency of Canada, Vaping-associated lung illness. aem, 2020.
16. Gouvernement du Québec, The legislation on cannabis. Regulation of cannabis in Québec, 2020.
17. Lucas, C.J., P. Galettis, and J. Schneider, The pharmacokinetics and the pharmacodynamics of cannabinoids. British Journal of Clinical Pharmacology, 2018. 84(11): p. 2477-2482.
18. Lemberger, L., et al., Comparative pharmacology of Delta9-tetrahydrocannabinol and its metabolite, 11-OH-Delta9-tetrahydrocannabinol. J Clin Invest, 1973. 52(10): p. 2411-7.
19. Goullé, J.P., E. Saussereau, and C. Lacroix, Pharmacocinétique du delta-9-tétrahydrocannabinol (THC). Annales Pharmaceutiques Françaises, 2008. 66(4): p. 232-244.
20. Lunn, S., et al., Human Pharmacokinetic Parameters of Orally Administered Δ9-Tetrahydrocannabinol Capsules Are Altered by Fed Versus Fasted Conditions and Sex Differences. Cannabis and Cannabinoid Research, 2019. 4(4): p. 255-264.
21. Taylor, L., et al., A Phase I, Randomized, Double-Blind, Placebo-Controlled, Single Ascending Dose, Multiple Dose, and Food Effect Trial of the Safety, Tolerability and Pharmacokinetics of Highly Purified Cannabidiol in Healthy Subjects. CNS Drugs, 2018. 32(11): p. 1053-1067.
22. MacCallum, C.A., et al., Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain. Front Pharmacol, 2021. 12: p. 633168.

I often get patients wondering in the same manner. There is still much reprehension about cannabis. Our society is unceasingly finding fault with it, no matter how its status has evolved. The public has yet to fully and intuitively confirm its moral direction. Cannabis perception is changing at a very slow pace. 

Even the method of administration is very much compatible to its malignant opinion. ‘’ I don’t want to smoke cannabis. I’m not a druggy.’’ one of our patients did say. The current terminology, slangs precisely, is still and probably throwing people off. Many of our patients do not want to be taking weed or puffing on a spliff. Our treatment plans are based on scientific data, and accordingly we make sure to use the appropriate terms to the purpose. 

Our esteemed doctors do not prescribe marijuana. They recommend inhaling dried cannabis for breakthrough pain. I would gently remind a patient when he or she uses such words as “pot” or “ganja”. The old proverbial ‘’to-may-to/to-mah-to’’ would ring out. So, what is the difference? Really? 

I believe words and how we understand them are very consequential moving forward. I remember back in the 1990’s, the semantics affecting the scope of the term ‘’death tax’’ eventually became the ‘’estate or inheritance tax’’ in the US? Basically, politicians and advocates tried to kill the bill by putting stress on how it harmed family farms and small businesses. They knowingly coined the term ‘’death tax’’ to get the public to consider their cause. Dying has more impact and meaning in the collective conscience. 

I think the transition toward a proper nomenclature in medical cannabis practice must be imposed, applied and supported by all parties involved. Indica dried cannabis, THC-rich, 3-4 inhalations at bedtime or as needed does serves as better example of a positive and trustworthy interpretation than 3-4 puffs of weed before going to bed. 

– Pheng Lim, LPN 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

This sequel focuses on medical cannabis, from its role regarding opioid substitution to the evidence supporting cannabinoids and features of a cannabis treatment. 

OPIOID SUBSTITUTION IN CHRONIC PAIN 

Chronic pain treatment generally consists of pharmacologic and non-pharmacologic approaches. In certain cases, pain and other symptoms are not successfully controlled, which can be difficult to manage, and it’s challenging to return to a pain-free state. Several non-opioid analgesics are available, but many have low efficacy, poor tolerability and significant adverse effects. [1] Opioids are widely prescribed to relieve chronic non-cancer pain, [2] but their prolonged use is problematic due to their addictive potential, the development of tolerance, the hyperalgesia they can induce and their adverse effects. [1]  

The ongoing opioid epidemic (and human deaths) is linked to habitual partiality in opioid prescriptions for chronic pain, [1] and has prompted a search for other analgesic options. Fuelled by public interest, medical cannabis makes a distinguished mark as a new yet centuries old option.  

Safety is the keyword in the case for cannabinoid-based medicines substitution for opioids: the predominant cannabinoid in cannabis, delta-9-tetrahydrocannabinol (THC), has a very low toxicity (“absence of mortality”—World Health Organization). [3] Cannabidiol (CBD), which is gaining in use, has a favourable safety profile as well. [4, 5] 

A recent Canadian initiative produced a consensus-based algorithm on the safe introduction of cannabinoid-based medicines and opioids taper in chronic pain patients. According to this algorithm, cannabinoid-based medicines can be considered in patients with chronic pain taking opioids and not reaching treatment goals, having opioid-related adverse effects and/or at risk of opioid-related harm. [6] 

But what about the evidence supporting the use of cannabinoid-based medicines for chronic pain? Contrary to what some politicians and uninformed healthcare professionals may say, there is evidence. The subject of debate should rather be: is there sufficient evidence?   

EVIDENCE FOR CANNABINOIDS USE IN PAIN MANAGEMENT 

Cannabinoid-based medicines still carry an important stigma in the research and medical fields.  

Interpretation of clinical trial results can vary between authors, but the variation is especially high when judging the evidence for cannabinoids’ efficacy. Indeed, depending on reviews, low to substantial evidence support cannabinoid-based treatments use to manage chronic non-cancer pain. [7-19]  

This is understandable since chronic non-cancer pain is an umbrella term that combines various pain conditions that have not been studied to the same extent (see Part 1 for pain classification). Also, reviews may obtain different results based on article design, such as inclusion vs. exclusion of non-randomized controlled trials, analysis per condition vs. “chronic pain” as a single condition, analysis per cannabinoid vs. pooled cannabinoids, etc.  

However, the fact remains that for some conditions like multiple sclerosis-related neuropathic pain, “the current literature has provided more reliable data for cannabinoids than for any other drugs”. [20] 

The following subsections cover the evidence in chronic neuropathic pain, fibromyalgia, and chronic pain with an inflammatory component – since those are common pain types seen at our clinic. 

CHRONIC NEUROPATHIC PAIN 

Chronic neuropathic pain is the best studied type of pain in clinical trials assessing cannabinoids and medical cannabis, [10, 19] with at least 23 published randomized controlled trials (RCTs). [21-46] 

The level and quality of the evidence is highly impacted by the quality of trials (questionable blinding to the treatment, small sample size, short trial duration, etc.). Despite the contribution of numerous trials, the evidence that cannabinoids and medical cannabis are effective in chronic neuropathic pain is limited or modest, depending on authors. [9-11, 15, 17, 47]  

The following table summarizes study results and shows the supporting evidence for pain reduction with cannabinoid-based medicines (in chronic neuropathic pain), with a modest effect size.  

A group of pain specialists and psychiatrists, researchers, and patient representatives compared 12 pharmacological treatments (including THC-rich, CBD-rich and THC:CBD 1:1 treatments) for the management of chronic neuropathic pain. In agreement with several reviews, cannabinoids (especially CBD) scored modestly in pain relief rates as compared to other medications (such as duloxetine, gabapentin, pregabalin, amitriptyline). [48] However, cannabinoids scored higher than all other medications when combining benefits and safety scores, with the benefits on quality-of-life contributing heavily to the cannabinoids scores. [48] 

FIBROMYALGIA 

Fibromyalgia is being more and more investigated in recent years and patients frequently turn to medical cannabis in the hope of getting some relief from their symptoms. [49, 50] Four published RCTs can be found, [51-54] as well as several observational and retrospective studies. [49, 50, 55-63] 

• Two RCTs assessed nabilone in fibromyalgia: one found improvement in pain, [51] while the other found no effect on pain but superior improvement in sleep as compared to amitriptyline. [52] 

• THC-rich cannabis oil decreased pain and improved functionality, mood and fatigue in a small all-female RCT. [54] 

• Medical cannabis (three dried cannabis formulations: THC-rich, THC:CBD in similar ratio and CBD-rich) was also assessed in one RCT. Cannabis with THC:CBD in similar ratio decreased pain significantly and THC-rich cannabis showed an analgesic effect in some measures. CBD-rich cannabis failed to show an analgesic effect. [53] 

CBD’s analgesic effect has yet to be evaluated in RCTs, but data from observational and cross-sectional studies show that fibromyalgia patients using CBD-rich products report improvement in pain, sleep and anxiety. [49] Patients report similar benefits from medical cannabis. [56-61] Patients also substitute medical cannabis (including CBD-rich products) for medications such as NSAIDs, opioids, gabapentinoids and benzodiazepines [58-61] due to fewer adverse effects and better symptom management. [63] 

CHRONIC PAIN WITH AN INFLAMMATORY COMPONENT 

Chronic pain with an inflammatory component can be a characteristic of several chronic conditions, such as rheumatoid arthritis, osteoarthritis, cancer, inflammatory bowel disease, and more. [64] 

Evidence suggests the endocannabinoid system is involved in the response to inflammation and cartilage degradation; patients with rheumatoid arthritis or osteoarthritis (but not healthy controls) present measurable levels of two endocannabinoids (anandamide and 2-Arachidonoylglycerol) in their synovial fluid. [65] Based on preclinical evidence, cannabinoids possess anti-inflammatory properties and could be useful to treat rheumatic conditions. [66-68]  

At this time, only one randomized controlled trial supports cannabinoid-based medicines potential.  

• Nabiximols was studied in patients with rheumatoid arthritis and demonstrated significant analgesic effect. [69]  

The review of the evidence about cannabinoids and pain would be incomplete without something about the difference between men and women. Current research frequently lacks sex-related reporting and analysis, but we are motivated to provide the best patient care – and that implies getting informed and promoting this important topic. 

EVIDENCE ABOUT SEX-RELATED DIFFERENCES WITH CANNABINOIDS AND PAIN  

Since women with chronic pain outnumber men, [70] and women count for over 60% of Santé Cannabis patients, we need to address the biological difference between women and men and its impact on cannabinoid-mediated analgesia and pain itself. Only a few clinical trials exist on this topic, and they provide initial evidence that women could be more sensitive to cannabis (or THC) than men. 

• Women experience the same acute effects as men despite lower THC blood concentrations, [71] and are more sensitive to a low THC dose (5 mg oral dose) as compared to men. [72]  

• Considering adverse effects, women are more likely to experience greater subjective anxiety or nervousness, restlessness, and racing heart after THC intake as compared to men (oral or inhaled intake, doses ranging from 5 to 25 mg THC, and controlling for weight and blood concentration). [73] 

Furthermore, preclinical evidence indicates hormones (like estrogen [74]) modulate pain perception, but the evidence is limited and mixed in clinical trials. [75-77] Preclinical evidence also shows that hormones influence the endocannabinoid system, from receptors’ expression to ligands affinity. [78] More research is greatly needed to better understand these complex interactions and their implication in clinical practice. 

In this last section, we teased out practical information from the scientific evidence to clarify some aspects of medical cannabis treatment. 

QUESTIONS ABOUT CANNABIS TREATMENT PLANS 

Disclaimer: this section is intended to explain the rationale behind some elements of a treatment plan, and is not meant to be a medical counsel nor a guide to self-medication. In all cases, it’s best to discuss your questions regarding medical cannabis with a healthcare professional. 

THC OR CBD FOR PAIN RELIEF? 

CBD possesses a favourable safety profile [4] and is often recommended at the beginning of the treatment. [79, 80] This is a prudent choice regarding adverse events, precautions/relative contraindications, and it is easier than starting patients on both THC and CBD products at once.  

However, the analgesic (pain relief) effects of CBD have yet to be demonstrated with the same level of evidence that is supporting the modest (but significant)[10] analgesic effects of THC and THC:CBD formulations. [81] Some patients may respond well to CBD-rich products (and/or to trace amounts of THC in these products), [79] but others may need more THC to obtain adequate pain relief. [81]  

WHY DO SOME TREATMENTS USE BOTH ORAL PRODUCTS AND DRIED CANNABIS? 

Baseline pain-relief treatment with medical cannabis uses oral administration, exploiting the long-lasting effects [82] and accurate dosing of ingested products. [81] Administration frequency varies according to pain frequency, from once daily to two or three times a day. [81] 

Inhalation administration can be helpful to quickly relieve breakthrough pain, [79, 80] with its onset of effects within minutes of inhalation [82-84]. Smoking is common but generally thought inadequate to deliver medication; [85, 86] in comparison, dried cannabis vapourization, which does not burn cannabis, is safer and preferred for treatment delivery. [79, 80, 82] 

CAN SOMEONE REPLACE OTHER MEDICATIONS WITH MEDICAL CANNABIS? 

That depends on the patient and should be done under medical supervision. 

Chronic pain patients frequently seek medical cannabis treatment for symptoms not adequately relieved by their current treatment and/or when their current treatment causes intolerable adverse effects. Some patients on a medical cannabis treatment report reducing or stopping other medications, [87] but this has not been reproduced in controlled clinical trials [88, 89]. 

Consensus recommendations do not recommend stopping other pain medications before starting a medical cannabis treatment. [6, 80] With appropriate medical monitoring, it’s possible to gradually taper other medications when the pain or function improves, when the medical cannabis treatment is stable, and/or when the patient requires less as-needed medication (like opioids) for pain relief. [6] 

This concludes our short series of chronic pain blog articles that we hope will be useful for our chronic pain patients, caregivers, healthcare professionals and all other interested readers. At Santé Cannabis, we advocate for patients’ right to access medical cannabis, but we are also committed to our patients’ safety – so we are much aware of the limits of the current evidence supporting medical cannabis use. In this light, it’s essential for us to first, share our knowledge on medical cannabis, and second, to correct misconceptions abounding around cannabis. 

For this new yet centuries old therapeutic option, do you agree that there is still no evidence whatsoever? Or should the public discourse evolve to be more nuanced and reflect the advances of modern research? 

Author: Charlotte Bastin  

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

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There is no better occasion to write about women, research, and bias than on International Women’s Day and during Women’s History Month. I‘m a woman working in STEM (Science, Technology, Engineering and Medicine), and I have a confession to make: during my studies in sciences, I believed that current research was done with equity for male and female health issues, that health guidelines were all designed to account for sex-related differences, and that it was obvious that male and female biology don’t always work the same. Well, that’s not always the case. And that realization shook my confidence in what I thought I knew. 

Interesting fact: “of the ten drugs withdrawn from the market between 1997 and 2001, eight posed greater health risks for women than for men.” (Sugimoto et al, 2019) 

While 21st century research has hugely improved and the situation isn’t so grim for women’s health as compared to previous centuries, we need to improve further. We need to raise awareness about bias in research concerning women (and non-male genders!); we need more people to feel concerned and curious to understand what are considered as facts based on current evidence. (Note that this is exactly how research is supposed to work: we draw conclusions from a set of results, until new results disprove, confirm, or nuance the conclusions.) 

At Santé Cannabis, a network of clinics dedicated to facilitating the access to medical cannabis treatments, medical-cannabis-related education, and global patient care, we’re most sensitive to knowledge gaps. Our dedicated research area is, of course, medical cannabis, but more than half of our patient population is female (technically, 64.9 % are assigned female sex at birth). Several health issues for which patients consult our clinic affect women more than men. Being a team powered and led by a majority of women, we feel concerned about how much we don’t know about several of those health issues and the sex-related differences in the effects of cannabis. 

Lack of Sex-Related Data Analysis 

Being aware of the knowledge gap on medical cannabis, Santé Cannabis leads an observational study collecting patient data to help better understand this treatment. However, we realized a while ago that we were overlooking a crucial element of analysis: sex-related analysis. We previously report results pooling male and female results, which causes an important bias. Also, we previously didn’t collect patient gender, which is important both for patient care and research purposes (more on that topic later). 

Does medical cannabis work the same for our female patients as compared to our male ones (referring to their assigned sex at birth)? We can’t say for sure until we analyzed the question. 

Unfortunately, sex-related analysis is commonly overlooked and under-reported in current research, (Welsh et al, 2017) and journals with high impact factors (like Sciences, Nature) may contribute to the problem: “Papers with sex-related reporting are more likely to appear in lower-impact journals than are those without sex-related reporting, even when controlling for specialty of publication.” (Sugimoto et al, 2019) 

One can’t help but wonder why; is it a lack of consideration for the biological difference between sexes, or do researchers avoid writing their sex-related results because they didn’t find any significant difference?   Even if there is no difference between sexes, no one can presume that a drug or a therapy works as well in men and women, for example, unless that result is captured and published. 

It’s hopeful that women in research are taking the matter into their hands and do better reporting; indeed, published articles with women as first or last author are more likely to report sex-related results. (Sugimoto et al, 2019) This recent review article (Wright et al, 2020) is an excellent example with a well-researched section discussing sex-related differences concerning anxiety and cannabinoids. 

Misogyny in Research 

Can some research be so deeply biased that it’s plainly misogynistic? 

According to this article (Merone et al, 2022), the answer is yes. By their definition, misogynistic research uses female subjective beauty as an indicator of health but doesn’t measure health or has no clinical practice application. 

Can you imagine a paper (Vercellini et al, 2013) grading the looks of patients with and without endometriosis (with breast to under breast ratio)? Only Caucasians were selected into this study, and it excluded women with children, acquired physical defects (like scars), visible piercing, tattoo, dental braces or dyed hair! The article was retracted in 2020, seven years after its publication. (The Guardian) 

One can also wonder about the usefulness of some study designs, like in this study (Pietruski et al, 2019) on breast attractiveness and symmetry, determined by where the gaze of observers spent more time. The authors “do not know how the visual pattern parameters translate on a subjective assessment of breast attractiveness”. 

Some hypotheses are plainly offensive; this study (Gray and Boothroyd, 2012) made the hypothesis that femininity, attractiveness, and positive mood in young women would mean less minor health issues (cold, stomach issues, infections).   Authors made the “assumption that aspects of facial appearance   signal mate quality”. The study based the health of the women on self-reported health issues, which is subject to recall bias, and didn’t collect socioeconomic status as a potential confounding variable. 

Misogyny in research and medical fields highly impact women’s health; some women have experienced healthcare professionals dismissing their health problems or their pain. A female cardiologist, Dr. Bernadette Healy, coined a term for that deeply ingrained bias: the Yentl syndrome. In this medical context, the term means that for a woman to be taken seriously about her illness, she needs to prove she’s as ill as a man would be. This syndrome, along with the research gap on women’s health issues, delays adequate testing and treatment for female patients. (Mertz, 2011) 

On the bright side, blatant misogyny isn’t commonplace in research, and the previous examples are a reminder to keep a watchful eye for bias against women. We must also celebrate the good research done for women, like these publications advancing the collective knowledge about the impact of the menstrual cycle on pain (Hellström and Anderberg, 2003) (Bartley and Rhudy, 2013).  

Beyond the Binary Model 

Sex refers to the biological, physiological and genetic processes in individuals, and more than male and female sexes exist. Researchers may find it very convenient to place everything in well-defined boxes; however, it’s less convenient for real humans who want to know how research impacts them in real life and when things don’t fit into said boxes. If we consider sex as a spectrum, with female and male on opposite ends, the in-between space is for intersex. Intersex persons are born with characteristics that don’t fit into the male or female typical definitions. (United Nations)  

Gender “is each person’s internal and individual experience of gender. It is their sense of being a woman, a man, both, neither, or anywhere along the gender spectrum”. (Justice Canada) Gender also refers to “roles, relationships, behaviours, relative power, and other traits” socially assigned to specific genders (like male and female). (Welsh et al, 2017) 

The current medical field considers male (or man) as the model on which research is done and guidelines are built. (Merone et al, 2022) This male centrism is problematic as it disserves all people who aren’t male or men, as well as those who get misgendered. 

It’s shocking how even today, people from the LGBTQ2+ community face barriers to access healthcare, coming from lack of education for healthcare professionals, historical oppression, structural injustice (like homelessness) – to name only these. (Schreiber et al, 2021) 

It’s urgent to pay more attention to LGBTQ2 + individuals in clinical guideline development and, most importantly, in how health care is delivered. As a medical clinic, we want to be a safe space for all patients and have been assessing how we deliver patient care. However, the current standard of care is only standard for people that are binary (self-identifying as either man or woman), heterosexual, and cisgendered (identifying with the same gender as the sex assigned at birth). 

One important action for more inclusive care is to improve communication with patients. A simple change that we’re currently working on implementing is asking for patient pronouns and preferred name. Such a change can go a long way in showing respect for everyone, as incorrectly labelling someone based on assumptions can be hurtful. There are also further simple, uncomplicated changes that any clinic can implement to be more inclusive. 

At Santé Cannabis, we’re not perfect, but we’re working hard to always improve. As part of our patient advocacy mission, we raise awareness about research gaps impacting patient safety and care, including gaps on health conditions that predominantly affect women. As part of our research work, we’re committed to better collect and analyze data, with more sex and gender data reporting. As part of our dedication to patient care, we created a diversity and inclusion committee and started concrete actions toward a safer patient space. We hope that our diversity and inclusion statement adequately translates our intention:   

At Santé Cannabis, our community is made up of patients, personnel and partners. We honour diversity by creating a safe space for every person to share their lived experiences. We welcome everyone and listen to different opinions, beliefs and ideas as we strive to continually learn what it means to be empathetic and active leaders of accessibility. 

Author: Charlotte Bastin 

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Pain is part of life, but for some people there is simply no respite from pain. When pain becomes chronic, it’s difficult to make it go away completely. Therefore, it’s no surprise that chronic pain is an enormous global public health problem. About one in four Canadians aged 15 or older (or an estimated 7.63 million people) live with chronic pain, and it is about one in five people in the United States. [1, 2] It is the leading cause of disability in working-age adults, impacting activities of daily living and quality of life. [3] 

We know how chronic pain can be difficult to manage, as most of our patients have chronic pain, or pain as part of a chronic condition. 

REAL-WORLD DATA FROM SANTÉ CANNABIS’ OBSERVATIONAL STUDY 

Chronic pain conditions are frequent in patients seen at Santé Cannabis’ clinics: pain-related diagnoses make over 50% of all diagnoses (figure 1) and pain symptoms affect 80% of the 1275 patients assessed between July 2020 and March 2021. 

Figure 1: Primary diagnoses proportions from 1275 patients followed at Santé Cannabis (July 14, 2020—March 31, 2021) 

Furthermore, chronic pain is frequently associated with a myriad of other frequent symptoms that are directly impacted by pain, such as sleep disturbances, [4, 5] anxiety and depression, [6, 7] fatigue, nausea, etc. The following graphic (figure 2) shows the most common secondary symptoms reported by patients living with pain at our clinics. 

Figure 2: Secondary symptoms in 1019 patients living with pain and followed at Santé Cannabis (July 14, 2020—March 31, 2021). 

CHRONIC PAIN IS NOT A MONOLITH 

Chronic pain is pain that persists or recurs for more than three months.[8] It is a convenient umbrella term, regrouping widely different pain types. 

Chronic pain is classified according to its cause, cancer and non-cancer origin, and by the way the pain is produced (its mechanism) in neuropathic pain, nociceptive pain, and mixed pain (including both neuropathic and nociceptive pain).  

Figure 3: Classification of pain  

We see a wide array of chronic pain conditions at our Santé Cannabis clinics, from neuropathic pain in multiple sclerosis to cancer pain, fibromyalgia and chronic low-back pain. It is common that patients consider our clinic as a last option to manage their chronic pain – and it makes sense, since there are several conventional treatments for chronic pain supported by better evidence than cannabinoid-based medicines currently are. 

MANAGEMENT OF CHRONIC PAIN 

The modern pharmacopeia possesses more than a few options for pain management. Cannabinoid-based medicines have their use in pain management as a third- or fourth-line treatment, [9] and generally recommended as adjunctive treatment. [10, 11] There are both pharmacological and non-pharmacological treatment options that can work in combination to relieve and cope with pain.  

Non-pharmacological therapies include (but are not limited to) physiotherapy, exercise, cognitive behavioural therapy (CBT), occupational therapy, acceptance and commitment therapy (ACT), mindfulness, massage, osteopathic manipulation, etc. [12-15] 

As for pharmacological treatments, the following analgesic ladder shows a simple strategy (figure 4); it is adapted from the World Health Organization analgesic ladder, initially intended for cancer pain, but now also applied to chronic non-cancer pain. [12, 16] 

NSAIDS: nonsteroidal anti-inflammatory drugs; TCAs: tricyclic antidepressants; SNRIs: serotonin-norepinephrine reuptake inhibitors 

Figure 4: Analgesic ladder (adapted from [12, 16]) 

When considering cannabinoid-based medicines, it is important that a discussion takes place between the healthcare provider and the patient in a shared decision-making process. [9] Indeed, cannabinoids efficacy, potential adverse effects, cost, and related stigma should be addressed so that patients are adequately informed.   

MULTIMODAL TREATMENT 

Chronic pain treatment includes more than pharmaceuticals, as these are often not as effective when used alone. Behavioural and other psychology-based therapies play an important role in chronic pain management to help patients cope with the emotions that accompany pain, such as anxiety, depression, frustration, etc. 

Furthermore, our medical team observes that chronic pain often occurs in individuals who underwent emotional trauma (resulting from violence, abuse, neglect, etc.)—highlighting the need for a multimodal therapy to help improve the combination of emotional and physical pain. 

We also believe that chronic pain patients benefit more from a holistic approach incorporating lifestyle changes, as pain and anxiety/stress act one upon another in a vicious circle. Indeed, patients living with unrelieved chronic pain often are trapped in a pain-centered pattern, where anxiety—and decreased activity, deconditioning and fatigue—contributes to worsening pain and reduce their quality of life (see figure 5). 

Chronic pain is generally recognized to impact sleep and contribute to depression, but it may not be common knowledge that persistent pain is also associated with memory decline. [17, 18] 

Figure 5: Pain-centered life 

At Santé Cannabis, the role of our medical team is to help patients help themselves. In our experience, patients who undertake a multimodal treatment obtain better therapeutic results. Promoting the practice of physical activities, providing strategies to manage stress, and improving sleep can prove extremely helpful to guide patients out of their pain-centred life (see figure 6). 

Some of our patients reported better coping with the practice of mindfulness—an example of simple, inexpensive, and empowering therapy for which we provide information and support through virtual talks and support groups meeting. Patients often do not realize how they can be empowered in their own healthcare and get control over their pain, rather than being victimized by it. 

“When their functionality improves, my patients say that they feel like they can control their pain instead of the pain controlling them.  

Some tell me they feel as if they had regained their lives.” Dr Michael Dworkind 

Figure 6: Function-centered life 

On a last note, the environment in which patients live also impacts pain levels directly or indirectly (e.g., through work-related stress levels). Evaluating the context and situation of a patient helps to better assess pain and pain-related symptoms, since they fluctuate according to what happens to the body and the mind. For example, if context has changed, it will likely affect the patient’s condition and, therefore, their response to treatment. 

PAIN AND STIGMA 

Chronic pain is incredibly hard to treat, and it is difficult for patients to find a treatment that will help them manage or overcome their pain. Many healthcare professionals do not receive extensive enough training on chronic pain; this affects their ability to provide adequate recommendations on pain management and in turn poses a serious threat to patients’ safety. [19, 20] 

Chronic pain patients need access to multimodal treatments, and they need to be able to have an honest discussion about their treatment expectations and outcomes with their healthcare provider. Due to the challenges and lengthy commitment needed with treating pain, stigma may affect perceptions about pain conditions and the patients who suffer from them. 

One example of stigma is when some healthcare professionals are dismissive about fibromyalgia, as the condition is hard to manage with success, and there has been an influencing notion passed around that it is a condition mainly caused by a patient’s mental state. 

If there is no measure to diagnose fibromyalgia, does it exist? 

Often, fibromyalgia patients must be very persistent in seeking treatment as well as in getting recognition for their condition. While remaining a diagnosis of exclusion—which means patients spend a long time with their physician and specialist(s) trying to determine the cause of their pain and other symptoms—more and more scientific evidence supports the validity of fibromyalgia as a pain disorder and its treatment. 

There is also persistent stigma associated with pain expression, in particular with those that are vocal about their pain (emotional outburst, cries) being often perceived as exaggerating. It is vital to acknowledge the cultural and gender-related differences in pain communication. If a patient is reporting pain, we as a medical clinic believe that healthcare professionals should remain sensitive and respectful, and provide a proper, objective and attentive assessment of the reported pain and symptoms. Ignoring or downplaying reported pain and symptoms is counterproductive and does not help patients get better. 

At Santé Cannabis, we know what stigma is – just read our name-, and we mean to push forward and fight stigmatization. We wish our patients to be heard, so we advocate for their rights; we want cannabinoid-based treatments to be prescribed and dispensed like other medications, so we advocate for improved access. We want more research on medical cannabis, so we contribute to the growing body of evidence on cannabinoid-based medicines with our ongoing observational study. To all the patients who accept to be part of this study, we thank you for your contribution to Science. We hope that our collective effort will help to improve patient care. 

Stay tuned for Part 2 of this blogpost, where we’ll go over the current evidence supporting cannabinoid-based medicines for pain management and much more!   

Author: Charlotte Bastin 

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REFERENCES 

1. Health Canada, Canadian Pain Task Force Report: September 2020. aem, 2020.
2. Zelaya, C.E., et al. Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019. NCHS Data Brief No. 390 2020 2020/12/02/T04:47:29Z; Available from: https://www.cdc.gov/nchs/products/databriefs/db390.htm.
3. Busse, J.W., et al., Guideline for opioid therapy and chronic noncancer pain. Cmaj, 2017. 189(18): p. E659-e666.
4. Gottschling, S., et al., Safety Considerations in Cannabinoid-Based Medicine. International journal of general medicine, 2020. 13: p. 1317-1333.
5. Ferguson, G. and M. Ware, Review Article: Sleep, Pain and Cannabis. Journal of Sleep Disorders & Therapy, 2015. 04(02).
6. Dominick, C.H., F.M. Blyth, and M.K. Nicholas, Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population. PAIN, 2012. 153(2): p. 293-304.
7. IsHak, W.W., et al., Pain and Depression: A Systematic Review. Harv Rev Psychiatry, 2018. 26(6): p. 352-363.
8. Treede, R.-D., et al., Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). PAIN, 2019. 160(1).
9. Chang, Y., et al., Medical Cannabis for Chronic Noncancer Pain: A Systematic Review of Health Care Recommendations. Pain research & management, 2021. 2021: p. 8857948-8857948.
10. Häuser, W., et al., European Pain Federation (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management. European Journal of Pain, 2018. 22(9): p. 1547-1564.
11. Haleem, R. and R. Wright, A Scoping Review on Clinical Trials of Pain Reduction With Cannabis Administration in Adults. 2020. 2020.
12. Hylands-White, N., R.V. Duarte, and J.H. Raphael, An overview of treatment approaches for chronic pain management. Rheumatol Int, 2017. 37(1): p. 29-42.
13. Canadian Agency for Drugs Technologies in Health. Research Gaps: Chronic Pain Management: Non-Pharmacologic Treatments. CADTH.ca 2019 2019/01/22; Available from: https://www.cadth.ca/tools/research-gaps-chronic-pain-management-non-pharmacologic-treatments.
14. Welsh, T.P., A.E. Yang, and U.E. Makris, Musculoskeletal Pain in Older Adults: A Clinical Review. The Medical clinics of North America, 2020. 104(5): p. 855-872.
15. Busse, J., The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain. Cancer Pain, 2017: p. 105.
16. Anekar, A.A. and M. Cascella, WHO Analgesic Ladder, in StatPearls. 2020, StatPearls Publishing: Treasure Island (FL).
17. Dick, B.D. and S. Rashiq, Disruption of attention and working memory traces in individuals with chronic pain. Anesth Analg, 2007. 104(5): p. 1223-9, tables of contents.
18. Whitlock, E.L., et al., Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders. JAMA Intern Med, 2017. 177(8): p. 1146-1153.
19. Zhao, J., et al., Health Care Providers’ Experiences and Perceptions Participating in a Chronic Pain Telementoring Education Program: A Qualitative Study. Canadian Journal of Pain, 2020. 4.
20. McGillion, M.H. and J. Watt-Watson, Pain Assessment and Management in Canada: We’ve Come a Long Way but there are Challenges on the Road Ahead. Can J Nurs Res, 2015. 47(1): p. 9-16.

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It’s very rewarding to know that as a research clinic we are collecting data for the advancement and development of medical cannabis. Much of the data we collect shows differences in effectiveness and side effects of cannabinoid treatments allowing us to better understand and therefore create valuable treatment plans. I’ve also noticed our research helps shift the mindset of some professionals who might know very little about this subject and tend to be apprehensive because of the limited evidence available. Similarly, we see a pattern that many physicians continue referring their patients to us, probably because they are encouraged by the results achieved.

Medical cannabis is a field where we treat our patients in a fairly multifaceted way. Most of our patients come to us for chronic pain relief, depending on the etiology. We also work in the mental health domain which, let’s face it, became more important due to the current pandemic. Each patient has a personalized treatment plan with the goal of reducing their symptoms.

Recently, I even observed a rather interesting pediatric case. We don’t see many minors, but we have a few isolated cases where we work closely with the patients’ doctors, and consider contraindications and proceed with caution. Liam, my pediatric patient, presented with a severe case of Gilles de la Tourette’s syndrome, which caused him to have a long series of associated symptoms including vocal tics, hyperactivity, generalized spasms, aggressiveness and self-injury.

Liam was very lucky to have incredibly involved parents who continued to look for solutions for their son. During his last follow-up, his mother was moved to tell me how he had been doing. It’s not easy to live with this type of syndrome and the current pharmacological treatments are quite limited. During the meeting, she explained to me that Liam has been able to considerably reduce his list of medications, many of which were not very effective. The CBD based treatment we had advised him on taking (a cannabis molecule called cannabidiol) provided a significant improvement in his overall condition, and according to his teachers, his behavioral problems had significantly decreased and his class periods were more enjoyable. There was a decline in his aggressive and impulsive behaviors, the elimination of dark thoughts, a proper and peaceful sleep and a decrease in his spasms. These changes were greatly appreciated by Liam, and those who surround and love him.

Certainly cannabis did not cure him and we don’t expect it to. However, I am proud to say, we were able to provide him with new and additional tools and support required to improve his quality of life. Our physicians work hand-in-hand with Liam’s specialists to ensure quality follow-up, and they have been pleased with the effectiveness of the treatment established.

*names have been changed to protect identity of our patients

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Author: Laura Libralesso

Today I woke up feeling blue, feeling stressed. I consider myself privileged, I have a job I enjoy, a healthy family and social circle I love and a comfortable house to live in. So why from one day to another,  can I feel happy, ready to get things done, then anxious and stressed about my day to come? This is all part of mental health; mental health is “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (WHO). Mental health affects the emotional, social and psychological domains of our life. It has an impact on how we think, how we feel, how we act, how we communicate. 

Mental health used to be only considered in terms of disorders, such as those described in the Diagnostic and Statistical Manual of mental disorders (DSM-V, 2013). However, mental illnesses and mental health are different. You can be free of a mental illness and still have poor mental health. 

The COVID-19 pandemic emphasized the importance of mental health in every individual as billions of people fell into confinement, greatly affecting their mental health status. Health workers and essential workers on the front-line during the pandemic were even more affected. A survey conducted in Canada showed that “one in four (25%) Canadians aged 18 and older screened positive for symptoms of depression, anxiety or posttraumatic stress disorder (PTSD) in spring 2021, up from one in five (21%) in fall 2020”(Statistic Canada, 2021).

The pandemic also highlighted the critical need for the government to provide better, more affordable, and faster access to mental health services. In Quebec, the current wait time for a public sector psychological consultation can be up to two years, which is problematic, as people seeking help may be in crises, and mental health conditions are likely to deteriorate during that time. 

This is why the theme for the 2021 world mental health day was “Mental health care for all: let’s make it a reality”.

At Santé Cannabis we recognize the need for multi prong approaches to mental health and wellbeing; that there is a need for therapy, medication, community, education, mindfulness, support and more in an individualized approach for each specific person. At Santé Cannabis we try to provide our patients and their community with as many of these supports as possible, but our primary ability is in providing access to trained professionals who can help people navigate medical cannabis to improve their mental health.  

How can Cannabinoid-Based Medicines (CBMs) Help? 

After years of tabous and marginalisation, mental health issues are now being discussed at the forefront and finally considered. CBM research is riding the wave with an increasing number of studies on the topic. Whereas we acknowledge many mental health symptoms and mental illnesses exist, the following sections will detail research on cannabinoid-based medicines (CBMs) and anxiety, depression, and post-traumatic stress disorder (PTSD). For those interested in reading more about current evidence on other mental health and psychiatric disorders, such as schizophrenia, attention-deficit hyperactivity deficit or bipolar disorder, several recent reviews have been published (Black et al., 2019; Sarris et al., 2020; Scherma et al., 2018). 

Anxiety and Depression in the Literature

As seen in the recent Statistic Canada survey, anxiety and depression are the most frequent mental health conditions experienced by Canadians. Despite limited clinical evidence from randomized clinical trials many observational studies show that mental health symptoms are the second reason for CBM use after chronic pain (Bonn-Miller et al., 2014; Lintzeris et al., 2020; Lucas et al., 2017).

Santé Cannabis recently published a blog post on anxiety and CBMs, discussing what anxiety is and how CBMs may be a treatment to consider.  CBMs generally contain diverse concentrations of the primary cannabinoids, Δ9-tetrahydrocannabinol (THC), and cannabidiol (CBD). Even though the exact mechanism of action is still not fully understood, CBD has shown to have anxiolytic (anti-anxiety) effects (Campos et al., 2012). Multiple clinical trials indicate a reduction in subjective anxiety ratings with CBD intake compared to placebo in response to an anxiety-provoking stimulus (Zuardi et al., 2017; Bergamaschi et al., 2011; Skelley et al., 2020 for a review on CBD and anxiety disorders). 

There is scarce scientific literature to address the relevance of CBMs for the treatment of depressive disorders (Turna et al., 2017). On the other hand, patients frequently use cannabis for medical purposes for the relief of depressive symptoms, and 7 out of 9 cross-sectional studies on medical cannabis reported mood improvement (Walsh et al., 2017). 

Besides, improvements in mood were generally reported in studies assessing medical cannabis for chronic pain, multiple sclerosis, HIV, and other conditions (Ellis et al., 2009; Lahat et al., 2012; Page & Verhoef, 2006; Ware et al., 2015)

Anxiety and Depression in our Clinical Experience

Observational evidence from Santé Cannabis patients are in line with the literature. Across the dataset of 1,342 Santé Cannabis patients assessed between 2017 and 2019, 5.4 % of patients have a primary diagnosis related to mental health. However, 59% of patients have identified anxiety or mood-related secondary symptoms. Furthermore, anxious and depressive symptoms frequently co-occur in patients with a primary diagnosis related to chronic pain: 73% of Santé Cannabis patients with a primary diagnosis of chronic pain also have anxiety or mood-related secondary symptoms. 

In a recent study, we also showed that patients reported decreased anxiety scores after three months of CBD treatment (Rapin et al., 2021). 

Post-Traumatic Stress Disorder in the literature

Post-Traumatic Stress Disorder (PTSD) is characterized by the exposure to trauma and symptoms such as intrusive memories, avoidance of distressing factors, increased arousal and alteration of mood/cognition. Nightmares and sleep disturbances are very frequent. PTSD can affect an estimated 9.2% of Canadians in their lifetime, with the disorder twice as prevalent in women compared to men  (Katzman et al. 2014).

CBMs are becoming more recognized as a potential treatment for PTSD symptoms; trials conducted on nabilone and THC have demonstrated some benefits in improving sleep disturbances, but larger and longer trials (and more randomized controlled trials) are needed to provide good-quality evidence for cannabinoids’ use in PTSD. 

That being said, there are increasing reports of patients self-treating with cannabis as well as anecdotal evidence and case reports that cannabis could reduce PTSD symptoms (Hindocha et al., 2020; Fernández-Ruiz et al., 2020). Anecdotal evidence may not be as scientifically or clinically lauded; but when little evidence from randomized controlled trials is available, anecdotal data should not be disregarded. Even-though, research is still in its infancy and has not yet found the exact cannabinoid formulation to alleviate patients’ PTSD-related symptoms, current trial results indicate promising therapeutic avenues that should be considered.

Post-Traumatic Stress Disorder in our Clinical Experience

“I feel a tremendous amount of compassion for people living with post-traumatic stress disorder. 

Since working at Santé Cannabis, I’ve been fortunate to be able to learn so much more about this condition during my interviews with patients with this diagnosis. What has stuck with me the most is all the areas of life that are affected by this disorder. I think of the nightmares, the anger, the pain, the vivid images that keep coming back, and the severe anxiety that prevents one from functioning but also makes interpersonal relationships very difficult. 

I think of one veteran in particular that I interviewed several years ago. He told me about having to make a few rounds around his house every night before he could go to bed. He also told me about all his former colleagues and friends that had PTSD and took their own lives because they couldn’t find a way to regain a reasonable quality of life. He had heard about medical cannabis from a veteran friend who said he had found a lot of relief from taking CBD oil. The patient I was evaluating was very shocked by this as he had been against cannabis all his life and after 20 years of researching and trying to find what would help him with his PTSD symptoms, he could not believe that the answer could be cannabis! 

What I can say is that, In my practice and that of many of my colleagues, we indeed see significant improvement in many of these patients with medical cannabis.” – Andrée Charbonneau, RN

During Dr. Howard Mitnick’s workshop at the Conference on Cannabinoid-based medicine on May 5th, 2021, Dr. Mitnick also shared his clinical experience with medical cannabis and post-traumatic stress disorder. In his clinical practice, particularly in 2016 when many soldiers deployed to Afghanistan returned, Dr. Mitnick said he was impressed by the very significant impact medical cannabis had on patients that were struggling with PTSD-related anxiety, grasping at anything to just stop their brain.

Despite this, statistics show that the Quebec population is under-represented in Canada’s pool of patients with access to medical cannabis and veterans are no exception, regardless of the extensive Veterans Affairs Canada coverage.

We also know that many veterans who have had a prescription do not have support from medical professionals to navigate their medical cannabis. We want to help improve this situation. That’s why we offer educational presentations open to the public to inform people living with post-traumatic stress disorder about this treatment option, and to let them know about our services and our mission. 

Next for CBMs and Mental Health Disorders

This brief overview on a few mental health disorders and symptoms demonstrates the pressing need of more research to evaluate and assert the impact of CBMs on such disorders. Increasing evidence points towards a beneficial effect of CBD on anxiety symptoms, however there is still little evidence for depression. THC may reduce PTSD symptoms but again, current evidence is too low to definitively conclude. 

We know that regardless of the formal, scientific evidence, people are using medical cannabis to treat their mental illness and try and improve mental health. We believe in empowering people to make the best decisions with the best evidence, and therefore we need continued study in this critical area.

While evidence is still weak, results are encouraging for future research to take place. The favorable safety profile of CBMs, compared to anxiolytics and antipsychotics for example, as well as the observational reports of patients mentioning decreased symptoms and improved quality of life following CBMs are to be considered to those resistant to further pursuing research on the topic. 

While we wait for strong clinical evidence to support the potential of CBMs in mental health disorders, mental health symptoms are still occurring in many people, negatively affecting their everyday life. 

The testimony of one of our patients illustrates accurately the impact of mental health symptoms on everyday life: 

“It took me a while to admit it to myself, but I have lived with a lot of anxiety since a very young age. This anxiety has had an impact on my ability to work and on my interpersonal relationships, not to mention the immense impact on my body: from daily painful tensions to gastrointestinal difficulties. However, I can say that recognizing anxiety has allowed me to better manage it, to regain my quality of life and my self-esteem.

I had to learn to say no to others, but also to myself. I learned to reduce my financial needs so that I could work less and have more time to invest in my general health.

I felt guilty about this and felt like an “imposter” who could have done better. However, my family doctor was very helpful in validating my feelings and praising me for taking care of myself. Just the fact that she took this approach with me was very helpful in accepting myself and my limitations. 

I think the support of my friends and my doctor made all the difference.”

– Nancy Raymond, Santé Cannabis patient

We know that mental health is extremely complex and even with treatments demonstrated for use through rigorous research people regularly need to trial and error a combination of treatments to find what works for them and this may change over their lifetime. Adding another treatment to this cause could be the treatment that works for the next person. 

In our clinical practice we have enough data to make informed decisions with our patients, understand drug interactions, and watch for contraindications. We spend time learning about each person before providing an individualized treatment plan and providing regular follow-up – with the objective to ensure that their CBM plan is working towards their mental health goals without side effects. We also know that many people continue to self-treat and may not understand the complexity of using CBMs to treat mental health issues. Mental health is health and needs to be treated with the same level of care and follow up as any other health condition and new medication treatment. We encourage the training of healthcare professionals to understand medical cannabis in the treatment of mental health issues, and support research to improve our evidence-base as we all work together to ensure that patients’ mental health is treated properly. 

Conclusion

Mental health plays a significant role in our life, it is crucial that it is taken seriously by both the individuals and governments. Health is not simply the absence of disease, it is a complete state of physical, mental and social wellbeing (WHO) and for many of us, the past 2 years have highlighted the important role our mental and social wellbeing play in our daily experience.

For me, when I start feeling anxious, I step away from screens, take a walk in my neighbourhood and try to put things into perspective – these are strategies I developed that work for me. Some days even that is hard to prioritize, yet I have learned that it  is essential to listen to my wellbeing and adjust my day to ensure favorable mental health. 

I’m fortunate that these strategies work for me, but in my life, work and research, I know that these strategies don’t work for everyone. For some, it can be helpful to have positive and good-hearted social interactions, satisfying sleep and eating habits, exercise, outdoors, work-family balance, and mindfulness. For others it may be the support of professionals with group or individualized therapy, and/or medication. At Santé Cannabis we hope that among the medications considered for mental health are CBMs, and we encourage further research, and for those interested in trying CBMs to reach out to their doctor.  

If you feel deterioration in your mental health it is important to seek help:

• https://wellnesstogether.ca/en-CA
• https://www.canada.ca/en/public-health/services/mental-health-services/mental-health-get-help.html
• https://www.quebec.ca/en/health/advice-and-prevention/mental-health
• https://www.crisisservicescanada.ca/en/

At Santé Cannabis, our clinicians and nurses are here to help our patients find the right treatment for their symptoms. We also offer our patients support groups, presentations and tools including stress management and mindfulness.

Santé Cannabis is committed to advancing knowledge about mental health and cannabinoid-based treatments, and as such, we offer research services to companies and institutions interested in developing clinical studies. 

For clinicians currently treating people with mental health symptoms who wish to include medical cannabis in their practice, our preceptorships are available to all local and international physicians. For prescribers in Quebec, we also offer a free training program on cannabinoid-based treatments and how to prescribe them.

Author: Lucile Rapin avec le soutien de Charlotte Bastin et Eva McMillan

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.