As part of this historic step, the federal government committed to conducting a review of the Cannabis Act within five years. This was to include a review of the medical cannabis framework in Canada.

It’s important to note that in Canada, medical cannabis is accessible only via a federal program where authorized patients can purchase products from federally licensed companies under specific requirements. Medical cannabis is not available in pharmacies and must be shipped by mail order to patients’ homes or residences.

When cannabis was legalized for non-medical or ‘recreational’ use in 2018, licensed storefronts sprang up all across Canada. These stores now total over 3,800 which represents a very significant growth rate in just 5 years.

In contrast, implementation of the Cannabis Act brought no significant access changes to medical cannabis. The mail order system, in place since 2013, remains the only option for patients and caregivers to access regulated cannabis products for medical use.

While adult Canadians may choose to purchase cannabis from recreational stores and utilize those products for therapeutic purposes, such products are not eligible for insurance coverage, medical expense tax credits.

The complexity of this one aspect of accessing medical cannabis demonstrates the barriers faced by Canadian patients today.

THE NEED FOR RESEARCH ON PATIENT EXPERIENCES

To inform the Cannabis Act review, and to ensure the needs of Canadians who access medical cannabis, or may benefit from it are well understood, our research team joined forces with collaborators to develop a nation-wide study, the Medical Cannabis Access Survey (MCAS). The study was launched in March 2022 to provide an opportunity for Canadians with lived experience of accessing medical cannabis to share their experiences, challenges and suggestions regarding future improvements to the medical cannabis framework in Canada.

Eligible participants included Canadian residents aged 16 years and older, who were currently, previously, or considering taking cannabis for medical purposes.

The survey asked about their current medical cannabis use, purpose, and reasons for taking medical cannabis, their authorization and access experiences, insurance coverage and costs associated with medical cannabis, and changes experienced since legalization of non-medical cannabis in 2018.

A total of 5,744 individuals from across Canada (62% woman) completed the survey, making it one of the largest ever done from the perspective of Canadians accessing cannabis for medical purposes.

Overall, 5,433 participants (95%) reported currently taking medical cannabis and 54% of these individuals held current medical authorization.Here we share the main findings of this study.

USE OF MEDICAL CANNABIS

Most of the participants had a lengthy history of taking medical cannabis and reported taking it every day for such health conditions as chronic pain, anxiety, and sleep issues.

With the growing medical and non-medical cannabis market in Canada, respondents currently taking medical cannabis reported utilizing a variety of cannabis products, with dried flower and oil being the most frequently reported.

In addition, participants with medical authorization were more likely to take oils and capsules than those without (68% vs. 44% and 35% vs 21% respectively). This finding highlights the potential importance of medical authorization in educating and directing individuals towards alternative and complementary medical cannabis products.

Estimating how much medical cannabis product they consumed on average each day, including the amount of tetrahydrocannabinol (THC) and cannabidiol (CBD), was difficult for most individuals to report.

The uncertainty surrounding dose and THC and CBD levels raises several concerns from a safety and harm reduction perspective. Furthermore, it’s possible that many individuals are not taking an optimal dose for their individual needs and may not achieve potential benefits.

Understanding the efficacy and side effects of medical cannabis in the absence of dosing information creates challenges for healthcare practitioners. So those care providers who are attempting to engage in shared treatment decision making with individuals may also experience significant challenges. In addition, documenting the efficacy of different doses of medical cannabis and THC and CBD levels across health conditions provides valuable clinical data for healthcare practitioners working in such a nascent field as medical cannabis, and offers an important starting point for future clinical trial research. In the context of harm reduction, the lack of dose and THC and CBD level information prevents healthcare practitioners from understanding the thresholds at which severe side effects may arise for certain individuals.

CHANGES SINCE LEGALISATION

Not surprisingly, considering the proliferation of cannabis stores, the most significant shift in medical cannabis since the legalization of non-medical cannabis was where individuals obtained their medical cannabis products.

Regulated sales points such as recreational stores, licensed sellers and growing at home has become more popular compared to unregulated sources such as dealers and family/friends.

More than half of individuals with authorization indicated accessing medical cannabis at a legal recreational store, where it is prohibited to provide medical advice about cannabis.

Even more striking was the fact that over 20% of individuals using medical cannabis before 2018 made the decision to no longer access it through the medical cannabis access program at all, highlighting the perceived and experienced barriers.

Legalization also brought a perceived change in attitudes towards medical cannabis, with respondents reporting feeling more comfortable discussing and suggesting medical cannabis to others, except for their employers. Given the continued reports of discrimination experienced by workers who take medical cannabis, restrictive workplace and human resources policies related to medical cannabis, and the continued public education campaign that emphasizes the harms of cannabis, this hesitancy to disclose to employers is understandable.

RETAINING THE MEDICAL PROGRAM

Despite the challenges experienced by participants in accessing the medical cannabis system and their use of the recreational market to obtain medical cannabis, nearly 57% of individuals with medical authorization agreed that there was a need to retain the medical cannabis program as separate from the recreational cannabis market. Policies exclusive to the medical cannabis framework that were most relevant to these individuals included being able to claim medical cannabis on federal tax forms (47%), receiving compassionate pricing (36%), and possession limits (29%).

Individuals identified numerous improvements that can be made to the medical cannabis program in Canada, including:

• reduction of costs by eliminating applicable taxes,
• introduction of access via community-based pharmacies,
• protections for use in public and private spaces,
• review of THC limits for edible products for therapeutic use, and
• an increased focus on medical cannabis research and education.

These study findings highlight the complex landscape of medical cannabis, access challenges and unmet needs among the patient community, supporting the importance of locating patients at the heart of consultations.

NEXT STEPS

The Cannabis Act review is still underway, and stakeholders can contact Health Canada and the Expert Panel at legreview-examenleg@hc-sc.gc.ca to give their feedback on what they would like to see changed.

Once again, we would like to thank the participants who took the time to share their experiences and take part in this research, as well as the patient advocacy groups who circulated the study.

The full report is available here.

How to cite the report: Balneaves, L.G., Brown, A., Green, M., et al. (2023). Medical cannabis access and experiences in Canada. Retrieved from: medicalcannabissurvey.ca.

We’re always happy to hear from you

Do the results of this study match your experience? Email us to let us know what you think.

Contact us

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?  

Find everything there is to know about our clinic.  

Click here

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

We have more for you! Check out our Modules written specifically for healthcare professionals participating in our Prescriber Training Program. 

Click here

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.

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.

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

Find everything there is to know about our clinic.  

Click here

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

We have more for you! Check out our Modules written specifically for healthcare professionals participating in our Prescriber Training Program. 

Click here

REFERENCES 

1. Hutchison, K.E., et al., Cannabinoids, Pain, and Opioid Use Reduction: The Importance of Distilling and Disseminating Existing Data. Cannabis and Cannabinoid Research, 2019. 4(3): p. 158-164.
2. Busse, J.W., et al., Guideline for opioid therapy and chronic noncancer pain. Cmaj, 2017. 189(18): p. E659-e666.
3. World Health Organization, WHO Expert Committee on Drug Dependence Pre-Review. 2018.
4. Chesney, E., et al., Adverse effects of cannabidiol: a systematic review and meta-analysis of randomized clinical trials. Neuropsychopharmacology, 2020. 45(11): p. 1799-1806.
5. Larsen, C. and J. Shahinas, Dosage, efficacy and safety of cannabidiol administration in adults: a systematic review of human trials. Journal of Clinical Medicine Research, 2020. 12(3): p. 129.
6. Sihota, A., et al., Consensus‐Based Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control. International journal of clinical practice, 2020: p. e13871.
7. National Academies of Sciences Engineering and Medecine, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research. 2017, Washington (DC).
8. Fisher, E., et al., Cannabinoids, cannabis, and cannabis-based medicine for pain management: a systematic review of randomised controlled trials. Pain, 2020.
9. Johal, H., et al., Cannabinoids in Chronic Non-Cancer Pain: A Systematic Review and Meta-Analysis. Clin Med Insights Arthritis Musculoskelet Disord, 2020. 13: p. 1179544120906461.
10. Wong, S.S.C., W.S. Chan, and C.W. Cheung, Analgesic Effects of Cannabinoids for Chronic Non-cancer Pain: a Systematic Review and Meta-Analysis with Meta-Regression. J Neuroimmune Pharmacol, 2020.
11. Stockings, E., et al., Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain, 2018. 159(10): p. 1932-1954.
12. Nugent, S.M., et al., The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review. Annals of Internal Medicine, 2017. 167(5): p. 319-331.
13. Aviram, J. and G. Samuelly-Leichtag, Efficacy of Cannabis-Based Medicines for Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Physician, 2017. 20(6).
14. Meng, H., et al., Selective Cannabinoids for Chronic Neuropathic Pain: A Systematic Review and Meta-analysis. Anesthesia & Analgesia, 2017. 125(5): p. 1638.
15. Allan, G.M., et al., Systematic review of systematic reviews for medical cannabinoids: Pain, nausea and vomiting, spasticity, and harms. Canadian Family Physician Medecin De Famille Canadien, 2018. 64(2): p. e78-e94.
16. Häuser, W., F. Petzke, and M.A. Fitzcharles, Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management – An overview of systematic reviews. European Journal of Pain, 2018. 22(3): p. 455-470.
17. Mücke, M., et al., Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews, 2018.
18. Yanes, J.A., et al., Effects of cannabinoid administration for pain: A meta-analysis and meta-regression. Experimental and clinical psychopharmacology, 2019. 27(4): p. 370-382.
19. Campbell, G., E. Stockings, and S. Nielsen, Understanding the evidence for medical cannabis and cannabis-based medicines for the treatment of chronic non-cancer pain. European Archives of Psychiatry and Clinical Neuroscience, 2019.
20. Chisari, C.G., et al., An update on the pharmacological management of pain in patients with multiple sclerosis. Expert Opin Pharmacother, 2020: p. 1-15.
21. Wissel, J., et al., Low dose treatment with the synthetic cannabinoid Nabilone significantly reduces spasticity-related pain – A double-blind placebo-controlled cross-over trial. Journal of neurology, 2006. 253: p. 1337-41.
22. Novotna, A., et al., A randomized, double-blind, placebo-controlled, parallel-group, enriched-design study of nabiximols* (Sativex®), as add-on therapy, in subjects with refractory spasticity caused by multiple sclerosis. European Journal of Neurology, 2011. 18(9): p. 1122-1131.
23. Markovà, J., et al., Sativex® as add-on therapy vs. further optimized first-line ANTispastics (SAVANT) in resistant multiple sclerosis spasticity: a double-blind, placebo-controlled randomised clinical trial. The International Journal of Neuroscience, 2019. 129(2): p. 119-128.
24. van Amerongen, G., et al., Effects on Spasticity and Neuropathic Pain of an Oral Formulation of Δ9-tetrahydrocannabinol in Patients With Progressive Multiple Sclerosis. Clinical Therapeutics, 2018. 40(9): p. 1467-1482.
25. Wade, D.T., et al., A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms. Clinical Rehabilitation, 2003. 17(1): p. 21-29.
26. Karst, M., et al., Analgesic effect of the synthetic cannabinoid CT-3 on chronic neuropathic pain: a randomized controlled trial. Jama, 2003. 290(13): p. 1757-62.
27. Berman, J.S., C. Symonds, and R. Birch, Efficacy of two cannabis based medicinal extracts for relief of central neuropathic pain from brachial plexus avulsion: results of a randomised controlled trial. Pain, 2004. 112(3): p. 299-306.
28. Nurmikko, T.J., et al., Sativex successfully treats neuropathic pain characterised by allodynia: a randomised, double-blind, placebo-controlled clinical trial. Pain, 2007. 133(1-3): p. 210-20.
29. Wilsey, B., et al., A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. The Journal of Pain: Official Journal of the American Pain Society, 2008. 9(6): p. 506-521.
30. Selvarajah, D., et al., Randomized Placebo-Controlled Double-Blind Clinical Trial of Cannabis-Based Medicinal Product (Sativex) in Painful Diabetic Neuropathy: Depression is a major confounding factor. Diabetes Care, 2010. 33(1): p. 128-130.
31. Toth, C., et al., An enriched-enrolment, randomized withdrawal, flexible-dose, double-blind, placebo-controlled, parallel assignment efficacy study of nabilone as adjuvant in the treatment of diabetic peripheral neuropathic pain. Pain, 2012. 153(10): p. 2073-82.
32. Wilsey, B., et al., Low-dose vaporized cannabis significantly improves neuropathic pain. The journal of pain : official journal of the American Pain Society, 2013. 14 2: p. 136-48.
33. Serpell, M., et al., A double-blind, randomized, placebo-controlled, parallel group study of THC/CBD spray in peripheral neuropathic pain treatment. Eur J Pain, 2014. 18(7): p. 999-1012.
34. Schimrigk, S., et al., Dronabinol Is a Safe Long-Term Treatment Option for Neuropathic Pain Patients. European neurology, 2017. 78(5-6): p. 320-329.
35. Xu, D.H., et al., The Effectiveness of Topical Cannabidiol Oil in Symptomatic Relief of Peripheral Neuropathy of the Lower Extremities. Current Pharmaceutical Biotechnology, 2019.
36. Abrams, D.I., et al., Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology, 2007. 68(7): p. 515-521.
37. Ellis, R.J., et al., Smoked Medicinal Cannabis for Neuropathic Pain in HIV: A Randomized, Crossover Clinical Trial. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology, 2009. 34(3): p. 672-680.
38. Wilsey, B., et al., An Exploratory Human Laboratory Experiment Evaluating Vaporized Cannabis in the Treatment of Neuropathic Pain From Spinal Cord Injury and Disease. The journal of pain, 2016. 17(9): p. 982-1000.
39. Almog, S., et al., The pharmacokinetics, efficacy, and safety of a novel selective-dose cannabis inhaler in patients with chronic pain: A randomized, double-blinded, placebo-controlled trial. Eur J Pain, 2020. 24(8): p. 1505-1516.
40. Svendsen, K.B., T.S. Jensen, and F.W. Bach, Does the cannabinoid dronabinol reduce central pain in multiple sclerosis? Randomised double blind placebo controlled crossover trial. BMJ : British Medical Journal, 2004. 329(7460): p. 253.
41. Langford, R.M., et al., A double-blind, randomized, placebo-controlled, parallel-group study of THC/CBD oromucosal spray in combination with the existing treatment regimen, in the relief of central neuropathic pain in patients with multiple sclerosis. Journal of Neurology, 2013. 260(4): p. 984-997.
42. Turcotte, D., et al., Nabilone as an Adjunctive to Gabapentin for Multiple Sclerosis-Induced Neuropathic Pain: A Randomized Controlled Trial. Pain Medicine, 2015. 16(1): p. 149-159.
43. Ware, M.A., et al., Smoked cannabis for chronic neuropathic pain: a randomized controlled trial. CMAJ, 2010. 182(14): p. E694-E701.
44. Frank, B., et al., Comparison of analgesic effects and patient tolerability of nabilone and dihydrocodeine for chronic neuropathic pain: randomised, crossover, double blind study. BMJ (Clinical research ed.), 2008. 336(7637): p. 199-201.
45. Corey-Bloom, J., et al., Smoked cannabis for spasticity in multiple sclerosis: a randomized, placebo-controlled trial. CMAJ, 2012. 184(10): p. 1143-1150.
46. Leocani, L., et al., Sativex® and clinical–neurophysiological measures of spasticity in progressive multiple sclerosis. Journal of Neurology, 2015. 262(11): p. 2520-2527.
47. Haleem, R. and R. Wright, A Scoping Review on Clinical Trials of Pain Reduction With Cannabis Administration in Adults. 2020. 2020.
48. Nutt, D.J., et al., A Multicriteria Decision Analysis Comparing Pharmacotherapy for Chronic Neuropathic Pain, Including Cannabinoids and Cannabis-Based Medical Products. Cannabis and Cannabinoid Research, 2021.
49. Boehnke, K.F., et al., Cannabidiol Use for Fibromyalgia: Prevalence of Use and Perceptions of Effectiveness in a Large Online Survey. The Journal of Pain, 2021.
50. Fitzcharles, M.A., et al., Use of medical cannabis by patients with fibromyalgia in Canada after cannabis legalisation: a cross-sectional study. Clin Exp Rheumatol, 2021.
51. Skrabek, R.Q., et al., Nabilone for the treatment of pain in fibromyalgia. J Pain, 2008. 9(2): p. 164-73.
52. Ware, M.A., et al., The effects of nabilone on sleep in fibromyalgia: results of a randomized controlled trial. Anesthesia and Analgesia, 2010. 110(2): p. 604-610.
53. van de Donk, T., et al., An experimental randomized study on the analgesic effects of pharmaceutical-grade cannabis in chronic pain patients with fibromyalgia. Pain, 2019. 160(4): p. 860-869.
54. Chaves, C., P.C.T. Bittencourt, and A. Pelegrini, Ingestion of a THC-Rich Cannabis Oil in People with Fibromyalgia: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Pain Med, 2020. 21(10): p. 2212-2218.
55. Weber, J., et al., Tetrahydrocannabinol (Delta 9-THC) Treatment in Chronic Central Neuropathic Pain and Fibromyalgia Patients: Results of a Multicenter Survey. Anesthesiol Res Pract, 2009. 2009.
56. Fiz, J., et al., Cannabis use in patients with fibromyalgia: effect on symptoms relief and health-related quality of life. PLoS One, 2011. 6(4): p. e18440.
57. Yassin, M., A. Oron, and D. Robinson, Effect of adding medical cannabis to analgesic treatment in patients with low back pain related to fibromyalgia: an observational cross-over single centre study. Clin Exp Rheumatol, 2019. 37 Suppl 116(1): p. 13-20.
58. Habib, G. and I. Avisar, The Consumption of Cannabis by Fibromyalgia Patients in Israel. Pain Res Treat, 2018. 2018: p. 7829427.
59. Habib, G. and S. Artul, Medical Cannabis for the Treatment of Fibromyalgia. J Clin Rheumatol, 2018. 24(5): p. 255-258.
60. Sagy, I., et al., Safety and Efficacy of Medical Cannabis in Fibromyalgia. Journal of Clinical Medicine, 2019. 8(6).
61. Giorgi, V., et al., Adding medical cannabis to standard analgesic treatment for fibromyalgia: a prospective observational study. Clin Exp Rheumatol, 2020. 38 Suppl 123(1): p. 53-59.
62. Anson, P., Marijuana Rated Most Effective for Treating Fibromyalgia, in National Pain Report. 2014: National Pain Report.
63. Boehnke, K.F., et al., Substituting Cannabidiol for Opioids and Pain Medications Among Individuals With Fibromyalgia: A Large Online Survey. J Pain, 2021.
64. Vučković, S., et al., Cannabinoids and Pain: New Insights From Old Molecules. Frontiers in Pharmacology, 2018. 9: p. 1259.
65. Richardson, D., et al., Characterisation of the cannabinoid receptor system in synovial tissue and fluid in patients with osteoarthritis and rheumatoid arthritis. Arthritis research & therapy, 2008. 10(2): p. R43-R43.
66. Lowin, T., M. Schneider, and G. Pongratz, Joints for joints: cannabinoids in the treatment of rheumatoid arthritis. Current Opinion in Rheumatology, 2019. 31(3): p. 271-278.
67. Gonen, T. and H. Amital, Cannabis and Cannabinoids in the Treatment of Rheumatic Diseases. Rambam Maimonides Med J, 2020. 11(1).
68. Fitzcharles, M.-A., et al., Efficacy, tolerability and safety of cannabinoids in chronic pain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis): A systematic review of randomized controlled trials. Schmerz (Berlin, Germany), 2016. 30(1): p. 47-61.
69. Blake, D.R., et al., Preliminary assessment of the efficacy, tolerability and safety of a cannabis-based medicine (Sativex) in the treatment of pain caused by rheumatoid arthritis. Rheumatology (Oxford, England), 2006. 45(1): p. 50-52.
70. Sorge, R.E. and S.K. Totsch, Sex Differences in Pain. J Neurosci Res, 2017. 95(6): p. 1271-1281.
71. Matheson, J., et al., Sex differences in the acute effects of smoked cannabis: evidence from a human laboratory study of young adults. Psychopharmacology (Berl), 2020. 237(2): p. 305-316.
72. Fogel, J.S., et al., Sex differences in the subjective effects of oral Δ(9)-THC in cannabis users. Pharmacology, biochemistry, and behavior, 2017. 152: p. 44-51.
73. Sholler, D.J., et al., Sex differences in the acute effects of oral and vaporized cannabis among healthy adults. Addiction Biology, 2020. n/a(n/a): p. e12968.
74. Chen, Q., et al., Estrogen receptors in pain modulation: cellular signaling. Biology of sex differences, 2021. 12(1): p. 22-22.
75. Piroli, A., et al., Influence of the Menstrual Cycle Phase on Pain Perception and Analgesic Requirements in Young Women Undergoing Gynecological Laparoscopy. Pain Pract, 2019. 19(2): p. 140-148.
76. Bartley, E.J. and J.L. Rhudy, Comparing pain sensitivity and the nociceptive flexion reflex threshold across the mid-follicular and late-luteal menstrual phases in healthy women. Clin J Pain, 2013. 29(2): p. 154-61.
77. Hellström, B. and U.M. Anderberg, Pain perception across the menstrual cycle phases in women with chronic pain. Percept Mot Skills, 2003. 96(1): p. 201-11.
78. Blanton, H.L., et al., Sex differences and the endocannabinoid system in pain. Pharmacol Biochem Behav, 2021. 202: p. 173107.
79. 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.
80. 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.
81. 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.
82. 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.
83. 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.
84. Grotenhermen, F., Pharmacokinetics and pharmacodynamics of cannabinoids. Clinical pharmacokinetics, 2003. 42(4): p. 327–360.
85. 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.
86. Notcutt, W.G., Clinical Use of Cannabinoids for Symptom Control in Multiple Sclerosis. Neurotherapeutics, 2015. 12(4): p. 769-777.
87. Meng, H., et al., Patient-reported outcomes in those consuming medical cannabis: a prospective longitudinal observational study in chronic pain patients. Can J Anaesth, 2021.
88. Nielsen, S., et al., Opioid-Sparing Effect of Cannabinoids: A Systematic Review and Meta-Analysis. Neuropsychopharmacology, 2017. 42(9): p. 1752-1765.
89. Noori, A., et al., Opioid-sparing effects of medical cannabis or cannabinoids for chronic pain: a systematic review and meta-analysis of randomised and observational studies. BMJ Open, 2021. 11(7): p. e047717.

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 

You are a healthcare professional and you found valuable information in this blogpost?

We have more for you! Check out our Modules written specifically for healthcare professionals participating in our Prescriber Training Program 

Click here to view more

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.

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

The Opioid Epidemic in North America

“Too many Canadians share the heartbreak of losing a loved one to a drug-related overdose…. Addiction and substance use is a health issue, not a moral one.”

The Honourable Patty Hajdu

Minister of Health

April 14, 2016 the British Columbia provincial health officer declared the opioid-related overdose deaths a public health emergency under the Public Health Act.  A count of days stays active on the Vancouver City page as many work tirelessly to end the state of emergency.

(1,959 days when taken from the site. The count continues here)

British Columbia and Alberta continue to be the most impacted regions of Canada, although rates are increasing in other regions including Ontario. “The COVID-19 outbreak is worsening the already deadly and ongoing public health crisis of opioid overdoses and death. It is having a tragic impact on people who use substances, their families, and communities across Canada.” (more references here and here)

Nationwide, Canada experienced 21,174 apparent opioid toxicity deaths between January 2016 and December 2020, with 6,214 of those deaths happening in 2020, (approximately 17 deaths per day), of which 96% were accidental (unintentional.)

Vancouver, one of the hardest-hit cities, has been trying to implement innovative solutions to the crisis, including: seeking to decriminalize simple possession of illicit drugs in Vancouver; approving the Four Pillars Drug Strategy – Harm Reduction, Prevention, Treatment and Enforcement based on successful programs in cities such as Geneva, Zurich Frankfurt and Sydney; and hosting North America’s first legal safe injection site and needle exchange.

Despite this crisis, opioids are still being prescribed on label every day by doctors primarily to treat pain. In places such as the USA, cannabis is still considered a schedule 1 drug, despite knowing that fatal overdoses are impossible with cannabis, while opioid overdoses are at the point of public health emergency. 

As opioids are used to treat pain, it follows that reducing the number of opioids being prescribed to pain patients could also decrease the number of people experiencing dependency on these substances.  The Federal government includes the Canadian Pain Task Force Report (CPTFR) March 2021 as a recent highlight of their actions on opioids: 

“Goal #2 – People have equitable and consistent access to a continuum of timely, evidence-informed, and person-centred pain care and supports across jurisdictions” includes “the development, dissemination, and evaluation of evidence-informed clinical guidance for health care professionals who authorize access to cannabis for medical purposes to treat and manage chronic pain while actively working to support more research into potential applications.”

Today on World Overdose Awareness Day, we are exploring some of the medical cannabis pain treatments that are being researched, also available at our clinic, and the associated outcomes. 

Opioids & Chronic Pain 

Opioids are a class of medication primarily used to treat pain. 

About 1 in 4 Canadian lives with chronic pain; it is an enormous global public health problem. 

Chronic pain is pain that lasts or reoccurs for more than 3 months. It is not limited to the painful experience and is not only physical; several other symptoms are associated with pain. Pain provokes an emotional response too, causing anxiety or stress, depression, etc. With unrelieved pain, life can become pain-centered.

Chronic pain is recognized as an enormous global public health problem. Despite highly variable data, the estimated prevalence of chronic pain in adults is 18.9% in Canada (Schopflocher et al., 2011). Management of pain includes pharmacological and non-pharmacological treatments, but opioid medications remain a mainstay despite significant safety concerns and risk of use disorder, estimated at 46.6% among opioid users (Marel et al., 2019). Opioid use disorder involves both prescribed opioids and illicitly manufactured opioids, such as heroin or highly potent street fentanyl.

Opioid Use Disorder Treatment

“Addiction is not a choice—it is a treatable medical condition that requires a broad range of care and treatment options.”

Opioid agonist therapy (OAT) is used to treat individuals with opioid use disorder. The therapy mainly consists of methadone, hydromorphone or buprenorphine/naloxone treatment. While this therapy may have an impact on opioid-related mortality, its effectiveness is still debatable with many individuals still using opioids while on therapy (Stone et al., 2018).

Several supervised injection sites make these drugs available for opioid users. 

The Centre for Addiction and Mental Health recently published a set of guidelines for treating Opioid Use Disorder with OAT (CAMH, 2021).

Cannabis as a Potential Adjunct Treatment for Chronic Non-Cancer Pain

To move patients from a pain-centred life, to a functional-centred life, we must empower patients to take control over their own health, to improve their functionality and their quality of life. Healthcare professionals at our practice help patients to help themselves.

In this context, the use of opioids in chronic pain management is a topic of significant debate and there is increased interest in alternative treatment options.

Opioids = not that effective, strong side effect, risk for dependency, overdose

CBM = somewhat effective, mild side effects, minimal risk for dependency, no overdose

Cannabinoid-based medicines (CBM) may offer a safe complementary therapeutic option to refractory pain and associated symptoms, due to their potential analgesic effects in chronic pain patients (Urits et al., 2019). Some observational studies have reported a reduction in opioid use for pain management after starting a CBM treatment (Boehnke et al., 2019; Safakish et al., 2020). ​​In a recent observational study, 28.1% of participants reported using opioids at baseline, decreasing at 11.3% at six-month following medical cannabis treatment (Lucas et al., 2021). 

A review by Okusanya and colleagues (2020) analyzed 9 studies (7222 participants) and showed “a 64–75% reduction in opioid dosage when used in combination with CBM and use of CBM for opioid substitution was reported by 32–59.3% of patients with non-cancer chronic pain”.

Cannabis-based Medicine Treatment for Chronic Pain at Santé Cannabis

“Chronic pain is an epidemic in North American society; treating it with opioids is leading to the crises with opiod overdoses. Medical cannabis has been proven to work for both malignant and non-malignant pain, and therefore can be enormously helpful as an individualized treatment with opioid sparing effects. 

Further, anxiety, depression and sleep disturbances are related to chronic pain, and all respond to some strains of medical cannabis.

A fatal overdose of medical cannabis is very unlikely (WHO, 2018), so on a whole, when we increase medical cannabis we can decrease opioids, which in turn will lead to a decrease in overdose deaths. With the correct supervision for patients, the correct dosage and strains, we hope to see a change in removing people from their long term opioid use.”

-Dr. Michael Dworkind, MD, Medical Director

Our most recent data shows that about 75% of our patients come to the clinic to examine CBM treatment for chronic non-cancer pain not alleviated by conventional treatments. After three months of treatment, pain severity and pain-related interference scores, measured with self-reported validated scales from 0 to 10, significantly decreased suggesting improvement in pain intensity.

Side effects are experienced by about 30% of patients and include drowsiness, dizziness, headache and fatigue. The majority of them are mild and transient. Our clinic staff is well trained on the monitoring of such side effects and strategies to mitigate those include decreasing the dose or adjusting the product formulation. Some of this data was presented at a recent scientific conference, you can find more information about this here.

Overall, cannabinoid-based medicines are generally recommended as adjunctive treatment for chronic non-cancer pain. 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  (Chang et al., 2021). Indeed, cannabinoid efficacy, potential adverse effects, cost, and related stigma should be addressed so that patients are adequately informed.

Further, data collected at Santé Cannabis shows that medical cannabis can address pain and sleep disturbances.  Our healthcare team uses medical cannabis as a tool that can serve as an adjunct treatment for chronic pain. (Häuser, W., et al. 2018)

Consensus-Based Algorithm

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 (Sihota et al., 2021). Notably, there is no age restriction in the algorithm, as there is no rationale to withhold cannabinoid-based medicines until a certain age if the patient already takes opioids.

Cannabis as a Potential Adjunct Treatment for Opioid Use Disorder 

We previously wrote about how CBM can help in substance use disorder (here). In this blog post, we focus on opioid use disorder. Population studies have recently identified reduction of opioids and opioid overdoses in states where medical cannabis has been legalized (Bachhuber et al., 2014; Bradford et al., 2018). Nevertheless, data is very limited in this area making conclusions hard to draw (McBrien et al., 2019). 

A recent paper examined the impact of cannabis and fentanyl use among people on OAT in Vancouver and found that participants using cannabis (with THC) were associated with a lower risk of exposure to fentanyl (Socias et al., 2021). 

Very few controlled studies on CBM and OUD exist. A double-blind randomized placebo-controlled study was conducted on the effect of CBD on cue-induced drug craving and anxiety in 42 drug-abstinent heroin users (Hurd et al.,2019). It assessed the effect of CBD (Epidiolex®) or placebo on behavioural, cognitive and physiological measures following oral intake of CBD (acute), then again after 3 consecutive days of treatment (short-term) and last 7 days after the last treatment (protracted). ​​Exposure to CBD resulted in a reduction in cue-induced anxiety and drug craving in heroin-abstinent persons starting as soon as 1 hour after ingestion and up to 1 week after the final administration. However, this effect was not observed on self-reported drug craving questionnaires, which could be explained by the different types of craving: home-general craving versus experimentally induced one. The same study also showed that CBD administration did not affect cognition but led to decreased cue-induced cortisol levels.

Research on CBM and OUD is still in its infancy and more controlled research similar to this one is needed to consolidate observational findings and clarify the potential effectiveness of cannabis as an adjunct treatment to OAT for OUD. 

Claims of the role of CBMs in the management of the opioid crisis are still preliminary, and in direct contrast with cannabis’s status in the US. Such findings require further validation in controlled settings to assess the opioid-sparing effect and the safety and effectiveness of long-term CBM use. The status quo sees no end to both opioid and chronic pain crises while cannabis use increases primarily without sufficient medical supervision.

Looking to End the State of Emergency

We look forward to the day where the opioid crisis is no longer considered a state of emergency. No one single strategy will solve this issue, projects from reducing stigma, preventing pain, providing rehabilitation centres, reduction of opioid use and more all need to work together to reduce the number of lives tragically lost.

At Santé Cannabis we are taking on one small part of the work that needs to be done, by providing people alternatives to opioids when treating chronic pain. We look forward to the day when medical cannabis is an option for more patients when seeking support for pain from their family doctors.  

For Quebec doctors and nurse practitioners interested in helping end the state of emergency, we offer the Prescriber Training Program to provide practical information about the clinical use of medical cannabis, and just published a new module on non-cancer pain and medical cannabis. Register for free here: 

Resources 

https://www.nature.com/articles/d41586-019-02686-2

https://pubmed.ncbi.nlm.nih.gov/32419434/

https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/maps

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

This year we were thrilled to be selected out of the many applications for both an oral presentation and two posters highlighting the work from not just our research team, but our entire clinic. 

The Symposium

“The International Cannabinoid Research Society is a non-political, non-religious organization dedicated to scientific research in all fields of cannabinoids, with more than 650 international Members researching the endogenous, plant-derived and synthetic cannabinoids and related bioactive lipids.” https://new.icrs.co/ICRS2021/ICRS2021/

Every year, the society holds a symposium to present the latest on cannabinoid research. 

Due to the COVID-19 pandemic, the symposium was held virtually this year; it was nonetheless a success with over 70 oral presentations and 180 posters, bringing together top researchers and clinicians from the medical cannabis community. Our presentations  discussed the impact of medical cannabis on pain management (one poster) and the role of cannabidiol (CBD) in symptom management (one poster and one oral presentation). 

CBMs for Chronic Pain 

The poster on cannabinoid-based medicines (CBMs) for chronic pain investigated the overall effectiveness of CBMs and the impact of treatment and population-based factors including treatment formulation, method of administration and pain mechanism. This study on 198 patients with pain as a primary symptom provided preliminary indication that CBMs may be considered as an adjunct for the treatment of various pain conditions besides neuropathic pain. Results are both novel and require further investigation. In contrast with current literature, oral CBD-rich products were the preferred product and method of administration.

Click to view CBM_for_Chronic_Pain poster

The CBD Craze

The other poster talked about the current CBD craze. Many countries are now legalizing CBD-rich products, yet validation of the therapeutic expectations of CBD products has fallen behind, and requires further research. The study compared effectiveness of CBD-rich products and THC:CBD products in 1,095 patients on symptom burden. Findings showed a modest improvement in symptom management with CBD-rich treatments and the necessity of both CBD and THC-based medical cannabis treatments to improve treatment effectiveness, for specific symptoms. 

The oral presentation assessed CBD-rich treatments on overall symptom burden and the effect of transition from a CBD-rich to a THC:CBD combination in 279 patients. Our results show that CBD-rich products may be effective to treat multiple symptom expressions simultaneously. Precisely, this study indicates a more significant positive impact of initiation of CBD treatments in patients who present with a higher number of severe symptoms, regardless of the product used after the first follow-up visit. 

We are very excited to announce that a full manuscript relating to this dataset was recently published in the Journal of Cannabis Research. 

Click to view The_CBD_Craze poster

What does CBD-rich, THC:CBD and THC-rich products mean, really?

Cannabis products, including medical cannabis ones, contain over 100 cannabinoids, among which Δ9-tetrahydrocannabinol (THC), and cannabidiol (CBD) are found in significant but variable concentrations and have garnered the most attention. Products available in Canada are categorised depending on their THC and CBD concentration, expressed either in weight concentration proportion (% w/w) for dried flowers or in volume (milligrams/milliliters; mg/mL) for oil products. When we talk about CBD-rich, THC:CBD and THC-rich, we group the products based on their CBD and THC concentration. 

CBD-rich means the product contains a high concentration of CBD and hardly any THC. In the Canadian medical cannabis program, CBD-rich cannabis oils contain approximately 0.5-1 mg of THC/mL and 20-25 mg of CBD/mL depending on the product manufacturer. In Canada, CBD-rich products can come from both hemp plants and other varieties of cannabis plants (more about CBD regulations in Canada here). 

THC:CBD means the product contains somewhat equivalent concentrations of both CBD and THC. 

THC-rich means the product contains a high concentration of THC and hardly any CBD. THC concentration can go up to 30% in dried flower cannabis products available in Canada. 

CBD, while  structurally similar to THC, does not cause intoxication or euphoria. Because CBD produces few adverse effects (Chesney et al.,2020), both patients and clinicians generally prefer to start medical cannabis treatment with CBD-rich products in order to limit the use of THC and its inherent potential adverse events (Brown, 2020). THC may be gradually added later to improve treatment effectiveness on specific symptoms. 

Table 1: THC and CBD contents and associated THC:CBD ratio for three of the most common oil products from each category authorized at Sante Cannabis.

Table 2: THC and CBD contents in percentage weight per weight (% w/w) and associated THC:CBD ratio for three of the most common dried flower products from each category authorized at Sante Cannabis.

To learn more about specific dosage to recommend to your patients, visit our international training page to find out about our unique clinical learning programs and preceptorships. 

Conclusion

As usual, the symposium was a great opportunity to learn more about all the exciting cannabinoid research that is happening around the world. So many people are dedicated to advancing knowledge on medical cannabis to improve access for patients, and we are proud to be able to play a part in advancing the world’s knowledge base. We are already looking forward to next year’s event, hopefully in person this time. 

Thank you to all our patients who participated in our real-world data observational study. These presentations would not have been possible without your dedication to advancing cannabis research. 

To find out more about our research programs and to get involved, visit our Research Partners Page

Author

Lucile Rapin

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

On World MS day (May 30th), we’re exploring the latest on Multiple Sclerosis and cannabinoid-based medicines (CBM). 

As clinicians and researchers, we’re sharing our takeaways for healthcare professionals, up-to-date literature on MS and CBMs, information from our clinics and the perspective from one of our active patient advocates.  

What is Multiple Sclerosis (MS)?

Multiple Sclerosis is an autoimmune and neurodegenerative disease affecting the spinal cord and the brain, which can lead to a variety of symptoms depending on what exact part of the central nervous system is affected. An autoimmune disease is a disease in which the immune system attacks healthy parts of the body. 

In MS, cells involved in neuro-inflammation mistake myelin (the protective barrier around neurons) for a foreign antigen and attack it repeatedly. As the myelin sheath can be repaired but not seamlessly, the accumulation of scars in multiple areas causes a wide range of symptoms. 

Most frequent symptoms include spasticity, pain, tremor, impaired balance and coordination, gait difficulties, fatigue, depression, bowel and bladder dysfunction, cognitive impairment, sensory impairment. No two cases are exactly alike, and different people will experience different symptoms in different severities. 

MS is separated into four subtypes according to the disease progression including the frequency of relapses (attacks): clinically isolated syndrome (CIS), relapsing-remitting (RRMS), secondary progressive (SPMS) and primary progressive (PPMS). 

Multiple sclerosis is one of the most common neurological diseases affecting 2.8 million people worldwide. Multiple sclerosis can occur at any age, however is typically diagnosed in individuals aged 20 to 49 years old. It is most frequently seen in women compared to men. 

Canada has one of the highest rates of MS with an estimated prevalence of 250 per 100,000 inhabitants. 

Top 9 takeaways for clinicians from the clinicians at Santé Cannabis:

1. In Quebec, medical cannabis should be considered only after first-line treatments are deemed ineffective. After attempting other treatments, you may want to discuss cannabinoid-based medicines  with your patient. If you don’t know where to start, you can sign up for our Prescriber Training Program for educational resources and access to a medical hotline. 
2. There is conclusive scientific evidence that supports the use of medical cannabis for MS related spasticity. (GW Pharma Ltd 2012)
3. Delta-9-Tetrahydrocannabinol (THC) is the cannabinoid identified in studies as being beneficial for spasticity in MS patients. Clinically, we typically see that THC can help with spasticity and MS related pain. However, cannabidiol (CBD) can help some patients with spasticity or pain. CBD has the advantage of not having many side effects and does not include the typical “euphoric” side effect associated with cannabis. 
4. THC has more side effects than CBD, including euphoria and the feeling of being “high”. However, it is possible to take THC medically without having side effects or being high: the key is starting at very low doses and titrating up very slowly.
5. The different treatment plans for the various MS-related symptoms are described in the educational material we offer within our Prescriber Training Program. 
6. Because of the very low amount of cannabinoid receptors in the medulla, it is impossible to die from a cannabis overdose (World Health Organization). However, accidents can be associated with impaired faculties due to cannabis side effects.  
7. Cannabis has contraindications like many other medications, it is important to know the contraindications and to assess patients prior to initiating a cannabinoid-based medicines treatment.
8. Capsules are concentrated oil placed in a capsule at specific doses and can replace cannabis oil for an ingested method of administration (long acting). This can make it a preferred method for certain patients.
9. Patients with multiple sclerosis often have trouble sleeping, cannabis at bedtime may help with sleep without worrying as much about side effects consequences (Zajicek et al. 2003; Schabas et al., 2019). 

“As a nurse myself, I know how important it is to seek out and research treatment options for the patients I see. As healthcare professionals we all have the responsibility to keep ourselves well informed for the sake of our patients’ safety and quality of life and this includes educating ourselves on cannabinoid-based medicines.” 

-Andrée Charbonneau, RN, Nurse coordinator

Current available treatments

There is currently no cure for MS however several pharmaceutical treatments exist to control inflammation, manage relapses and concomitant MS symptoms. Disease-modifying therapies alter the course of the disease; they are generally effective for RRMS and early treatment may  be helpful to prevent long-term disability. Symptomatic therapies are used to alleviate specific symptoms, notably neuropathic pain may be treated with antidepressants, antiepileptics and opioids and spasticity may be treated with muscle relaxants. 

General lifestyle recommendations such as exercise and balanced nutrition may also benefit patients.

Cannabinoid-based Medicines in MS 

Research on MS and cannabinoids started over fifteen years ago with a large randomized, placebo-controlled trial on 630 patients with stable multiple sclerosis and muscle spasticity (Zajicek et al. 2003, 2005). Patients were randomized to placebo, oral cannabis extract (THC:CBD), or delta-9-THC, starting with a daily dose of 5 mg to a maximum dose of 25 mg/day of active medication for a total duration of 15 weeks. 

The objective of the study was to ascertain the efficacy of cannabis extract or delta-9-THC for the treatment of spasticity and other MS symptoms. The findings indicated a reduction in patients’ perceptions of the effect of spasticity.  An unexpected secondary outcome result was a reduction of hospital admissions for relapses in both cannabis extract and delta-9-THC groups. Authors mentioned that trial patients had a slowly progressing MS, and since there are cannabinoid receptors on immune system cells, the reduced relapse rate in such an autoimmune condition is a finding that would benefit from further investigation.

Spasticity, pain, bladder dysfunction

Since then, the potential efficacy of cannabinoid-based medicines has been investigated mostly for spasticity, pain and bladder dysfunction symptoms (read more about MS spasticity and cannabinoid treatments here). Cannabinoids, and the endocannabinoid system, have been demonstrated to play a role in reducing spasticity in animal models (Chiurchiù et al. 2018; Baker et al. 2001; Nielsen et al. 2018; Zettl et al. 2016). Delta-9-Tetrahydrocannabinol (THC) appears to be effective in reducing spasticity in animal models and humans (Nielsen et al. 2018).

Systematic Reviews 

Two recent systematic reviews provide details: 

Nielsen and colleagues (2019) reviewed 27 studies and examined spasticity in adult patients with a range of conditions including multiple sclerosis (21 studies). 

• The reviewed studies examined the effect of THC, CBD, THC:CBD formulations, synthetic cannabinoids dronabinol and nabilone, inhaled (smoked) cannabis, and oral cannabinoid extracts. 
• Results were inconsistent between studies identified in the review, with many reporting positive effects on some but not all measures of spasticity and with most positive effects based on patient-rated measures rather than clinician-rated measures.

Nielsen and colleagues (2018), in their review of 11 reviews (32 studies) on MS symptoms and cannabis/cannabinoids, concluded that reviews identified evidence that would support trials of cannabinoids for the treatment of spasticity in patients with MS.

Torres-Moreno and colleagues (2018) reviewed 17 randomized clinical trials to assess the

efficacy and tolerability of cannabinoid-based medicines compared to placebo for symptom

(spasticity, pain, and bladder dysfunction) treatment in patients with MS. 

• The studied experimental interventions were oral cannabis extract; oromucosal cannabis extract/nabiximols; oral dronabinol; and oral nabilone evaluated as an adjunctive treatment to gabapentin (anticonvulsant). 
• Results for the pain symptom showed statistically significant differences in favor of cannabis extract, nabilone, and dronabinol. 
• There were statistically significant differences in favor of cannabis extract and dronabinol vs placebo for bladder dysfunction. 
• Nevertheless, most of the reported therapeutic effects for both symptoms were small. 

Overall, studies demonstrate cannabinoids have therapeutic properties useful for the treatment of some symptoms in MS. Cannabinoid-based medicines, whether plant-based or synthetic appear to improve patients’ perception of spasticity, pain and bladder dysfunction symptoms. Yet this perceived effectiveness is not clearly demonstrated in objective clinicians-based measures. This is both a downside, as it limits the supporting evidence for cannabinoid-based medicines, and an interesting indicator, as patients may be more sensitive to symptom improvement than clinician measuring tools.

Expectations for clinicians

Clinicians should have realistic expectations about cannabinoids’ efficacy, as the therapeutic effects may be small. There are other applications/MS symptoms in which cannabinoids could help (disease-modifying properties, bladder function), but the supporting evidence is mixed.

Research on MS and CBM is a good example of where we can go when we pursue rigorous studies; after several randomized clinical trials the oromucosal formulation of nabiximols was approved in Canada for the indication of spasms in this disease. (GW Pharma Ltd 2012). However, a recent notice from Health Canada stated nabiximols is no longer recognized as neuropathic pain management therapy in MS due to lack of evidence.

As is the case with most medical indications, research on CBMs and MS must continue to further these findings. There are currently very few (two) recruiting phase III clinical trials on multiple sclerosis and cannabinoid-based medicines. 

At Santé Cannabis, our clinicians use the ongoing research findings to provide treatment recommendations for their patients with MS. 

MS at Santé Cannabis

From our most recent database review of 1,275 patients between July 2020 and March 2021, 34 (2.7%) patients had a primary diagnosis of MS, and were aged from 23 to 68 years old (average 49 years). 25 of them (73.5%) identified as women. 

Of these patients with MS, 70% (24 patients) came to Sante Cannabis to evaluate CBM treatment for pain and 15% for spasticity. The others (5 patients) came for sleep disorders, headaches, numbness in legs and muscle rigidity. All patients also experienced secondary symptoms including sleep disturbances (19%), fatigue (18%), anxiety (14%), spasticity (14%), depression (10%), migraines and headaches (6%), stress (4%), nutrition-related issues (3%),  and muscle stiffness (3%). This multiple symptom presentation corroborates the wide spectrum of MS profiles in individuals and confirms patients are looking to alleviate multiple symptoms simultaneously. 

With regards to cannabis use history, most patients were not cannabis-naive: 50% had tried cannabis as a self-attempted medical treatment, 26.5% had tried it recreationally and 14.7% had never tried it.

Almost all patients were authorized with at least one ingested oil extract. 65% of patients were prescribed balanced CBD-THC, as while the literature suggests using THC to manage some MS symptoms, CBD can help to offset some of the side effects of THC.

With the use of our real-world data, our clinic is dedicated to offer better patient care through better science.  

“I have been living with multiple sclerosis for 42 years now. I took all kinds of medications and little by little my doses had to increase and I ended up with very high doses of several medications. I had many side effects and sometimes I felt like a zombie. I was still in a lot of pain and yet I was on the highest doses. That’s when my neurologist told me about a very serious study on medical cannabis and suggested that I participate. So I took a chance despite my apprehensions about cannabis in general… Eventually, …, I was able to both reduce my medication and control my pain. I feel fortunate that my neurologist sent me in this direction. ” Read more from Joanne, a patient at Santé Cannabis here

The combination of formal healthcare professional training and high-quality research is key to increasing the selection of treatments for MS and providing the best patient care.

Join us as we work towards the highest quality treatment for people with multiple sclerosis. Santé Cannabis is committed to advancing the knowledge on MS and CBM, and as such, we offer research services to companies and institutions interested in developing clinical studies. 

For clinicians currently treating people with MS who are interested in adding medical cannabis to their practice, our Preceptorships are available for any local and international physicians. For prescribers in Quebec we also offer a free Training Program more about CBM, and how to prescribe it.

Author

Dr. Lucile Rapin

with special thanks to the Clinical Education Team

Resources

https://mssociety.ca/

https://mssociety.ca/hot-topics/cannabis

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

Substance Use Disorder is defined as problematic patterns of substance consumption that lead to impairment and distress. According to a 2012 study, more than 21% of Canadians meet the criteria for a substance use disorder at one point in their lifetime.

Alcohol (18%) and tobacco (16%) are the two most common substance use disorders among Canadians, while nearly 7% of Canadians are thought to abuse or have developed a dependence to cannabis. Opioids meanwhile were responsible for more than 25% of all drug overdose deaths worldwide in 2017. Over 9,000 people have died from opioid overdoses in Canada since 2016. 

While it is important to remain cautious about the risks of cannabis use disorder in this patient population, carefully developed and closely monitored medical cannabis treatment plans can be an option for those who are struggling to manage cravings and other symptoms of withdrawal. 

SUBSTANCE USE DISORDER AND THE ENDOCANNABINOID SYSTEM: CBD & THC

The role of cannabinoid receptor CB1R in the modulation of dopamine activity is the basis for using medical cannabis as a possible treatment option for SUD. 

“The ECS, by direct CB1R activity, modulates and is modulated by mesolimbic[dopamine] activity […] It is thus thought that the disruption of endocannabinoid signaling may prove effective in treating SUDs”. (Chye et al. 2019)

Both preclinical and clinical studies indicate that CBD has the potential to help relieve withdrawal symptoms like convulsions, as well as reduce cravings and drug intake. Trials have found that CBD may also attenuate the impulsive discounting of delayed rewards, which may help diminish the risks of relapse in substance users who are already in remission. 

In a short article for Neuropsychopharmacology, Friedbert Weiss and Gustavo Gonzalez-Cuevas suggest that CBD may also be an advantageous treatment for SUD due to its efficacy with multiple substances, including cocaine, opiates, cannabis and alcohol. 

According to Weiss and Gonzalez: “Since co-abuse of opiates and cocaine with alcohol is common, the reported anti-reinstatement actions of CBD across three major classes of abused drugs further add to the putative treatment drug promise of this phytocannabinoid” 

Since CBD has a low potential for abuse, it may be aninteresting option for patients who might bet at moderate risks of developing a Cannabis Use Disorder. 

THC also shows some promise in the treatment for SUD, particularly for the treatment of opioid use disorder.  

Preclinical evidence suggests the use of THC-based pharmacological products like nabiximols and dronabinol could help mitigate the severity of precipitated opioid withdrawal. Researchers posit the mechanism for this process could be a result of cannabinoid agonists like THC modulating opioid signaling in noradrenergic cells of coeruleo-cortical pathways. 

OUR CLINICAL EXPERIENCE

The two most common administration methods in clinical trials for SUD were oral administration of ingestible CBD oil, dronabinol or nabilone capsules and oromucosal sprays like nabiximols. 

Conversely, Santé Cannabis’ clinical experience prefers the use of ingestible oils and nabilone over nabiximols or dronabinol (as it is not available in Canada). 

As for CBD, patients at Santé Cannabis tend to be prescribed doses that are significantly lower than the typical dose found in existing clinical trials. For instance, most clinical trials used doses of more than 100mg of CBD, but most patients take daily doses lower than 100 mg CBD at Santé Cannabis. CBD-rich products are expensive, therefore CBD daily dose is not increased further than 100 mg if there is no benefit and if the patient cannot afford it.

Nabilone doses in clinical research studies also ranged from 6 to 8mg/day, whereas the maximum dose of nabilone prescribed at Santé Cannabis was 6mg per day. 

Approaches to treating substance use disorders have sought shed taboos about addiction and dependence, and prioritize interventions like behavioral therapy and pharmacological treatments. 

CBD, SUBSTANCE USE DISORDER & YOUR PRACTICE

At Santé Cannabis we work alongside patients to help them achieve their desired health outcomes, including assessing if medical cannabis is an appropriate medication and ensure that they are receiving the correct dosing. We have developed dosing instructions and titration charts, and we modify these for our individual patients using our years of experience while considering findings coming from recent research. 

Interested to learn more about CBD and the correct dosing for your patients, but not sure how especially during COVID-19? We offer a training program for Quebec doctors, available online, free of charge, including learning modules, webinars, and virtual preceptorships. Registered doctors also have access to our support line with direct calls to our knowledgeable nursing team.

You can sign up here

A soon to be published two-year study from Santé Cannabis however suggests that CBD-rich medical cannabis treatments may on their own lead to only modest improvement of symptoms.

So does the clinical evidence for CBD’s therapeutic benefits support the hype?

LIMITED TO MODERATE EVIDENCE OF SYMPTOM RELIEF

Cannabidiol, or CBD, is the primary cannabinoid found in hemp, and is usually the second most common cannabinoid found in the cannabis plant. More recently, in Canada’s medical cannabis program, cannabis varieties and medical cannabis products have been developed to contain primarily CBD, though trace amounts of THC and other cannabinoids are present.

CBD is known for antiepileptic and anxiolytic effects supported by both clinical and pre-clinical evidence, with several studies also finding anti-inflammatory, immunomodulatory, antipsychotic and neuroprotective effects. Yet the mechanisms of CBD’s effects remain poorly understood and a lack of evidence supporting many of its potential therapeutic properties has proven to be a barrier to its clinical use.

Seizures associated with refractory epilepsy are the symptoms for which there is the most evidence supporting the use of CBD. Epidiolex^®, the first CBD-based pharmaceutical product, was approved by the U.S. Food and Drug Administration (FDA) in 2018 as an anticonvulsant in the treatment of Lennox-Gastaut syndrome and Dravet syndrome. It was also approved by the European Medicines Agency in 2019 but remains unavailable in Canada for the moment.

Findings coming from 5 randomized controlled trials also suggest moderate evidence that CBD can help reduce symptoms of psychosis.

Although the evidence supporting CBD as an anxiolytic is limited, Santé Cannabis clinicians have observed good results using CBD-rich treatment to relieve symptoms of anxiety. A recent surge in long term, high-quality studies on CBD and anxiety could offer more conclusive findings over the next few years. All the same, mental health conditions like anxiety for the moment only account for about 6% of patient cases at Santé Cannabis.

There is also limited evidence that CBD might serve as a treatment for symptoms of withdrawal and cravings associated with Substance Use Disorder.

IF YOU WANT TO FIND OUT MORE ABOUT CBD AND THE USE OF MEDICAL CANNABIS TREATMENTS, SIGN UP TO OUR PRESCRIBER TRAINING PORTAL

CBD vs CBD & THC

CBD’s popularity has grown partially due to its good safety profile and the fact that it doesn’t impart the psychoactive effects typically associated with THC.

These characteristics have to some extent helped create the perception that CBD holds greater medical and therapeutic value than THC. In certain countries, regulators have even launched medical cannabis access programs that exclusively rely on CBD treatment plans.

The latest clinical study from Santé Cannabis however indicates CBD-rich treatments may in fact only produce limited improvements in symptom management, compared to treatment plans that combine both CBD and THC. In many contexts, the use of THC in might be necessary for patients to derive greater benefits from their medical cannabis treatment.

The Santé Cannabis study was set to be presented to the Annual Symposium of the International Cannabinoid Research Society and will be published later this year.

It was conducted with patients who initiated medical cannabis treatment at one of our four clinics in Quebec between 2017 and 2019. The study followed two groups during this period: a group of 715 patients who were prescribed CBD-rich treatments and a group of 380 patients who were prescribed both THC and CBD treatments.

The effectiveness of treatments was assessed using standardized medical questionnaire and validated assessment tools like the Edmonton Symptom Assessment Scale (ESAS), Brief Pain Inventory (BPI) and EQ5D at baseline (BL), as well as 3-month (FUP1) and 6-month (FUP2) follow-up.

The study found that patients with treatment plans that relied on CBD-only products reported fewer improvements and benefits than those who incorporated both THC and CBD into their treatment. The CBD and THC patient group showed a more important improvement for almost all assessed elements by a statistically and clinically significant margin.

Additional data and a deeper investigation are still required to further validate these findings and to address control for potential biases.

In the meantime, in the absence of results from further studies, it is probably best to approach the CBD craze with caution and perhaps a dose of scepticism. Santé Cannabis however remains eager to continue clinical research into the matter in cooperation with other participants in the scientific, pharmaceutical and medical cannabis fields.