Medical Marajuana: Consortium of Multiple Sclerosis Centers
Faculty: Allen Bowling, MD PhD and Mark A. Ware MD
Reported by Cherie C. Binns RN BS MSCN
This is the first in a series of articles on topics covered in classes I attended at the annual Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) in Orlando, Florida between May 29 and June 1, 2013. In a symposium entitled “Complementary and Alternative Medicine: Controversial and Unconventional Therapies”, Drs Bowling and Wade discussed the history and use of Medical Marijuana and canniboid derivatives currently approved by the FDA.
In his introduction, Dr. Bowling told us that the use of Medical Marijuana is now legal in 19 States, the District of Columbia and Canada. Its legality has also been legislated for any adult wishing to use it for other reasons in the States of Colorado and Washington. HOWEVER, it is still illegal to cross State lines or International borders in possession of prescription Marijuana in any amount and is subject to high fines and even imprisonment if caught. This is true even if crossing from one legal domain into another. Therefore, he asks patients using this product to let him know prior to travel and he will see to it that they have a prescription for a legal canniboid derivative such as Marinol®.
For centuries and in countries around the globe, Humans have identified the medicinal benefits of pain relief, sleep enhancement, relief of spasticity , relief of nausea and a number of other properties of smoking or eating portions of the marijuana plant. It was freely used in the United States until the 1930s when a National Law was enacted vetoing its use. Many people continued to use the Plant in medicinal ways until the 1960s when it gained favor in higher doses with greater frequency as a recreational drug. The struggle between users of this drug and Federal and State Governments continues as States are, one by one, approving the use of it in certain populations for specific purposes.
Currently there are two drugs on the Market , Cannador® and Sativex®, that use an extract of the Cannabis plant to treat the pain and spasticity of Multiple Sclerosis (MS) in patients and have also been found useful in reducing nausea, and enhancing sleep in those with disordered sleep patterns. Sativex® has been available by prescription in Canada for many years and is anticipated to be approved for use in the USA later this year. It comes in the form of a nasal spray , while Cannador® comes in an oral form. THC, a derivative of cannabis, is medically available in the drug Marinol®. Marinol® was approved to manage the nausea of chemotherapy several years ago but has also been reported by some to reduce the pain and spasticity of Multiple Sclerosis.
Over the past decade and a half, multiple clinical trials have been performed using various forms of the cannabis plant (smoked, extract, THC only ) against placebo, and all have shown mild to moderate benefit over placebo. Smoked or inhaled (and vaporized) product reaches the Central Nervous system and blood stream the fastest (within a few minutes) and ingested comes next with a point of therapy reached in 45 minutes on average. This latter category includes Cannador® and Marinol® while Sativex®, a nasal spray, reaches the blood stream and effectiveness within minutes of administration. The two drugs noted that are derived from extract also appear to be more effective in managing pain and spasticity and promoting sleep than does the medication that is only derived from THC.
While legal amounts vary from State to State, Bowling made the point that, on average, persons using Marijuana and its derivatives for medicinal purposes (pain and spasticity relief specifically) use 20 times less than the average recreational user and an average of 4 joints daily is generally the maximum intake of the Person with Multiple Sclerosis (PWMS). Often 1-3 inhaled and held puffs with give relief from pain and spasticity then the “joint” may be extinguished and relighted 2-4 hours later as symptoms begin to build again.
Used as a sleep therapy, it appears to be helpful for those who have problems falling asleep but is not seen to be effective in keeping people asleep and the dosing may need to be repeated throughout the night when spasticity peaks or bladder issues wake the PWMS. Caution must be exercised (as with any smoked product) to avoid fire while smoking (dosing) in bed or in a compromised level of alertness.
Regarding mental impact, Medical Marijuana appeared to have significantly less impact on alertness and cognitive decline than did prescription drugs such as Neurontin®, anti-depressants and anti-spasmodics such as Baclofen®or Zanaflex®. Dr. Wade brought up the point that if patients are able to use canniboids such as Marijuana or Sativex® , often they are able to decrease the use of prescription drugs with higher side effect profiles and their alertness improves as does cognition so they are actually seeing what looks like people improving their alertness for driving. This, however needs further closely monitored study. He did caution those of us listening to this presentation NOT to suggest our patients use it as an aid to improved driving skill!
Whereas 5 years ago, we were seeing literature in the Medical Community stating that Marijuana had no documented Medical benefit, now we are seeing an improvement in patient reported pain and spasticity relief and a resultant objective improvement in function across several levels (walking, fatigue, cognition) when patients are switching from some of the standard pharmaceuticals to occasional use of canniboids for symptom relief.
Dr. Wade noted that Canada has had a program in place for twelve years now to administer Medical Marijuana to persons with various medical disorders including Multiple Sclerosis. HOWEVER, it is goal directed. One must show improvement in symptoms for which they use Marijuana and (hopefully) reduce the need for or dependence upon prescription symptom management drugs. If need for prescriptive medication is not reduced or quality of life and function not improved, prescriptions for Marijuana are not renewed.
This was a lengthy and informative discussion and I do have references available upon request. If you need references to these talks as they were being prepared, you can contact me through the “Ask the MS Nurse Link under the Information Tab on the home Page of MS Views and News or email me at firstname.lastname@example.org and I will send the referenced articles to you via email.
June 4, 2013
Reported by Cherie C. Binns RN BS MSCN
References on Use of Medical Marijuana
Bowling, AC Marijuana and MS: An Unfinished Story,MMomentum Fall 2010 pp 33-35
Iversen, LL The Science of Marijuana Oxford Press 2010
Corey-Bloom J. et al Smoked Cannabis for spasticity in Multiple Sclerosis: A randomized placebo controlled Trial. CMAJ 2012;184:1143-1150
Greenberg HS, et al. short term effects of smoking marijuana on balance in patients with MS and normal volunteers Clin Pharm Ther 1994;55:324-328
Petro DJ, Ellenberger C. treatment of human spasticity with tetrahydrocannabinol. Journal Clinical Pharm 1981; 21: 413S-416S
Ungerleider JT. Therapeutic issues of marijuana and THC. Int Jour Addictions 1985;20:691-699
Ungerleider JT. Delta-9-THC in the treatment of spasticity associated with multiple sclerosis. Pharm issues and Substa Abuse 1988;7:39-50
Vaney C, et al. efficacy, safety, tole5rability of an orally administered cannabis extract in the treatment of spasticity in patients with multiple sclerosis. Mult Scler 2004;10:417-424
Wade DT, et al. long term use of a cannabis-based medicine in the treatment of spasticity and other symptoms in multiple sclerosis. Mult Scler 2006;12:639-645
Wade DT, et al. do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? Mult Scler 2004;10:434-441
Zajicek JP, Apostu VI. Role of canniboids in multiple sclerosis. CNS drugs 2011;25:187-201
Zajicek JP, et al. canniboids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study) Lancet 2003;362: 1517-1526