Patient Access to Medical Marijuana - the Michigan Dilemma

In Michigan, Marijuana/Cannabis is legal. Local communities may opt-in for either medical marijuana, recreational marijuana or both. Rural communities such as ours are rightfully considering support for medical marijuana dispensaries; currently patients with pain and seizures must drive three hours for the nearest dispensary.
Dispensaries are highly regulated, highly taxed and require businesses to spend nearly half a million dollars to open, which limits availability to patients. As a physician and educator, I remain concerned about the misinformation regarding marijuana but remain hopeful this community demonstrates compassion toward patients hoping for some relief from suffering known to be alleviated by marijuana and its biologically active compounds.
For recreational purposes, the word marijuana refers to the leaves and female flowers of the cannabis plant, the only parts containing compounds known to create the “high” when activated by heat. In contrast, medical cannabis (medical marijuana) is the whole plant or chemicals in the plant used for medical purposes, focusing on two main cannabinoids.
Cannabinoids are substances in cannabis acting in the body via cannabinoid receptors. Humans have naturally-occurring cannabinoids receptors in brain, spinal cord and nerves, including the nerves in the gastrointestinal tissues. Two most-studied cannabinoids are:
• Tetrahydrocannabinol (THC) which can stop nausea and causes the psychoactive effect of "getting high";
• Cannabidiol (CBD) which does not cause psychoactive effect. (This substance is now approved by the FDA to reduce seizures in epilepsy).
Pain and Muscle Spasms. Clinical trials with cannabis using varying ratios of THC to CBD demonstrate cannabinoids may be useful in neuropathy, spasticity due to multiple sclerosis, and other symptoms caused by nerve dysfunction.
Outside the US, cannabis extracts are legal as capsules (CannadorR), with the main constituents being THC and CDB in a ratio of 2:1. Rectal suppositories are also available to deliver THC in patients who cannot swallow safely or have intractable vomiting. Studies in Multiple Sclerosis (MS) demonstrate improvement in pain and spasticity at daily doses of THC ranging from 7.5mg to 27.5mg.
Most research using oral preparations has targeted neuropathic pain and spasticity associated with multiple sclerosis (MS). These trials suggest that dronabinol (up to 25 mg daily) significantly reduces pain compared to placebo (50% “improved” on dronabinol compared to 30% on placebo). Dronabinol available by prescription for patients who can swallow capsules, however the FDA indication is for nausea and chronic wasting.
One study with 12-month follow-up concluded there may be sustained relief for pain associated with multiple sclerosis. 30% of cannabinoid-treated participants had relief at 12 months compared to 15% on placebo, with dose limited to 25mg THC daily. This suggests pain relief
may be sustained without increasing doses, unlike conventional pain medications.
Results consistently indicated that cannabis significantly reduced pain intensity, with patients reporting 34%-40% decrease on cannabis compared to 17-20% on placebo. (A 30% decrease in pain intensity is generally associated with reports of improved life quality.) In a similar study, the effect of 25 mg doses of smoked cannabis at various potencies, administered three times daily for 14 days demonstrated that 9.4% THC produced some analgesic effects in patients who failed respond to conventional pain medication.
Seizures. Epidiolex (a CBD formulation) was approved by the FDA in 2018 to treat seizures in children and adults in whom traditional anti-seizure medications are ineffective; clinical studies showed seizures decreased by 41.9% when compared to 17.2% in placebo. Other studies showed that when added to prescription medications, CBD further reduced seizures by 36.5%.
Thus, when conventional treatments do not work (roughly 30% of people with epilepsy), it is reasonable to consider CBD oil. Unfortunately pharmaceutical-grade CBD cost for one year is roughly $32,000, similar to most new anti-epileptics. In contrast, whole plant cannabis costs about $5,000 per year.
Limitations. Cannabis is not a panacea; it fails to control overactive bladder and fails to stop the side-effect tremors from Parkinson’s and Schizophrenia medications. It has no effect on cancer survival and can interfere with some psychiatry and neurology medications.
In considering cannabis, communities should be mindful that the medications currently used for pain or spasticity also have adverse effects. Opioids produce sedation, nausea, constipation and dependence, Tricyclic antidepressants and antiepileptic drugs commonly prescribed for chronic pain cause sedation, constipation, dizziness, heart arrhythmias and urine retention. Muscle spasm medications cause sedation and syncope. Benzodiazepines cause sedation, falls, memory lapses and worsen dementia. In short, all currently available medications for chronic pain have side-effects, including death from overdose.
Unlike traditional pain medications, fatal overdose with cannabis alone does not occur. Therefore, judgments on benefits and risks of cannabinoids as medicines should be viewed within the broader context of risk-benefit of other agents as well.
A local medical dispensary allows patients and their physicians an additional tool to alleviate chronic suffering and improve life quality in a regulated setting.