Cannabis as a treatment for pain is finally moving outside its dedicated community to a wider patient population of historical non-users.
A large number of Canadians, through the medical market or otherwise, already treat their pain with weed. And while there’s research that affirms cannabis’s strong role in pain management, its effects are hugely complex and more study is required to isolate how its diverse compounds interact with pain pathways in humans.
National Pain Awareness Week, running from Nov. 1–7, brings awareness to the roughly 7 million Canadian citizens living with chronic pain.
1 in 4 Canadians live with chronic pain, affecting their health and preventing them from enjoying everyday activities. As we mark #NPAW2020, we’re supporting three projects to help provide support and access to care for people living with chronic pain. https://t.co/u4M7cnyzxe pic.twitter.com/JI3XPj3Eko
— Patty Hajdu (@PattyHajdu) November 6, 2020
Over the past decade, Mark Ware has been the director of clinical research at the Alan Edwards Pain Management Unit at the McGill University Health Centre, and executive director of the non-profit Canadian Consortium for the Investigation of Cannabinoids. And as Canopy Growth’s chief medical officer, Ware oversees the advancement of research at Spectrum Therapeutics, the company’s global medical cannabis brand.
This week, Ware spoke with Mugglehead about the all-encompassing nature of chronic pain, and how people navigate it with cannabis in an overwhelming sea of information. The following interview has been edited for length and clarity.
Whether it’s athletes or veterans, weed as a therapeutic tool is well out in the open. What key things should we be thinking about right now in terms of pain management and cannabis?
Well, I guess the best place to start is by recognizing just how big a problem pain is in our society — chronic pain in particular, which is pain that’s gone on for more than three months, after an injury or accidental trauma, surgery etc.
Normally pain helps. We have pain for a reason: It protects us and helps us avoid injury. But there are times when pain persists, and goes on much longer than the typical healing time. One-in-five Canadians suffers with pain that goes on longer than three months.
It becomes really difficult to manage, because it’s not something that responds the same way to medications. When you have a headache or a toothache, or you hurt your knee, you can take an anti-inflammatory. There are basic over-the-counter pain meds that are very effective for acute pain. But when it becomes chronic, it becomes very hard to manage.
Not only is it difficult to manage with medications, but also it becomes associated with other problems like difficulty sleeping, problems with mood and poor quality of life. And then that starts to spiral into a very vicious cycle, where patients get trapped with chronic pain, depression, poor sleep. They lose their jobs, their families. I spent 20 years at McGill treating patients with chronic pain. And I was really struck by how hard it is to get patients out of this trap.
It’s true. In my own personal life, I’ve seen people with chronic pain — back pain in particular — go down some very dark roads. How does cannabis come into play with chronic pain management?
It comes into this story from two different trajectories. One is because cannabis has been used in society socially and recreationally for for many years. And there are people who suffer from chronic pain who have discovered — I almost want to say by accident, but maybe out of desperation or just pure need — that when they use cannabis it actually helps their pain.
This has been recognized for a long time in surveys we’ve done in pain clinics: Somewhere between 10 and 20 per cent of patients attending a pain management clinic are already using cannabis in some way to try and map and manage their pain. We’ve interviewed them to understand what they’re using it for, and they say it’s not just about pain control — it seems to be able to make the pain less unpleasant.
They also say it helps with sleep, improves their mood and helps them function better. So you have this very powerful pain patient experience, which is one trajectory that we know.
The other thing that the last 20–30 years has taught us is that cannabinoids, the active substances unique to cannabis, work through a series of special receptors and ligands in the body — in the brain and the spinal cord and all of the tissues you would expect to be involved. In the tissues responsible for detecting and modulating pain signals, cannabinoid receptors play a very interesting role.
So we have these two streams of information: Patients telling us that it helps, and a basic scientific understanding of neuroscience telling us that cannabinoid systems may play a role in pain management. And when you’re faced with a patient who’s tried all of the standard therapies, whether they’re on prescription meds or non-prescription therapies, any good pain management centre will not just use medications. They’ll use psychotherapy approaches, physical approaches, complementary and alternative therapies — anything that can be used to help a patient out of this vicious cycle of chronic pain. And so perhaps cannabis is a tool to be included in that toolbox.
Right now there are people considering cannabis as a possible way to treat their pain. There’s tons of informal information available out there. But in Canada, regulations prohibit the industry from communicating health-related claims to consumers, and much of the medical community won’t speak on therapies that don’t have strong clinical evidence. Given weed’s potential to be an effective pain management tool today, how do you imagine bridging that informational gap?
It’s a difficult question. Because you’re quite right in that there’s a very large reservoir of knowledge to draw from. As you’ve said, we have knowledge about receptors and ligands. And we have knowledge about the endocannabinoid system, which by and large, doesn’t really have any counter-argument. It’s real, it exists. There’s no question that this is a valid therapeutic target.
It’s very tempting to talk about it as if it was one thing but we recognize that cannabis contains hundreds of compounds, which potentially have therapeutic properties, both beneficial and probably non-beneficial. So cannabis is not one thing. It’s a huge family of different compounds.
Then added to that complication, people take it in different ways — topically, inhaled, smoked, orally, cooked — all of which change the properties of the drug, how it’s absorbed and how quickly it works.
So we have a fair bit of knowledge around these basic fundamentals. And that reservoir of knowledge is there to draw from, through searches on the web, through colleagues in the community.
Unfortunately, what happens is then you get this gap between that knowledge and clinical trial data, which the typical evidence-based clinician who is sitting in the clinic talking to a patient relies on. Often the the argument that you’ll hear from the medical community is, ‘This may all well be true, but we don’t have any trials that show that this is effective compared to placebo, or compared to another existing therapy.’
That’s something that Spectrum and others are working on, to try to fill that gap knowledge gap. Those studies are expensive, they take a long time, and there’s going to be a ways to go before that gap is filled.
The other problem is the patient asking about cannabis gets very stigmatized, because cannabis is also a drug of abuse — it’s a recreational substance. There’s this perception that the person wanting cannabis for pain control, actually just wants it for recreational purposes, is using it to get stoned or is addicted to it.
That complicates the whole equation. And so it’s not just about giving information; breaking down stigma is very important.
For people experiencing pain, who may or may not have used cannabis, how should they chart their journey amid swathes of dubious information and in the absence of hard clinical evidence?
Anyone interested in pursuing alternatives for pain management should first speak to their primary care physician. If that physician is not comfortable evaluating medical cannabis as an option, the patient can ask for a referral to a medical cannabis clinic or reach out to one directly as they share the goal of helping Canadians manage their symptoms safely and effectively.
Additionally, Spectrum Therapeutics has a wealth of information that is accessible to the public on its website. For example, here is a great article on how to talk to your health care professional about medical cannabis in addition to how to document your journey.
Correction (2020-11-09 9:11 a.m.): A previous version of this story said Mark Ware was still practicing medicine, as is stated on Canopy’s website. He is no longer practicing medicine.