23 Jan 2019
Bernard Lee, MD, knows all too well the misery of living with chronic pain. As the Vice President of Medical Affairs for MJHS, a non-hospital-based hospice and palliative care system and a physician who treats patients with pain, he, too, suffered from long-term chronic pain.
Then, on July 7, 2014, Governor Andrew Cuomo signed into law a comprehensive medical marijuana program for New York. Just a year and a half later, New Yorkers were able to obtain medical marijuana and Dr. Lee finally got relief from his chronic back pain by taking cannabis, or marijuana, in pill form. He has been taking it ever since and says he’s never felt better.
“Anecdotally speaking, cannabis has been an impressive game changer for me and for my patients,” says Dr. Lee, who has treated hundreds of patients with cannabis, many from his palliative medicine practice at Scarsdale Integrative Medicine.
Of the 26 states to legalize marijuana, New York was the first to require physicians be trained and certified in order to prescribe cannabis. Additionally, the conditions for which cannabis may be prescribed are clearly defined. From the start, patients in New York could receive a prescription for conditions including HIV infection or AIDS, amyotrophic lateral sclerosis (ALS), cancer, inflammatory bowel disease, epilepsy, spinal cord injury, Parkinson’s disease, Huntington’s disease and multiple sclerosis. In March of 2017, chronic pain was added to the list.
To receive a prescription for chronic pain, the New York State Department of Health requires “documented evidence” that the pain has lasted at least three months or is expected to last three or more months. The statistics for NY state bear out that most medical marijuana is being used to treat chronic pain (53.1% of cannabis patients).
As of July 2018, any condition for which an opioid could be prescribed, “provided that the precise underlying condition is expressly stated on the patient’s certification,” was added to the list of conditions that qualify for treatment with medical marijuana. Patients with an opioid use disorder may also qualify for cannabis treatment, provided they’re enrolled in a certified treatment program.
According to Dr. Lee, misconceptions about medical marijuana abound. Some people think you must smoke cannabis to get the effect, and that you experience the same high you would get from smoking marijuana.
Dr. Lee explains that while there are more than 100 cannabinoids in the cannabis plant, the two that are most important in terms of treatment are the naturally occurring cannabinoids purified from plant sources: cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC).
“THC is the one that gives you a high,” says Dr. Lee. “It also has wonderful medicinal properties. It can stimulate the appetite and calm stomach pain.” CBD, on the other hand, modulates the high that occurs with THC and also has anti-inflammatory properties. “CBD and THC may even have cancer-fighting properties.”
There are several ways patients can consume cannabis. Smoking medical marijuana is not permissible, but patients can vape (inhale the cannabis “vapor”). Vaping cannabis allows a patient to begin to feel the effects within minutes. “When you vape, there is no combustion, and you are not inhaling,” explains Dr. Lee. “The oil is extracted from the plant and reconstituted so it has the appropriate levels of CBD and THC. The patient gets a balance of the two.”
For those who vape, the effects of the medical marijuana peak at around 15 minutes. It offers close to immediate relief from pain and nausea, says Dr. Lee, but the downside of vaping is that the effects only last for around two hours. For chronic pain patients, a longer-lasting option are the capsules, which maintain their effect for four to six hours – even up to eight hours. “The downside is that you have to digest the capsule, so it takes longer to feel the effects,” Dr. Lee says. “You can start to feel the effects at 45 minutes to an hour, and you are at full effect at around two hours.”
Some chronic pain patients may “mix and match,” says Dr. Lee. “A pain patient may wake up in the morning and use the vape pen and do their inhalations,” he says. “This helps them start their morning routine. Then they take their capsules, so as the vape is wearing off, the capsules are starting to work.”
Patients for whom this routine works well include those with herniations along their spine, patients with rheumatological disorders like rheumatoid arthritis, and patients with migraines or with fibromyalgia.
Besides vaping and capsules, the other common legal route for medical marijuana is an oral solution, or tincture. “This is a good route for really sick patients and for those who are bedbound,” says Dr. Lee. “If you swallow it, it goes to your stomach and needs to be digested, but if you hold it in your mouth for two minutes, then you get what we call sublingual [under the tongue] absorption. This is when it goes directly to your bloodstream and begins to work.”
Unfortunately, because it is still not legal in all states, medical marijuana is not covered by insurance. Treatment can cost $400 or more per month, making it unattainable for many.
For patients with pain, cannabis can be life-changing. “But it is not just one magic bullet,” cautions Dr. Lee. “It is not just one medicine to take care of your problems. Treating pain is also about acupuncture, electrical stimulation, and nutrition.”
Medical marijuana is not for everyone, admits Dr. Lee. “It doesn’t help all patients, but nothing in medicine does,” he says. “Still, we are able to help people in so many more ways now with cannabis than we could before.”