Use of Medical Cannabis for Intractable Advisory Panel Questions and Public Comment

Transcription

1 Use of Medical Cannabis for Intractable Advisory Panel Questions and Public Comment Meeting Notes for June 15, 2015 Present: Arthur Wineman, Nancy Jaworski, Orlando Charry, Neal Walker, Daniel Truax, Mary Pat Noonan, Amy Anderly-Dotson, Erin Krebs MDH Staff Present: Commissioner Ellinger, Deputy Commissioner Pollack, Michelle Larson, Tom Arneson, Alix Noonan, Alison Bjork Presenter: Dr. Miles Belgrade Critical Information Needed from Advisory Panel Is there a fatal dose of medical cannabis? Is there a risk patients will overdose? Study results relevant to the use of medical cannabis and intractable pain More information on components of the drug, such as THC, that will be used and how pharmacies will make decisions about its composition Interaction of cannabinoids with other medicines used to treat pain How to define intractable pain and what to do to get there o Definition offered by Dr. Belgrade s presentation: Pain is intractable when there exists no treatment or strategies that will alleviate it. Social and public risks of the use of medical cannabis and how to balance those risks with medical evidence What have other states done? o State information compiled in packet Because the use of cannabis is still against federal law, how does that work? How much could it potentially hurt someone? How does that compare to other intractable pain treatments? o Potential information exists in studies of recreational use Question and Answer with Dr. Miles Belgrade Question: Chronic pain is complex and multifaceted and cannabis will not solve all these problems. What perspective do you have on chronic pain versus suffering? It would be very important to keep those two interrelated terms in mind. Answer: They are different. I saw a patient with severe neuropathic pain. He s not suffering; he would just like to see improvement. But some patients with relatively smaller neuropathology are suffering a lot. 1

2 Question: What about patients that are palliative without the expectation of their function improving? Answer: The legislature will be looking at whether there is an improvement in function. Some of those are in the literature review. Some have physical function measurements. Question: What we do in this country to address pain isn t entirely working. What is the lack? Is it the lack of the modalities? Or is it how our system is arranged, so we don t get the right modalities to the patients when they need them? Answer: Both. Some would really benefit from an interdisciplinary pain approach. Insurance in many clinics isn t going to pay for that kind of thing. It takes time and money. I also think we don t have a silver bullet. We would like one. Glial cell activation is showing promise. Every level of the nervous system gets impacted. Discussion Pain in children is often a representation of what s happening in society. Some kids come to the hospital because it s a safe place, and they see pain and going to the hospital as a way to get their needs meet. If that cycle gets perpetuated into adulthood, how do we help them become independent if medicine is their ticket because their home isn t safe or there s food insecurity? Pain for kids can start early, and it s really hard to transition them into health services because they don t have a trusted adult. There are multiple levels of complexity. In our clinic we have a multimodal approach, but we operate off a foundation subsidy. Question: Is there a shift in how insurance companies are paying for hospitals? I talked a lot about that with the integrated care system. You get $3000 for each patient but primarily with adults. Answer: We did it in the 1990s but it s a capitated system. But that will just make things more difficult. Question: Is there any sort of movement toward paying more for multimodal care? Answer: I think Obama was trying that before. In chemical dependency and maybe for other specific funds there is. But you re talking about the whole integrated care system. That young person may not be comfortable in the hospital setting but in the institutional settings. Fairview is providing integrated care and find it is saving money. Thirty to fifty percent of people with chronic pain have a personality disorder, and that makes it harder in our clinics and on opioids. Personality disorders are formed early and are enduring. It s difficult to communicate, and some personality disorders by nature are anti-rule. So they don t follow instructions. But this 2

3 applies to every high-risk treatment or treatment that requires good communication between the caregiver and patient. Question: What about Naltrexone, the opiate antagonist? Have you used that with some of your chronic pain people? Answer: I haven t but one study looked at it with fibromyalgia. And then Naltrexone as a glial cell activator. They use it for anti-craving but also for chronic pain, and they use Subutex/Suboxone for treatment of heroin and opiate addiction. Question: A common denominator with doing poorly with pain treatment is that we don t have the long view in helping someone reduce pain. As a society we like a fix or magic bullet. Part of it is really getting someone to buy into it and get religious and engaged in their treatment plan. One concern I hear is that they may people prevent from engaging proactively with those more proactive methods. Answer: Many are dissociative which makes you lose motivation and get by. Over time you get by with a little more medication until you re kind of miserable like before but you re more apathetic of that. It also happens with antidepressants. Some patients who are the extreme example beg to be knocked out for three days. Medical marijuana is very different from recreational marijuana, but there s also too much prescription of opioids and more diversion of opioids. There s got to be a lot more holistic care and look at the social/emotional/physical/spiritual piece of that. Question: There s the hope that using medical cannabis for pain will allow patients to reduce or eliminate their opioid use. I m not finding too much information on this. Do you have any observations to make? Answer: My experience is users are as likely or more likely to want to continue their opioid medication and continue at the same rate. No one has asked to be taken off the opioids When e-cigarettes first came out, a study of veterans found that those who used e-cigarettes to quit were actually the least likely to quit. Question: Have the prescriptions for opioids went down in other states? Our new theory of pain is that opioids work doesn t affect the pain level but the way they respond to it. It s not helping the pain it s helping the suffering. Answer: The pain is the same, but with opioids they don t care as much about it. Of the patients that I treat that I know are smoking marijuana, it might actually make them opioid-seeking. 3

4 Some people take opioids inadvertently for their anxiety. Is it more useful as an anti-anxiety medication? Maybe. And is it more effective than other anti-anxiety medications? Question: When we treat pain there are three basic things we look to do: decrease the amount of pain, decrease the amount of pain medications, and decrease antipathy, so they can be more motivated and be more active. How would cannabinoids impact those three areas? Answer: I often see patients on oxycodone and hydrocodone and a long-acting morphine. They take hydrocodone for their head pain and oxycodone for back pain, but neither works for both types of pain. They re not willing to give up one opioid. They hang on to all of them. Question: Is it safe and effective? Making that decision should not be tied to whether or not they replace opioids. That doesn t answer the question of whether it s safe and effective. Answer: Yes, but if I thought for a second I could get a patient off opiates by using cannabinoids I d do it in a heartbeat. Question: Maybe I just need to read more but what else does cannabis have to offer? My biggest worry for chronic pain patients is their level of self-destruction. Will medical cannabis create harm? Is it really safe in the long term? Answer: How do you diagnose chronic pain? It s really subjective. That s why I struggle with intractability. Because often there are other options that they may have tried but never truly engaged in and found something to focus on that they got joy from. The chemical in their brains will start to shift. How many patients have jumped through all the hoops and get to the opioids? There isn t anything objective. It s not a slam dunk, and I have patients I think and hope cannabis might help. Intractable is, I think of, PTSD. Question: When you look some of the people with mental health disorders, they may be more hypersensitive to physical pain. Or are they drug seeking? Some patients it s not because something physical happens; it s because something emotional happens. It is adverse selection: the people least likely to benefit and the most likely to be harmed are the ones that will receive the highest dose regimens. Answer: I just believe they have pain, but I try to see what the pain is coming from and their continuing factors. The doctor is tasked to with not just listening to pain but actually understanding the pain and selling people on the strategy to relieve the pain. 4

5 Public Comment Speaker 1: I m from Minneapolis and have been in remission for Crohn s Disease for six years exclusively on cannabis, so please keep an open mind. Don t assume everyone on cannabis is lazy and unmotivated. I wouldn t have graduated and gotten work or even be here without it. Please leave your assumptions at the door. Speaker 2: Thank you for having me here today and having this conversation in general. The human body currently has an endocannabinoid system that produces an Anandamine that is similar to THC and if the Anandamine is providing pain relief it seems like a very easy step to make that a substance similar to the Anandamine. THC also provides pain relief to the human body and it s possible that some people don t have an adequate endocannabinoid system and a plant could help supplement that. Contrasting that plant with opium or synthetic derivatives, it seems like a no-brainer that people with extreme pain should have access to it. Under the Minnesota medical cannabis statute, there are only liquids, oils or pills available, any of which would be a felony under Minnesota criminal law. Even one pill is a felony. Your decisions is: for patients that have intractable pain, should they have the legal right to possess these materials and not be branded a felon because they re trying to take care of themselves? Everyone has the right to life to preserve their bodies, liberty to choose the substances they put into their bodies, and the pursuit of happiness intractable pain results in depression. There are a lot of people that are suffering in Minnesota, and I ask that people on this panel try to be as empathetic as possible and listen to the stories that are out there. People are using this for therapy. If you practice listening skills you will learn that there are people in Minnesota that really need this for relief. Don t look at medical studies only, and do this job as a whole human being. 5