Spring 2016 (Volume 26, Number 1)
Dis-jointed?
Download PDF
This issue’s Joint Count is going up in smoke!
The CRA featured A Smokin’ Panel as the 2016 Controversies in Rheumatology session at the Annual Scientific Meeting (ASM). The CRA surveyed members who attended the session, as well as those members who were unable to attend the ASM. Here’s what came out from amid the smoke and mirrors. The left sides of the tables report results from non-attendees, while the results on the right sides are those collected onsite at the ASM through the Sli.do app.
As a primer, Dr. Andy Thompson and his RheumReporters noted that the endocannabinoid system is important for the maintenance of homeostasis. This endocannabinoid system down regulates the sympathetic nervous system’s “fight vs. flight” system. Endocannabinoids reduce stress, and improve appetite, sleep, and pain.1
Chronic pain is prevalent. In Canada, about one in five individuals suffer from chronic pain; this figure translates into about six million individuals nationally.1 Chronic pain is a constellation of symptoms that can include pain, insomnia, nausea, cognitive difficulties, depression, and anxiety. Opioids are frequently used in the management of chronic pain but a Cochrane Collaboration review
concluded that opioids have only a small effect on pain and physical function.1
Dr. John Pereira opened the Controversies in Rheumatology session, offering perspectives from a prescriber and
challenging the audience to consider whether medical
marijuana is riskier than standard opioids currently used for chronic pain management, from the perspective of tolerance, addiction, and overdose (Table 1). Of those surveyed, 84% of respondents outside the ASM and 97% of those who attended the Controversies in Rheumatology session noted that this statement was false. Dr. Pereira urged the audience to keep their minds open and to consider medical marijuana, including strains that are minimally psychoactive. Physicians should acknowledge that we generally lack great treatment possibilities for chronic pain and we should consider alternatives.1
Continuing the discussion, Dr. Mary-Ann Fitzcharles asked whether the option to Smoke those Joints Away is the best course of action for patients with chronic pain.2
She asked about the most compelling evidence for addiction to marijuana. There was no dis-joint in the answers given (Table 2), with 82% of those who did not attend the ASM and 92% of attendees responding that marijuana causes changes in the amygdala and nucleus accumbens of young recreational users when using daily cannabis. Addiction occurs in 9% of all users.1
Dr. Steven Bellemare ended the session with an overview of medical-legal considerations for prescribing cannabinoids for rheumatic-related conditions. He set up a scenario where a physician is considering signing the medical document to provide access to medical marijuana for one of her patients. In the scenario, the physician consults a number of resources in order to ensure her practice falls within the acceptable standard of care. He then asked the audience which body’s guidelines or advice is it most important to align one’s practice with (Table 3). Of those surveyed outside the ASM, 75% reported that the provincial regulatory body should guide practice. The vast majority (91%) of those who attended the session selected the same response. Again, no dis-joint in understanding there!
The takeaway message from the Controversies in Rheumatology session was that there is some smoke and mirrors at play when discussing medical marijuana usage in chronic pain patients. The general consensus was that physicians should be wary of risks to patients and society when considering alternative treatment options with data available thus far.
References
1. Thompson A. Medical Marijuana for Chronic Pain - All Smoke and Mirrors? Available at: www.rheumreports.com/?report=373&title=Medical_Marijuana_for_Chronic_Pain-All_Smoke_and_Mirrors%3F&c=2016_CRA_AHPA&r=%
2Freporters.php%3Fview%3DAndyThompson%26c%3D2016_CRA_AHPA%26r%3%
252Freporters.php
2. Fitzcharles MA. Smoke that joint away. A prescription for herbal cannabis: Primum non nocere. Available at: www.rheum.ca/images/documents/Smoke_those_
Joints_Away_-_Mary-Ann_Fitzcharles.pdf |
