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Study Finds “Insufficient Evidence” to Support the Use of Medical Cannabis for Pain Management

In Summary:

In a recent review of systematic reviews and controlled studies, researchers were unable to find sufficient evidence to support the clinical use of medical cannabis or the pharmaceutical formulations for gastrointestinal, cancer, or rheumatic pain, or weight loss in cancer of AIDS. Many data from previous studies were either statistically insignificant or were of low quality. However, the authors did find that existing literature sufficiently supported the treatment of neuropathic pain with cannabis. Additional controlled studies may shed more light on the use of cannabis for general pain management. Interestingly, while the authors do raise two important limitations of the studies that they highlight in the article (inadequate size of some studies and generally limited supply of traditional scientific studies from which to draw conclusions) they do not address some of the more fundamental concerns with the reporting.

Dr. Caplan and the #MDTake:

The limitations of studies in cannabis are numerous and an important consideration for researchers as they study cannabis, and equally essentially to consider for those of us reading the study product. To my personal count, there are at least 40 different types of biases that can skew data in a way that delivers information other than a precise description of actual events. This study, as many like it, presumptuously assumes that, if data doesn’t show a trend that so-mocked “anecdotal” data shows, then surely the anecdote must be incorrect. What if the reviews are simply not yet accurately recording what human iteration has discovered repeatedly for millennia?

The conclusion the review draws follows:

Conclusion: The public perception of the efficacy, tolerability, and safety of cannabis-based medicines in pain management and palliative medicine con- flicts with the findings of systematic reviews and prospective observational studies conducted according to the standards of evidence-based medicine.

BUT…

Is the right question for science to question the validity of the stories that individuals are telling, against an imperfect science of information collection, as well as the limited scope of statistical validity for understanding data? Or is the right task for science to question its own methods of assumptions in discovery and understanding?

On the one hand, we have millions of people calling the color of the ocean “blue.” On the other hand, we have data that tells us that water, in fact, has no color. Similarly, the anecdotes from cannabis consumers are telling a story that is starkly different from the currently available data.

For those interested in combing through a close inspection of the many ways that data can be misrepresented and misunderstood, check out https://first10em.com/bias/

and/or watch the video below:

View this review (yellow link) or download:

This paper is also stored here:   http://bit.ly/34NXhQV      inside the CED Foundation Archive

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Benjamin Caplan, MDStudy Finds “Insufficient Evidence” to Support the Use of Medical Cannabis for Pain Management
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Dr Caplan’s response to Surgeon General advisory statement

Last week’s statement by the US Surgeon General

https://www.hhs.gov/surgeongeneral/reports-and-publications/addiction-and-substance-misuse/advisory-on-marijuana-use-and-developing-brain/index.html

View this (yellow link) or download:

This review is also stored here:    http://bit.ly/34KRgEm     inside the CED Foundation Archive

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Benjamin Caplan, MDDr Caplan’s response to Surgeon General advisory statement
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Cannabinoid Receptors Play Important Roles in Anti-inflammation, Anti-depression, Immune modulation, and HIV support

Cannabinoid receptor 2: Potential role in immunomodulation and neuroinflammation Review

Summary Info:

Previous research and characterization of cannabinoid receptors (CBs) have consistently demonstrated the therapeutic potential for many medical conditions. CB1, the receptor responsible for the intoxicating (and other psychoactive) effects of cannabis, has demonstrated the ability to modulate concentrations of certain other neurotransmitters, giving it the capability of acting as an antidepressant. Additionally, mice lacking CB1 receptors exhibited increased neurodegeneration, increased susceptibility for autoimmune encephalomyelitis, and inferior recovery to some traumatic nerve injuries. The CB2 receptor is generally attributed to support for modulating the immune system and calming some of the body’s natural, core inflammatory signaling systems. Activation of the receptor has been found to associate with neuroinflammatory conditions in the brain, and in appropriate circumstances, can result in the programming of cell death among some immune cells. This effect points toward a role in communication, inflammation and autoimmune diseases. Furthermore, evidence points to CB2 holding significant potential in HIV therapy. Binding partners of CB2 inhibit the HIV-1 infection and help to diminish HIV replication. Historically, these staggering findings have escaped traditional modern medical understanding. Further investigation into the therapeutic potential of cannabis, with respect to the treatment of inflammation, depression, autoimmune diseases, and HIV is at a minimum, clearly warranted for a more comprehensive understanding of effective medical therapy.

Dr Caplan and the #MDTake:

The main points here no longer seem to be investigational trends, but just pillars of Cannabis Medicine that are embarrassingly new, and poorly recognized by the modern medical establishment. While the bulk of consumers, including patients, may not engage with the science on a molecular basis, by iterative or intuitive science, individuals are diligently discovering what forms of cannabis serve their personal interests more effectively. This is, through a scientific lens, a trial-and-error adventure through products, which have various ratios of cannabinoid-receptor activation or inhibition, that ultimately achieves a similar result, which is a clinical relief for a particular ailment. Does the fact that the process does not begin with a clear understanding of the involved receptors and receptor modulators really matter? If one of the primary objectives of Medicine is to treat and/or ease suffering, and the products are built upon a bedrock of chemical safety (misuse, inappropriate, or misinformed production of products notwithstanding), it should not matter that people discover it by happy accident, or through more direct achievement.

View this review (yellow link) or download:

This paper is also stored here:   http://bit.ly/34CN89F      inside the CED Foundation Archive

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Benjamin Caplan, MDCannabinoid Receptors Play Important Roles in Anti-inflammation, Anti-depression, Immune modulation, and HIV support
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Adolescent Cannabis Use Linked to Sleep Disturbances

Sleep Disturbances, Psychosocial Difficulties and Health Risk Behavior

Summary info:

A Dutch study investigated sleep disturbances in adolescents. Sleep disruption was linked to cannabis use, psychosocial difficulties, health risk behavior, and increased suicidality. Additionally, gender disparity in results suggests that girls may be more susceptible to sleep disturbances than boys , a result consistent with past recognition of some gender discrepancies in cannabis activity. These results highlight the importance of discouraging haphazard cannabis use, during adolescence, and the need for further gender-focused research surrounding sleep habits and cannabis use.

Dr Caplan, CED Foundation, and the #MDTake:

There are a few important issues that converge in this review. Generally, the question of adolescents’ use, (as an alternative way of describing the question of effects on a developing brain.) Also, this paper raises valuable questions about how cannabis may be interacting with sleep hygiene, for better or for worse. Psychosocial impact and risky behaviors are very complex topics to engage, even with a fairly large population sample of (n=16,781.) There are lots of intercorrelated topics assessed, analyzed, and discussed in the review, and it is all-too-easy to want to find causal patterns that are not apparent, again for better or worse, unless one chooses to construe the results or interpretation with causation in mind. Realistically, it is very likely to find overlap in a population of adolescents who have psychosocial difficulties, engage in risky behaviors, have increased risk of suicidality, and consume cannabis. To point to one of the components, arbitrarily, as the primary cause of the others is to unnecessarily and unjustly oversimplify a complex set of circumstances. The essential tenet, different genders seem to react differently with cannabis, is an excellent take-away, and also that we have much more still to learn.

View this review (yellow link) or download:

This paper is also stored here:    http://bit.ly/314TsEC     inside the CED Foundation Archive

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Benjamin Caplan, MDAdolescent Cannabis Use Linked to Sleep Disturbances
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Hope for Cannabis as a Future Treatment for Tourette’s Syndrome

Single center experience with medical cannabis in Gilles de la Tourette syndrome

A small study on adult Tourette’s patients demonstrated a reduction in tics after treatment with medical cannabis. Treatment with cannabis resulted in a global impression of efficacy score of 3.85 out of 5, signifying an improvement of symptoms. However, many patients reported undesirable effects that resulted in their withdrawal from the trial. Cannabis holds potential for Tourette’s syndrome treatment, however, more work is required to better understand what is causing the positive effects and to flush out reproducible benefits while minimizing the undesirables.

View this review (yellow link) or download:

This paper is also stored here:    http://bit.ly/34gcp9k     inside the CED Foundation Archive

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Benjamin Caplan, MDHope for Cannabis as a Future Treatment for Tourette’s Syndrome
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Vape-Gate 2019: Review of The Risks of vaping

Risks on the Production Side of the Market:

  • Bacteria: Within facilities that lack appropriate oversight, any bacteria present during the manufacturing of a vaped product can be a source of risk for the consumer.
  • Fungus: Similarly, fungus can be a normal part of ambient air and life on earth, particularly around plants and soil. If production facilities do not have state-of-the-science monitoring or control mechanisms to limit mold, fungus can accumulate during the manufacturing process and can be transmitted to consumers.
  • Particles: Nicotine- or cannabis-containing products that are not produced in regulated facilities (home-grown and/or street-sold real or counterfeit products) may contain dangerous solvents, including solutions that contain lipid content that does not belong inside human lungs. Equally concerning, even in states with strict regulatory oversight over cannabis, the regulations may not cover particulate matter which may come into the consumer’s body from the containers that store tested cannabis products. For example, labs across the US have identified particles of vapor cartridge construction materials that become airborne during the heating process of vaporization. There is currently no testing standard for such circumstances. More, the sheer volume of particles emitted by a tool producing vapor is unregulated. With respect to its effects on the lungs, it is likely that there are meaningful differences (and potential risk differences) between a vaporizer which produces a small cloud of particles compared with one that produces a large, dense cloud.
  • Nicotine/E-liquids: Many nicotine vaporizers contain flavoring, coloring, preservative liquids that can be irritating to the lungs and breathing architecture. Non-nicotine liquid mixers can include sugary substances which promote dangerous growth of bacteria, inside the lungs.
  • Supervision: Street or home-produced products lack quality control measures to ensure that they are made safely, and/or contain safe ingredients, and are being delivered inside safe devices. In contrast, most FDA-overseen nicotine products and state-overseen cannabis production facilities limit many risk factors for currently-known threats to health

Risks on the Consumer Side of the Market:

  • Bacteria: Once purchased, products exposed to everyday life can acquire potentially dangerous bacteria after they are produced and sold. When used with poor maintenance practices, or by a consumer with hygiene practices that may add additional risk, bacterial infections can arise.
  • Fungus: Like bacteria exposure and potential infections, mold/fungus can accumulate after a vaping product is purchased. Good maintenance/cleansing practices help to prevent this risk, and appropriate hygiene around the consumption of vaping products typically minimizes this concern.
  • Particulate Matter: When using and re-using vaporizer tools (pens, vaporizer ovens, edibles), foreign particulate matter may break-off from cartridges, or may accidentally enter into products that were previously free of these contaminants. Many of the popular vaporizer cartridges, for example, seem to come from three facilities in China and are sold, worldwide, because of the attractive low price-point. Across the US, lab evidence has discovered evidence of small particles of the cartridges themselves (plastics, metals, other materials.) These particles can cause irritation to, or have toxic local effects on, the lungs. These reactions can certainly stimulate an inflammatory response which is sometimes equally uncomfortable as the offending irritation.
  • Coughing: Vaporizing a product which causes the user to cough excessively can risk the accidental aspiration of bacteria or particles from the mouth. These particles, if small enough, can cause inflammation or infection in the lungs.
  • Nicotine: In addition to the well-documented increased risk of cancer from the consumption of nicotine, this chemical is an irritant to the tissues with which it interacts, causing arterial wall constriction and thickening. It increases blood pressure and heart rate, promotes increased inflammation and suppresses normal immune system function. More, it also artificially elevates dopamine, norepinephrine, and acetylcholine, with poorly understood consequences that are unlikely to be healthy for the lungs.
  • Maintenance: Vaporizing old or poorly-kept products may ignore the very real effects of deterioration of materials which may pose health concerns. A product which is not well-maintained or regularly cleaned may contain infectious particles, irritating particles, toxic elements which may also be found in a pocket or storage container (insecticides, animal poisons, other chemicals which may preserve or protect during production or travel)

Individual Differences:

Between the production and the consumer sides of the vaporization arena, individual differences and outside influences can have a tremendous impact on the experience of vapor. Someone with a history of lung disease may tolerate a very different product than someone without such a history. Similarly, someone with a weakened immune system may have a more difficult time healing from an average exposure (to an irritant or an infectious particle) than someone with different circumstances. These are not likely to explain a large incidence of illnesses, but in addition to the concerns above, they may help explain a smaller portion.


Some of the Medical Illnesses Potentially Associated with Vaping:

1. Pneumonia (bacterial)

2. Aspiration Pneumonia

3. Idiopathic Acute Eosinophilic Pneumonia

4. Hypersensitivity Pneumonitis (extrinsic allergic alveolitis)

Typically this is related to the components of e-cigarettes: nicotine, propylene glycol/glycerol, ethylene glycol, any of >7000 flavorings, metals including tin, lead, nickel, chromium, manganese, and arsenic (have all been found in e-cigarette liquids), also nitrosamines common to tobacco, carbonyl compounds, volatile organic compounds, and phenolic compounds.


General Recommendations for Safer Consumption:

  • Use state-supervised companies, including dispensaries for cannabis-related vaporizer materials, and reputable nicotine suppliers
  • Convection vaporizer ovens that involve safe heating materials (ceramic, glass, quartz) are preferable to vaporizer cartridges.
  • Any means of detaching product from direct contact with a heat source is preferable. For example, stainless-steel containers that hold product, and are then placed into a heating chamber, is likely to be safer than placing product directly against heat.
  • Safe heating elements: chamber-based convection/conduction heating
  • Avoid direct contact with coils, and avoid combustion
  • Use fresh products from state-sponsored dispensaries or stores
  • Avoid products that are repeatedly reused (including vaporizer pens and vaporizer heating tools that stay full of organic material for more than a brief period of time
  • Prefer systems that include the opportunity to easily clean and replace individual used components
  • Use rubbing alcohol to clean any heating tools regularly

In Infographic form :


Sample Reference News Articles:

All about Vitamin E Acetate:

1.

https://www.nytimes.com/2019/08/31/health/vaping-marijuana-ecigarettes-sickness.html?smid=nytcore-ios-share

2.

3.

https://www.washingtonpost.com/health/2019/09/05/contaminant-found-vaping-products-linked-deadly-lung-illnesses-state-federal-labs-show/

4.

https://www.foxbusiness.com/healthcare/electronic-cigarettes-vapes-scott-gottlieb

5.

https://www.cnbc.com/2019/08/26/fake-juul-pods-fill-shelves-after-vaping-giant-pulled-fruity-flavors.html

6.

https://www.latimes.com/california/story/2019-08-25/knockoff-cannabis-products-headache-for-california-legal-weed

To explore related information, click the keywords below:

Benjamin Caplan, MDVape-Gate 2019: Review of The Risks of vaping
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Reducing Cannabis Use Equally Effective as Abstinence in Treating Cannabis Use Disorder

Reduction in Cannabis Use and Functional Status in Physical Health, Mental Health, and Cognition

In a survey of 111 cannabis use disorder (CUD) patients with abstinent, low use, or heavy use of cannabis, similar benefits were experienced by patients who reduced their use to zero or low use. Both groups exhibited significantly better outcomes than the heavy use group with respect to overall health, appetite, and depression. According to the study, CUD patients “who used cannabis at a low level did not differ from the abstinent individuals in any of the functional outcome measures.” With a relatively small subject population, it is challenging to know if this is applicable to broader audiences, but regardless, It is likely to open up some new treatment option for CUD patients.

View this review (yellow link) or download:

This paper is also stored here:   http://bit.ly/2MTBOAm      inside the CED Foundation Archive

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Benjamin Caplan, MDReducing Cannabis Use Equally Effective as Abstinence in Treating Cannabis Use Disorder
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Psychiatric Disorders Reduce Survival Among Immune-Mediated Inflammatory Disease Patients

Psychiatric comorbidity increases mortality in immune-mediated inflammatory diseases

Summary Information:

A new study finds that a diagnosis of depression, anxiety, and/or bipolar disorder increases mortality rates for patients of one of three immune-mediated inflammatory diseases (IMID):

1) multiple sclerosis (MS), or

2) inflammatory bowel disease (IBD), or

3) rheumatoid arthritis (RA).

Depression and bipolar disorder can cause poor health behaviors in patients, as depression, bipolar disorder, and anxiety disorders are “associated with increased inflammation and immune dysregulation.” Suicide risk and attempts are increased among IMID patients with mental illness, compared with IMID patients who are not also suffering from one of these additional battles. Given that cannabis has shown promise in treating both inflammation and a range of psychiatric disorders, there is reason to be optimistic for further cannabis research to uncover multifunctional treatment options.  

Dr Caplan and the #MDTake:

Clinically, it’s rare to see medical patients who have only one concern. Sure, there are some who are hoping that cannabis will help them to treat seizures, headaches, anxiety, sleep troubles, or terrible back pain, but more often, it is a combination of several troubles that each add to a cumulative tipping point.

Naturally, very few individual systems act alone. When a body part is injured, sleeping (or not sleeping) effects the course of illness. Similarly, feeling less anxious, or improving sleep, may make symptoms of a struggle with consistent headaches seem more tolerable. Even when there aren’t direct connections between symptoms, a treatment which implements a systemic treatment can have multiplied benefits.

Many patients have found that cannabis offers them a way to attack more than one problem, with a single actor. Some with Diabetes are finding that some formulations are not only helping them reduce blood sugar levels, but also reducing appetite. Similarly, some patients with ADD are turning to cannabis options which may help them focus, without their ability to get to sleep at night.

To a related note, many elderly patients are treated with too many medications. Modern Western medical treatment often compels patients into silos of treatments by isolated specialists, who are not always monitoring the patient as a being beyond individual organ systems. Medications, such as cannabis, which have the opportunity to treat more than one system, without multiplying the risk of potential drug-drug interactions presents a much safer approach to care

View this review (yellow link) or download:

This paper is also stored here:  http://bit.ly/2MRDfiP       inside the CED Foundation Archive

To explore related information, click the keywords below:

Benjamin Caplan, MDPsychiatric Disorders Reduce Survival Among Immune-Mediated Inflammatory Disease Patients
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Info about Traveling & Cannabis

Here is a nice summary of information for US medical cannabis patients with respect to traveling while on a cannabis regimen (what to think about, including plane/trains/automobiles, helpful tips, which states have reciprocity, and/or access to medical cannabis options, etc)

https://www.safeaccessnow.org/travel

Benjamin Caplan, MDInfo about Traveling & Cannabis
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A case of an abnormal heart rhythm. Is cannabis to blame?

Article title: Atrioventricular Nodal Reentrant Tachycardia Triggered by Marijuana Use: A case report and review of the literature

Summary:

The effect of cannabis on the heart is not yet well-understood. This report highlights a case of one 40-year-old patient who had, an hour after smoking cannabis, a specific type of cardiac rhythm abnormality (arrhythmia) called atrioventricular nodal reentrant tachycardia (AVNRT).  There is a physical component of this abnormality, an errant track where aberrant rhythms re-enter the heart and can cause rapid heartbeats (tachycardia.) In the discussion, the authors suggest that cannabis use, at higher doses, may stimulate the parasympathetic system, which happens to be involved in electrical current tracks in our heart. The authors further hypothesize that in susceptible people, as in this case, cannabis may affect this electrical pathway in the heart, and may disrupt a stable rhythm.

Dr Caplan and the #MDTake:

Abnormal heart rhythm disorders can be life-concerning conditions, however, there have only been 17 or so reported cases (see Table 1) of life-threatening cases in the medical literature. As it is exceedingly rare, it can be difficult to determine if cannabis is implicated or not.

Clinical Impressions:

Including rare, serious heart conditions, relatively benign circumstances, and conditions related to structural heart disease, arrhythmias are a relatively uncommon condition. Nevertheless, CED Clinic has seen many patients who have atrial fibrillation, a smaller but significant number of patients who have stable low or elevated heart rates, and a rare few with irregularly irregular abnormalities. Some patients have embraced cannabis while anticoagulated (helpful to reduce the risks of potentially dangerous clots), and some who are engaging with cannabis have been treated surgically. The approach to cannabis that most seem to prefer is a slow, gradually increasing dosage routine, where one can become accustomed to low doses, prior to advancing to something which may be more therapeutic, while minimizing the potential cardiac impact. Fortunately, to date, we have observed no grave repercussions that seemed caused, correlated or attributable to cannabis.

ECG showing AVNRT at the time of presentation.

View this review (yellow link) or download:

This paper is also stored here:    http://bit.ly/2MPc7Rl     inside the CED Foundation Archive

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Benjamin Caplan, MDA case of an abnormal heart rhythm. Is cannabis to blame?
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