Cannabis chronicles 1

He’s a biker, even if his shoulder-length hair and beard are turning white and his once muscled body has wasted to lean bordering on frail. His Moto Guzzi sits in the shed, in front of the bench where he grows cannabis under LED lights. He’s smoked weed most of his life, but these “girls” as he refers to his female plants, will never be immolated. Gray says he hasn’t smoked since he began extracting cannabis oils a year ago.

Gray has MDS, myelodysplastic syndrome, a form of blood cancer. The immature blood cells his bone marrow produces don’t mature. Some patients with lower-risk forms of MDS can live five years or more. In 30 per cent of cases MDS degenerates into acute myeloid leukaemia, a form with a far shorter life expectancy.

When Gray was diagnosed with MDS, his doctor told him he had 18 months and put him on Darbepoetin to raise his hemoglobin level. For three years he received the $1,580 injections every three weeks. He was also prescribed up to eight Oxycontin tablets a day.

Three years later, Gray was barely functioning. His hemoglobin/white cell counts continued to decline. That and the Oxycontin left him wasted, so he stopped the darbepoetin and replaced the Oxy with Percocet, a combination of acetaminophen and oxycontin. Online, he’d been following the advice of Rick Smith, a Canadian cancer survivor who counsels supplanting or supplementing conventional treatments with a mix of tetrahydrocannabinol (THC) and cannabidiol (CBD) extracted from dried cannabis. Like Smith, Gray believes a THC-rich blend is more effective in killing cancer cells.

He continued to monitor his hemoglobin level and white cell count, both of which rebounded. When his cannabis extract supply ran out in October, his levels dropped so fast and far, he required two blood transfusions. Since then, he makes sure he has the raw materials to maintain a steady supply.

He’s still taking the opioid Percocet, but at lower levels than prescribed. “There are days I’ll feel like popping a perk,” he says. He believes opioids helps him function in the mornings.

He doesn’t share his self-medicating details with his doctors. “Oh, they know, but they don’t want to know.” He’s a firm believer in the conspiracy theory placing the self-regulating bodies that oversee Canadian medical professionals in bed with Big Pharma. Doctors are encouraged to continue prescribing prescription painkillers and discouraged from assisting their patients in exploring alternatives. Career-wise, it’s safer for a doctor to continue prescribing opioids despite a North American epidemic of overdose-related deaths.

Long before the Oct. 17/18 legalization of recreational cannabis, the federal health establishment and its provincial agencies strove to keep the cannabis discussion focussed on regulatory issues for fear of being drawn into a larger discussion concerning the use of cannabinoids as effective, health-insurable prescription drugs.

Since 2013, any doctor in Canada is legally permitted to prescribe cannabinoids without the patient having to enrol in a clinical trial. The exception at that time was Quebec, where as of April 2014 cannabis could only be prescribed “within a research framework,” as it is not a medically recognized treatment.

To satisfy the Collège des medécins’ demand for a framework, a group of doctors and researchers announced in May 2015 the creation of the world’s first research database on the use of cannabis for medical purposes, the Quebec Cannabis Registry (www.registrecannabisquebec.com).

“We need this database to help develop and answer future questions on the medical use of cannabis, such as who uses it, for what reasons, through which methods, and at what dose.” — Dr. Mark Ware, Director of Clinical Research of the Alan Edwards Pain Management Unit at the MUHC and associate professor in Family Medicine and Anesthesia at McGill University.

The Quebec Cannabis Registry collects, compiles and store clinical data collected from patients who use medical marijuana. Participants agree to provide data for four years after recruitment. Any licensed doctor practising in the province wishing to authorize cannabis for their adult patients can thus enrol participants in the registry. The Registry’s creators set a goal of 3,000 participants over a 10-year period beginning in 2015. (It stopped taking registrants this fall after enrolling the 3,000.) 

April, 2018: Quebec’s Collège des medécins cautions members against prescribing cannabinoids pending further research into efficacy, dosage and side effects. “Does one prescribe three grammes a day or five,” demands Collège secretary Yves Robert. “And five grammes of what? Cookies? Oil? Inhalation?” Doctors who prescribe cannabinoids instead of opiates had better be able to justify their choice, Robert warns.

The Collège argues that the Registry doesn’t satisfy the criteria of true scientific research and therefore can’t demonstrate that cannabinoids offer a solid alternative to opioids for chronic pain relief.

Quebec’s growing network of private cannabis clinics accuses the Collège of using veiled threats to fearmonger doctors into refusing to consider cannabis as an alternative to opioid painkillers. 

Sept 20/18: Three weeks prior to the legalization of recreational cannabis, the CMQ revises its prescription protocols for medical cannabis. Quebec doctors can now prescribe cannabis outside the framework of a research project subject to the following caveats: 

— A doctor must know the limits of his expertise and should not prescribe unless medically necessary. 

— Based on the principle of ‘first, do no harm,’ the doctor must also ensure that a prescription’s therapeutic benefits must outweigh undesirable potential effects and risks such as dependency.

— Cannabis must not be the first treatment choice. Before considering it for treatment of a medical condition, the doctor must ensure that the patient’s response to other treatments is inconclusive. The doctor must make note of treatments tried and deemed ineffective by the patient.

— The doctor must become aware of policies regarding the use of cannabis for medical purposes as listed on the Health Canada website. The prescription of cannabis isn’t appropriate for anyone under the age of 25, anyone presenting a risk or history of dependancy, those with a family history of psychosis, anyone with cardiovascular or respiratory disease, women breastfeeding, expecting or hoping to be. The doctor must also weigh the risk to ex-smokers of prescribing inhaled cannabis.

— Upon prescribing, the doctor must carry out a full medical evaluation, in person, and must note the patient’s free and informed consent in his file. He must inform the patient of possible effects and complications on the patient’s health (depression, psychosis, mental illnesses, lung disease, connitive decline, memory loss, reduction in professional or scholastic performance). — The patient must be aware of his responsibilities in following this treatment, specifically while driving and preventing the drug’s use by minors.

— The patient must schedule visits to the doctor as needed to ensure adequate followup of his medical condition. A first followup visit should take place within three months of the initial prescription depending on the clinical conditions and until the stabilization of the patient.

The patient must not sell or traffic in prescribed drugs.

— The doctor must cease prescribing cannabis in the event of a complication or if the patient doesn’t fulfill his obligations.

— Treatment must begin with the lowest possible dose and increases must be managed with care.

— In all cases, treatment must be signalled to the the treating physician as well as to other doctors following the patient with the patient’s consent. 

— The doctor must note in the patient’s file the indication for which the cannabis is prescribed.

— The doctor must keep a register of patients for whom he has prescribed cannabis so as to permit control and adequate followup of his clientele and rapid access to files.

 The CMQ protocol also addresses potential conflicts of interest:

The authorization or prescription for the use of medical cannabis or supplementary fees cannot be billed by the physician. The doctor cannot derive profit from prescribing medical cannabis and cannot directly sell or provide it to the patient.

— The prescribing physician must allow the patient the freedom to choose a supplier.

— The physician must safeguard his professional independence at all times and avoid any situation in which he would be in a conflict of interests. To this end, if the physician has financial interests in an enterprise engaged in the production of cannabis, must so inform the patient as well as the milieu where he practices.

Pain specialists expressed disgust at the CMQ’s latest edicts, arguing that opioids, with their known risks of addiction and abuse, are the real problem. Research has shown phytocannabinoids THC and CBD can work in harmony with the body’s own endocannabinoids to mitigate pain. “The pharmeconomy would save millions, maybe billions, in drug and treatment costs with cannabinoids,” a Quebec GP told me. 

October 2018: The Quebec Automobile Insurance Board refuses to reimburse the cost of cannabinoids prescribed as a cost-effective pain treatment alternative to opioids such as dilaudid, fentanyl and methadone. Only medications bearing a DIN and listed in the Régime général d’assurance médicaments (RGAM) are reimbursable. (CNESST, Quebec’s workplace health and safety agency, will consider reimbursing the cost of prescribed cannabinoids.) 

Of the provinces, Quebec maintains the hardest stance on cannabis. The current government proposes to raise the legal consumption age to 21 regardless of the federal legal age, 18. Quebec is the only province to ban unlicenced cannabis production (not even the federally sanctioned four plants), yet outlets of the SCDQ, the provincially managed cannabis marketing structure, are closed half the week for lack of product. Who benefits from that?

Gold-rush hucksterism

This past April, I attended a cannabis industry conference in Montreal and blogged about it (https://thousandlashes.ca/2018/04/16/cannabis-update-risk-vs-potential/). Major producers Canopy Growth, Aurora and Hypothecary were there, along with Health Canada and a jam of lawyers and lobbyists — regulatory and governance specialists, branding and trademark lawyers, M&A suits. I met venture capitalists and insurance actuaries, producers and foodies.

Researchers provided a reality check to the gold-rush huckerism. A mid-morning panel on the scientific and medical implications of legalization featured McGill’s Dr. Mark Ware, the Université de Sherbrooke’s Dr. Serge Marchand and New Brunswick Health Research Foundation head Dr. Bruno Battistini. They foresaw serious public health issues resulting from Canada’s legalization of the recreational use of cannabis, at that point still six months away. Their biggest concern —the 20 per cent of recreational pot users at risk of mental illness. THC, the psychoactive component of cannabis, latches onto receptors in the brain that trigger certain pleasure reflexes. This 20% is at risk of developing psychotic reactions, especially among adolescents and young adults.

The panel stressed the need for extensive research into phyto-cannabinoids, the collective label given to 142 molecules found in various cannabis strains. The two best-known cannabinoids are delta-9-tetrahydrocannabidiol, or THC, and cannabidiol, or CBD. THC is responsible for many of the pharmacological effects of cannabis, including the psychoactive effect — the high. CBD doesn’t have any of the intoxicating, euphoric effects of THC.

The researchers described CBD’s potential as a medical ‘magic bullet.” Cannabidiol is being used to treat a growing list of conditions — Crohn’s and other inflammatory bowel diseases, PTSD and other psychological disorders, fibromyalgia, rheumatoid arthritis, epilepsy, MS, Parkinson’s, Alzheimer and dementia, austism spectrum disorders, acne — and opioid addiction. But without clinical trials and scientific methodology, the medical cannabis industry can’t advance past the anecdotal stage and opiates will remain North America’s default prescription painkillers despite their toxicity and potential for abuse.

Ware, who has since gone on to become chief medical officer for Canopy Growth, is a West Island family doctor who co-founded the Canadian Consortium for the Investigation of Cannabinoids (CCIC) while serving as director of clinical research at the MUHC’s Alan Edwards Pain Management Unit. He described how difficult it was to convince doctors to enrol their patients in cannabinoid clinical trials because of resistance from the profession’s governing bodies. (To get around Quebec’s Collège des médecins and its convoluted protocol for the prescribing of cannabinoids, Ware and a group of pain specialists in May 2015 launched the Quebec Cannabis Registry (www.registrecannabisquebec.com), the world’s first research database on the use of cannabis for medical purposes. In late 2018, registration was closed at 3,000 patients.)

Drs. Ware, Marchand and Battistini concluded on a down note: In legalizing recreational weed, Canada has opened the door to cannabis’s medical applications. However, they warned, it was a matter of time before the U.S. removed CBD from the DEA’s list of Schedule 1 drugs (no currently accepted medical use, high potential for abuse). Once that happens, Canada would lose its advantage.

As they predicted, the U.S. Drug Enforcement Administration five months later moved CBD from Schedule 1 to Schedule 5, allowing the prescribing and sale of CBD-derived formulations with levels of THC below 0.1%. In December, the Hemp Farming Act of 2018 was signed into law, making CBD a legal agricultural product. Estimates peg the U.S. CBD market at $23B annually within 10 years.

Equally sudden has been the opioid backlash directed at producers and distributors. In the U.S. the attorneys-general of 41 states have served five major opioid producers and three distributors with subpoenas seeking information about how these companies marketed, sold and distributed prescription opioids. Civil class-action lawsuits alleging the industry misrepresented the effectiveness and addictive nature of opioid painkillers are being filed across America.

In Canada, the opioid backlash so far has been limited to B.C., which in August announced it would file a class-action lawsuit against dozens of players in the opioid industry. The province’s attorney-general alleges 20 years of misinformation and deception about the effectiveness and risks of addiction and asked other provinces to join B.C.’s action. Although a number of provinces with their own skyrocketing opioid-overdose death rates said they would review B.C.’s action with an eye to joining it, none have stepped forward.

Why the silence? None of the professionals I spoke with wished to be quoted, but they generally agreed the problem lies with Canada’s medical insurance structure. Public and private insurers buy in bulk from the distributors, who motivate doctors and pharmacists to prescribe.

Are opioids effective, non-addictive painkillers when used as prescribed? Here’s what one Quebec pain and addiction specialist told me: “I came to realize that my patients taking opioids for pain relief were fat, lazy, sweaty, non-functional — and still in pain.” The condition is called opioid-induced hyperalgesia, characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.

Urinalysis and close questioning led to his discovery that some of his pain patients were trading their prescribed drugs for more powerful alternatives. Others were selling all or part of their prescription for cash. His doctor-patient relationship prevented him from turning them over to the police. The response from the Quebec Collège des médecins? Stop prescribing.