Medical Cannabis for Chronic Pain: a Response to an Epidemic
Chronic pain is defined as pain lasting longer than 3 months and it is also the most common motive for people to seek out healthcare. There are more people in the US that suffer from chronic pain than cardiovascular disease, diabetes and cancer combined.  Chronic pain is a very complex event that may be physical, chemical or emotional. Classically, the most notorious forms of chronic pain are divided into 2 categories; “nociceptive pain” or pain that is caused by stimulation of nerve receptors; most commonly by tissue damage. The other is “neuropathic” pain or pain that is related to damage to the nervous system. These two categories help to simplify a complex truth, in which; both acute and chronic pain are induced by several exterior and interior mechanisms. These mechanisms are constantly interacting with one another and several pain-modulating systems. 
The main complication, with chronic pain, is the current lack of treatment options. Health care providers that work with chronic pain patients are often tasked with finding effective, yet safe treatment options. Prescription opioid medications are commonly prescribed for chronic pain; however, the bene?¬?ts of long-term opioid therapy remain unclear. Additionally, long-term opioid use is linked with adverse e?¬?ects such motor vehicle accidents, cardiovascular complications, drug abuse, and overdose.  The treatment of chronic pain with opioids has been met with widely publicized deficits, finishing with the current opioid epidemic affecting the United States.
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Opioids do have an initial role in the management of pain, however; nonopioid pain-relieving alternatives should be examined to increase the collection of available treatments to health care providers. The medical treatment of chronic pain is an ever- evolving challenge that changes with modification of existing tactics, development of new medications and procedures, and cognizance of potential harms and side effects. One of the most obscuring changes in chronic pain has been the expansion of epidemic levels of opioid use and abuse, prompting the need for alternative strategies. 
A current, focal-point in many political and medical debates is the use of medical cannabis (medical marijuana) for treatment of various illnesses and diseases. For this study, we will only focus on the use of medical cannabis for the treatment of chronic pain. In order to discuss the future of medical cannabis, it is important to view the historical-context of cannabis to gauge its current socioeconomic status in the United States.
The 1st-recorded medicinal use of cannabis is written on a Chinese document dating back to the 2nd century. Hippocrates and Galen often prescribed cannabis orally, according to 3rd century Greek record. They would often treat a wide-array of symptoms ranging from headaches to GI issues. Dr. William B. O’Shaughnessy, an Irish physician, is attributed with introducing cannabis into Western medicine after his involvement with Indian hemp, during his time there introducing the area to the telegraph. In contrast, the United States has a relatively short-lived history with medical cannabis. In 1916, Sir William Osler, wrote in The Principles and Practice of Medicine, and he recommended the use of medical cannabis for the treatment of migraines.
At the time, the recreational use of cannabis was associated with minorities, specifically African Americans. Racism was well-known in this time and it caused a stigmatization of cannabis use. Unfortunately, that racism often powered the prohibition of cannabis at the state level and federal level with the 1937 Cannabis Tax Act.  In today’s society, cannabis use is becoming more accepted as a medical treatment and a social norm. With the current facts about tobacoo, alcohol and opioid use, the public is becoming more aware and informed about the potential benefits and decreased risks associated with cannabis use.
Medical cannabis is available in several forms. In general, oral consumption is either through smoke/vapor inhalation, consuming baked goods, cooking products, or concentrates (and other concentrates). Vaporizers heat the medical cannabis up to 400?°F, when the plant material will heat to the point that vapors form, but below the point of combustion. Many cannabis users prefer vaping to avoid the potentially carcinogenic by-product of combustion burning. 
Medical cannabis can be effective and presents less risk in treating patients with chronic pain, as compared to treatment with opioid painkillers. However, there has been minimal research performed on medical cannabis to back this claim. Social stigma and government laws need to be lightened so they do not prohibit proper research and patient distribution of medical cannabis, in regards to the treatment of chronic pain.
The United States is currently in the middle of an opioid crisis, with an estimated 3.8 million adults abusing prescription opioid medications. Reports suggest that opioid abuse can progress to heroin abuse and a 200% increase rate of death from overdose.  The most common prescription opioids involved in overdose deaths are oxycodone, hydrocodone and methadone. These 3 opioids alone caused over 15,000 deaths in 2015. Last year, the President of the United States issued a national public health emergency regarding the current opioid crisis. The opioid epidemic remains a major public health crisis, despite the national demand for prescription opioid, harm reduction strategies, and finding safer alternatives. 
The opioid epidemic can be an advanced system, consisting of a collection of different individuals interacting with one another. From opioid users, prescribers, other medical providers, drug dealers, law enforcement and family/friends are part of a network of individuals involved in the epidemic.  Working in a pharmacy, as a technician for 3 years, I received direct insight to the current opioid crisis. The number of patients that I encountered, that came in to fill an opioid prescription every month, was astounding. The amount of lives impacted with this epidemic is unfathomable to the general public.
In order for health care providers to consider medical cannabis for as a treatment option for their patients, it’s first important for them to understand how the human body reacts with medical cannabis on a chemical level. There are more than 60 active cannabinoids found in medical cannabis, the main 2 chemicals to be focused on are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is the phytochemical believed to produce feelings of euphoria, anti-inflammatory effects, and possible psychosis. CBD is the phytochemical thought to be minimally euphoric, anxiolytic, and antipsychotic. Different strains of cannabis have different concentrations of active cannabinoids; Indica is usually higher in THC, and sativa is usually lower in THC.
Nevertheless, significant disparity occurs between strains, and THC to CBD ratios can only be generalized.  THC is the primary psychoactive chemical in cannabis and it performs as a partial agonist with high-affinity at 2 cannabinoid receptors 1 and 2 (CB1 and CB2). Cannabidiol receptors are found in high concentrations in areas of the brain that control nociceptive pain in comparable amounts and locations to that of opioid receptors.
Cannabinoid receptor 1 is also found in the amygdala, an area of the brain that influences the emotional response to pain. One study confirmed THC’s effect on the amygdala leads to pain relief in the human body. Cannabinoid receptor 2s are extensive and are related to cells of the immune system. THC may apply analgesic effects through both receptors, mitigating perception of pain at CB1 and performing through anti-inflammatory mechanisms at CB2. 
Although, Cannabis has started to be researched and is growing as a treatment option for patients with chronic pain, cannabis remains a Schedule I controlled substance under federal law.  A Schedule I substance is one that is believed to have no medical use and a high abuse potential. LSD and heroin are a couple examples of other Schedule I substances. However, comparing drugs by their abuse potential and ratio of active dose to lethal dose specifies that cannabis can be relatively safe compared with alcohol, opioids, and tobaccoo.  Even with the Schedule I designation, cannabis is currently the most commonly used illicit drug with 22.2 million Americans (12 years and older) self-reported as current users (used in the past 30 days), either for medicinal or recreational purposes (Center for Behavioral Health Statistics and Quality, 2016). 
There are current logistical barriers to conducting quality research on cannabis. A cannabis study involves DEA registration for investigating with a schedule 1 substance and an Independent New Drug (IND) request to be on file with the FDA. The National Institute of Drug Abuse (NIDA) works with the University of Mississippi to serve as the only provider for the growth and dispensation of cannabis for research. In June 2015, the Department of Health and Human Services removed a regulation that required privately-funded studies to undergo Public Health Service Review additionally to FDA review. Moreover, current regulatory changes have increased the amount of cannabis that may be cultivated and produced by the University from 46 pounds to 1,400 pounds. 
There are approximately 50 potential randomized controlled trials exploring the medicinal application of cannabinoids. The US Food and Drug Administration has acknowledged oral cannabinoids for the treatment of nausea and vomiting associated with chemotherapy. Cannabis has also been approved as an appetite stimulus in wasting illnesses. . Besides the potential treatment of indicated diseases, the best data from randomized controlled trials are for the treatment of chronic and neuropathic along with spasticity, commonly associated with multiple sclerosis.  The National Academies of Science, Engineering, and Medicine (NASEM) determined that there is “substantial evidence that cannabis is an effective treatment for chronic pain in adults” 
It is not only important to know what ways a patient can benefit from medical cannabis, but it is even more important to know the potential health risks that a patient might face when medicating with cannabis. Data collected from multiple systemic reviews that examined the use of cannabis for chronic pain suggest that medical cannabis may be associated with a higher risk of short-term adverse effects, although rates of adverse events did not significantly differ between groups in other trials that were reviewed. There is evidence from 2 cohort studies suggesting high-level of cannabis smoking (daily) has the potential to cause adverse pulmonary effects over time, however, the studies also suggested that low levels of cannabis smoking do not adversely impact lung function after patients 20 years or older. 
Certain acute medical conditions may arise from cannabis use. The risk is predicted by age, dose used, frequency, mode of use, and the individual’s temperament. Such acute medical conditions may include panic and mania attacks, impaired concentration/attention, decreased motor skills, nausea, withdrawal/addictive symptoms, psychosis, anxiety, and previously mentioned cardiovascular and pulmonary diseases.
Abundant risk aspects for cannabis consumption have been acknowledged. There is also a possible relationship between cannabis consumption and bipolar disorders, however, there appears to be no relationship between cannabis consumption and depression.  Early age and long-term and heavy consumption are defined risk factors. Early onset is defined as initiation of use at an age younger than 15??‰ years old.
Evidence does suggest that cannabis use is associated with increased risk of motor vehicle accidents, especially fatal collisions. The established legal thresholds for driver impairment due to cannabis are inconsistent and vary by region. It should be noted that other chronic pain treatments, including prescription opioids and benzodiazepines, may impair a driver’s ability to operate a motor vehicle. Another concern regarding the cannabis, is the use by pregnant females because little is known about the effects that cannabis may have on a fetus. There is a higher risk of non-serious adverse events, among cannabis-using patients compared with comparable control groups.
Opioid-prescribed patients often undergo a comprehensive evaluation that consists of medical, functional, and behavioral specialists that try to determine the proper treatment options for the patient. They also evaluate the risk for aberrant drug behaviors in potential opioid patients. There is also a chance that a patient may not respond well to opioid treatment, so they are evaluated for this, as well.
Another crucial process is the evaluation of a patient’s functional abilities and addictive-behavior habits. Going over the peer-reviewed material, there is a noted deficiency of guidance concerning the evaluation and supervision for cannabis when compared to the published guidelines concerning opioid treatment. The implementation of clinical procedures, comparable to those suggested for opioid treatment, is strongly recommended given the known risks associated with cannabis use.
There is little known about the benefits of medical cannabis, moderately due to the barriers mentioned previously. Still, it is important for health care providers to know the risks and benefits certain treatment options compared to others. Regarding this study, we will be comparing benefits and risks of medical cannabis and opioid painkillers in the treatment of chronic pain. Improving a chronic-pain patient’s overall quality of life is best seen in the simple decrease of patient’s subjective pain scores, but also through adaptive changes and enhancements in functional levels. Anecdotally, patients who claim relief with cannabis use often report 1) experiencing some slight degree of pain relief; 2) separation from the pain without variation in pain severity; or 3) slight functional improvement, which often came in the form of better-quality sleep. 
In a retrospective, mirror-image study, CANNABIS improved quality of life and pain outcomes in patients with chronic pain. This was best noted with the positive pain outcomes that were produced by the study. These results are reliable with previous reports signifying cannabis’s effectiveness in treatment of neuropathic pain.  A vital question concerning cannabis pain relief is whether cannabis treatment is proficient enough to provide enough relief to become a viable substitute for opioid use for chronic pain.
There is also evidence that suggests cannabinoids have the potential to raise the pain-relief effect of prescription opioids. This can lead to a patient needs a decreased amount of medication to accomplish proper pain relief. Nevertheless, studies show that these opioid-reducing effects of medical cannabis are inadequate. Furthermore, a decrease in monthly painkiller prescription costs was detected, due to a decrease in the number of opioids prescriptions used. 
Two other studies noticed the replacement of cannabis for prescription opioids and reported cannabis use was associated with decreased opioid use. An online survey that was conducted in Michigan, polled medical cannabis users and found that cannabis use was associated with a 64% decrease in prescription opioid use and 45% improvement in quality of life. Another Californian study, found that 97% of cannabis users reported decreasing use of opioid medication when using cannabis concurrently with their opioid medication. 93% of the patients polled reported a preference of CANNABIS compared to their prescription opioids. 
Another cohort study was performed in New Mexico that observed patients who were enrolled in a medical cannabis program (MCP) were more likely to reduce daily opioid prescription usage (83.8% versus 44.8%) or to cease filling opioid prescriptions altogether (40.5% versus 3.4%), between the beginning and end of the sample period. The percentage point change in daily opioid prescription dosages also differed between the two groups with MCP patients reducing their dosages by 47 per centage points, while the comparison group increased dosages by 10.4 percentage points. In addition, MCP patients consistently reported reduced pain and improved quality of life, social interactions, and activity levels as a result of their participation in the MCP. 
Some recent studies also have proposed that cannabis may be comparatively safer for long-term use in adults. They also determined that cannabis is usually well-tolerated by patients.  Another cohort study found substantial improvements in pain intensity and the quality of life over 1 year, among the cannabis users compared with controls. There was also significant improvement among cannabis users in the measure of the sensory pain, symptom distress, and total mood disturbance. These were not the primary findings of the study but are very important when discussing the risk-benefit ratio of medicinal cannabis. 
The economic impact of medicinal cannabis may also be measured given the current burden of opioid crisis on healthcare systems. These systems have been forced to conduct costly alterations to general patient care practices, some of these include; drug screenings, treatment of drug abuse and addiction, prescription monitoring programs, more frequent doctor-patient interactions, and other treatment options that may be associated with reducing opioid-related liability. 
Medical cannabis can be effective and presents less risk in treating patients with chronic pain, as compared to treatment with opioid painkillers. However, there has been minimal research performed on medical cannabis to back this claim. Social stigma and government laws need to be lightened so they do not prohibit proper research and patient distribution of medical cannabis, in regard to the treatment of chronic pain.
There was slight evidence discovered throughout the research that suggests medical cannabis, can have the ability to improve neuropathic pain but insufficient evidence in patients with different conditions. Most medical cannabis studies are small, and can present with different flaws. There is also little known about the long-term effects given the short follow-up period of many studies. Applying these findings to current practice may be tricky due to the inconsistency of the product and the research.  In conclusion, if medical cannabis can serve as an alternative to prescription opioids for at least some patients, health care providers and legislators alike, may want to contemplate medical cannabis programs as a viable option for fighting the current opioid epidemic.