Office Experience for Medicinal Cannabis Recommendations in California
Brubaker, DB, Brubaker
Muscular Skeletal Medical Associates
3726 North First Street
Fresno, CA 93726
This study was designed to answer several questions. The main question was to scrutinize whether patients met the criteria for medicinal cannabis? Other questions were centered on demographics, such as age, sex, socioeconomic status, health insurance status, and addiction data about cannabis. The method of study was a survey of 473 patients in whom the data was collected and entered into SSPS statistical computer program. Results showed 70 % .of patients were over age 30 and 40% of these patients were over age 50. Medicinal cannabis was used for chronic pain in 60 % of patients with the remaining 40 % meeting all other criteria for using cannabis. 46 % had no health insurance. 37 % ingest it through edibles; while the remaining 63% smoke it in some form, e.g. vaporizer, pipe. Surveying addiction starting from 10 years of age to 18 indicated the exposure to alcohol and cannabis was nearly equal, however 72 % used alcohol before using cannabis. 69 % stated that cannabis is not addictive. The conclusion is that patients are using medicinal cannabis for the correct diagnoses with low addictive qualities and that alcohol is more of a gateway drug than cannabis.
Medical cannabis refers to the use of parts of the herb cannabis (also referred to as medical marijuana) as a physician-recommended form of medicine or herbal therapy. The cannabis drug, which is derived from the Cannabis plant, has a long history of medicinal use, with evidence dating back to 2,737 BCE. 
The medicinal value of cannabis is controversial. A majority of governments do not recognize the use of the plant Cannabis Sativa\Indica as something that doctors can recommend to their patients. More of these governments, including several states under the U.S. government are recognizing the medicinal value of cannabis. The National Academy of Sciences Institute of Medicine (IOM) has stated that: “Scientific data indicate the potential therapeutic value of cannabinoid drugs, primarily THC, for pain relief, control of nausea and vomiting, and appetite stimulation. … For certain patients, such as the terminally ill or those with debilitating symptoms, the long-term risks [associated with smoking] are not of great concern. … [Therefore,] clinical trials of marijuana for medical purposes should be conducted. … There are patients with debilitating symptoms for whom smoked marijuana might provide relief. Except for the harms associated with smoking, the adverse effects of marijuana use are within the range of effects tolerated for other medications.” 
More studies have been done as suggested by the Institute of Medicine. Studies have shown that medical cannabis is effective in the treatment of nausea, vomiting, premenstrual syndrome, insomnia, anorexia, muscle spasm and spasticity, neurogenic pain, asthma, many types of cancers, glaucom, a alcohol abuse, bipolar disorder,  depression epilepsy, Alzheimer’s disease,  inflammatory bowel disease, migraines, fibromyalgia,  collagen-induced arthritis,  and many others. It relieves some of the symptoms of multiple sclerosis,  AIDs and the side effects of medications for this disease, chemotherapy for cancers, and spinal cord injuries. 
The United States Food and Drug Administration has never reported deaths directly resulting from cannabis use,  however the herb has been shown to increase incidents of lung cancer and chronic obstructive lung disease when smoked in conjunction with cigarettes. These effects can be eliminated by alternative methods of consumption, which include vaporizers and cannabis ingestion. 
There are several excellent reviews of the cannabinoid system, and several sociopolitical issues regarding medicinal cannabis, which prompted this study. Therefore, the purpose of this study is to determine the frequency of the diseases and medical problems that are known to benefit from cannabis; to determine efficacy; to evaluate the socioeconomic and demographic profile of patients seeking the use of cannabis; and to determine risks and the addictive qualities of cannabis.
A sixty question survey was provided to 500 new patients scheduled for cannabis recommendations over the course of one year. All patients sign a consent form by law in the state of California. No names were used, but rather patient numbers were assignedto each survey. The questionnaire obtained demographics such as age, reason for using cannabis, health insurance status, socioeconomic status, addiction history, method of use, and means of obtaining cannabis. Health insurance questions included: no insurance, Medicaid (MediCal), Medicare, Private, and HMO or Health Maintenance Organizations (Kaiser and Non-Kaiser). The socioeconomic groups were arbitrarily divided for the purposes of this study into annual incomes: very poor (< $10,000), poor ($10,000 to $20,000), somewhat poor ($20,000 to $40,000), middle of the road ($50,000 to $70,000), doing good ($ 75,000 to $100,000), got some wealth ($100,000 to $150,000), and over-the-top (> $150,000),
Addiction history was also addressed. Cigarette use was not included in the survey, but was a part of the patient’s social history. Rather, alcohol as a mind altering drug was considered, instead of cigarettes. All illicit drugs were considered, e.g., cocaine, methamphetamine, Heroin, etc. For this study, cannabis was not considered an illicit drug, even though the World Health Organization and US Drug Enforcement Agency consider it a Schedul I drug. Prescription drugs were also included because they have become a major addictive problem in the United States. The age at which a person became addicted was studied. This was further evaluated by the sequence of drugs that were used to form an abuse issue. Other addictions, such as food, sex, work, and gambling were also considered. Addiction was considered a repetitive compulsive behavior that is harmful to self and others when continued over time. Drug addiction was defined as a chronic relapsing condition characterized by compulsive drug-seeking and abuse by long-lasting chemical changes in the brain that is harmful to self.
The main question concerns whether patients are seeking medicinal cannabis that have legitimate medical problems. The diagnosis was made with a good faith history and physical that included height, weight and vital signs. The doctor spent between 15 to 30 minutes with each patient, less time if they had records and/or had obvious disabilities such as paraplegic, amputations, and wheel chair bound. Table 1 lists the groups seen by medical condition. The chronic pain was mostly due to low back pain, with degenerative disc disease resulting from motor vehicle accidents, work injuries, or in fewer patients, sports injuries. 15 percent of these patients had a radiculopathy. In younger patients, the cause for back pain and limb pain resulted from dirt bike and motor cross accidents, skate board accidents, and snow board accidents. The remaining 35.2 percent were due to medical conditions that fit the criteria by the National Academy of Sciences Institute of Medicine. Interesting observations with several patients (not a part of the survey) was that a patient may have cervical disc producing pain, insomnia from pain, and anxiety as a result of a severe motor vehicle accident. These patients were taking 3-4 medications whereas cannabis covered the several medications used prior to them using cannabis.
|Table 1. Medical conditions||treated|
|Mental Health, e.g., Bipolar||28||5.9|
|Sleep Apnea & Sleep Dis.||5||1.1|
|Nausea and Vomiting||1||0.2|
Age is another factor that is important in the use of medicinal cannabis, because recreational use is an issue with young persons who usually do not have medical problems. We found the following: 30 years and over equal 70.4 % or 332 patients vs 141 patients under 30 years of age. 40% of the 70% are 50 years or older. Figure 1 shows the graph according to ages. The male to female ratio was 4:1.
Figure 1. Age of patients seeking medicinal cannabis recommendations.
Socioeconomic Groups and Health Insurance Role in Predicting Cannabis Use.
A very important question concerned access to health care and whether patients taking control of their health with alternative medicine such as medicinal cannabis? The results were remarkable for very limited access to health care which led the patients to finding a means to their end by using cannabis. Interesting also was the fact that those with good health care elected to use cannabis, because it is natural and they didn’t want to take multiple medications. However, in the survey, this prevailed for both groups, Table 2.
Table 2. Do you use Cannabis because it is natural?
|Frequency||Percent||Valid Percent||Cumulative Percent|
Figure 2. This addresses insurance access in patients using medicinal cannabis.
A common theme that was prominent in this study had to do with healthcare access and whether they could afford medications and doctor visits. The socioeconomic groups, at least in a very poor part of California are obvious in Figures 2 and 3.
Figure 3. The frequency of different socioeconomic groups using medicinal cannabis.
Patients Want Medicinal Cannabis to be regulated by Medical Doctors
Despite all of the different socioeconomic groups with and without insurance who, patients want doctors to be in charge of medicinal cannabis as noted in Table 3.
Table 3. Would you allow only the medical doctor to decide who has access?
|Frequency||Percent||Valid Percent||Cumulative Percent|
Addiction Issue: An issue that we wanted to evaluate was addiction and whether cannabis a gateway drug as suggested by the National Institute of Drug Abuse. This was addressed by questions that determined if young persons were first exposed to alcohol or cannabis. And, does alcohol lead to the use of cannabis, or is the opposite true. Tables 4 and 5 address this issue. Table 4 shows the frequency by age of teenager’s first use of alcohol and cannabis. This shows that the frequency by each age group was essentially equal, except the exposure was higher for cannabis in patients over 25 years of age. The frequency of exposure in children 10 years old and younger was twice as high for alcohol. We also found only 98 of the 351 or 27.9 % who used cannabis before using alcohol. We therefore found 71.2 % used alcohol before using cannabis
Table 4. Initial Age of alcohol and cannabis use.
Table 5. Did you use cannabis before you used alcohol?
yes no Total
|Frequency||Percent||Valid Percent||Cumulative Percent|
Objective Data and Observations not included in the survey.
There were several observations over the study year and the following year. I would discover on average one hypertensive a week, who I managed until their blood pressure was stable or until they found a doctor to help monitor their medications. Three patients were referred to cardiologist for arrhythmias. One patient was referred for bariatric surgery. Three patients were referred to neurosurgeons for surgery due to severe foot drop. Two patients were referred to orthopedic surgeons for rotator cuff tears..
Two other observations also deserve mention. The 4 asthmatics in the study and 18 other asthmatics all reduced or eliminated their dependency on nebulizers, inhalers and medications. Their visits to the ER stopped and they were functioning better. Wheezing I heard on their initial visit was not present on the second visit.
Management of pain was another interesting finding. On the initial visit 65% of chronic pain patients were using a form of narcotic, usually Vicadin, Norco, Percoset, OxyContin, morphine of methadone. Virtually all patients wanted to discontinue the opioids.. Within a year all but 2% were completely off opioids or reduced their use substantially.. Prior to treating patients with cannabis recommendation, I was involved in pain management with opioids. I was never able to take the patient’s visual analog score (VAS) from a 9/10 to less than 5-6/10. With the use of cannabis, the pain patients have diminished scores from 9/10 to 2-4/10. This is a consistent observation, except in patients who still use opoiods with cannabis, there scores are 5-6/10.
Pain is the seminal cause for patients seeking cannabis recommendations in my practice. By examining the patients with various orthopedic tests, pain can be elicited to document their history. The question remains, “is ther enough pain in the patient to warrant the use of cannabis, or is this gimmick. Certainly, the patient providing records and at least medication bottles help reduce that concern. Although this data is helpful, nothing can replace a good physical exam to determine pain. The question remains as to cannabis’ effect on reducing pain?
Cannabinoids inhibit pain in virtually every experimental pain settings or paradigms. This takes place by way of the CB1 receptor or by the CB2-like activity in supraspinal, spinal, or peripheral regions, dependent on the type of nociceptive pathway. [17,18] This finding is consistent with high concentrations of CB1 receptors on primary different nociceptiors, particularly in the dorsal spinal cord, whereas peripheral CB2 –like receptors have been implicated in the control of inflammatory pain [19,20].
The observation that that patient in the survey and who was not a part of the survey all had a common nominator with the denominator being chronic pain, which was that cannabis was either eliminating or reducing the demand for opioids for pain. Research supports this observation. Injections of THC eliminate dependence on opiates in stressed rats,  Deprived of their mothers at birth, rats become hypersensitive to the rewarding effect of morphine and heroin, and rapidly become dependent. When these rats were administered THC, they no longer developed typical morphine-dependent behavior. In the stiatum, a region of the brain involved in drug dependence, the production of endogenous enkephalin was restored under THC, whereas it diminished in rats stressed from birth which had not received THC. 
In humans, drug treatment subjects who use cannabis intermittently are found to be more likely to adhere to treatment for opioid dependence. Historically, similar findings were reported by Edward Birch, who, in 1889, reported success in treating opiate and chloral addiction with cannabis 
The visual analog scores in cannabis patients versus opioid patients for chronic pain is an interesting observation. When I was prescribing narcotics for chronic pain, I was unable to diminish pain below 5/10 in any of the moderate to severe pain patients. In the cannabis patients, all patients are less than 5/10. One could argue the narcotic patients did not want there pain to be low so they could remain on narcotics and the cannabis patients want there pain low so to obtain another recommendation for cannabis. However, further evaluation is more physiologic than psychological. The narcotic patients on chronic opioids develop hyperalgesia syndrome or opioid-induced hyperalgesia. This entity results from long-term opioid use and in those on high-dose opioids for the treatment of chronic pain. They experience pain out of proportion to physical fingings, which is considered a common cause of for loss of efficacy.  This is misinterpreted as tolerance. Patients who came to me on high doses of opioids had more pain than their condition warranted and by diminishing the opioid, their pain decreased substantially, but to diminish doses was next to impossible.
Opioid-induced hyperalgesia is defined as chronic hyperstimulation of the opioid receptors resulting in altered homeostasis of the pain signaling pathways in the body with several mechanisms of action, one major pathway is through stimulation of the nociceptive receptor. Blocking this pathway, as noted above with cannabis blocks this pathway which is a means to preventing opioid-induced hyperalgesia.
The gateway drug theory is the theory that the use of less deleterious drugs may lead to a future risk of using more dangerous hard drugs. . It is often attributed to the use of several drugs, including tobacco, alcohol, and cannabis.
While some research shows that many hard drug users used cannabis or alcohol before moving on to the harder substances, other research shows that some serious drug abusers have used other drugs before using cannabis or alcohol. The former is particularly evident in individual drug-abuse histories which tend to show that “hard drug” users do progress from one drug to another.
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