Intractable Pain Health Care Practitioner Comments
Comments posted 8/10/15
Hi. As a practitioner and medical director of a community health center, I would not want “intractable pain” to be a certifiable condition. We have difficulties with abuse of narcotics already for pain and “intractable“ is so subjective. In our community - the community we serve - a lot of people smoke marijuana and they will want the state program to pay for their marijuana. I would vote “no” on this indication. (posted 8/10/15)
Comments posted 9/2/15
I am a Pain Physician recently moved to MN from Vermont. We have had medical marijuana available for a few years in VT. I work with Chronic Pain and had around eighty patients involved in the program. The dispensaries used high CBD, low THC strains in smokable, vaporizable, tincture, and edible forms. Few chose the smokable form as they had children in the home, or lung disease. My patients had a variety of pain problems, such as peripheral neuropathy, headache, back pain, abdominal pain, fibromyagia. Sleep, nausea, and anxiety improved. Most patients had improvement, some did very well. Many were able to decrease their opioids. One patient stopped his Methadone 100 mg daily. Another got off Oxycodone 80 mg daily. I communicated with their family, therapists, primary care providers. No patients sat around high, given the low THC, rather they tended to improve their function. There were no problems for diversion that I was aware, given the low THC content, and the cost was close to street value of that with high THC. The rules for Vermont indicated a doctor had to certify they had a covered condition, which chronic pain was one, and that they had a six month relationship with this patient as a provider. This helped with the concern some providers may have with being overwhelmed by new patients seeking to find someone to help certify the patient. There were no legal issues or law enforcement problems that I was aware of. There were no problems with exacerbation of substance abuse problems that I was aware of. Many of my patients were also on Suboxone and followed closely by substance abuse counselors so this issue would likely have been noticed. There is a study that reflects states that allow medical marijuana have a 25 % decrease in deaths associated with opioid abuse. I don't have the data for Vermont, but I had a sense that applies. I support intractable pain be a covered condition for intractable pain. I follow many patients now in MN on complicated treatment plan, with medications with side effects and risks. Many are on opioids and desire a chance to decrease the use and try medical cannabis. [name redacted]
I am an orthopedic surgeon who daily sees the challenges of managing patients with chronic pain. We are in the middle of an unprecedented narcotic pain medication epidemic that severely affects patients and their families. Medical cannabis has been shown time and time again to decrease the use of narcotic medications in the setting of chronic pain. I have yet to hear of a patient dying from THC overdose but have had many patients who have overdosed on narcotic pain medication, some suffering very poor outcomes.
I am an RN that works in the field of mental health and addictions. Intractable pain should, without a doubt, be added to the list of qualifying conditions in the Minnesota Medical Cannabis Program. In this day of more overdoses on opiates than car accidents, cannabis would be a safe alternative for pain. It's time for Minnesota to come out of the dark ages and recognize the benefits cannabis has on health and the enormous problems we now have with opiates. Please consider adding intractable pain to the list of qualifying conditions to be added.
Comments posted 9/11/15
Though I’m not flat out opposed to people who have legitimately no other options, I work in the field of public health and prevention. I’m concerned about diversion, abuse of the system, and norms that are shifting and continue to shift as a result of policy. The state set up the current system to avoid issues other states struggle with, but intractable pain is a slippery slope. My family has intractable pain and addiction, but we need to think of what’s best for the patients—for patients that already have complex medical issues. They say medical cannabis is addictive and significantly increases the chance of developing brain disease. Data show that 1 in 10 marijuana users become addicted and that jumps to 1 in 2 for daily users. Dr. Miles Belgrade said to your panel that his patients are as likely (or more) to want to continue to use opioids even when adding medical marijuana. Medical professionals are to “do no harm,” but marijuana use has known risks of harm. “Intractable pain” is subjective, and including this opens up the system to a whole host of complications. Those who are most likely to provide public comment are those with personal experience of use and provide anecdotal evidence—not science—to advocate for inclusion of intractable pain. Addiction, access to youth, increase in mental illness, traffic safety issues, less employee productivity, decreased perception of harm, cost to society from all previous reasons. There are also quotes from “Big Marijuana” organizations such as NORML and MPP stating how medical marijuana is how they will open the door to full legalization. They say that people that use medical cannabis have depression, and NAMI says it’s not helpful and works through anxiety or depression or schizophrenia and patients often don’t follow through on appointments. The comments here and on the website lean one way and will continue to do so. People in my field are afraid to speak up for fear they will lose their job, credibility, and grant funding.
Comments posted 10/2/15
Cannabis for intractable pain is something that I think is necessary. As a nurse, I would watch many who were in pain be under the influence of opioids. With opioids, the patient would often find very little pain relief, suffer from dependence, and sometimes become "snowed" - thus losing valuable time with family, or frankly just being able to have their own mind in control. Cannabis is clearly the better choice, as there is no potential for dependence, and used correctly it allows the patient to be in control. It's obvious, cannabis is the better choice. If we value patients and want the best for them, giving them addictive substances to control their pain goes against that. August 25, 2015 [name and address redacted]
Re: Public input on medical marijuana use
My name is [name redacted] and I am both a medical provider and a severely ill patient with auto immune disorders. As a medical provider, I opened a chain of pharmacies in Beverly Hills, California; San Francisco, California; Van Nuys, California; and Chatsworth, California. I am still licensed by the DEA to purchase and dispense Schedule I-IV narcotics, and am also licensed by the California State Board of Pharmacy [Pharmacy name redacted] [Pharmacy name redacted]- Beverly Hills, San Francisco, Van Nuys, and Chatsworth, CA [Pharmacy name redacted] The majority of our locations were specialty HIV pharmacies. We were most recognized for managing AIDS related wasting, and for lipodystophy. Our Chatsworth location is a sterile compounding pharmacy. We make to order specialized pharmaceutical compounds such as BHRT (bioequivalent hormone replacement therapy) unavailable or discontinued medications (e.g. testosterone), alternate route of administration medications (e.g. IV, IM, Subcutaneous, Optic, Otis, Transdermal, Topical, Suspensions, Capsules, Suppository, Creams, Tinctures, Lotions, and medicated candles)
Although we do not dispense any form of cannabis what so ever, a large percentage of our patients were using medical marijuana, and I daily seen the benefits that it provided to them.
About my own medical condition:
- Diagnosed in 2000 with a malignant thymoma, and pure red blood cell aplasia.
- Received blood transfusions every other week for 10 months.
- Diagnosed with Myasthenia Gravis in 2001, and rheumatoid arthritis.
- Diagnosed with Lupus in 2002
- Diagnosed with Diverticulitis in 2003, chronic oral lichen planus
- Myocardial infection 2004 & 2005
- Diagnosed with dysphasia due to lichen planus in 2012
- Diagnosed with degenerative disc disease in 2012
- Diagnosed with progressive paralysis in 2013
- I receive IVIG infusions weekly to help manage my autoimmune disorders.
As I have maintained a home in both California, and Minnesota, I have been prescribed medical marijuana since 2001. I can personally attest to its benefits as an antiemetic, as a pain reliever, as an appetite stimulant, and helping to relieve my depression and anxiety by controlling these aforementioned conditions. As a pharmacy medical provider, I can attest to the benefits that I have seen with many of our patients.
Its use should be extended to other areas which include (but not limited to) chronic neurological pain, auto immune related inflammatory disease, select eating disorders, and Lupus. I also believe that in select situations, it will provide palliative relief to patients suffering from both anxiety and depression.
I think it was a wise decision to remove cannabis from a schedule I category to a usable schedule II category, but I believe your findings will eventually lead you to allowing it to be categorized as a schedule III category, thus providing legitimate palliative relief and quality of life improvements for a substantially larger patient population than what is currently being met. Sincerely,
[name and contact information redacted]
I am an internist who treats many patients with chronic illness, including chronic pain. I am also a provider in the Fibromylgia Treatment Program at my institution. The statutory definition of “intractable pain” is problematic in that it mentions the possibility of “cure” and it references specialists “of the area, system, or organ of the body perceived as the source of the pain.” This definition of “intractable pain” does not recognize the fact that chronic pain is incurable nor does it realize the relevance of central nervous system sensitization for all pain states. Chronic pain is an incurable condition that is manageable utilizing a multimodal approach. I am against expanding the indication of medical cannabis for “intractable pain” for several reasons. 1. Using medical cannabis will not address the other contributors of chronic pain which include social pain, sleep disorders, mental illness, co-morbid medical illnesses and spiritual pain. 2. Medical cannabis has not been shown in clinical trials to be superior to other FDA approved medications for treatment of chronic pain. 3. The medical cannabis dispensed by the state of Minnesota is not regulated by the FDA, therefore the purity, efficacy and safety may be suspect. 4. Patients suffering from chronic pain will be given a false hope of “cure” with the additional risk of addiction and cannabis side effects. 5. With multiple pharmaceutical cannabinoids currently on the market and more in phase 3 clinical trials, I do not see the need to expand the indications for plant medical cannabis in the state of Minnesota.
[Already submitted written comment] I’m the Medical Director at the Health East Pain Clinic in St. Paul and just moved here a few months ago. I had followed people at the pain clinic in Vermont for 4 to 5 years, maybe 60-80 patients. As a physician I would certify a patient for chronic pain. We had dispensaries in town that would dispense it in forms that were smokeable among other options, high CBD to help with sleep and pain and low THC, so they don’t sit around high. I helped an ex-cop get off methadone for peripheral neuropathy, Crohn’s disease, and lumbar pain. People did well. I would be in contact with families and providers to see how people were doing. People function well and have a higher quality of life. I did have some patients that died of opioids. I get the idea there’s not a lot of providers that understand this, so I thought I would come here and share my experience and I’d be happy to share more. [Follow up question: Do you have criteria for establishing who might or might not be a good candidate?] I didn’t have any restrictions. By the time they have come to see me they have been through a number of things already, such as opioids and neuropathics. So I look to cannabinoids. And often they bring it up too because they’ve done their research. [Follow up question: Did you use cannabinoids on children?] I didn’t see a lot of pediatric patients—some with seizures, fibromyalgia, and headaches. They were generally in their 30’s or older. There’s some concern doctors don’t want those kinds of patients in their offices. Most of my patients were like middle aged social studies teachers with debilitating pain. They often didn’t want to smoke it because they had kids at home. [Follow up question: Many of the studies included in prior reviews and one in currently in process have been of FDA cannabis derivatives. These reviews often loop that in with whole plant extract. I never see Dronabinol prescribed for pain. Did you try those first?] Those are really hard to get through insurance, rarely Marinol, so it’s unaffordable. I tried to get Sativex from Canada, which is CBD and not THC, but even then I’d see people come to the dispensaries and who knows exactly what the component is of that? It’s really hard to sort out what’s going on; there’s a lot of interest in getting marijuana rated as class 2. It’s very confusing and anecdotal. This is very different than any other medication. I’d rather continue to have this option to work with than trying to get one more opioid. [Follow up question: Did you observe any adverse effects from the use of medical cannabis?] Rarely did I see an adverse effect—maybe a little headache or nausea, but they would work with people in the dispensary to try different things. So I rely on them [dispensaries] but I talk to them pretty often. Did not see major side effects, and by being able to cut down on other medications there would be lot less. [Follow up question: It’s helpful to hear people who have found medical cannabis helpful. You’re the first physician I’ve talked to who’s actually used it. Can we contact you with further questions?] Absolutely. I’ve registered a few people with other conditions and I’d be happy to answer questions. I consider it part of my role to do that. I am not flat-out opposed to people who legitimately have no other options receiving access to something that may be helpful, but as someone who works in the field of public health and prevention (who is here on my own time), I have some serious concerns about expanding the qualifying conditions for this program. Among my top concerns are diversion, abuse of the system, and the norms created by shifting public policy. Our state’s program is currently set up to avoid many of the unintentional consequences that other states are struggling with, but I fear that adding intractable pain is dangerous step out onto a slippery slope.
Coming from a family surrounded by people who both struggle with pain and addiction, I also think it’s important to remember what’s best for the patients. In attempting to provide compassionate care, we must first remember to do no harm.
Marijuana addiction is a real threat. For patients who already have complex medical issues, adding a significant risk of developing the chronic brain disease of addiction, will only make things more challenging.
Residents of states with “medical” marijuana have marijuana abuse/dependence rates almost twice as high than states without such laws.
Cerda, M. et al. (in press). Medical cannabis laws in 50 states: ‘Investigating the relationship between state legalization of medical cannabis and cannabis use, abuse and dependence.” Drug and Alcohol Dependence. Available at http://www.columbia.edu/~dsh2/pdf/MedicalCannabis.pdf
1 in 6 teen users becomes addicted, and the rate rises to up to 1 in 2 among daily users.
Hall et al., (2009). Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61037-0/abstract
Additionally, in reading the notes from your last Advisory Panel meeting, it sounds like the doctor who presented noted that, in his experience, those using marijuana do not decrease opioid use, and in fact, marijuana use may lead to opioid seeking tendencies in some patients.
Many patients who struggle with intractable pain also struggle with a mental illness. According to the National Alliance of Mental Illness, “The overwhelming consensus from mental health professionals is that marijuana is not helpful—and potentially dangerous—for people with mental illness. Using marijuana can directly worsen symptoms of anxiety, depression or schizophrenia through its actions on the brain. People who smoke marijuana are also less likely to actively participate in their treatment—missing more appointments and having more difficulty with medication-adherence—than people who abstain from using this drug.”
Lastly, I want to note that comments have been leaning one way, because many people in my field are too scared to speak up in fear of being bullied, harassed, or losing our jobs or grant funding that comes with lobbying restrictions, and I think the conversation will continue to be one sided.
Thank you for your time and this opportunity to provide input.
Comments posted 10/7/15
To Whom It May Concern: In general, I have not been strongly in favor of medical cannabis in the past. My opinion has changed recently, because I have some patients with poorly controlled or intractable pain and I see the need for medical cannabis to improve her quality of life. I am hoping that the committee will consider that to be one of the indications for referral to the medical cannabis program. I have not been able to find any other good options for patients, and consequently I don't have anything else for them. thanks for your consideration
I support the inclusion of intractable pain as an indication for the use of medical cannabis. I work with a patient population that suffers from epidermolysis bullosa (EB), a group of inherited conditions where the body does not produce one of the proteins necessary to bond the layers of the mucocutaneous membranes and skin together. The devastating wounds that result from everyday friction, both internal and external, are a source of severe and unrelenting pain akin to severe burns. Additionally, these wounds do not heal in the normal way, resulting in either contracting scarring or chronic sores. I know of no study that has researched the efficacy of medical cannabis in this population; however, I know anecdotally of teenagers with the milder forms of EB who smoke marijuana for pain relief. This is dangerous, as their immune systems are compromised and risk of life-threatening fungal infection from this behavior is high. There is no alternative medication or set of medications that can control their pain, save for putting them into a drug-induced coma. Therefore, I would like to support the case for having medical cannabis available to them (and others in intractable pain) in a legal and controlled way.
I am a family practice physician who is concerned about adding intractable pain to the list of qualifying conditions. I think the research is still not to the level of quality that evidence based medicine demands. What is the optimal form? What is the optimal dosing? Are there long term side effects? We are still reeling from the epidemic of opiate abuse. There was such a big push a few years ago to treat pain aggressively with narcotics. Now we are having to back away from that approach. I think the push should be at the federal level to allow more controlled studies. Yes, I have chronic pain patients that smoke marijuana. That said, "intractable" pain is very subjective. Too often a drug is the quick fix that folks are looking for. This is too open for fraud and abuse. I'm also bothered that we "certify" someone, then they are free to obtain the drug independently of medical oversight and without necessarily coordinating with other modalities. This is a politically driven solution to a medical problem. I am against adding it at this point.
I have a patient who suffered from a spinal cord injury and they treated him with narcotics. The pain level was only slightly reduced, but he started have such bowel problems. The symptoms he was getting as a result of the medications didn't warrant taking the medication. He turned to using marijuana. He is able to control the pain and not suffer any side effects that he is aware of. I feel that it is much safer for him to use cannabis that the prescribed medications he was on.
[Already submitted written comment]: I treat children with cancer for a living. I’m here to make a pitch for other thing I treat a blistering skin disease, which is the most horrible thing I’ve ever seen. The child’s skin will blister and peal and will never heal in their short life. No opiates or pain medications I can prescribe will control the pain. I would have to induce them in a medical coma. The condition is not a cancer and wouldn’t fit into the category of terminal illness. This is one of the most common conditions I can think of for intractable pain. Everyone I talk to has a tragedy in their lives. Most people, I can tell them that their child will live. But for children with this, I can’t tell them. I don’t know. We are the only center in the world that treats this, but we need help controlling pain. I had two teenagers that died from smoking marijuana. I didn’t know that they were getting on it on the street somehow. That’s exactly what I don’t want to happen. They get spores from the leaves in their lungs that form an untreatable fungus for those that don’t have a functional immunes system due to a bone marrow transplant. I ask the panel and the commissioner to do this.
It should definitely be added to the list of usages. I was a hospice nurse for 15 years and saw firsthand the benefits of marijuana as an effective pain reliever. Please, please work on the last issue for those less fortunate and the disabled.
Intractable pain should be added to the use of qualifying conditions. Not only for patients with cancer but also other conditions, namely a skin disorder called Epidermolysis Bullosa. This is a horrific skin blistering disease that leaves the patients in 24/7 extreme pain for their whole life.
Comments posted 10/25/15
I have been a Registered Nurse for over 40 years and I feel very strongly that cannabis use for intractable pain must be monitored extremely carefully. This is where the program will have issues. Intractable pain is subjective and anyone can complain of it- and will. The program will be compromised if this is included. If you chose to include it, it MUST be VERY restrictive and very closely monitored and reviewed. There WILL be abuse if you chose to include intractable pain. Thank you for listening to my comments. Please take them from a medical professional seriously!
As a pediatric pain specialist, I do STRONGLY DO NOT support to notion of " intractable pain should be added to the list of qualifying conditions in the Minnesota Medical Cannabis Program" - ABSOLUTELY NOT for children and teenagers with normal life-expectancy younger than 18 years for the following 6 reasons: (1) Evidence has shown that cannabis does NOT provide analgesia beyond a placebo effect: - beneficial effects may be partially (or completely) offset by potentially serious harms • alterations to perception: NNH 6-9 • motor function: NNH 4-6 • altered cognitive function: NNH 6-12 Systematic review and meta-analysis of cannabis treatment for chronic pain. Pain Med. 2009 Nov;10(8):1353-68. Martín-Sánchez E1, Furukawa TA, Taylor J, Martin JL.• • Systematic review of randomized controlled trials Cannabinoids: NNT: ns; NNH 12.1 - Only 2 out of 9 trials positive Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet. Neurology. Feb 2015;14(2):162-173. • RCT Cancer pain: not effective Portenoy RK, Ganae-Motan ED, Allende S, Yanagihara R, Shaiova L, Weinstein S, et al. Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: a randomized, placebo-controlled, graded-dose trial. J Pain 2012 May;13(5):438-49 (2) Youthful exposure leads to earlier onset & more severe psychosis, incl. schizophrenia Correlation between mental illness and consumption of cannabis, especially earlier onset of schizophrenia in young people: Correlation with mental illness Casadio, P., et al., Cannabis use in young people: the risk for schizophrenia. Neurosci Biobehav Rev, 2011. 35(8): p. 1779-87.; Hermens, D.F., et al., Frequent alcohol, nicotine or cannabis use is common in young persons presenting for mental healthcare: a crosssectional study. BMJ Open, 2013. 3(2).; Lev-Ran, S., et al., Exploring the association between lifetime prevalence of mental illness and transition from substance use to substance use disorders: results from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC). Am J Addict, 2013. 22(2): p. 93-8.; Lev-Ran, S., et al., Cannabis use and cannabis use disorders among individuals with mental illness. Compr Psychiatry, 2013. 54(6): p. 589-98. Smith, M.J., et al., Prevalence of psychotic symptoms in substance users: a comparison (3) 3 studies show positive correlation between marijuana use and testicular cancer Lacson JC, Carroll JD, Tuazon E, Castelao EJ, Bernstein L, Cortessis VK. Population-based case control study of recreational drug use and testis cancer risk confirms an association between marijuana use and nonseminoma risk. Cancer. Nov 1 2012;118(21):5374-5383. (2) Trabert B, Sigurdson AJ, Sweeney AM, Strom SS, McGlynn KA. Marijuana use and testicular germ cell tumors. Cancer. Feb 15 2011;117(4):848-853. (3) Daling JR, Doody DR, Sun X, et al. Association of marijuana use and the incidence of testicular germ cell tumors. Cancer. Mar 15 2009;115(6):1215-1223. (4) Early-Onset, Regular Cannabis Use Is Linked to IQ Decline Study participants who initiated weekly cannabis use before age 18 dropped IQ points in proportion to how long they persisted in using the drug, while nonusers gained a fraction of a point. Meier, M.H.; Caspi, A.; Ambler, A.; Harrington, H.; Houts, R.; Keefe, R.S.E.; McDonald, K.; Ward, A.; Poulton, R.; and Moffitt, T. Persistent cannabis users show neuropsychological decline from childhood to midlife. Proceedings of the National Academy of Sciences 109(40):E2657–E2664, 2012. Moffitt, T.E.; Meier, M.H.; Caspi, A.; and Poulton, R. Reply to Rogeberg and Daly: No evidence that socioeconomic status or personality differences confound the association between cannabis use and IQ decline. Proceeding of the National Academy of Sciences 110(11):E980-E982, 2013. (5) 9% of adults (17% teens) who experiment with marijuana become dependent (6) Updated 2015 American Academy of Pediatrics (AAP) policy opposes marijuana use, citing potential harms, lack of research http:// aapnews.aappublications.org/content/early/2015/01/26/aapnews.20150126-1 - American Academy of Pediatrics (AAP) Handout for parents "Despite relaxed regulations, marijuana harms developing brain": http:// aapnews.aappublications.org/content/36/3/4.full.pdf+html
I work with chronic pain patients in a pain management clinic. I am opposed to legalizing marijuana for intractable pain. The definition "intractable" pain is so vague and hard to quantify. I think I saw the definition as pain that is not curable and unresponsive to other types of treatments. So, does that mean that patients that are getting 50% or 75% improvement with opioids wouldn't be eligible or fit the definition of "intractable." Would it only be a treatment offered to patients not currently managed on opiates? (If they were managed on opiates then I presume they are deriving benefits from the medication and therefore don't have definable "intractable pain.). There is so much 'secondary gain' in regards to obtaining opiates. Are you really going to get a reliable assessment of chronic pain when another secondary gain is obtaining legal Marijuana?? I don't think so. There is an epidemic of opiate use, misuse and addiction. Most chronic pain patients are high risk for opiate misuse. We simply monitor them very closely to intervene early. Many already have a dependence on tobacco in addition to an opioid dependence. Now, let's just add another dependence on legal marijuana??!!! That is not in their best interest. It's a reality that even if you are successful in reducing a patients pain to a mild level of pain, they never get off disability and return to work. Legal marijuana would add another barrier to a return to work goal. Workplace drug testing is a whole new issue. I see diversion of legalized marijuana as an issue as well. It's not the norm but pain patients do use other family member/friends pain meds and I can only expect the same will be the case for legalized marijuana. It presents a problem for tox screening our patients. Will we be able to see a difference between legal and illegal marijuana? Can we decipher when a patient is using legal marijuana, street drug marijuana, and both street and legal marijuana together? We check a THC level to assess use of marijuana. Will this be negative for legalized marijuana which I believed wouldn't have the "high" producing THC? I certainly want to be able to help patients so they don't suffer in pain. I feel that management on too many controlled substances is not a goal to be striving towards. Under circumstances where opioids have failed (meeting a definition of intractable) and they are not maintained on any opiates then I could see it worth a trial. That would prove the true benefit of marijuana for intractable pain!! Thank you.
The Minnesota Nurses Association has passed a resolution on October 6, 2015 in favor of adding intractable pain to the list of qualifying conditions for medical cannabis in addition to other suggestions regarding medical cannabis and health care facilities. Minnesota Nurses Association Resolution (PDF)