Why MMJ Sense for Chronic Pain

The explosion of coverage on opioid abuse has been chilling for many chronic pain patients who use opioids responsibly to manage their pain. In many cases, with heightened scrutiny over its merits of use, reduced access becomes an issue.

Many chronic pain sufferers have turned to medical marijuana, which has far fewer side effects than opioids. The problem there is also access. Medical marijuana is only available in 23 states and the District of Columbia and, of course, there are complications because the federal government still deems marijuana illegal so people in the federal health care system (like the VA and Medicare for instance) often can’t get medical marijuana prescribed.

Dr Gary Witman

Dr. Gary Witman is an internist and former emergency room physician who now practices in the Fall River location of Canna Care Docs, which are located in several states in the northeast. His practice focuses on opioid replacement therapy—substituting medical marijuana for opioids.

He agreed to share his thoughts with the National Pain Report on the issue of medical marijuana.

National Pain Report:  What do you feel is the biggest hurdle?

Dr. Witman:  The fact that the DEA has classified medical marijuana as a schedule one agent. Now I am completely opposed to the usage of recreational marijuana. I believe it should be closely monitored by physicians with specific classifications of criteria for which would provide the greatest clinical benefits.

National Pain Report:  Why hasn’t Congress changed the rules about medical marijuana?

Dr. Witman: Because I think that people believe that there is a slippery slope, they believe that individuals, who start with medical marijuana, or any marijuana, will want to go to drugs such as cocaine and heroin.

National Pain Report: Do you think the DEA and the federal government’s auxiliary agencies and nongovernmental agencies like American Board of Medical Specialties have a stake in keeping medical marijuana illegal and un-researched?

Dr. Witman: It would be my goal, my wish for the DEA to welcome applications to their agency to perform appropriate clinical trials. Yes they are keeping it illegal right now. I have absolutely no understanding of why they’re keeping it illegal. I mean I think we’re up to 37 states now that allow us to provide this particular drug treatment to a qualified patient population. Hopefully soon it will be 50 states.

National Pain Report:  What evidence then is going to be sufficient enough for them to say, ok we know that maybe this not a gateway drug or this is not a slippery slope. Is it anecdotal evidence or is it research that is needed?

Dr. Witman: No, I think that all we’re looking for is the usage of this drug for medical indications. I think that congress, in general, believes that we’re looking for this for recreational usage, and to get high. Remember most strains of medical marijuana right now are CBDs rather than THC. We’re not looking for high THC’s…we’re looking for only those strains which provide medical benefits. And I don’t think that congress has been adequately educated about what forms of medical marijuana physicians are looking or requesting to have legalized.

National Pain Report: Why do you think there has been no serious study on medical marijuana for chronic pain?

Dr. Witman: Because there’s been a lack of funding to provide for the most appropriate clinical trials.

National Pain Report: If there is adequate funding — where would that come from?

Dr. Witman: That would come from the National Institutes of Health

National Pain Report: How are [National Institutes of Health] persuaded then, to start this research?

Dr. Witman: They would need to do a prospective clinical trial, and I have one in mind. It would be in patients with brain tumors. Medical marijuana has been demonstrated in cancer cell lines to cause apoptosis, which is program cell death, plus effects on angiogenesis. It inhibits the production of new blood cells and I think that would be an important clinical trial. And it would demonstrate that it would be no decrease in benefit, in fact, I believe it will improve survival rates for persons with brain cancer.

National Pain Report: Do you think that the research will change people’s minds and is that the only thing that will change their minds?

Dr. Witman: Well, I think that will be the best way, yes.  I don’t think anecdotal materials are important. I think that clinical based evidence on a sufficient cohort of subjects is necessary to be able to reach a conclusion.

National Pain Report: Is anecdotal evidence any less factual?

Dr. Witman Not at all, it just doesn’t provide sufficient, in the subject’s eyes, any statistical…you acquire enough individual with demonstrable clinical benefit before you can say with any medical certainly that something in fact is true.

National Pain Report: do you think the federal government changes and then the states follow?

Dr. Witman: It’s really the south that has been most resistant. In virtually the entire northern portion of the United States have welcomed the introduction of marijuana treatment. but it’s the south that has been most resistant.

National Pain Report: The state of Georgia] spoke of isolating CBD, not use the rest of the plant, and disregard the “entourage effect”…all of the things you probably shouldn’t be doing — trying to synthesize it and replicate its [properties]. I found that astonishing and steeped within the culture of the south and within their own social attitudes against it.

Dr. Witman: First of all, I think you’re in a tough state, Georgia, to be able to move forward very far. I think there is some great resistant in Georgia to provide dispersement of medical marijuana products. If you can get it through in Georgia, God bless you.

The second part of our interview with Dr. Witman will discuss differences between vaporizing and smoking, his recommended way to consume cannabis, and how proposed monitoring of patients will work.

 
 Part two;

Dr. Gary Witman is a New England physician who believes that medical marijuana has a place—an important place in the practice of medicine.  Dr. Witman, who is a quadriplegic from an injury that occurred while swimming in the ocean, works with Fall River Canna Care Docs in Massachusetts, one of many practices that specialize in the use of medical marijuana in several states in the Northeast.

In part one of the interview with the National Pain Report, Dr. Witman emphasized the need for real research into the use of medical marijuana. Research has been hamstrung because the DEA still labels marijuana as an illegal drug. What makes it confusing is that marijuana used for medicinal purposes (including chronic pain) is legal in half the states and the District of Columbia.

Dr. Witman also believes that marijuana is a worthy substitute for opioids and much of his practice is devoted to helping patients taper off opioids and use marijuana to treat their chronic pain.

Here’s part two of the interview where Dr. Witman talks about the best ways to use medical marijuana including vaporizing, edibles, and smoking (with some interesting thoughts on how to smoke it).

National Pain Report: Do you encounter patients that suffer from hyperalgesia?

Dr. Witman: In my current work, where I work with patients who are looking for medical marijuana, I do experience and encounter that. What I am actively doing is I am taking those patients who use opioids off of them through a gradual tapering over a period of a month. And we’re having them transition to the administration of medical marijuana with significant clinical benefits. By blocking the immune receptors and enhancing the endocannabinoid receptors, we’re demonstrating significant clinical benefits.

National Pain Report: People are finding more relief from medical marijuana than they are with opioids correct?

Dr. Witman: Absolutely.

National Pain Report: Do you think that any of that has to do with hyperalgesia with the fact that people become hypersensitive to pain stimuli?

Dr. Witman: I think so.

National Pain Report: Do you actively pursue people/patients to try medical marijuana and to switch from opioids to medical marijuana?

Dr. Witman: Those individuals who come and see me, if they demonstrate the necessary criteria, absolutely.

National Pain Report: And what are the benefits that you express to them [advocating] to switch?

Dr. Witman: A reduction in anxiety, improve concentration, improved focus, improved performance status.

National Pain Report: And the criteria are what exactly? Is it [general] lack of relief?

Dr. Witman: They are things like glaucoma, nausea (which is intractable), migraines (which are intractable to other forms of treatment), post-traumatic pain, post-traumatic stress disorder, ADHA, anxiety, restless leg syndrome, HIV.

National Pain Report: In the article that you were interviewed for, the Boston Herald, there were…I think two doctors who were interviewed said that the only safeguard is to just follow up with their patients…

Dr. Witman: Carefully monitoring the patients…

National Pain Report: What does that entail, carefully monitoring?

Dr. Witman: Well, we strongly encourage them to return in six months tops. We carefully go through their physical signs, we go through their experience with the use of cannabinoids…whether they’re using it vaporized, smoking, or some other method. We go over their strains; we go over the regular frequency of usage because it’s most critical. We feel that those individuals who would most benefit from medical cannabinoids, would most benefit from it being delivered in a vaporized fashion and with regular usage. We find it’s critical for regular usage in order to provide the greatest therapeutic benefits. Remember, we only want them to use auxiliary drugs such as Tramadol, or Neurontin, or Lyrica or low doses opioid only with the greatest of breakthrough pain. Because we want to go carefully with them through their clinical experience.

National Pain Report: And frequency is key, and obviously the method and route of delivery is key too. What about Vaporizing is preferred?

Dr. Witman: Well first of all in terms of the reason we don’t like smoking is that smoking the temperature goes up to 1200 degrees [Fahrenheit] with a significant amount of ash residue. Plus it delivers to your lungs aryl hydrocarbon hydroxylase which increases your risk for lung cancer and chronic obstructive pulmonary disease. For those reasons alone, we recommend that no individuals smoke marijuana.

National Pain Report: That’s interesting, so with smoking it, you’re increasing your risk of lung problems in the future.

Dr. Witman: Yeah so we don’t recommend smoking to any of the individuals.

National Pain Report: You do recommend vaporizing it. There are a few different types of vaporizers: the oil based vaporizers and oven type vaporizers that provide the decarboxylate [process]. That, I was told and read about is the most beneficial.

Dr. Witman: Absolutely most correct

National Pain Report: And that method of heating it up, in a sense, what about that is beneficial other than the fact it’s not a carcinogen and cause future lung problems?

Dr. Witman: What’s most beneficial is the onset and is within 30-60 seconds after the initiation of treatment with the duration lasting from 4-5 hours. There’s no residue, t’s clean, and it can be done with discretion.

National Pain Report: Do you feel that with smoking it, which is a tried and true method, is it the fact that that’s the only way there could be a potential for future lung problems or even with vaporizing is there a potential for injury to the lung?

Dr. Witman: No it’s something that can be done easily using a tube, using a pipe. For those individuals who wish to have the greatest experience, we encourage them to acquire a device called The Volcano; it costs around six hundred dollars.

National Pain Report: Other than vaporizing do you recommend any other method of consuming such as eating edibles.

Dr. Witman: Yes, the other recommendation is for the usage in edibles. Cookies, brownies, gummies, any of the edible products.

National Pain Report: Do you feel there are pros in cons to the edibles?

Dr. Witman: The only downside with the edible is that it requires about one hour to absorb. The other problem is there’s such a prolonged duration of therapy; it can last up to 15 hours. For those individuals who are gainfully employed — it may have an impact on their work performance, the subsequent morning, as well as their driving abilities.

National Pain Report: It also kind of gives a hangover effect which I thought was very unique. If the edibles aren’t cooked properly they won’t have any effect which for people who live in areas without any kind of regulation at all and in an illegal environment — you kind of are getting whatever comes to you. And in those instances it is hard to know whether edibles actually work or if it is that particular edible that wasn’t made properly. For oils and tinctures do you recommend those? They’re very popular in Georgia — do you feel it’s an effective method?

Dr. Witman: As well they should be. They’re very popular here too. They’re extremely well tolerated; I have found no side effects from them whatsoever.

National Pain Report: Is it better to use a tincture/oil than it is to have an edible or to vaporize? What would be the top recommended?

Dr. Witman: Vaporizing by far. I like the duration; I like the immediate onset of treatment and consistent therapeutic benefit.

Summary:

The most controversial comment made during the interview is that smoking medical marijuana via a joint (paper wrapper) or blunt (cigar wrapper) and lighting it on fire is harmful to the lungs — increasing risk of lung injury including lung cancer and COPD. This is a contentiously debated claim within the marijuana community and in direct contradiction to the community’sno harm done mantra. Dr. Witman’s comments certainly add to a commonly heard complaint among many in the medical marijuana community, and particularly among chronic pain providers: the lack scientific study is hurting our understanding and as a result potentially the treatment of potential patients.

Click here for a previous NationalPainReport article: Vaporized Cannibis Reduces Neuropathy Pain.

 

Our website provides our patients with information on our various strains and educates each individual with current medical marijuana facts and laws.

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