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Cannabis + Chronic Pain

An Interview with Dr. Gregory Sonn of the Iona Cannabis Clinic

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I found myself sitting in a room of twenty or so recently-hired budtenders in Boulder, Colorado, listening to a lecture from our new managers on qualifying conditions for medical marijuana patients. “Who in this room has experienced chronic pain?” asked one of the trainers. To my surprise, nearly all hands in the room shot up into the air, and most of those hands belonged to women. It may have been shocking at the time, but chronic pain—medically-defined as pain that lasts longer than three months—is no stranger to the vast majority of Americans. And just like that room full of newly-hired employees, over half of Americans struggling with pain that lingers are female.

Chronic pain affects about 100 million people or one third of the population.1 Combine those in the United States suffering from diabetes, cardiovascular disease, and cancer, and their numbers still aren’t as great as those suffering from this common condition. Of those with chronic pain, a whopping 70% are women.2 On top of this, an estimated and staggering 80% of our population suffers with some form of depression and anxiety, which is often associated with the coping of physical pain. And, you guessed it, from the age of puberty to the age of menopause, a woman is twice as likely to have an anxiety disorder as a man.3

It’s no wonder, then, that a 2017 report found that of the 813, 917 registered cannabis users in the United states, 62.2% were using it to treat their enduring pain.4 This represented the largest group of people using cannabis for evidence-based conditions in the study and appears to mirror what we see in dispensaries and doctor’s offices around us. It seems that across the board, chronic pain has become an epidemic. Thankfully, medical cannabis offers a viable option for relief, and healthcare professionals in the cannabis space are here to help guide the way for patients seeking help.

I sat down with Dr. Gregory Sonn of the Iona Cannabis Clinic to get a better idea of what chronic pain means, involves, and what new patients should keep in mind during treatment with cannabis products. 

“Unfortunately, the way doctors treat most ailments is based on understandings of male physiology4,  and women thusly experience a higher rate of misdiagnosis.”

Chronic Pain is the number one diagnosis that Dr. Sonn treats in his practice. He defines chronic pain as any type of physical and or emotional pain that has extended past the normal period of time. Of course, what is considered normal often varies person to person. 

“For a PTSD or emotional pain patient,” says Sonn, “the expectation for pain to linger is six months. For a physical pain patient, it is three months. So, for example, if there is a death in the family and a person is still severely grieving after 6 months, that is considered chronic. For a physical pain patient: pain that lingers after the initial onset that should have dissipated, but has not, is considered chronic.” 

As is proven in study after study, women’s health is a unique entity. The female body responds differently than the male body when it comes to many forms of treatment; it also responds completely differently to pain. A substantial amount of data even suggests that women feel pain more strongly and acutely than men. Unfortunately, the way doctors treat most ailments is based on understandings of male physiology4,  and women thusly experience a higher rate of misdiagnosis. One study even found that women were seven times more likely to be misdiagnosed and sent home from the hospital in the middle of having a heart attack than their male counterparts.5 

Interestingly, women are also less likely to turn to opioids for their chronic pain. Perhaps this is why Dr. Sonn recognizes some of the unique trends amongst his female patients that he keeps in mind when considering cannabis treatment options. 

“In general, the women I see are more likely to acknowledge significant pain issues and potential treatments. They seem in general to be more open to natural alternative options,” he says. “There are definitely groups of people (women aged 30 to 50 years old, for example) that have this unbelievable amount of anxiety and depression that they are willing to acknowledge and treat. When we get to the 50 to 80-year-old-women, they definitely acknowledge the greater pain aspect and treatments more openly.” 

The doctor’s experiences run parallel to findings from a review of 18 studies completed by Miaskowski and colleagues, who observed lower opioid consumption postoperatively among women.6 Could this be due to a higher tendency amongst women to consider and seek out natural alternative therapies? 

“There are a myriad of options for women seeking chronic pain relief through medical cannabis.”

There are a myriad of options for women seeking chronic pain relief through medical cannabis. Transdermal patches, salves, and skin creams containing CBD and other cannabinoids are used by many patients with joint pain, menstrual cramps, and muscle soreness. Tinctures, tablets, and concentrates provide a familiar route of delivery for patients who are trying to reduce or discontinue their opioid medications. Full-spectrum products and whole flower cannabis for vaporizing or smoking are also options some patients use for more intense or psychological pain. Each patient’s ideal dose and delivery method is unique. 

“My patients greater than 50, for example, generally prefer oral medicines specifically and find pretty good comfort, confidence, and success,” Sonn says, “While my younger groups of female patients are definitely finding their way to inhalation products.” 

Talking to your doctor about your home state’s available options is the best way to determine the best product or method for you.

Dr. Sonn finds a high level of success with most of his chronic pain patients who seek medical cannabis as an option. However, there are a few conditions that are tricky to treat and do not always respond well to cannabis therapies. 

“In my practice, I’ve had poor responses in women with iatrogenic tremors,” says Sonn. “It unfortunately is not one of the things I see good results for. I also see a lot of women with Rheumatoid Arthritis (RA). The problem with advanced RA is that cannabis works best with this when prescribed at an early age, before the condition has had a chance to advance.” 

For this reason, Dr. Sonn encourages any young women diagnosed with any type of RA to get into their state’s cannabis program as soon as possible to prevent the advancement of this—or any—disease. 

“My recommendation, when it comes to a medical cannabis evaluation, is to do it as soon as you have a thought about it,” Sonn says. “If you are thinking about cannabis as a treatment option, try it. Because if you think it will help, it likely will. And the sooner you can break those cycles of chronic pain, the better you will feel.”


References:

1 Ivker, Dr. Rav. Cannabis for Chronic Pain. New York: Touchtone, 2017. Print.

2 https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562

3 https://adaa.org/living-with-anxiety/women/facts

4 http://www.nationalacademies.org/hmd/Reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx

5 https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562

6 https://www.nejm.org/doi/full/10.1056/NEJM200008243430809

7 https://www.jpain.org/article/S1526-5900(04)01114-9/fulltext

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Turmeric

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Turmeric is a root vegetable commonly used as a spice in various Indian and other cultures’ dishes. Turmeric is in the zingiberaceae family, as is ginger. The turmeric plant is native to the southeastern region of Asia and commonly harvested in places like India, Sri Lanka, China, Indonesia, and Taiwan. It is responsible for curry’s signature orange color, and its vibrant pigment will give essentially any meal an orange hue. 

Turmeric contains a substance called curcumin, and curcumin has been shown through research to offer anti-inflammatory and other therapeutic benefits. The scientific name for the turmeric plant is Curcuma Longa, and likely where the name curcumin comes from. When people are talking about the health benefits of turmeric, they are referencing curcumin so you may hear the two names used interchangeably. Curcumin is part of a group called curcuminoids, with curcumin being the most active and the most beneficial for health. Flavonoids are another substance found in various plants and give these plants their color. Curcumin is a flavonoid and is responsible for providing that bright orange color to turmeric. In addition to providing aesthetic value, flavonoids are also strong antioxidants with anti-inflammatory and immune-boosting properties.

The Journal of Biological Chemistry published a study done by Sanjaya Singh and Bharat B. Aggarwal of the Cytokine Research Laboratory at the world-renowned cancer hospital, M.D. Anderson. The study found that curcumin suppressed NF-κB, a protein complex responsible for controlling inflammatory responses. In other words, turmeric shuts off the body’s inflammatory response. Anti-inflammatories can be beneficial for many different ailments, including chronic pain and digestive disorders. A lot of CBD companies even put curcumin in their products because of its benefits. It is believed to be a synergistic pair with complementary therapeutic properties. The thought is that the two plant medicines are powerful on their own; as a combination, they can deliver even more anti-inflammatory and medicinal benefits. 

Many people simply add turmeric to their dishes as a way to easily incorporate it into their daily routine. It is pretty mild in flavor and can be added to many dishes without changing the overall taste too drastically. Some say that turmeric isn’t strong enough on its own to receive the anti-inflammatory properties that curcumin provides, and therefore recommend a curcumin supplement. Research varies on that, so in the end it is just up to personal preference and your doctor’s approval. Curcumin supplements come most available in capsules. Pregnant women can safely use turmeric as an addition to their food, but should avoid taking high-dosage supplements. Those who are interested in supplementing with curcumin products should talk with their doctor first. 

M.D. Anderson Cancer Center did another study in 2007 exploring curcumin for cancer treatment. The study found that curcumin inhibits ovarian cancer growth and angiogenesis (the development of new blood vessels). It does this by targeting and manipulating the NF-κB pathway, the same protein complex responsible for controlling inflammatory response. According to a report published by the National Center for Biotechnology Information, “The nuclear factor NF-κB pathway has long been considered a prototypical proinflammatory signaling pathway, largely based on the role of NF-κB in the expression of proinflammatory genes including cytokines, chemokines, and adhesion molecules.”  

The trend with curcumin seems to be it’s ability to control inflammatory responses in the body. It does this by multiple pathways, but a commonly researched one is the NF-κB protein complex. Because this pathway is able to be manipulated by curcumin to encourage anti-inflammatory expressions, its potential for successfully treating various ailments is there.

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Psilocybin + Magic Mushrooms

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When many think of plant medicine, specifically those plants with psychoactive effects, they think of “magic mushrooms,” or fungi containing psilocybin and psilocin that can cause hallucinations depending on the dosage consumed. In many states, there are active efforts to decriminalize these otherwise scheduled substances, lowering penalties for their use and possession. But what value do psilocybin-containing mushrooms offer? New research suggests a range of therapeutic and psychological value ranging from the treatment of substance abuse to anxiety and depression management.  

What are Magic Mushrooms?

Magic Mushroom use dates back to 10,000 BCE and references continue throughout the era. Their modern popularity began when the term “magic mushroom” was coined by two etnomycologists who learned of a Harvard study on local doctors in Mexico using these substances, noting the substance’s ability to affect the nervous system. These findings were eventually published in Life magazine in 1957, and the term became the universal reference for psychoactive fungi and truffles, specifically those containing high concentrations of psilocybin and psilocin.

Psilocybin & Psilocin: The “Magic” in Magic Mushrooms

Psilocybin and psilocin are part of a family of psychedelic compounds found in magic mushrooms. Psilocin is pharmacologically active, and psilocybin is converted into psilocin when consumed or activated. Similar in structure to serotonin, there are more than 50 species of mushrooms and a variety of truffles that produce both the precursor, psilocybin, and the psychoactive compound, psilocin. Unlike LSD, magic mushrooms do not affect dopamine receptors, solely targeting serotonin sites

How are Magic Mushrooms used?

Magic mushrooms are often used for recreational, therapeutic and medicinal reasons. “Effects range from mild feelings of relaxation, giddiness, euphoria, visual enhancement (seeing colors brighter), visual disturbances (moving surfaces, waves), to delusions, altered perception of real events, images and faces, or real hallucinations.” Recreationally, this is often known as “tripping.” As an alternative health option, these fungi are being used for anxiety, depression, PTSD, and trauma, as well as psychological disorders such as substance abuse disorders, and science is beginning to back the potential for these applications.

Research on Mushrooms

Evaluations of currently available scientific studies suggest a growing number of therapeutic benefits and treatment options. “In the past few years, a growing number of studies using human volunteers have begun to explore the possible therapeutic benefits of drugs such as psilocybin…looking at psilocybin and other hallucinogens to treat a number of otherwise intractable psychiatric disorders, including chronic depression, post-traumatic stress disorder, and drug or alcohol dependency.”

Magic mushrooms have been respected as a “safe & natural healing sacrament for millennia throughout Mexico, Central America and the world,” and are known to be beneficial for depression, recidivism (the tendency to repeat past transgressions), and encourages openness, creativity, as well as personal and spiritual growth. UCLA and NYC have done studies on the applications of magic mushrooms in the treatment of end-of-life anxiety and other studies have backed up the use of psilocybin and psilocin in the treatment of substance use disorders, depression (especially in cases of terminal conditions like cancer as well as treatment-resistant depression), and reducing depression and anxiety overall.

Best way for people to consume?

When it comes to the consumption of mushrooms, advice on dosage is about as specific as it was with cannabis under prohibition. Consumers must purchase on the black market and are subject to whatever may be available. 

“Recreational doses range from 1–5 grams of dry mushrooms depending on the species and individual strength of the specimens… After ingestion, the psilocybin is enzymatically converted to psilocin. Absorbed from the gastro-intestinal tract, hallucinogenic effects usually occur within 30 minutes of ingestion with a duration of effect of 4–6 hours.” 

My recommendation as someone who has used magic mushrooms both for recreational and therapeutic purposes, is to grind the mushrooms into a fine powder and either encapsulate them in small increments and/or combine with lemon juice. Capsules will allow you to titrate your dosage as needed with a recognizable increment, while lemon juice will expedite onset time.  

The Legality of Magic Mushrooms

In the United States, psilocybin is a Schedule I controlled substance, with no accepted medicinal value and a high potential for abuse. In contrast, the Drug Policy Alliance states that “Physically, psilocybin mushrooms are considered to be one of the least toxic drugs known.” With that being said, local efforts such as Decriminalize Nature – Oakland and Decriminalize Denver have pushed for and successfully passed initiatives and legislation to reduce penalties and make enforcement a low priority, as was done in the early days of cannabis activism. This has spurred multiple local and international efforts to “Decriminalize Nature,” efforts that we learn more about in this month’s feature.

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Ginkgo Biloba

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Ginkgo biloba is an ancient tree; its roots originate in China. The ginkgo biloba tree is also sometimes known as the maidenhair tree or the Japanese silver apricot, and it produces a foul-smelling fruit commonly harvested for its seeds known as “ginkgo nuts”. Ginkgo nuts are popularly used in Asian cuisine. 

The ginkgo biloba tree’s fan-shaped leaves are used to make ginkgo biloba extract, a supplement traditionally used in Chinese medicine, but has since garnered the attention of cultures worldwide. The supplement comes in liquid extracts, capsules, and tablets. The leaves can also be dried to make tea. The type of ginkgo biloba extract supplement someone takes is all a matter of personal preference, and depends on the user’s already existing regimen. If you do not already drink tea, a ginkgo biloba tea may not implement easily into your lifestyle, thus a greater chance for inconsistency or erratic results. But if you take vitamins or other supplements regularly, after a doctor’s approval you can easily incorporate an additional capsule or tablet into your daily routine. 

The 16th-century Compendium of Materia Medica or Ben Cao Gang Mu is revered as the most comprehensive text ever written in the history of traditional Chinese medicine. This text reveals that ginkgo biloba seeds were used as a topical extract for antimicrobial purposes on the skin. Traditional Chinese Medicine also uses the leaves for tea and attributes it to soothing coughs and activating blood circulation, as well as other benefits like respiratory and digestive ailments. 

A common use for ginkgo biloba is to preserve memory and prevent cognitive decline. Dr. Hiroko Dodge of Oregon State University at Corvallis and his research team followed 118 people for three years aged 85 years and older, in good health, and showing no signs of dementia or memory loss at the beginning of the study. Half took ginkgo biloba and half took a placebo over three years. The patients taking it regularly had a 70% lower risk of developing dementia. According to the study, the other variables included considered “basic demographic variables including age, sex, years of education, and living arrangement (living alone vs living with someone).” 

The National Center for Biotechnology and Information published a study exploring ginkgo as a potential remedy for anxiety and, “The authors reported a significant improvement in psychopathological symptoms. Response rates were 44% in the high-dose group, 31% in the low-dose group, and 22% with placebo. Additionally, the percentages of clinically significant responses were 81%, 67%, and 38% for the high-dose, the low-dose, and the placebo groups, respectively.”2

A 2008 study reinforced the idea behind Traditional Chinese Medicine that ginkgo biloba improves blood circulation. The study shows ginkgo biloba extract to improve coronary artery circulation in patients with coronary artery disease. The study notes, “GBE (ginkgo biloba extract) treatment demonstrated a significant improvement in maximal diastolic peak velocity (MDPV), maximal systolic peak velocity (MSPV) and diastolic time velocity integral (DTVI) compared with controls.”3 In other words, ginkgo biloba extract is a great contender as a treatment to improve blood flow. 

Like cannabis and other medicinal plants, ginkgo has terpenes and flavonoids. Both of these compounds have therapeutic properties, and can provide anti-inflammatory benefits as well as being packed with antioxidants. Anti-inflammatory effects can serve many different ailments, especially relieving pain of various kinds. Antioxidants are thought to protect our bodies from free radicals, which are unstable molecules that can cause harm to the body. Terpenes are also responsible for giving plants their unique and flavorful smell. Flavonoids are the compounds that give plants their vibrant and diverse colors, and are the largest group of phytonutrients. There are approximately 6,00 different types of flavonoids. 

A few years back, the National Toxicology Program released a detailed report on ginkgo biloba extract. It dissects the toxicity and carcinogenic properties of ginkgo biloba using rodent test subjects. The report made its rounds as proof that ginkgo biloba causes cancer, because the rodents developed cancer at high-rates over two year periods. Per the American Botanical Council, “Adjusted for bodyweight, dosage levels given to the animals were up to 55 to 108 times higher than levels of ginkgo normally ingested by human beings taking ginkgo supplements.” Many people have been using this report to warn against the supplement, but Bill J. Gurley, Ph.D., a professor of pharmaceutical sciences at the University of Arkansas School for Medical Sciences, Little Rock said, “Almost anything will create cancer in rats and mice when it’s fed to them at high doses for two years.” The American Botanical Council also claims the ginkgo biloba extract used in the rodent experiment was of lesser quality, and not meeting European standards. 

Though this seemingly negative research on ginkgo can be explained, it is still important to discuss any kind of supplement addition with your doctor, especially if you are on other supplements or pharmaceutical prescriptions.

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