Characteristics and Experiences of a
At the conclusion of the clinical evaluation, patients were assigned a principal diagnosis, based on DH judgment concerning the nature of the patient's chief underlying clinical problem. Where appropriate, one or more secondary diagnoses were also assigned. Chronic pain due to previous musculoskeletal trauma was divided into back, neck, and extremity pain (e.g., shoulder or knee). Pain in the extremities due to arthritis was coded as arthritis.
We tabulated the principal diagnoses assigned to each patient in our sample. In a separate analysis, we tabulated the top 10 combined principal and secondary diagnoses in order to provide a single indicator of the major conditions from which the patients in this sample were suffering.
We recorded all side effects reported by our patients. The question about side effects on the intake form was open ended insofar as patients had to write in the side effect rather than ticking a box on a list of side effects. Where more than one side effect was listed, only the first one was coded. Both of these factors (adopted for practical reasons) may have contributed to some degree of under-reporting of side effects.
Where patients circled both "somewhat" and either "very" or "not at all" in Questions 3 and 4, this was coded as "somewhat". This double response occurred in about 20 cases, approximately equally divided between co-circling "very" and "not at all". We doubt whether this phenomenon produced any significant bias in the responses to these questions.
In all cases, patients reported that CM was more effective than other drugs they had tried for their condition. Many patients continued to use prescription or over-the-counter pharmaceutical drugs in conjunction with CM.
One hundred eleven of our patients were female (22.7 percent). The age distribution is depicted in Table 1. Principal diagnoses and combined principal and secondary diagnoses are shown in Tables 2 and 3. Reported side effects are tabulated in Table 4. Total patient counts vary due to missing data.
|1||Chronic back pain||140||28.6|
|2||Chronic extremity pain||84||17.2|
|7||Headache (not migraine)||21||4.3|
|9||Chronic neck pain||19||3.9|
|21||High blood pressure||2||0.4|
|32||Spinal cord injury||1||0.2|
|45||Chronic ear pain||1||0.2|
|1 Back pain||166||27.1|
|2 Extremity pain||114||18.6|
|6 Neck pain||40||6.5|
|8 Headache (not migr.)||33||5.4|
|Short-term memory loss||7||1.7|
|Lack of concentration||3||0.7|
|Possible upset balance||1||0.2|
|Loss of appetite||1||0.2|
|Doctor response (if told)?|
|Didn't agree but not hostile||73||36|
|How "high" do you get when medicating?||Number||Percent|
|Not at all||15||3.6|
|How important is the "high" to the medical effect?|
|Not at all||93||22.0|
Our patients were younger than those registered to receive CM in Hawaii and Oregon. Thirty-eight point four percent of our patients were over 40 years of age, in contrast to 70 percent in those states. This larger proportion of younger patients may in part reflect differences in geographical age demographics. Case-mix differences do not appear to explain the age difference. Our sample was weighted somewhat more in favor of males than those reported in other states (77 percent versus about 70 percent).
The diagnostic case-mix of patients in this sample is comparable to what is seen in other outpatient or primary care settings, including general practices, ambulatory care clinics, and emergency departments. Most of our patients had been seen previously in such settings, often many times, for evaluation and treatment of chronic pain and other symptoms. Almost all had already tried without much success the usual pharmacopoeia typically prescribed to suffering patients by physicians - with hydrocodone and anti-depressants heading the list. Without exception, CM proved more effective than these standard pharmaceutical products. (Of course, many patients that we did not see may be gaining perfectly adequate relief from these products.)
Our patients were a small sample of the large population of patients with chronic pain. Several studies have demonstrated that physicians commonly under-treat chronic pain, due in large part to the twin fears of producing addictions in their patients and of drawing the attention of the DEA for "over-prescribing". I encourage physicians to begin discussions concerning the role of CM within the broader, multi-modality treatment of patients with chronic pain. Recent research conducted into interactions between cannabinoid receptors and opiate receptors in the brain and peripheral nerves confirms clinical observations that cannabis can reduce the need for opiate analgesics by 50 percent or more.
Side effects were reported by about 25 percent of our patients. These were mostly mild in nature, with increased appetite being the most commonly reported effect. Even taking into account a possible under-reporting of side effects due to the design of the intake form and coding practices (see Methods section), the safety and tolerability of CM relative to other therapeutically active agents can be considered confirmed by this sample.
Of those patients who reported having primary providers (not always physicians), a little over half reported having discussed their cannabis use with these providers, 25 percent of whom "agreed enthusiastically" with the patient use, while 35 percent and 36 percent, respectively, reportedly "agreed reluctantly" and "didn't agree but not hostile". Only 9 physicians (4 percent) were described as being "hostile" to the idea of CM.
Thus, a total of 60 percent of physicians were reported to agree with their patient use of cannabis, while 40 percent disagreed. This is probably a much higher level of support than would be observed among physicians in most other parts of the country, the difference likely being due to the relatively high profile that CM and Proposition 215 have received in Northern California. Nevertheless, patients uniformly reported that even those physicians who were supportive of their cannabis use were "too afraid" to write recommendations. We encouraged these patients to further educate their doctors on this topic and to ask them to consider providing any future approvals for CM.
Only about 10 percent of patients reported getting "very"
high while medicating, 87 percent said they got "somewhat"
high and 15 patients (3.6 percent) denied getting high at all. Based on
previous communications with other providers with experience in CM, we
would have expected more patients to say they didn't get high at
all, while the percentage reporting getting very high is about what I
would have expected.
27 percent of our patients said that the high was "very important" to achieving clinical benefit from CM, about half (51 percent) said it was "somewhat important" and the remaining 22 percent said it wasn't important "at all". This seems congruent with our expectations.
Policy implications emerging from these findings include the need to educate physicians about the safety and effectiveness of cannabis medicines in patients with chronic pain. Patients should also be encouraged to educate their physicians about the effects they have experienced through their use of cannabis medicines. Physicians learn mostly from their patients, as we tell our patients. Several streams of activity are underway that will likely contribute to the education of both physicians and patients about cannabis medicines, including development of a CME course and creation of guidelines by the Medical Board of California, with the input of the California Medical Association, on appropriate practice in this area.
Our findings concerning the persistence of euphoric effects and their contribution to the therapeutic effect are somewhat of a mixed bag. Clearly not many patients are getting "very high", but disproportionately more patients who get only "somewhat" high consider it "very important" to the therapeutic effect. But for most patients, the high is only "somewhat" important, and for almost one-quarter of the patients the high was not deemed important at all. It appears that the "high" is a significant contributor for some, but not all patients.
Additional evidence in support of this conclusion comes from work done in the UK by GW Pharmaceuticals, which has shown that most patients treated for pain and spasticity with their standardized CM for symptoms of multiple sclerosis and related conditions gain significant relief without experiencing a "high". These are often middle-aged women with little or no prior experience with cannabis. Similarly, anecdotal reports from a variety of sources suggest that elderly patients may not generally experience much of a high, though they often do gain significant symptom relief.
Although the patients in our practice seem similar to patients in other
outpatient settings, they are not necessarily representative of all the
patients who could benefit from CM. In particular, relatively few
of our patients had cancer, multiple sclerosis, or HIV-AIDS. It is
possible that many patients with these and other very serious or
terminal conditions are already obtaining recommendations or approvals
from their regular physicians, and some may already be obtaining (or
cultivating) cannabis for their medical needs but do not wish to discuss
the situation with a physician because of concerns about confidentiality.
For the most part, however, patients with these conditions may simply be going without the benefits of CM. The coming promulgation of clinical guidelines for appropriate use of CM may encourage an increasing number of physicians to offer the benefits of these medicines safely to their patients. We hope that our positive experiences to date, as reported above, will also have a reassuring effect in this regard.