American Society of Regional Anesthesia and Pain Medicine May 2018 - 32
The High Road to Chronic Pain Management With Medical
Marijuana
M
arijuana (Cannabis sativa) has
been used for medical purposes
throughout recorded history.1
The plant was prescribed historically
for myriad purposes, including appetite
stimulation, treating epilepsy, managing
grief, and assuaging labor pain,
headaches, and sore muscles.2 The
Cannabis genus of flowering plants has
also provided nutrition from its seeds
and fiber for rope, paper, and textiles
from its stem.1 In the United States,
however, the Marihuana Tax Act of 1937
imposed a registration tax and strict
regulations on cannabis distribution that
effectively dissuaded its prescription.3
Subsequently, the Controlled Substances
Act of 1970 classified cannabis as
a schedule I drug with no accepted
medicinal value.4
Connie Bruno, MD
Anesthesiology Resident
Despite cannabis prohibition in the United States and many
countries worldwide, it has been widely produced and used
unabated. In the scientific community, however, designation as a
schedule I drug greatly limits cannabis research. In fact, the few
investigators authorized to
conduct clinical research
with cannabis are limited to
one strain from the University
of Mississippi.1 As an illegal
drug with harsh federal
restrictions, the taboos about
marijuana continue.
Sara Jane Ward, PhD
Assistant Professor, Pharmacology
Rany Abdallah, MD, PhD
Assistant Professor, Anesthesiology
Temple University Health System, Philadelphia, Pennsylvania
Section Editor: Lynn Kohan, MD
patients. We have much to learn about the benefits and side effects
of medical cannabis and our ability to regulate its safe usage, but
we have a body of knowledge from which to start.
Medical cannabis is an overarching term that describes all
serviceable cannabinoids and a vast assortment of cannabis
products that are consumed as smoke, vapors, oil, or capsules.
Botanical cannabis and
medical cannabis are
notably overlapping
terms, because botanical
cannabis use is frequently
reported for medical
purposes. Cannabinoids
are a chemical class of
neuromodulators that
function in the ECS,
which participates in
"relax, eat, sleep, forget, and protect" and may also play a role in
ameliorating refractory nausea, muscle spasticity, seizures, pain,
and inflammation.7
"We have much to learn about the
benefits and side effects of medical
cannabis and our ability to regulate
its safe usage, but we have a body of
knowledge from which to start."
Recently, though, insight
into the endocannabinoid
system (ECS) and rising public awareness have renewed interest
in exploring therapeutic and social potentials for cannabinoids.
Beginning in 2009, the Department of Justice decided against
enforcement of the federal laws, and most states in the United
States have legalized either medical or recreational use.5,6 Congress
has since continued to uphold the Rohrabacher-Farr amendment,
which prohibits the Justice Department from spending funds to
interfere with the implementation of state medical cannabis laws.
Despite this, stigma against cannabis is still widely prevalent,
including within the medical community.
Cannabinoids are recognized in 3 groups: endocannabinoids
(naturally synthesized by our bodies from membrane-bound lipid
precursors), phytocannabinoids (derived from the Cannabis sativa
plant species, that is, botanical), and synthetic cannabinoids
(designed in the laboratory to mimic the effects of endo- or
phytocannabinoids).2
How can we create a paradigm shift about medical cannabis?
Perhaps we can restructure our decisions by reexamining our
knowledge base. In the age of the opioid epidemic, the need
for redefining chronic pain treatments is ever present, and
medical cannabis is a promising group of agents for chronic pain
Phytocannabinoids represent more than 100 lipid molecules
found in botanical cannabis and are a subset of more than 400
natural compounds found in the Cannabis sativa plant, including
potentially bioactive terpenes and flavonoids. Two major active
phytocannabinoids of interest are δ-9-tetrahydrocannabinol
32
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2018
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