Is cannabis an effective painkiller?

Cannabis is set to become a booming industry in South Africa. It is estimated that the global Cannabis market is worth $150bn. Supporters claim it is a healthy alternative to chronic pain medication and is proven to reduce nausea in cancer patients and Parkinson symptoms.

But what is real and what is rumour?

Earlier this month I asked Shelley McGee, a pharmacist and full-time researcher with the South African Medical Association (SAMA) for her personal views on the advantages and disadvantages of using Cannabis to treat chronic pain. 

I also spoke to Dr Russel Raath, a specialist anaesthetist who, for the past twelve years, has treated many chronic pain sufferers at his pain management clinic in Pretoria. 

In addition, 2019 Comrades winner Gerda Steyntalks about her phenomenal record breaking win and her plans for the future.

Dr Russel Raath: Specialist anaesthesiologist and pain management specialist: Jacaranda Hospital Pretoria. 

For many years Cannabis was stigmatised as a dangerous drug, but more recently it is being touted as an effective alternative to treating chronic pain conditions. What is your opinion?

Long term pain medication can be very harmful. That is one of the reasons why I treat patients who suffer from chronic pain with interventions that get them off medication eventually. 

Cannabis is increasingly being marketed as an effective drug that cures anything from ingrown toenails to chronic pain. Fans say it is a natural alternative which relieves pain without the side effects of chronic medication. 

But does it help? I believe not much.

Many entrepreneurs and investors are hoping that it will open a floodgate of opportunity and new wealth. They hope they can make a killing now that it’s no longer illegal to use it in the private space, but its efficacy in treating chronic pain is still unproven and anecdotal. 

The Cannabis plant contains hundreds of different chemicals and molecules. One cannot patent a natural plant. The chemical or molecule in Cannabis that ameliorates pain still needs to be identified. Once this is established it has to go through a stringent process where it is extracted, tested and finally approved. It can only be marketed when it has beaten the placebo effect and past the gold standard of testing. 

There are however some indications that it can help relieve symptoms of Alzheimers,  Parkinson and nausea and reduce seizures. I can’t really speak about those benefits because it is not my field. 

Many patients have told me that they have tried cannabis, and some say it helps them. So, I believe that if you think it helps you, then by all means go for it. Even if it is as a result of the placebo effect it is good enough for me if it can improve one’s life.

One must remember that every drug has a placebo effect that could be up to 30%. Even morphine has a placebo effect. It works because you believe it. But scientifically cannabis hasn’t been proven to beat the placebo.

At the moment buying cannabis oil from an unregulated dealer could be dangerous. You don’t know under what type of conditions it has been manufactured and how strong it is. It is often sold at an exorbitant price and you don’t know what you are getting. It is just a money-making racket.  

The weed has a calming effect, so it can help someone sleep better, but then one can easily achieve the same effect by using a sleeping tablet. Why pay for such an expensive oil if there are much cheaper, safer and more efficient alternatives available?

If it were such a panacea, I would be out of a job, but pain sufferers are pouring in. Many who have tried it, are disappointed.  Maybe in future we will identify the chemical in the plant that can alleviate pain.

If cannabis doesn’t relieve pain and medication for chronic pain is harmful what can one do if you want to participate in sport and suffer chronic pain?

I am often regarded as an outlier when it comes to pain treatment. My basic philosophy is to get patients off medication or greatly reduce it. I don’t believe people suffer from pain as a result of what is known as a biopsychosocial cycle. In 99% of cases one can find the cause and treat it without prescribing pain medication. America is battling with a huge number of people that are addicted to opioids or morphine or codeine derivatives. Most chronic medication has side-effects and will lose its effect long term. So it’s much better to look for the physical cause and treat it. There is a repertoire of interventions or procedures available that can result in full recovery. What works for one person doesn’t necessarily work for another. The best is to sort out the cause of pain especially if you participate in sport.  Painkillers will not necessarily improve one’s performance but can give one an unfair advantage because they mask the pain. This is why most pain killers are banned in competitive sport.

So what exactly is cannabis?

Shelley McGee: Health Policy Researcher : Knowledge Management and Research Department at the South African Medical Association (SAMA) shares her knowledge on the subject.

Medicinal cannabis is perhaps a misnomer, given that the starting material is no different to “non-medicinal cannabis”. 

What is known as “medicinal cannabis” is generally referred to as synthetically developed cannabinoid. These have existed for a long time and resemble chemicals that come from the plant. They are approved in other parts of the world where they are manufactured in a laboratory and proven and approved to treat medical conditions such as multiple sclerosis, nausea and vomiting. 

The hype at the moment is actually about the cannabis plant – generally understood to be cannabis sativa – a large herbaceous member of the Cannabacea family. Because this is a plant, it contains hundreds of different phytochemicals (plant chemicals) some of which we know about and some of which are still poorly researched and understood. The main chemicals of interest are collectively called the phytocannabinoids. There are over one hundred of these known to exist in cannabis species. 

The two which have been of greatest interest in the debate over cannabis have been delta-9 tetrahydrocannabinol (THC) and cannabidiol which are two closely related compounds. We know THC to be responsible for most of cannabis’s “high” inducing effects. 

When people ingest or inhale THC, it stimulates the brain's cannabinoid receptors.

THC is a psychoactive compound as it binds to cannabinoid receptors and produces an elevated state of mind, known as a high.

CBD does not cause a high, although it does interact with receptors to exert pain-relieving and anti-inflammatory effects.

So overall, CBD is considered the “medicinal compound” in cannabis and this is what our regulator has allowed for medical prescriptions.

However, if you are a purist, you will argue that ALL the compounds in cannabis are necessary for it to have its true effects. It will not do the trick if a single chemical is taken out.

How is cannabidiol manufactured or processed?

Cannabis for medicinal purposes is refined into cannabidiol through extraction of the composite chemicals.

Cannabis extractors take raw plant material and turn it into concentrates, such as oil. These concentrates are highly potent substances that emphasize the cannabinoids, or compounds unique to cannabis, like THC and CBD.

In what form is it taken?

Cannabis and cannabis derivatives may be smoked, ingested or inhaled. Smoking is a particularly harmful way, mainly because carcinogenic substances are inhaled directly into the lungs.  They contain at least 50 of the same carcinogens as tobacco.

Where can one obtain safe cannabis in South Africa?

In South Africa, cannabis products are unregulated. One does not know what one is buying, what raw material is used and whether it comprises what it claims to contain. There are also different processing modalities and some destroy the chemicals one is looking for. At the moment one can’t make safe recommendations on the South African market. There are of course regulated products that one can get at a cost from overseas.

Approved medicines are produced under strict conditions: that way, doctors who are prescribing them (as well as people who are using them) know exactly what is in them. It is important that doctors know that medicines have been tested and that each dose is the same. This means doctors can monitor the effects of the drug and doses can be adjusted according to a patient’s needs. When recreational cannabis is used as medicine, doctors and patients can’t be sure of these things – they don’t know how strong it is or the mix of chemicals and as a result, doses differ.

That is probably one of the reasons that one should rather grow one’s own. The  intention is to get regulated so that the quality is assured. 

Are there various strains of cannabis?

Yes – both phenotypically and chemotypically. And all the different strains contain differentconcentrations of THC, CBD and other chemicals.

Historically, cannabis strains available for recreational use have been selectively produced to have high concentrations of THC – for the high. “Medicinal” strains are different in that their chemical make-up is different and the raw material is likely to contain more CBD.

Again, depending on what you want to treat, you may want a balance of the two – e.g. the trials done on products for spasticity in multiple sclerosis, used a 50:50 ratio oil of THC and CBD.

 What is South Africa’s current policy on the right to use cannabis?

In September 2018, the Constitutional Court ruled that one can use cannabis in the privacy of one’s own home. As a result Parliament has been given two years to change the Drugs and Drug trafficking and Medicine Control Acts to decriminalise  possession of cannabis.   

  

What are the benefits and dangers of the use of medicinal cannabis for chronic pain management?

The majority of people who use cannabis medicinally do so for chronic pain – a survey published earlier this year on use in the United States suggests that about 63% of people using medicinal (synthetic) cannabis to treat pain symptoms. Well-designed trials have shown that medicinal cannabis works for chronic pain management. 

Results of studies done for the use of the plant extract in the treatment of chronic pain are not great and are fairly anecdotal. Given all the hype, I am surprised to see how little evidence is available of real positive effects in commonly promoted uses such as glaucoma, mental illnesses and cancer in particular.

But one must remember that research has been hampered by the fact that cannabis and cannabis-derived substances have spent so much time being illegal – conducting decent clinical trials has not been easy. 

Pain is subjective and difficult to measure. If someone tells you it works for them, then one can’t dispute that.  It is also a complicated condition and often not managed very well. One of the reasons that researchers are looking at cannabis now is because cannabis may provide an alternative to patients who otherwise may find themselves addicted to long term use of opioids (e.g. codeine and morphine), which are addictive, and have fatal effects in overdose. One recent study reported survey data from patrons of a Michigan medical marijuana dispensary suggesting that medical cannabis use in pain patients was associated with a 64 percent reduction in opioid use. 

Any choice in treatment of a condition must be risk-benefit based. 

What are the most common side effects?

Breathing problems, dizziness, addiction which occurs in 9 percent of people who begin use in adulthood,  interactions with other medication, loss of concentration, memory issues, rapid heart rate, withdrawal symptoms

Can it be used as a performance enhancer?

While the effects of marijuana can decrease hand-eye coordination and distort spatial perception, there are other effects that can be performance enhancing for some athletes and sport disciplines. Cannabis can cause muscle relaxation and reduce pain during post-workout recovery. It can also decrease anxiety and tension, resulting in better sport performance under pressure. 

Frequent cannabis smokers can experience respiratory problems including more frequent acute chest illness and a heightened risk of lung infections. Cannabis use raises the heart rate by 20-100 percent shortly after smoking which can increase the risk of heart attack. Chronic use has also been linked to mental illness including paranoia and psychosis.

Is it regarded as a prohibitive substance by international sport federations?

The List of Prohibited Substances and Methods (List) is published yearly by WADA (World Anti-doping Authority), and substances are considered for inclusion if they meet 2 the following 3 criteria: (1) potential to or enhances sport performance; (2) actual or potential risk to health; and (3) against the spirit of sport. 

Cannabis has been on the WADA Prohibited List since 2004. Despite the lack of hard evidence on the ergogenic effect, it is recognized that there are some health risks associated with the use of cannabis and many still believe that cannabis contravenes the spirit of sport, as defined in the World Anti-Doping Code.

Cannabis is prohibited in competition only. In recognition that a number of athletes were being sanctioned due to the fact that cannabis remained in their system after out of competition recreational use, the threshold level for cannabis metabolite was raised in 2011, so it is now more lenient.

In 2018, CBD was excluded from the Prohibited List as it is not a cannabimimetic and does not have psychoactive properties.

Who is likely to benefit from it?
Based on the evidence available currently, I would only recommend that people try it for chronic pain or for nausea and vomiting in chemotherapy. This is where there may actually be positive effects.

At the moment most of the evidence available has been trialled against placebo – meaning the cannabis has shown to be better than nothing in some cases. So, I would still advise that patients with these symptoms try cannabis as a last resort, instead of more addictive substances like opioids.

How addictive is cannabis?
Data shows that the addiction rates are about 9% in adults, and higher in children who use cannabis. But remember this has been based on the whole plant, generally, not extracts, like cannabidiol, which does not seem to have physiological addiction properties.

Are you excited about the future of cannabis?

I am hesitant. When I started along this road I was excited? But I am an evidence person and for now the evidence does not live up to the hype. 

Gerda Steyn: female winner of Comrades 2019

You seemed to have run the perfect race. Where there any surprises?

No not really. Last year I came second despite training to win.  This year I set my sights on first place and thought that I would have to smash a record in order to achieve this. Fortunately, towards the end of my race I was running against the clock and did not have to worry about beating a competitor. So yes, it worked out as I had planned.

Did you approach the race with a specific strategy or mantra?

Yes, I approach every race with a mental or race plan. The first half of Comrades I just try and enjoy the race, the supporters and the atmosphere.  Planning helps me cope with the second half when the going gets tough. It is very important to remain positive. This year I made sure I had close friends waiting for me at specific points. I then ran towards them.  My fiancé was waiting at the finish line and I tried to get to him as fast as I could.

What makes a winner?

I believe it’s a combination of things. I feel very blessed because I am generally a happy person.  Running is an added joy in my life, but it’s not essential to make me happy. I don’t need running to fulfill me. I believe if one is happy and content in all aspects of one’s life, then one can cope with the demands of such a grueling race. 

 What did you eat and drink during the run?

I was part of the Nedbank team which has tables and team support along the way where we can stock our personal drinks and supplements. I had bottles with fresh drinks which contained amino acids and caffeine. I also had gels. It’s very important to replace the  nutrients one’s body loses. They give me strength to perform optimally. 

How do you control your nerves? 

I try to visualize the race from start to finish and create every possible scenario before the run. I then decide how I will handle unexpected issues. On race day I convince myself that I will be okay because I have covered all eventualities.

Who is your coach and manager?

Nick Bester is my coach and manager. He’s always believed I have potential. I speak to him on a daily basis no matter where I am and follow his advice from day to day.

What do you do to prevent a cold or flu before a race? 

I try to avoid crowds and shopping centres. I don’t go from hot to cold temperatures. I have not taken anti-biotics for many years and I think this helps boost my immunity. I also try to eat more Vitamin C in the colder months.

Do you follow a specific diet plan a few weeks before a race?

No, I don’t, but ensure I eat lots of protein, carbs and fats daily. Women’s bodies are sensitive. If one doesn’t eat properly and do excessive training one could develop hormone problems. This could have an adverse effect on one’s performance. I know that my body takes a hammering and I take care to feed it properly. 

Have you started training again?

No not really it has been so hectic. I have gone on short jogs with a friend but am just giving my body and mind a break. I hope to swim and cycle once my life gets back to normal.

Do you do any Pilates or yoga?

I know that it is valuable, but I don’t have time to attend classes. I do some stretching on my own. 

Have you been approached by many sponsors since your win?

Yes, and I feel very thankful, but I have decided not to support a product just because it is financially beneficial. I have to be convinced that it is really a worthy product. 

 How has your win impacted on your social media profile?

It has had a massive effect. It’s really wonderful but I battle to respond to all the comments personally. At the moment I am just trying to do my best. Running is so accessible to everyone and has the potential to really break down barriers and promote reconciliation.

You have been invited to participate in the New York marathon in November. How will you adapt your training?

I am not supposed to discuss it until they have made the official announcement. But yes, I will have to adapt my programme and do shorter and faster runs. If I compare my times with the top marathon runners I still have some work to do. Pace, strength and endurance are important when preparing for a marathon. Some believe the Comrades could make one run slower, but I think it makes one tougher. Running a marathon is a different challenge and anything is possible on the day. There are always uncontrollable factors on the day which impact on participants.

Are you anticipating much tougher competition since the world’s best athletes will be competing? 

Yes, I do. Winning Comrades is very different from winning a marathon. I will be out of my comfort zone because I know I will compete against many world class athletes.  Although some athletes may be faster, one never knows how the weather and uncontrollable events could affect their performance on the day. So, it is important to just focus on one’s race and try one’s best regardless of the unexpected.

The 2019 London marathon winner did not eat or drink along the way.  Would you consider going without anything.

No, I doubt it. I focus on taking in nutrients. Maybe it’s just in my head, but I believe my body needs it. It will certainly throw me if I don’t eat. I don’t think I will change what works for me.

What is the best advice you have been given?

I have received many wonderful tips that inspire me from day to day. But I think the most important lesson I learnt was when I came second in 2018. I planned and trained to win. I ran a certain time and I thought would help me come first, but unfortunately it didn’t happen. Although I had improved my time from previous years and despite the fact that second place was still very good, I was devastated. Nick helped me accept that one needs to be patient. Many previous winners also had to come second or third before winning. The important thing is not to give up. This was a very valuable lesson. At the end of the day it made me more determined to win. I also realised that it didn’t mean that I had to change my  pro

gramme and work harder, but instead I had to consistently do what I was doing and give it time. And that is exactly what happened.

How has your success affected your relationship?

My fiancée, Duncan Ross, in fact introduced me to running. He is a pilot and both of us worked in Dubai where we met. We joined a running club there and started training together. At the moment he is still based in Dubai and over weekends we spend time in the Alps in France where he has a property. I can’t really train in Dubai because it is so flat, so I either train in France or South Africa. We will probably get married in the foreseeable future but actually it is not a priority now. When it happens, it will just be a small private celebration.