BREAKTHROUGH PAIN

BY MATT JACKSON, PHD

According to the National Cancer Institute (NCI), breakthrough pain is “a sudden increase in pain that may occur in patients who already have chronic pain from cancer, arthritis, fibromyalgia, or other conditions.” 1 Sometimes you can predict that you’ll trigger the pain and take medications beforehand; say, you know you’re going to be playing with your grandchildren soon, and you’ll be more active than usual. But other times, breakthrough pain comes out of nowhere, builds slowly, and stays longer. 2

Recently, the definition for breakthrough pain was rewritten. Just a few years ago, it was defined as pain breaking through “a stable opioid regimen.” 2 You could feel the political whiplash as the NCI removed opioids from the definition—rightly so considering that 47,600 people in the U.S. died from opioid overdoses in 2017 alone. 3

PATIENTS ARE REPORTING MEDICAL CANNABIS IS EFFECTIVE FOR MANAGING CHRONIC AND

Many patients are turning to medical cannabis as an alternative for opioids, 4 but some medical experts have expressed concern and speak of “an uncomfortable parallel” between medical cannabis and opioids. 5 They argue both cannabis and opioids provide chronic pain relief, but mass prescribing either is concerning without evidence of safety (detailing the risk–benefit ratio). Well, at least we agree that cannabis can relieve chronic pain, but before medical cannabis gets tainted by the opioid epidemic, let’s revisit history.

Over a century ago, heroin and morphine use was rampant until the U.S. Harrison Narcotic Control Act of 1914. Few of us remember the ensuing “opiophobia,” but it was strong. Doctors in the 1950s weaned terminally ill cancer patients off morphine, who suffered until they died. 6 Then, the Food and Drug Administration (FDA) greenlit Purdue Pharma to distribute controlled-release morphine in 1987, a stunning fit of amnesia that was repeated with even stronger OxyContin in 1995. 3,6 Encouraged by medical experts, opioids then spread beyond cancer patients and into the general public. And in 2000, an influential nonprofit that accredits healthcare organizations, The Joint Commission, mandated doctors with a duty to control pain. At that point, a doctor refusing to prescribe opioids could be legally sued for undertreating pain. 6

I think we can agree there is a fundamental difference between the frustratingly slow decriminalization of medical cannabis and pressuring doctors to prescribe opioids more potent than morphine. But what about safety? It seems common sense: cannabis is safer than morphine, but the absence of safety studies draws criticism for cannabis. Clinical trials are on the way, so the European Pain Federation is waiting until 2021 before making a formal recommendation. 7

There is scientific evidence that cannabis might be a saving grace for patients using opioids for chronic pain. The earliest published reports focused on individual patients with HIV, multiple sclerosis, or traumatic injuries who reduced opioid consumption by 60–100% after starting medical cannabis. 8 These reports have proved surprisingly accurate as thousands of patients began reporting their experiences. In one survey, almost 1,000 patients in the U.S. said medical cannabis decreased pain, increased overall health, and helped them decrease or eliminate opioid use, and those results have been replicated in several other countries 4 (see the Research Corner on pages 6-7).

Many patients have reported medical cannabis was so effective, they could wean themselves off opioids completely, 4 but this may not be the case for everyone. Some patients might need to supplement pain relievers with medical cannabis, THC, and/or CBD. Indeed, there are consistent reports that THC and opioids can complement one another, meaning that patients could augment very small doses of opioids with cannabis and achieve the same pain relief as a full opioid dose. A full dose of opioids has a high risk of overdose and respiratory depression, so any reduction in opioids increases patient safety. Alternatively, some studies have suggested that CBD can help stave off opioid cravings and addiction. 4

Overall, patients are reporting medical cannabis is effective for managing chronic and breakthrough pain, and current scientific evidence supports their claims. Science has shown cannabis is not a one-size-fits-all medicine. Cultivars vary widely in cannabinoid composition, and thus in symptom relief and side effects.

Unfortunately, federal laws prevent research using cultivars that have enough potency and diversity to match the products at dispensaries. 9 Considering the opioid epidemic, it is easy to become frustrated with federal limits against cannabis research. People are dying, but some patients are replacing lethal opioids with medical cannabis. They say they have been successful, but the medical community has been tepid. It’s time to start listening to patients and take their experiences seriously. As with every choice in medicine, it comes down to the patient and healthcare professional weighing the risks and benefits and making the best decision they can.