Cannabis & Cannabinoids in the Treatment of Chronic Non-Cancer Pain

My 90 year old patient with spinal stenosis, diffuse osteoarthritis and now polycythemia vera was in for an office visit. He had been to see his hematologist and had been phlebotomized removing a unit of blood to control his overproducing bone marrow. He mentioned that the hematologist had sent him to a medical marijuana clinic run by a pain physician colleague of his.

The patient proudly showed me his marijuana registration license. “It doesn’t work you know. In fact I feel poorly after I take some. I have tried the oils and some edibles but it really doesn’t affect my pain in a positive way.”

Many of my patients now are licensed to receive medical marijuana for chronic pain. It’s a big business here in the state of Florida where senior citizens with chronic aches and pains are always looking for that magical pill to restore their vitality and youthfulness. His experience is unfortunately supported in the medical literature. In the May 25, 2018 issue of Pain magazine which looked at the pain relief of patients with rheumatoid arthritis, fibromyalgia, neuropathic pain and 48 other non-cancer pain conditions. The study was a literature review looking at the 104 studies published on this subject.

The findings were sobering and disappointing. They found that cannabinoids had no appreciable positive impact on pain relief. In addition it didn’t help sleep, there was no positive impression of change and there was no significant impact upon physical or emotional functioning.

I am not an anti-marijuana crusader. I see its positive impact in treating glaucoma. I see the studies citing it is more effective to deliver by smoking it than eating it or taking it in pill form.

The review studies included all forms of administration of cannabis. I just want to make sure that when authorities legalize a substance for use in pain control it is effective and not just profitable snake oil for a strong lobby of well-healed and crafty businesspeople.

Advertisements

More Good News for Coffee Drinkers

When I first started practicing, fresh out of my internal medicine residency and board certification, we were taught that consuming more than five cups of coffee per day increased your chances of developing pancreatic cancer. Thankfully that theory has been proven to be false.

Last week I reviewed a publication in a peer reviewed journal which showed that if you infused the equivalent of four cups of coffee into the energy producing heart cell mitochondria of older rodents, those mitochondria behaved like the mitochondria found in very young healthy rats. The authors of that article made the great leap of faith by suggesting that four cups of caffeinated coffee per day was heart healthy.

This week’s Journal of the American Medical Association Internal Medicine published a study which said if you drank eight cups of coffee per day your mortality from all causes diminished inversely. Their study included individuals who were found to be fast and slow metabolizers of caffeine. It additionally made no distinction between ground coffee, instant coffee or decaffeinated coffee.

The research study investigated 498,134 adults who participated in the UK Biobank study. The mean age of the group was 57 years with 54% women and 78% coffee drinkers. The study participants filled out questionnaires detailing how much coffee they drank and what kind. During a 10 year follow-up there were 14,225 deaths with 58% due to cancer and 20% due to cardiovascular disease. As coffee consumption increased, the risk of death from all causes decreased. While instant coffee and decaffeinated coffee showed this trend, ground coffee showed the strongest trend of lowering the mortality risk.

This is an observational study and, by design, observational studies do not prove cause and effect. It is comforting to know however that having an extra cup or two seems to be protective rather than harmful. At some point a blinded study with true controls will need to be done to prove their point. If the caffeine doesn’t keep you up or make you too jittery, and the coffee itself dehydrate you or give you frequent stools, then drink away if you enjoy coffee in large volume.

Coffee and the Healthy Heart

Two German biologists are stating there is sufficient data to claim that four cups of caffeinated coffee is the optimal daily dosage to maintain a healthy heart. Their findings were published in Plos Biology and summarized in Inverse Magazine. The scientists cite past warnings by public health officials of the danger of caffeine when given to people with heart conditions. Quite the contrary. They believe that up to four cups of coffee per day are actually therapeutic for the heart.

In their research they noted caffeine helps a protein called “p27” enter the energy producing mitochondria of heart cells making them function more efficiently. They experimented with rats comparing the mitochondrial function of old rats and young rats. When they injected the older rats with the caffeine equivalent of four cups of coffee, their aging mitochondria performed at the level of young rats’ mitochondria. They then experimentally caused the older rats to have a heart attack or myocardial infarction. Half of these heart damaged rats were injected with the equivalent of four cups of coffee and their heart cells repaired themselves at a far more rapid rate than those not exposed to that dose of coffee and caffeine.

The researchers conclude that four cups of coffee is probably the optimal daily dosage of coffee for a healthy heart. They caution that certain patients, especially those with malignant tumors, should probably avoid that much coffee because it may promote growth of blood vessels to the tumors. They additionally caution against using caffeine pills or energy drinks because their research was done with coffee.

Coffee in moderation is probably not harmful for any human adult.

Keep in mind, this biologic evidence was obtained in rats not human beings. Fortunately, I have not seen rats breaking into my local Dunkin Donuts and Starbucks craving a lifesaving nutrient.

Coffee has been associated with preventing cognitive dysfunction, preventing diabetes and now keeping your heart healthy. If you enjoy coffee, drinking it in moderation makes sense to me.

The American Cancer Society and Colorectal Cancer Screening

Colorectal cancer is the fourth most common cancer with 140,000 diagnoses in the nation annually. It causes 50,000 deaths per year and is the number two cause of death due to cancer.

Colorectal cancer screening guidelines have called for digital rectal examinations beginning at age 40 and colonoscopies at age 50 in low risk individuals. An aggressive public awareness campaign has resulted in a marked decrease in deaths from this disease in men and women over age 65.

The same cannot be said for men and women younger than 55 years old where there is an increased incidence of colorectal cancer by 51% with an increased mortality of 11%. Experts believe the increase may be due to lifestyle issues including tobacco and alcohol usage, obesity, ingestion of processed meats and poorer sleep habits.

To combat this increase, the American Cancer Society has changed its recommendations on screening suggesting that at age 45 we give patients the option of:

  • Fecal immunochemical test yearly
  • Fecal Occult Blood High Sensitivity Guaiac Based Yearly
  • Stool DNA Test (e.g., Cologuard) every 3 years
  • CT Scan Virtual Colonoscopy every 5 years
  • Flexible Sigmoidoscopy every 5 years
  • Colonoscopy every 10 years.

Their position paper points out that people of color, American Indians and Alaskan natives have a higher incidence of colon cancer and mortality than other populations.  Therefore, these groups should be screened more diligently. They additionally note that they discourage screening in adults over the age of 85 years old. This decision should be individualized based on the patient’s health and expected independent longevity.

As a practicing physician these are sensible guidelines. The CT Virtual Colonoscopy involves a large X irradiation exposure and necessitates a pre- procedure prep. Cologuard and DNA testing misses few malignancies but has shown many false positives necessitating a colonoscopy. Both CT Virtual Colonoscopy and Cologuard may not be covered by your insurer, and they are expensive, so consider the cost in your choice of screening.

I still believe Flexible Sigmoidoscopy must be combined with the Fecal Occult Blood High Sensitivity Testing and prepping.  Looking at only part of the colon makes little sense to me in screening.

Colonoscopy is still the gold standard for detecting colorectal cancer.

Does Curcumin Use Help with Cognitive Dysfunction?

Recently, more and more patients have been adding curcumin or turmeric to their cooking to help with their memory. Curcumin is a metabolite of Turmeric and has been available in health food stores for years.

A study a few years back on Alzheimer’s patients published by J. Ringman and Associates showed no benefit in slowing the development of symptoms and no improvement in symptoms when supplied with curcumin. When they looked closely at their study, and analyzed the participant’s blood, they found that curcumin was not absorbed and never really entered the bloodstream.

Last month a study was published in the American Journal of Geriatric Psychiatry by Dr. Gary Small and colleagues. They looked at 40 patients with mild memory complaints aged 50 – 90.  Some were administered a placebo and others were administered nanoparticles of curcumin in a product called “Theracumin”. The participants were randomized and blinded to the product they were testing. The study designers felt the nanoparticles would be absorbed better than other products and would actually test whether this substance was helpful or not. At 18 months, memory improved in patients taking the nanoparticles of curcumin and they had less amyloid deposition in areas it usually found relating to Alzheimers Disease.

Robert Isaacson MD, the director of the Alzheimer’s Prevention Clinic at Weil Cornell Medicine and New York- Presbyterian, has been suggesting his patients cook with curcumin for years. Until the development of the Theracumin nanoparticles, cooking with curcumin was the best way to have it absorbed after ingestion. There is now some evidence to suggest that curcumin, in this specific nanoparticle form, may play a role in both the risk reduction and potential therapeutic management of Alzheimers Disease.

Fitness Lowers Your Risk of Dementia

Over the years I have read and passed on to my patients the benefits of exercise on quality of life and healthy aging. This hypothesis was supported by a recent publication in the journal “Primary Care” by Peter Lin, MD, CCFP. Dr Lin and colleagues followed a group of woman aged 38 to 60 years for 44 years to determine the relationship between fitness and development of dementia. They chose to follow 191 women from a group of 1462 patients and selected a balanced number of patients in each age group up to age 60. They performed a physical fitness test on the women in 1968 and then grouped them into high fitness category, intermediate fitness category and low fitness category based on their performance in the physical fitness test. The women then received neuropsychiatric evaluations in 1974, 1980, 1992, 2000, 2005 and 2009.

The patients within the high fitness group showed an 88% reduction in dementia rate compared to those with medium fitness. Those in the lowest fitness group had a 41% increase d risk of dementia compared to the medium fitness group. Those patients in the high fitness group who developed dementia showed symptoms 9.5 years later on average than the patients in the medium fitness group.

The message for young adults is simple. Stay fit at a high level doing something you enjoy and you may reduce your risk of developing dementia by up to 90%.

Fish, Fish Oils and Cardiovascular Disease

Years ago the scientific researcher responsible for the promotion of fish oils as an antioxidant and protector against vascular disease recommended we all eat two fleshy fish meals of cold water fish a week. He continued to endorse this dietary addition and included canned tuna fish and canned salmon in the types of fish that produced this positive effect.

Over the years I heard him lecture at a large annual medical conference held in Broward County and he fretted about the growth of the supplement industry encouraging taking fish oils rather than eating fish. He worried about the warnings against eating all fish to women of child bearing age because of the fear of heavy metal contamination and knew that the fish oils and omega 3 Fatty Acids played a developmental role in a growing fetus and child.

I then attended lectures, in particular one sponsored by the Cleveland Clinic, during which they promoted Krill oil as the chosen form of fish oil supplements because it remained liquid and viscous at body temperature of 98.6 while others solidified. I listened to this debate only to hear the father of the science speak again and this time advocate that one or two fleshy fish meals a month was adequate to obtain the protective effect of Omega 3 Fatty acids. He felt that the supplements did not actually provide a protective effect as eating real fish did. Since I love to eat fresh fish I had no problem with this message but others are not comfortable buying and preparing fish at home or eating it at a restaurant. Supplements to them were the answer.

Steve Kopecky, M.D. examined the question in an article published in JAMA Cardiology this week. He looked at 77,917 high risk individuals already diagnosed with coronary artery disease and vascular disease who were taking supplements to prevent a second event. His study concluded that taking these omega 3 supplements had no effect on the prevention of recurrent cardiovascular events. The study did not discuss primary prevention for those who have not yet had a vascular illness or event.

Once again it seems that eating fish in moderation, like most anything, is the best choice. I will continue to eat my fresh fish meals one or two times per week, not necessarily for the health benefit but because I enjoy eating fresh fish.

I advise those worried about preventing primary or secondary heart and vascular disease to find a form of fish they can enjoy if they want this benefit. If you really wish to reduce your risk of a cardiovascular event; I suggest you stop smoking, control your blood pressure and lipid profile, stay active and eat those fresh fish meals.