July 1st – July 8th, 2022
The Use of Medical Cannabis as an Alternative Agent for Opioids in Managing Musculoskeletal Pain
A new study found that patients suffering from musculoskeletal pain conditions reported notable reductions in pain after using medical cannabis as an alternative to traditional painkillers.
The rise of prescription opioids in the past two decades has been unsettling in the medical field, owing to the substance’s adverse effects, highly addictive properties, and overdose deaths. Since 1999, approximately 500,000 people have died from an opioid overdose, marking the age of an opioid misuse epidemic in the United States. [1] Nearly half of these deaths can be attributed to prescription opioids, causing medical professionals to reevaluate the ramifications of opioids and investigate potential surrogates.
Orthopedic surgeons are responsible for approximately 7.7% of all opioid prescriptions in the United States, due to their effectiveness in reducing post-procedural pain. [2] Previous studies have found success in nonopioid-based alternative pain management such as gabapentin and acetaminophen, as well as lesser potent narcotics, including Schedule IV drugs such as IV tramadol. [3], [4]Additionally, Δ9-tetrahydrocannabinol (Δ9-THC), the most studied cannabinoid in the cannabis plant, have the potential to suppress pain and inflammation. [5] However, due to negative stigma and limited access, few studies have been performed attempting to determine the efficacy of cannabis towards pain management. [6]
Utilizing a cross-sectional study consisting of 28 questions, Manguel-Pérez et al., investigated the perceived efficacy of cannabis as a painkiller alternative in musculoskeletal conditions. [7] The questionnaire addressed demographics, medical history, cannabis usage and perspective, as well as an analgesic efficacy evaluation, utilizing the Numeric Rating Scale (NRS). Results indicated that medical cannabis patients identified cannabis to be an effective pain management alternative in comparison to narcotics. Some of the study limitations included using questionnaires as the research tool which may increase bias, lack of details behind cannabis products, route of administration, and the cannabinoid quantity used among patients which may affect perceived pain levels.
The authors concluded: “The use of medical cannabis among patients with musculoskeletal conditions effectively reduced pain levels based on their NRS reported scores. In addition, most patients using medical cannabis considered that this drug represents a better option than narcotics (i.e., opioids) for adequate pain management. Additional studies on medical cannabis should evaluate whether the experience and perspective presented through this study could translate into satisfactory and consistent clinical outcomes.”
Impairment and Kinetic Patterns Associated with Hemp-Derived Δ8-Tetrahydrocannabinol (Δ8-THC): Results from Three Subjects
Δ8-tetrahydrocannabinol (Δ8-THC) shared similar impairment and kinetic patterns compared to Δ9-Tetrahydrocannabinol (Δ9-THC), a new study finds.
Δ8-tetrahydrocannabinol (Δ8-THC) is a naturally occurring, psychoactive cannabinoid found in the cannabis plant. ∆8-THC is chemically similar to Δ9-tetrahydrocannabinol (∆9-THC), but the location of the carbon-carbon interaction differs in each; it is located on the 8th carbon for ∆8-THC and on the 9th carbon for ∆9-THC, hence the different names. In comparison to Δ9-THC, Δ8-THC is less abundant and hence, often chemically synthesized using cannabidiol (CBD) through acidification and isomerization. [8] Additionally, reports indicate that Δ8-THC is less psychotropic with experiences being less intense and somewhat shorter in duration than those with Δ9-THC. [9]
A previous study by Huffman et al., found that the two THC molecules were nearly equipotent at the cannabinoid receptors 1 and 2 (CB1R and CB2R), bringing into question the capacity and value of using Δ8-THC in medicine (3). [10] Additionally, due to the increasing access to Δ8-THC products, further studies are needed to understand the implications of the substance and its potential ability to replace Δ9-THC in the clinical space. However, it is important to note that the FDA and the CDC sent warning statements regarding the use of Δ8-THC products due to the increase numbers of adverse events. [11],[12]
Wurz et al., recruited three healthy adult subjects to take part in a vaporization study to investigate the impairment and cannabinoid kinetic patterns associated with Δ8-THC, administered by vaporization ad libitum (“in accordance with one’s wishes”). [13] To assess impairment, horizontal gaze nystagmus (HGN) (i.e., involuntary movement or jerking of the eyes as the participants gaze to the other side and is a part of the sobriety testing) was evaluated as well as analysis of exhaled breath and capillary blood samples before and after vaporization to evaluate cannabinoid kinetic patterns were recorded. Results demonstrated impairment peaking in the first hour following vaporization and disappearing by 3-hours post-vaporization, similar to Δ9-THC. Additionally, the observed kinetic patterns for Δ8-THC were similar to those for Δ9-THC, including a short half-life within the first hour post-vaporization.
The authors concluded: “The patterns of self-assessed impairment and HGN in three case subjects after vaporization of hemp-derived Δ8-THC were similar to the ∆9-THC-induced impairment patterns observed in the same three subjects after smoking cannabis. The potential for impairment by Δ8-THC products derived from hemp, which have been increasing in popularity since the U.S. legalization of industrial hemp in 2018, needs to be considered by employers, law enforcement authorities, and any other agencies or regulatory bodies responsible for setting drug use policy, and Δ8-THC needs to be incorporated into standard drug testing panels.”
Minnesota Passes a Law Allowing Low Tetrahydrocannabinol (THC) Edibles and Beverages for Adults
Is it the state’s successful step towards recreational cannabis legalization?
As of July 1st, 2022, Minnesota has enforced a new law allowing people ages 21 and older to purchase hemp-based products containing up to 5 milligrams of THC. [14] However, these products cannot contain more than 0.3% of Δ9-tetrahydrocannabinol (Δ9-THC). Electors of this bill shared concerns on the previously unregulated sales of Δ8-tetrahydrocannabinol (Δ8-THC), reaffirming that the purpose of the adoption is to ensure the proper sale of products and safety of the youth, who were previously being targeted by the cannabis industry with irrationally high dosages and misleading products.
Other states that have legalized recreational cannabis also share similar restrictions. In California, a state which has legalized recreational cannabis under Proposition 64, edible products may only have up to 10 milligrams of THC per serving and a total of 100 milligrams per package. [15]
Ryan Winkler, leader of the Minnesota House of Representatives and advocate for cannabis legalization, emphasized: “We have a lot of work to do in Minnesota on cannabis legalization, but this is an important step forward—and the door is now open to consumers having access to products containing THC that many of them prefer to consume. I don’t think we are going to go backwards.” [16]
Medical cannabis is legal in Minnesota since 2014 but recreational use remains illegal. [17]
WNBA Star Brittney Griner Pleads Guilty to Cannabis Charge in Russia
Brittney Griner awaits a Russian ruling after pleading guilty to cannabis charges, while many urge the Biden administration to ensure her safe return.
On February 17th, 2022, WNBA star Brittney Griner was detained in a Russian airport for carrying cannabis vape cartridges and arrested on drug possession charges. [18] Recently, Briner pleaded guilty and could face up to 10 years in prison in Russia, due to the country’s strict illegality of the substance. [19] Russia, under Article 228 of Russia’s Criminal Code, has the highest number of people imprisoned for drug offenses in Europe. The article prohibits the possession, distribution, and purchase of cannabis, regardless of the amount of THC it contains, making the country’s strict substance laws comparative to those of Singapore, United Arab Emirates, and Malaysia. [20]
Griner’s case has gained immense media attention, as Americans urge the Biden administration to secure Britney Griner’s safe release. Although President Biden has reassured Griner’s wife of the nation’s continued efforts regarding her wife’s return, current international tensions, as well as Russia’s tough stance against international cannabis policy reform calls for increased fragility in handling the matter. Additionally, Russian officials have emphasized the hypocrisy of the United States’ stance, given the continued criminalization of the substance in American federal law under the Controlled Substances Act of 1970. [21]
Griner’s case continues to gain recognition, increasing the scrutiny placed on both the Russian and American governments.
References:
[1] Soelberg CD, Brown RE, Jr., Du Vivier D, Meyer JE, Ramachandran BK. The US Opioid Crisis: Current Federal and State Legal Issues. Anesth Analg 2017;125(5):1675-1681. DOI: 10.1213/ANE.0000000000002403.
[2] Boddapati V, Padaki AS, Lehman RA, Lenke LG, Levine WN, Riew KD. Opioid Prescriptions by Orthopaedic Surgeons in a Medicare Population: Recent Trends, Potential Complications, and Characteristics of High Prescribers. J Am Acad Orthop Surg 2021;29(5):e232-e237. DOI: 10.5435/JAAOS-D-20-00612.
[3] Sabesan VJ, Chatha K, Koen S, Dawoud M, Gilot G. Innovative patient education and pain management protocols to achieve opioid-free shoulder arthroplasty. JSES Int 2020;4(2):362-365. DOI: 10.1016/j.jseint.2020.01.005.
[4] Minkowitz H, Leiman D, Lu L, et al. IV Tramadol – A New Treatment Option for Management of Post-Operative Pain in the US: An Open-Label, Single-Arm, Safety Trial Including Various Types of Surgery. J Pain Res 2020;13:1155-1162. DOI: 10.2147/JPR.S251175.
[5] Russo EB. Cannabinoids in the management of difficult to treat pain. Ther Clin Risk Manag 2008;4(1):245-59. DOI: 10.2147/tcrm.s1928.
[6] Bruni N, Della Pepa C, Oliaro-Bosso S, Pessione E, Gastaldi D, Dosio F. Cannabinoid Delivery Systems for Pain and Inflammation Treatment. Molecules 2018;23(10). DOI: 10.3390/molecules23102478.
[7] Mangual-Perez D, Tresgallo-Pares R, Ramirez-Gonzalez M, et al. Patient Experience and Perspective on Medical Cannabis as an Alternative for Musculoskeletal Pain Management. J Am Acad Orthop Surg Glob Res Rev 2022;6(7). DOI: e22.00055
10.5435/JAAOSGlobal-D-22-00055.
[8] Gaoni Y, Mechoulam R. Hashish—VII: The isomerization of cannabidiol to tetrahydrocannabinols. Tetrahedron. 1966;22(4):1481–8.
[9] Kruger JS, Kruger DJ. Delta-8-THC: Delta-9-THC’s nicer younger sibling? J Cannabis Res 2022;4(1):4. DOI: 10.1186/s42238-021-00115-8.
[10] Huffman JW, Liddle J, Yu S, et al. 3-(1′,1′-Dimethylbutyl)-1-deoxy-delta8-THC and related compounds: synthesis of selective ligands for the CB2 receptor. Bioorg Med Chem 1999;7(12):2905-14. DOI: 10.1016/s0968-0896(99)00219-9.
[11] https://www.fda.gov/consumers/consumer-updates/5-things-know-about-delta-8-tetrahydrocannabinol-delta-8-thc, assessed on July 8th, 2022
[12] https://www.fda.gov/news-events/press-announcements/fda-issues-warning-letters-companies-illegally-selling-cbd-and-delta-8-thc-products, assessed on July 8th, 2022
[13] Wurz GT, Montoya E, DeGregorio MW. Examining impairment and kinetic patterns associated with recent use of hemp-derived Delta(8)-tetrahydrocannabinol: case studies. J Cannabis Res 2022;4(1):36. DOI: 10.1186/s42238-022-00146-9.
[14] https://www.duluthnewstribune.com/news/minnesota/cannabis-edibles-containing-psychoactive-thc-legal-in-minnesota-friday, assessed on July 8th, 2022
[15] https://www.shouselaw.com/ca/defense/laws/marijuana/, assessed on July 8th, 2022
[16] https://www.audacy.com/wccoradio/news/local/lawmakers-explain-minnesotas-new-law-legalizing-edibles, assessed on July 8th, 2022
[17] https://www.revisor.mn.gov/laws/2014/0/Session+Law/Chapter/311/, assessed on July 8th, 2022
[18] https://www.nytimes.com/2022/03/05/sports/basketball/russia-brittney-griner.html, assessed on July 8th, 2022
[19] https://cannadelics.com/2020/03/08/how-the-ruskeys-do-cannabis-a-look-at-regulation-in-russia/, assessed on July 8th, 2022
[20] https://www.imolin.org/doc/amlid/Russian_Federation_Criminal_Code.pdf, assessed on July 8th, 2022
[21] https://uscode.house.gov/view.xhtml?path=/prelim@title21/chapter13&edition=prelim, assessed on July 8th, 2022
