SPOTLIGHT going to try and help inform over the next couple of years. CC: There seems to be this rush for legalization of recreational cannabis from the government’s perspective. Does that concern you? JB: Oh, absolutely. I think there’s going to be a lot of adjustments. A lot of the policies are going to be quite vague, at least initially. There are a lot of questions out there right now so they are trying to put some sort of framework to it. The business interest is huge. The black market in Canada has been estimated at around $7 billion per year; in Ontario it’s around $2.5 billion per year. It’s not certain how [legalization] is going to unfold, so I do think there is an enormous challenge. In terms of the legal aspect, prohibition hasn’t worked, and the government is spending a lot of money on law enforcement. Now they are saying, “let’s put the money into standardizing the product, ensuring good education, ensuring better safety around it, and maybe try and take some of the wind out of the sales of the criminal enterprises that are making tremendous profits off this right now.” When you look at other countries or even states that have legalized other illicit substances or even cannabis, the concern is that there will be a big spike in users. The evidence, so far, does not bear that out. It seems when you’ve decriminalized or legalized cannabis, you get an initial little spike in use, particularly amongst younger people, but overtime it tends to flatten out. People that are already using simply move into the legal stream, as opposed to everyone decides all of a sudden they’re going to become [smokers of] cannabis. CC: What do we know for certain about cannabis for medical purposes? JB: I can say that from the work that we are currently doing, there appears to be moderate quality evidence that medicinal cannabis in a range of different forms appears to provide small but important pain relief for people dealing with chronic non-cancer pain. Now when I say small but important, 10 Canadian Chiropractor June 2018 “There appears to be moderate quality evidence that medicinal cannabis ... provide[s] small but important pain relief for ... chronic, non-cancer pain.” what we found is on average the effect tends to be small. When you focus on average effects, you have to do that with the understanding that not everyone is going to have the same response. So there are probably some patients that are not going to experience any benefit at all and there are some that might get more than an average benefit, and there are some that are going to fall high on the average. We do know, especially with some formulations out there that do contain higher levels of THC, there is a trade-off between things like sedation and dizziness. Is it working well enough for them that they are willing to continue using it? So, we do have at least moderate-level evidence of a small but important benefit for pain relief in people with chronic non-cancer pain. Other areas – like PTSD – people are very interested in it, but there’s not a lot of PTSD studies out there. I know Veterans Affairs actually reimburses for medicinal cannabis and they have thousands of service people that are currently using for PTSD and they are quite interested to know if it works. So we’ve had some discussions with [Veterans Affairs] about what a study can look like to help answer that question. There just isn’t enough good evidence out there to say, “yes” or “no.” CC: What are the top areas of research around cannabis you think should be the focus right now? JB: I think we need to better understand the potential benefits for chronic non-cancer pain – and harms – because a lot of individuals dealing with chronic pain do report concurrent use of cannabis. And with all the pressure to get off opioids, I think there’s going to be even more interest in moving in that direction. Again, I think we need to have a much better understanding about the long-term harms. We really don’t know what to tell people when they say, “I have a chronic condition, my rheumatoid arthritis is not going to get better, so what do I have to understand about being on [cannabis] for 10 years or 20 years?” We don’t know the answers to that yet. I think we also need to better understand – this is not a pill, this is a plant. This is medieval medicine. There is over a hundred different active cannabinoids in cannabis. What works? Is it the THC? Is it the CBD? Is it the turpines? Is there an entourage effect where you need to get the whole thing? Can you actually just come up with a synthetic derivative like nabilone? Or is that not very effective? Right now it’s a bit of a Wild West. Even if you look at the trials, everybody is kind of using different things. I think right now with this push, it’s now becoming available as a legitimate therapy. I’ve certainly met with a lot of producers that are really trying to up their game, and they’ve got tight quality control and they have very particular strains and they know that they are getting a consistent product. Now we have to start testing it to see. For example, if someone is using it for chronic pain where they have associated difficulty sleeping, do you want to get them on high CBD during the day so there’s no euphoria? Then at nighttime maybe that dose changes to include more THC to help with sleep. I mean there’s so much that we don’t know about cannabis. We need to understand what is going to work for people to address their particular condition [without] side effects that are going to make it problematic for them to function. Continued on page 21 www.canadianchiropractor.ca
Chiropractic + Naturopathic Doctor June 2018: Page 10
