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The Future Of Marijuana In Clinical Practice: Q&A With Dr. Sunil Aggarwal
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Dr. Sunil Aggarwal is a graduate of the MD/Ph.D program at the University of Washington and is currently in his last year of residency at a large academic medical center in New York City. He is the author of a number of research papers on medical marijuana, which are compiled on his website (www.cannabinergy.com)

Dr. Aggarwal is also a board member of Americans for Safe Access Foundation, Patients Out of Time, and the Center for the Study of Cannabis and Social Policy

Q: You’ve published a lot of research and articles on medical marijuana. What influence has it had on your medical training?

I’m in my fourth year of residency and I see it becoming more and more relevant to my resident life as I go along. I’m also educating my peers about cannabis, because it’s relevant to my field, rehabilitation medicine, as well as pain management and palliative care – and those are all things that I’m interested in.

[pullquote align=”left”]”It’s too bad that a simple cannabis botanical is so hard to study and use.”[/pullquote]Next year, after I finish here in New York, I’m going to the National Institutes of Health (NIH) for a one year fellowship.

It’s the largest research hospital in the world and another place, like New York, where it’s too bad that a simple cannabis botanical is so hard to study and use. That’s something I’m interested in trying to question and push.

Of course, since the NIH is the heart of the federal system and the federal government considers cannabis a Schedule I drug – meaning it has no recognized medical use – it just creates a big political headache for them.

It’s really sad that they put politics ahead of science, even at the world’s largest research hospital.

Q: How is cannabis relevant to the field of rehabilitation/palliative medicine?

Most of the highest level of clinical evidence for cannabis – either inhaled or orally ingested – is for the palliation of certain diseases.

For example, pain and nausea in cancer, appetite loss and wasting in HIV/AIDS, and spasticity in multiple sclerosis. If these patients were to receive cannabis in the real world, a palliative doctor could be the one doing that. For these serious, life-limiting illnesses, cannabis has been shown to be effective.

And there’s a lot of other data – lower level, but still really compelling – for other palliative indications too.

[pullquote align=”right”]”In some of these cases, you don’t really need a whole stack of clinical trials. It just makes sense. “[/pullquote]The other interesting thing is the area of actually dying.

When you’re in a hospice and you have 6 months to live, is it possible for cannabis to be used? Let’s say you have pain and still want to be present with your loved ones before you pass away. Is it possible to not be completely sedated and looped out on opioids by adding cannabis into the mix?

Those are some of the topics I’ve covered in my work. In some of these cases, you don’t really need a whole stack of clinical trials. It just makes sense – it’s reasonable to do and we should just do it and have it available.

The American Academy of Hospice and Palliative Medicine actually gave me an award earlier this year at their annual meeting for my poster on cannabinoid medicines. Several of my articles have also been accepted in palliative journals.

Q: Does it have potential in other areas of medicine as well?

Of course, cannabis also has disease modifying potential. It’s not just palliative, it’s also curative.

I think some really interesting stuff is coming out in that area. It’s not just like we can potentially help with your MS [multiple sclerosis] pain, but maybe we can slow your MS down. That’s very exciting.

There are many promising areas. Dr. Sanjay Gupta’s documentary covered its potential in treating a lot of cancers, and there’s neurodegenerative diseases like Alzheimer’s, recovery from stroke and brain injuries, inflammatory bowel disease, etc.

Q: Cannabis seems to be quite popular in pain management. How does it compare with other pain drugs?

It’s very variable. In some types of pain like in post-operative settings, THC didn’t seem to be as effective as other traditional opioids used. But I’ve also seen other studies of acute pain where they said that THC was just as effective as codeine.

In chronic pain, it’s really interesting. For example, in HIV neuropathy – a special type of pain in the nerves that HIV patients get – there are a number of studies where cannabis has been tested in a randomized, double-blinded, placebo-controlled fashion. Turns out that when you compare all the other treatments that we know of in the world and have been studied in this condition, cannabis beats them.

[pullquote align=”left”]”When you compare all the other treatments that we know of in the world and have been studied in this condition, cannabis beats them.”[/pullquote]It has what is called a lower number needed to treat (NNT), which is a term we use in evidence-based medicine for the number of patients that need to be treated to achieve a positive response in just one. The NNT for herbal cannabis in HIV neuropathy is the lowest of all studied therapeutic interventions for that condition. So for that particular condition, we have the best evidence that cannabis is the most effective.

There are also studies that have been done involving experimental pain in healthy people and then they give them herbal cannabis cigarettes of various strength verses placebo to see if their pain has gone down or not.

Turns out there’s kind of a ‘Goldilocks’ phenomenon. In some of the higher potency preparations patients report increased pain, in lower preparations they report a little bit of pain relief and in the medium dose they report superior pain relief.

So there are some cases where less is more – if you take less, you have better pain relief. So dosing does matter.

[pullquote align=”right”]”Sometimes just after one puff, patients’ pain scores will drop by something like 70 to 80%.”[/pullquote]In terms of chronic, difficult-to-treat pain conditions, I think Dr. Donald Abrams has said that if you can get greater than 30% relief of pain, you’ve met a certain standard. And cannabis has been shown to achieve that standard in nerve pain.

What’s really amazing – you’ll see in those studies – sometimes just after one puff, patients’ pain scores will drop by something like 70 to 80%. It’s quite remarkable, although I’m not talking about aggregate analysis, but by individual. Then again, medicine is about taking care of the individual person. So for those people, cannabis is working like no other drug that they’ve taken before. It’s very promising.

Q: What do you think about the criticism that medical marijuana has received because of the large number of prescriptions written for pain?

People who say that have no good training in medicine. Because once you dig into the patients’ charts, look at their histories and examine them – you understand the correlations.

But there’s certainly a physiological dimension of pain, and I think there are ways of treating pain without drugs. So it’s certainly not the only way to treat pain, but it’s certainly a lot less toxic to the body than other stronger medicines. You can’t die from it, whereas you have this massive epidemic of people dying from other pain medicines.

Pain is not taken seriously as a legitimate condition. In many of these states in the U.S. where cannabis has recently been legalized for medical use, they’ve been excluding pain as a diagnosis because of the politics of pain.

[pullquote align=”right”]”You can’t punish the vast majority of people because of a few.”[/pullquote]I think it’s a sad testament. I mean some people will fake pain, but that’s been happening forever. But the vast majority of people will not do that and you can’t punish the vast majority of people because of a few.

Eventually, people won’t feel the need to pretend they’re in pain to see a doctor. Their government will have figured out that if people want to use this and they’re adults than it’s probably okay, because we let them use alcohol and tobacco anyway and this is probably safer for them.

Q: Not many doctors are outspoken about their support for medical marijuana. Why is that?

The fact is there have been more than 10,000 physicians in the U.S. who have participated in medical cannabis programs – who are treating their patients and authorizing their patients to use it.

I think being a doctor is a conservative profession. I think it has become the way that we use what’s in our pharmacies. How do you take care of patients? Well, what do we have? That’s how we take care of them [laughs].

[pullquote]”How do you take care of patients? Well, what do we have? That’s how we take care of them.”[/pullquote]It’s sort of a necessity thing. There aren’t a lot of doctors out there trying to look for new drugs. We use what we’ve learned – or are learning now from pharmaceutical reps who come and say (x) is now available.

But with Dr. Gupta coming out and everything – it’s certainly changed my own father’s attitude, who is a physician and was pretty much neutral or on the negative side of it. But having seen a very established, prominent neurosurgeon coming out in favor of it has changed his view.

And if there is some value to my speaking and writing, I’ll keep doing that because I think there is a lot of good we can do with it if we’re responsible.

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Q: Is there anything being taught in medical school about marijuana and the endocannabinoid system?

I started medical school in ’02. There were a few mentions, I have to say, in my curriculum of endocannabinoid signaling.

Certain professors would bring it up in reference to G-protein coupled receptors in the retina or the brain. And someone else would mention it in terms of chronic pain syndromes. Now that I recall, neither of those professors were MD’s, they were Ph.D’s.

There was one professor who was an MD/Ph.D – a psychopharmacologist – who mentioned it. He was just talking about the usual marijuana abuse stuff and how it works through the CB1 receptors.

[pullquote align=”right”]”You can also stimulate the endocannabinoid system through running, osteopathic treatments, and acupuncture.”[/pullquote]But nobody is saying this is a widespread, homeostatic modulatory system which has the most prevalent neurotransmitter in the brain on a per second basis and regulates mood, appetite, memory, pain, inflammation, muscle relaxation, bone remodeling, reproduction, etc.

You could do that. You could teach that, but so what? How can I use that in my practice? Well, you can prescribe a medicine that your patients can’t get access to [laughs].

Actually, that’s not even true. You can also stimulate the endocannabinoid system through running, osteopathic treatments, and acupuncture. It could be understood in a much more widespread fashion, so there is definitely a huge gap there to fill. That’s why I’ve been publishing papers and I’ve written some textbook chapters, but there has to be more thorough curricular work done.

I think doctors are also going to learn a lot of this from their own patients – it’s coming from both directions.

[pullquote]”It’s not just about training the doctors.”[/pullquote]The public has sort of been forced to learn about it as well, so it’s not just about training the doctors. If cannabis can also be available without prescription or if people can use it on their own without having to go see a doctor without a prescription, the public will have their own incentive to learn as responsible health consumers.

So I think it’s going to be both parties – patients and doctors – that will have to get up to speed.

Q: What do you see yourself being involved with in the future?

It really depends a lot on what happens in the next two years and where we are policy-wise.

I think I’ll always have one foot in some sort of academic setting because you can ask certain questions and be involved with furthering knowledge and also have access to research funds and staff.

[pullquote align=”left”]”I’m also interested in policy. Not just being a clinician.”[/pullquote]But I’m also interested in policy. Not just being a clinician, but also being a person that helps to guide how people can set these programs up or make cannabis more easily available – and changing international laws so that in other countries in the world it can be more available.

I’m also interested in the availability of other medicines in general. Opioids are actually important too, but they’re extremely hard to get in other parts of the world where people have severe pain that cannabis isn’t going to be the only thing that can help.

Another one of my interests is psychedelic medicine – like the therapeutic potential of psychedelic mushrooms – but that’s a whole other discussion. It’s another drug or botanical that’s gotten a severely bad rap and is also classified as Schedule I.

One of the things I’m really trying to get my mind around is the whole spiritual use of cannabis, because I think there’s something about the human-environment relationship that gets neglected in these discussions.

[pullquote align=”right”]”How humans connect to the plant kingdom is going to be increasingly important.”[/pullquote]That is to say that cannabis is a plant and humans have been interacting with plants for eons. It’s a member of the plant kingdom and how humans connect to the plant kingdom is going to be increasingly important – especially in this day and age of global warming and fossil fuel burning.

We’ve got to get more green. Anything that can help facilitate the human-plant relationship might have some spiritual or holistic angle. I want to try and foster that kind of thinking, although I’m not sure about how just yet.

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