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Transcript — Programme 114: You, Your Drugs, and the Law: Gabapentinoids and medicinal cannabis

How does the law affect peo­ple who use drugs to man­age their pain?

To lis­ten to this pro­gramme, please click here.

On 1 April 2019, Pre­ga­balin and Gabapentin, drugs rec­om­mend­ed for the man­age­ment of neu­ro­path­ic pain, were re-clas­si­fied as class C con­trolled substances.

Med­i­c­i­nal Cannabis: Is it safe? Does it work for pain? Is it legal? Where do peo­ple who use these drugs to man­age their chron­ic pain now stand with­in UK law?

In this edi­tion of Air­ing Pain, con­trib­u­tors Blair Smith, Con­sul­tant in Pain Med­i­cine at NHS Tay­side, and Nation­al Lead Clin­i­cian for Chron­ic Pain in Scot­land, Steve Alexan­der, Asso­ciate Pro­fes­sor in Mol­e­c­u­lar Phar­ma­col­o­gy at Not­ting­ham Uni­ver­si­ty and Cameron Rashide who lives with neu­ro­path­ic pain.

Issues cov­ered in this pro­gramme include: Cannabi­noids, cannabis, epilep­sy, seizures, drugs, med­ica­tion, pol­i­cy, gabapentin, clas­si­fi­ca­tion, legal­i­ty, pre­scrip­tion, neu­ro­path­ic pain, pre­ga­balin, Sched­ule One drugs and Sched­ule Two drugs.

Paul Evans: This is Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and for health­care pro­fes­sion­als. I’m Paul Evans, this edi­tion of Air­ing Pain has been fund­ed by Foun­da­tion Scotland.

Cameron Rashide: There are peo­ple out there that have found out this is a strong drug, and want it. But peo­ple like us are strug­gling every day. From the moment we open our eyes to the moment we try to close them. We’re not tak­ing it for the fun of it. We’re tak­ing it to ease our body. We have to live with this pain that a nor­mal per­son does­n’t have to live with. So why make it so dif­fi­cult for us? Why make it hard­er for us to go and get some­thing that you pre­scribed? You asked us to take because you said it was good for us. And now you’re say­ing it’s a pro­hib­it­ed drug.

Evans: On the first of April 2019, pre­ga­balin and gabapentin, drugs rec­om­mend­ed by the Nation­al Insti­tute for Health and Care Excel­lence as being effec­tive at reduc­ing neu­ro­path­ic pain and are safe and cost effec­tive, were reclas­si­fied as Class C con­trolled sub­stances in the UK. The change means it’s ille­gal to pos­sess pre­ga­balin and gabapentin with­out a pre­scrip­tion, and it’s ille­gal to sup­ply or sell them to oth­ers. It also means that doc­tors will now need to phys­i­cal­ly sign pre­scrip­tions rather than elec­tron­ic copies being accept­ed by the phar­ma­cists. And phar­ma­cists, for their part must dis­pense the drug with­in 28 days of the pre­scrip­tion being writ­ten. If calls to the Pain Con­cern helplines are any­thing to go by, it’s a change that’s made peo­ple who live with neu­ro­path­ic pain absolute­ly furi­ous. Cameron Rashide lives with chron­ic pain.

Rashide: My chron­ic pain start­ed short­ly after I had a car acci­dent. And then in the same week, I fell down quite a lot of stairs. So, it just – it was like dou­ble impact on the spine. Straight away I did­n’t go to the hos­pi­tal. So, then it was like slow­ly start­ed build­ing and got worse. So lit­er­al­ly, I’ve been liv­ing with it [for] 30 years.

Evans:  So how does it affect you?

Rashide: I’ve had to give up work, which I real­ly liked. It lit­er­al­ly got to the stage that I used to push through the pain and go to work. I live in East Lon­don and I was work­ing in Rich­mond. So, the trav­el­ling took a big impact on me. And then when I had to give it up, that was the line of me real­is­ing [that] this is too much.

Evans: A strange ques­tion, but how does your pain feel?

Rashide: You know, when you have a can of Coke and you want to smash it? I am the can of Coke and you’re smash­ing me. That is lit­er­al­ly an every­day thing from top to toe.

Evans: So, you’re being crushed, basically.

Rashide: Total­ly, every day. And not even giv­ing me a breather in between.

Evans: So, is this neu­ro­path­ic pain?

Rashide: First, I was told it was just the disc. And then it’s turned into neu­ro­path­ic pain. So, they realised I had that short­ly after I had the stroke.

Evans: So, you’ve had a stroke as well. Can I ask you about your medication?

Rashide: I’ve been tak­ing pre­ga­balin for over three years now.

Evans: How does that help?

Rashide: I take it in the evening, and if the pain flares up dur­ing the day time. It does­n’t delete, but it eas­es the pain to the point that you can relax and try to sleep. You won’t have a full night’s sleep but you’ll have some sort of sleep.

Evans: Now they’ve just changed the clas­si­fi­ca­tion of pre­ga­balin and gabapentin, how does that make you feel?

Rashide: I’m on oth­er pro­hib­it­ed drugs. So, it’s like, ‘Okay, am I tak­ing too much?’ This is also one thing that we learned in the group about your med­ica­tion, the lev­el of med­ica­tion that we’ve been giv­en. Are they going to help you? Or is it going to stop your pain? I think with it going into pro­hib­it­ed, you’re actu­al­ly mak­ing peo­ple think, ‘Okay, if it’s going to help them, it’s going to help them.’ But I’ve start­ed to think, ‘Am I tak­ing too many drugs, that are going to mess me up lat­er on in life?’ Because, obvi­ous­ly, depend­ing on your [tol­er­ance], and so on, what’s going to hap­pen? Because some­times, obvi­ous­ly, the doc­tors need to change your dos­es. You can up them [or] down them, so some peo­ple start rely­ing on drugs. I’m one of these [peo­ple that believes] in alter­na­tive ther­a­py, but I realised as well that you need to take med­ica­tion when you have to take it but hav­ing it now clas­si­fied – I was­n’t real­ly hap­py [about] that. It actu­al­ly made me feel [that] I’m tak­ing some­thing that is a high-lev­el drug, because you can’t, now, have a repeat done. You can’t ask the chemist to drop it off no more. You per­son­al­ly have to go to the surgery. You have to ask the doc­tor for it. And then you have to give it to the chemist to fulfil.

Evans: It’s almost as if they don’t trust you.

Rashide: Yeah. There was one time like, my GP did get annoyed and said, ‘Look, she can’t walk, she can’t come surgery to get it. Why can’t you just repeat it?’ And it’s like, okay, it’s a pro­hib­it­ed drug. First of all, why are you giv­ing out then if it’s so strong? Why are you giv­ing it on pre­scrip­tion, why are you giv­ing it to any­body? If you have giv­en it out, why are you still giv­ing it out if you think it’s pro­hib­it­ed? Why didn’t you stop it before you made it prohibited?

Evans: So, let me get this straight in my own head. You have to vis­it your GP once a month. Now you get a month supply.

Rashide: Yeah.

Evans: And he or she has to say: ‘Yes, she’s good for anoth­er month’. 

Rashide: Yeah.

Evans: And you’ve had pain for thir­ty years.

Rashide: Exact­ly. So that it annoys you, because you’ve got to go through this every month just to pick up one med­ica­tion. If you were going to do this, you should either have this reg­is­ter – i.e. like in Amer­i­ca, they give you lit­tle cards. Why don’t you do that with all the patients that have it already? That have got to have it? Why do they have to go through this con­tin­u­ous – Go to the surgery – The doc­tor has to check you out? All right, there are peo­ple out there that have found out this is a strong drug and want it but peo­ple like us are strug­gling every day. From the moment we open our eyes to the moment we try to close them. We’re not tak­ing it for the fun of it. We’re tak­ing it to ease our body. We have to live with this pain that a nor­mal per­son does­n’t have to live with. So why make it so dif­fi­cult for us? Why make it hard­er for us to go and get some­thing that you pre­scribed? You asked us to take it, because you said it was good for us. And now you’re say­ing it’s a pro­hib­it­ed drug.

Evans: Are they say­ing it’s not good for you?

Rashide: That’s the ques­tion. They’ve nev­er said it’s not good for you. But they’ve clas­si­fied it as prohibited.

Evans: What does your GP say about it?

Rashide: The first week it hap­pened, when they made it pro­hib­it­ed. She did the mis­take of giv­ing me a six-months repeat. Okay, so she made six pre­scrip­tions up like she would do for my repeats. They were tak­en to the chemists to cut and the chemist point blank refused to fill them. Then I had to go back to the surgery to pick up anoth­er pre­scrip­tion to be filled. So, in oth­er words, I’ve gone through two dif­fer­ent has­sles. And none of the GPs that I’ve vis­it­ed have actu­al­ly com­ment­ed on the way they’ve had to do it now. They’ve said, ‘The law is the law.’

Evans: It seems strange to me that they’re not crim­i­nal­is­ing peo­ple, but they’re not just bur­den­ing you, the per­son who lives with pain, who needs these drugs, but they’re also putting the GPs into the same box, that they can’t be trust­ed either.

Rashide: Yeah, it is. Because it’s like, who are they giv­ing it out to? Are they giv­ing it out the right patients? Or are they giv­ing it to these peo­ple? I’m not one of these that always say, ‘Oh, the gov­ern­ment does­n’t trust us,’ and so on. But it’s start­ing to look like that now. It’s like the old say­ing, ‘If some­thing’s work­ing, why change it?’ Doc­tors are wise enough not to give it to [just] any­body. They’re not going to give it to Tom that’s just bro­ken his thumb. They’re going to give it to Peter that’s been suf­fer­ing of thir­ty years or forty years, who has been on it for a rea­son. They are sen­si­ble enough, after all, they did go through med­ical school. The gov­ern­ment did­n’t, so why are doing this?

Evans: That’s Cameron Rashide. Blair Smith is a con­sul­tant in pain med­i­cine at NHS Tay­side. He’s nation­al lead clin­i­cian for chron­ic pain in Scot­land. His research inter­ests have been to look at the rates of pre­scrib­ing of some of the drugs used in the man­age­ment of chron­ic pain, includ­ing pre­ga­balin and gabapentin.

Blair Smith: The rea­sons for its intro­duc­tion are to improve the safe­ty of pre­scrib­ing at a pop­u­la­tion lev­el, to min­imise the risk of peo­ple who are obtain­ing the drug and tak­ing high­er dos­es than nec­es­sary, or peo­ple who are per­haps even divert­ing the drug to the streets, or to min­imise the risks of the increase in drug-relat­ed deaths that have been asso­ci­at­ed with gabapentin and pre­ga­balin. So, it’s done for patient safe­ty rea­sons. It isn’t done to pun­ish peo­ple who are obtain­ing ben­e­fit from the drug, tak­en for the cor­rect indi­ca­tions. It’s impor­tant to state, at this stage, that gabapentin and pre­ga­balin are actu­al­ly very use­ful drugs for treat­ing par­tic­u­lar­ly neu­ro­path­ic pain. And any­body who is tak­ing these drugs and deriv­ing ben­e­fit from them, for their neu­ro­path­ic pain, should­n’t be con­cerned because they are going to con­tin­ue to be avail­able. And they are going to be able to get their drugs and the med­i­cines when they need them.

Evans: But the chron­ic pain patient com­mu­ni­ties are very dis­turbed by this, very upset by this. Explain why.

Blair Smith: Well, I think because of the pub­lic­i­ty that’s attached to it, and because of the per­ceived – and in some cas­es – maybe actu­al slight increase in dif­fi­cul­ty with get­ting pre­scrip­tions, I can under­stand that peo­ple who are obtain­ing great relief from their very dis­tress­ing neu­ro­path­ic pain will be con­cerned that this is going to be tak­en away from them. And that was real­ly what I was mean­ing before: they should­n’t be con­cerned about that because they’re going to con­tin­ue to be avail­able through the same routes as before, nor­mal­ly through their gen­er­al practitioner.

I think there’s prob­a­bly also con­cern that, because of the pub­lic­i­ty attached to it and oth­er pub­lic­i­ty sur­round­ing the iden­ti­fied increased in pre­scrib­ing rates, that there’s a per­ceived stig­ma attached to it. They per­ceive that they are being per­ceived as drug addicts, I suppose.

Evans: It’s almost like crim­i­nal­is­ing them.

Blair Smith: Yes, well, I can under­stand why that per­cep­tion goes ahead. Cer­tain­ly, there isn’t that per­cep­tion with­in the med­ical com­mu­ni­ty and with­in the health­care pro­fes­sion­al com­mu­ni­ty, for whom any­one who’s obtain­ing ben­e­fit from gabapentin or pre­ga­balin, usu­al­ly for neu­ro­path­ic pain should cer­tain­ly con­tin­ue to get them with­out any prob­lem or issue.

Evans: Are they addictive?

Blair Smith: If you read the press, there’s an assump­tion that they are addic­tive, but I have yet to read any evi­dence of their addic­tive­ness, and that’s research that needs to be done. We’ve been dis­cussing that with col­leagues in Dundee. It’s not even clear what the effect of them is, oth­er than pain relief. There clear­ly is some effect to make them valu­able cur­ren­cy on the street and in pris­ons. We think it might be to do with poten­tial­ly enhanc­ing the effect of opi­oids tak­en at the same time. That’s the – that’s the the­o­ry. So, if you’re tak­ing an opi­oid, whether it’s hero­in or mor­phine or Tra­madol, what­ev­er, if you’re tak­ing that in order to gen­er­ate plea­sur­able sen­sa­tions, [such as] eupho­ria, there may be an addi­tive effect of gabapentin [or] pre­ga­balin [can] pro­long [the effect] or [reduces] the dose of the opi­oid that you need to take in order to gain the same euphor­ic effect. But by them­selves, I don’t know of any evi­dence to say that the gabapentin or pre­ga­balin are addic­tive. If you’re tak­ing a strong opi­oid, such as mor­phine, there’s a thing called tol­er­ance which often devel­ops, which means that the effect that you have at a cer­tain dose reduces in terms of its pain relief, so you have to take a slight­ly high­er dose to get the same effect. And that keeps going so, poten­tial­ly, you could keep hav­ing to increase your dose and then you find your­self in a very high dose and unable to come off it because a depen­den­cy has set in. I’ve not seen that with gabapentin or pre­ga­balin, and I’ve not read any evi­dence of it. Once you reach the dose of pre­ga­balin that is most effec­tive for your pain, then that dose can remain sta­ble, with the same effect, for long term.

Evans: Pro­fes­sor Blair Smith. Well, Pain Con­cern pub­lish­es its own leaflets, writ­ten by lead­ing experts, on how to man­age your med­ica­tions for chron­ic pain, includ­ing one specif­i­cal­ly on pre­ga­balin and gabapentin. You can down­load it from Pain Concern’s web­site which is painconcern.org.uk and from there, you’ll also be able to lis­ten to all 114 addi­tions of Air­ing Pain, and also find details of our mag­a­zine, Pain Mat­ters. Now, anoth­er drug that’s cre­at­ing its own media fren­zy over its legal sta­tus for med­ical use, is cannabis. Steve Alexan­der is Asso­ciate Pro­fes­sor in Mol­e­c­u­lar Phar­ma­col­o­gy at Not­ting­ham University.

Steve Alexan­der: In par­tic­u­lar, I’ve been inter­est­ed in cannabis-relat­ed med­i­cines and cannabi­noids for about twen­ty years. And of course, that’s rel­e­vant to pain because of the over­lap in the use of cannabis in many areas the world, and the hypoth­e­sis that endoge­nous cannabi­noids can maybe reg­u­late pain mechanisms.

Evans: Well it’s very apt as well because cannabis and cannabi­noids are hot sto­ries in the news at the moment. Now, tell me what is the prob­lem with using cannabis for pain-relat­ed [pur­pos­es]? If there is a problem?

Alexan­der: There are sev­er­al issues. The first one is legal­i­ty. Clear­ly, we’re in a sit­u­a­tion where only very recent­ly has there been a move to move cannabis-derived med­i­c­i­nal prepa­ra­tions out of sched­ule one. I should point out that cannabis, itself, is still sched­ule one in this coun­try. But what has hap­pened in Novem­ber was the move to sched­ule two licenc­ing for cannabis-derived med­i­c­i­nal preparations.

Evans: Just explain that sched­ule one and sched­ule two. What the dif­fer­ence is and do they gov­ern what the pub­lic can do or what the pro­fes­sion­als can do?

Alexan­der: So, sched­ul­ing has been around since the ’50s. And dif­fer­ent coun­tries have slight­ly dif­fer­ent ver­sions of it. But essen­tial­ly, as derived by the Unit­ed Nations, a sched­ule-one com­pound would be some­thing that has no med­i­c­i­nal val­ue. So aside from raw cannabis, com­pounds like LSD, and MDMA, are described as sched­ule one. Where, at the moment, there’s no per­ceived clin­i­cal ben­e­fit. Low­er lev­els of sched­ul­ing, describe drugs which should be con­trolled, where there is a poten­tial for abuse, for exam­ple, but where there is med­i­c­i­nal val­ue. And so, the sched­ule lev­el is meant to reflect the sort of sever­i­ty of poten­tial dam­age or diver­sion or abuse that could be asso­ci­at­ed with those. It’s kind of a dif­fi­cult one because we know that ille­gal cannabis is very wide­ly con­sumed in this coun­try. But it still remains a sched­uled drug.

Evans: I do know peo­ple who use ille­gal cannabis, who smoke cannabis, who swear that it is very good for man­ag­ing their chron­ic pain.

Alexan­der: There is, as you say, an awful lot of accu­mu­la­tion of anec­do­tal evi­dence. And it’s a dif­fi­cult one to, you know, if you come from it from the sci­en­tif­ic clin­i­cal aspect, you want to see clin­i­cal tri­als where things are done in a rig­or­ous, side-by-side man­ner where you can point to a clear dif­fer­ence between peo­ple who have the active ingre­di­ent and peo­ple who don’t have the active ingre­di­ent and see that it’s a pos­i­tive. And there have been a lot of those sort of clin­i­cal tri­als con­duct­ed in the past. If you look at the sort of meta-analy­sis, there is a ben­e­fit [of cannabis] to be had in pain. It’s not huge. And I think the rea­son for that, which we can come back to in a sec­ond, [is that] I think indi­vid­u­als who see that ben­e­fit – you can under­stand that they’re will­ing to break the law. For chron­ic pain suf­fer­ers, if their alter­na­tive med­ica­tion, their exist­ing med­ica­tion, isn’t doing the job, I absolute­ly empathise with them about [their] need to break the law.

Evans: Empa­thy is per­fect­ly under­stand­able. But the fact is that cannabis, raw cannabis, street cannabis, has its dan­gers as well.

Alexan­der: Absolute­ly. So, there are two issues I have with ille­gal drugs. And the first is that they are ille­gal and the sec­ond is there is no qual­i­ty con­trol. So, you don’t know what you’re get­ting. Even if you go back to the same indi­vid­ual, you will be get­ting things which vary quite a lot. And what we also say, you know, it’s not just that there is a change in the sort of con­tent, the high lev­els of THC that peo­ple would describe as ‘skunk’, but there’s also occa­sion­al lev­els of adul­ter­ation: peo­ple using syn­thet­ic cannabi­noids and adding them to cannabis, and that can be poten­tial­ly dan­ger­ous as well. So, although it’s not overt­ly life threat­en­ing, does­n’t mean it’s safe. So, THC is, I sup­pose, the most famous cannabi­noid, so the cannabis plant is won­der­ful­ly rich in its diver­si­ty. It’s got over a hun­dred – what appear to be – unique metabo­lites to that plant, and we still don’t under­stand why. It’s an inter­est­ing sort of facet of botany. But the one that is regard­ed as the major psy­choac­tive enti­ty in terms of giv­ing the high that non-med­i­c­i­nal users want, appears to be THC: tetrahy­dro­cannabi­nol. So that’s also effec­tive in terms of deliv­er­ing anal­ge­sia but the down­side is it pro­duces this dis­so­ci­a­tion from the envi­ron­ment, hyper-loco­mo­tion, so peo­ple go into a sort of – not a cata­ton­ic state because it’s not quite that, but short-term mem­o­ry loss, impair­ment of some of the visu­al ideas as well. So clear­ly, if we’re want­i­ng peo­ple to be func­tion­al, and to have pain relief, then that is far from ide­al. And so that has been an issue about the use of cannabis.

One of the things that is kind of inter­est­ing is try­ing to fig­ure out, if you can choose a dose that might be ben­e­fi­cial in terms of pro­vid­ing pain relief, and not being too bad in terms of remov­ing you from your envi­ron­ment, that’s prov­ing a lit­tle bit dif­fi­cult because of the way in which peo­ple take cannabis. So, smok­ing is by far the most com­mon way that peo­ple take non-med­i­c­i­nal cannabis. And with that, you can do a lit­tle bit of titra­tion, because there’s a rel­a­tive­ly short delay between tak­ing a hit and feel­ing those sen­sa­tions. But clear­ly that’s not some­thing you can pro­mote as a mech­a­nism for treat­ing an ill­ness. So, the alter­na­tive routes of oral admin­is­tra­tion are very slow, in terms of onset; these are not very well absorbed com­pounds. And so, get­ting the right dose for an indi­vid­ual is actu­al­ly quite dif­fi­cult. And that’s one of the sorts of things that I think would real­ly help, would be to have a bit more pre­ci­sion about the deliv­ery of these agents. So that the places in the world where med­i­c­i­nal cannabis is avail­able and where you do have qual­i­ty con­trol and repro­ducible lev­els of par­tic­u­lar cannabi­noids in those prepa­ra­tions, they often try and per­son­alise it and per­son­alised med­i­cine is great. It’s one of the things that we’re try­ing to advo­cate for peo­ple in gen­er­al. It’s real­ly nice to be able to iden­ti­fy that peo­ple are dif­fer­ent, they respond very dif­fer­ent­ly in the ways in which they han­dle the drugs and the effects. So, it’s nice to have that per­son­al­i­sa­tion, but it’s a real­ly dif­fi­cult one to start off with, if you like. So, with an estab­lished med­i­cine, to look at how peo­ple are dif­fer­ent in their respons­es, and then pick those who are much more like­ly to respond, is kind of the accept­ed way of doing it. But start­ing off with some­thing which we know is quite vari­able, and then try­ing to pick peo­ple who are going to be bet­ter respon­ders and peo­ple are not going to respond as well – that’s not as straight­for­ward. So often what goes on in the oth­er coun­tries where med­i­c­i­nal cannabis is legal, is that they start off with low dos­es. So, it’s the sort of tra­di­tion, ‘Start low, go slow,’ and vary the dose and some­times vary the con­tent, so the THC that we know pro­vides some anal­ge­sia – you kind of try and ramp that one up until a time where the patient feels they get the opti­mum benefit.

Evans: Now you’re talk­ing about cannabi­noids and cannabis. What is a cannabinoid?

Alexan­der: Cannabis is the plant. We’ve had ver­sions of cannabis in the UK for hun­dreds of years. We’ve used it over many years as a source of fibre. So, in the Eliz­a­bethan era, it was grown and, in fact, if you had a par­tic­u­lar size of land, you had to grow hemp for the rope and sail that was used in the Roy­al Navy. But that was very low in the cannabi­noids. So, it did­n’t have the high lev­els of the active ingre­di­ents that we talk about in terms of the med­i­c­i­nal prop­er­ties. As with most plants, there is a huge vari­a­tion depend­ing on the seed that you use in the first place, how you grow it, where you grow it, how you har­vest it, how you store it, and all those sorts of things – which parts of the plant to use as well. Cannabi­noids were often called sec­ondary metabo­lites. They’re not actu­al­ly need­ed for the basic metab­o­lism of the plant, but they accu­mu­late and they might be some­thing to do with the plant’s own immune sys­tem, because there’s a sto­ry that maybe it reduces par­a­sitic infec­tion of the plant itself, and so they thrive. So, these accu­mu­late par­tic­u­lar­ly in the female buds, some peo­ple have list­ed maybe 114 of these which seem to be rel­a­tive­ly unique to the cannabis plant, and those are the things that have been asso­ci­at­ed with things like reli­gious prac­tices in India and the Caribbean. And then the sort of abuse, if you like, this street use that we think of pri­mar­i­ly when some­body says ‘cannabis’ to you.

Evans: In terms of legal­i­ty in the UK any­way, you can buy cannabis oil on the high street. So, what is that?

Alexan­der: So that’s pri­mar­i­ly derived from the seed. So, the legal­i­ty of the sit­u­a­tion is that they should not con­tain above a cer­tain mea­sure of THC. So, the prin­ci­ple is that they’re obtained from ver­sions of the plant which maybe have a low THC con­tent, the deriva­tion of the oil is as much as you would [derive] from any seed, it’s kind of a press­ing process, and the oil is extract­ed. Many of these con­tain one of the oth­er cannabi­noids called cannabid­i­ol. A com­pound which is very inter­est­ing in terms of treat­ing child­hood epilep­sy. So that par­tic­u­lar agent of puri­fied cannabid­i­ol has recent­ly been approved in the Unit­ed States for treat­ment of par­tic­u­lar ver­sions of infan­tile, intractable epilep­sy. So, [for] kids who just don’t respond to nor­mal med­ica­tion, and have forty/fifty seizures a week – hor­ri­ble. And in some of those [cas­es], not all by any means, but in some of those cannabid­i­ols seems to reduce that to some­thing which is manageable.

Evans: And these are the sto­ries that are mak­ing the head­lines at this moment.

Alexan­der: So, as you’re prob­a­bly aware, last spring and sum­mer, there was quite a major sort of cam­paign high­light­ing a cou­ple of inci­dences in the UK, where kids who have this dis­or­der, were being treat­ed up to a point with ver­sions of cannabi­noids, main­ly cannabid­i­ol. Which – [it’s] very dif­fi­cult to know for sure what the con­tent of those things were. But yeah, that became such a high-pro­file [cam­paign] that I think that prompt­ed the politi­cians to look at the sit­u­a­tion and ask the sci­en­tif­ic clin­i­cal com­mu­ni­ty to re-eval­u­ate kind of striv­ing into some prepa­ra­tions and that prompt­ed the change in the law. Because there are so many dif­fer­ent metabo­lites, we’ve real­ly got good infor­ma­tion on the two, THC and CBD: tetrahy­dro­cannabi­nol and cannabid­i­ol. But the oth­ers – we’re begin­ning to iden­ti­fy that they do have bioac­tiv­i­ty. Whether that’s use­ful or not, we don’t know. Some – most of the med­i­c­i­nal cannabis pro­duc­ers focus on those because we’ve got good evi­dence that they may have use­ful effects at the right dos­es. And then, because they’re rel­a­tive­ly minor metabo­lites, the oth­ers, they kind of leave them to one side. But we’re begin­ning to appre­ci­ate that they may have ben­e­fi­cial effects as well. I think one of the oth­er things to say is that, quite often, drugs are not giv­en in iso­la­tion. And obvi­ous­ly with an elder­ly pop­u­la­tion, as peo­ple grow old­er, they accu­mu­late more issues, and so it’s much more com­mon for them to have com­bi­na­tions of med­i­cines. The over­lap between how drugs might be metabolised by the body, and the poten­tial inter­ac­tions that might hap­pen, is clear­ly an area that needs clar­i­fi­ca­tion with co-admin­is­tra­tion of many medicines.

Evans: Let me clar­i­fy this in my own mind. The THC that is not – or [is] at very reduced lev­els, in the cannabi­noid oils and things like that: that’s the sub­stance that gives you a high, in ille­gal cannabis.

Alexan­der: So, to the best of our knowl­edge it’s the pri­ma­ry psy­chotrop­ic agent, the mood-alter­ing agent in cannabis. Because of its promi­nence in terms of our under­stand­ing of it and the abun­dance in the plant, it’s the one that we focus on the most. It’s not impos­si­ble that some of the oth­ers have some minor effects. But we don’t wor­ry so much about them because they don’t accu­mu­late in the same ways as THC.

Evans: Just for peo­ple who are total­ly con­fused by this cannabis/cannabinoid thing. Should they be ner­vous of going into a health food shop and buy­ing cannabi­noid oil?

Alexan­der: I think the evi­dence that we have so far is that there is not a lev­el of con­sis­ten­cy about the com­po­nents – the con­stituents – that are around. I think for the moment, it’s still not sub­ject to the reg­u­la­tion that would allow a sort of con­sis­ten­cy of content.

Evans: That’s Steve Alexan­der, Asso­ciate Pro­fes­sor in Mol­e­c­u­lar Phar­ma­col­o­gy at Not­ting­ham Uni­ver­si­ty. Now, this edi­tion of Air­ing Pain is being record­ed in May 2019. Guide­lines do change so please do check them. But the cur­rent NHS Eng­land guide­lines for the use of med­ical cannabis say that many cannabis-based prod­ucts are avail­able to buy online, but their qual­i­ty and con­tent is not known. They may be ille­gal and poten­tial­ly dan­ger­ous. Some prod­ucts that might claim to be med­ical cannabis, such as CBD oil or hemp oil, are avail­able to buy legal­ly as food sup­ple­ments from health stores. But there’s no guar­an­tee that these are of good qual­i­ty or pro­vide any health ben­e­fits. I’ll just add to that, that whilst we in Pain Con­cern believe [that] the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sounds based on the best judg­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well-being. He or she is the only per­son who knows you and your cir­cum­stances and, there­fore, [the one who knows] the appro­pri­ate action to take on your behalf. Well, I don’t want you to leave this edi­tion of Air­ing pain under a cloud of gloom and doom. There’s more to the man­age­ment of chron­ic pain than just drugs, legal or oth­er­wise. So, in the next edi­tion of Air­ing Pain, I’ll be explor­ing neu­ro­path­ic pain. And how self-man­age­ment tech­niques learned through a pain man­age­ment pro­gramme can turn your life around. I leave you with Cameron Rashide, who spoke at the start of this edi­tion of Air­ing Pain.

Rashide: Before I start­ed this group, lit­er­al­ly it was hos­pi­tal-home, hos­pi­tal-doc­tor, hos­pi­tal-home. In the last eight years, I lit­er­al­ly stayed at home because the pain is too much for me. I stopped going out to cof­fee shops and would­n’t go out shop­ping on my own – every­thing online. Now, [the group has taught us] to prac­ti­cal­ly do some­thing out­side the house. Last week, my week­ly goal was to go to a cof­fee bar. And I did that – even though I was uncom­fort­able, I was in pain, but it was enough to pace myself, but not over­do it. So, it’s lit­tle goals, but achiev­able goals.


Con­trib­u­tors:

  • Dr Blair Smith, Con­sul­tant in Pain Med­i­cine at NHS Tay­side, and Nation­al Lead Clin­i­cian for Chron­ic Pain in Scotland
  • Dr Steve Alexan­der, Asso­ciate Pro­fes­sor in Mol­e­c­u­lar Phar­ma­col­o­gy at Not­ting­ham University 
  • Cameron Rashide, who lives with neu­ro­path­ic pain.

Tran­scrip­tion by Oliane Newman-Savey

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