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Monday, June 27, 2022

“Medical cannabis isn’t a joint, it’s another drug”

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A subcommittee of the House of Representatives is expected to approve a report this Tuesday authorizing the use of therapeutic cannabis in Spain. In the absence of details on the application, the step forward is imminent: the Ministry of Health has already pledged to take on board the recommendations agreed by parliamentarians. The regulation of this substance as a medicine has the approval of the Spanish Pain Society (SED), which recently changed its traditional position to position itself in favor of certain cases. Its President, María Madariaga (Madrid, 49 years old), Coordinator of the Pain Units of the Santa Sofía University Hospital and the HM Torrelodones Hospital, asks to “open your hand” to offer patients new alternatives and continue to generate knowledge in their field , the largest niche for medicinal cannabis.

Questions. What is the reason for this change of position of the SED? Why are you in favor of medicinal cannabis now?

Answer. It is a position that advocates a laxity in acknowledging the scientific evidence that may support the use of medicinal cannabis for certain types of chronic pain in certain patients, with extensive, rigorous follow-up that has to do with the change in attitude of the European Federation of Pain in accordance with the changes in legislation in Spain and other countries.

P So the change of position is not motivated by new evidence?

R It’s what we need: to open the hand with the evidence classification system. That means you use [el cannabis medicinal] for a pathology, with a specific group, with a treatment of X, and you assess the evolution over time, the response to pain, the side effects, the improvement in the quality of life … It takes time and money. If you want evidence and quality studies that will allow you to safely recommend medical cannabis for a group of patients, you need more of these studies and if we don’t open our hands we won’t be able to do it [tenerlos]. That’s the problem, it’s not like the single molecule system for clinical trials [con el que se prueban la mayoría de los medicamentos en el mercado]. It is much more difficult and takes much longer. It is the whiting biting its own tail. Chronic pain is very difficult to treat. We have few drugs, and the ones we have raise two fundamental problems: the cardiovascular risk of anti-inflammatory drugs added to their lack of effectiveness, and the risk associated with the use of major opioids.

Severe patients with intense, refractory chronic pain who require devices, rehabilitation, medication… are overwhelmed and continue to be in pain. Medicinal cannabis seems to work for some types of chronic pain. Not always, but it seems to work and it’s certainly a good pain reliever that has its risks and benefits. We must be in real conditions to know how long we can recommend it, in what dose, in what pathology, what side effects we can find and how to treat them as doctors that we are. The patient is currently being cared for outside [del sistema sanitario]: On the Internet they look for friends, neighbors. everything is crazy

P Would the regulation apply the reality principle?

R Try applying the scientific method to the reality of use and the pressure to find new alternatives to treat chronic pain that is so difficult to treat. But we need to know more about cannabinoids. You can’t tell us how the patients themselves act, that’s absurd because they combine it with other drugs. we need data

P Will it be like a clinical trial in the real world?

R It is necessary to assess the patient’s response to specific combinations of cannabinoids, THC and CBD [los dos principios activos] combine with others and assess the response to joint pain, such as chronic sciatic pain or pain due to a central nervous system lesion at the spinal cord level; and how it affects the quality of life, the quality of sleep. We know positively that cannabinoids improve nausea, vomiting associated with chemotherapy; They also improve appetite in cancer patients, end-stage patients, or those with acquired immunodeficiency disease. These are potential benefits, but there are also side effects. We know that cannabinoids don’t always get along well. The stronger they are as pain relievers, the more side effects they produce. But of course, if we look the other way, we only get an amplification of the problem.

P Other colleagues of yours point out that the pharmaceutical industry has no interest in spending money on clinical trials because they are not patentable.

R I believe there are companies that are very interested in medicinal cannabis, but I can’t judge that, it’s not my responsibility. Our interest is to advance knowledge about pain, its treatment and to improve the quality of life of our patients. How can we do that? Observational studies can be started and followed up; that costs a lot of money. But it needs to be done and have uninteresting funding to get real data on what’s happening in the short and long term.

P In the SED’s new position, they recommend these drugs as a third line of treatment, what does that mean?

R [Es para] Patients who are already taking everything in high doses or who have been refractory and have severe pain, uncontrollable pain… thank god it’s a very small percentage of our patients. Over time, others may be able to find relief, even if not as severe, but for that we need this indication data. Because if it works for one type of pain, it may work for another.

P Basically, what are the two lines of treatment that patients should pursue to gain access to medicinal cannabis?

R The basis would be analgesics and anti-inflammatory drugs. Second would be the minor opioids and then the major opioids. We will try to find alternatives to clinical trials controlled and that will give us [la posibilidad de estudiar a] a large number of patients with different pathologies and really assess what happens to them in the long term. It’s the same kind of studies that were started in the United States when the opioid epidemic started. They found that older opioids didn’t work after three months of continuous use. These dates are golden and have been achieved very recently and that’s really something we could try in Spain as well [con el cannabis].

P Given its use in countries where it is more consolidated, it could be concluded that in Spain more than 200,000 people can benefit from it.

R Yes, sometimes there is talk of 200,000, 400,000. They are many. And when they work on the more serious ones, we can gauge the reaction on others. But of course we need safety data, we don’t want patients to think that smoking a joint is; We are talking about an oral route and at most an inhaled route, authorized and controlled all with a donor. It’s not about smoking a joint, that’s very important to know. It’s a different drug. It will be necessary to assess the risk of developing other problems due to long-term use of cannabinoids, just as we did with opioids.

P There are those who believe that opening your hand to medicinal cannabis could be the Trojan horse for getting started with recreational use.

R We have that clear. But we still think that regulating medicinal cannabis can’t be bad, quite the opposite. What we need are control mechanisms and indications for patient follow-up and very strict control. We all have to be up to the task: our political managers and also the doctors, who by the way need a lot of training in medicinal cannabis.

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Source elpais.com

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