Is it true that Cannabis can help people with multiple sclerosis?

Posted on 12 March 2019 in MS treatment

Cannabis and its products have been used medically and recreationally for thousands of years. Cannabis is the most widely used illicit drug in the world with the UN estimating that worldwide 3-5% of adults use cannabis!

Cannabis is widely used to self-medicate by many people with neurological disorders such as Multiple Sclerosis, Epilepsy, Alzheimer’s disease, and Parkinson disease. In the majority of cases, it is highly unlikely that this practice is supported by sound medical advices.

There has been much interest in the medical use of cannabis in the media recently, where the action of a few people with children with epilepsy has led the UK Government to legalise cannabis for medical uses.

What is Cannabis?

Cannabis (or marijuana) is made up of more than 100 substances called cannabinoids. The main types studied for their medical effect are THC (tetrahydrocannabinol), which gives the ‘high’, and CBD (cannabidiol), which doesn’t. THC has psychoactive effects, such as cognitive impairments, psychosis, and anxiety. CBD is non-intoxicating and has anti-inflammatory, pain-relieving, antipsychotic properties and can counter several unwanted side effects of THC.

Depending on the type, the main ways they are taken are by smoking, vapourising or eating it in things like cakes.

CBD is not a controlled substance, Cannabis oils containing CBD can be sold legally in the UK providing they contain negligible amounts of THC, they do not make any claims for medical benefit and are not sold as medicines.

Some believe that as Cannabis is natural it is better than pharma drugs!

Cannabis is still a class-B drug in the UK. Possessing, producing and supplying it are against the law. Supply includes sharing with someone or giving it to friends or family members. The law doesn’t allow you to use the fact you were using it for your medical condition as a defence.

The spectrum of the legal positions world-wide are very diverse. There are an increasing number of countries where recreational and/or medical uses are legal. Others have severe restrictions for both.

Medicinal cannabis refers to the use of cannabis for medical purposes rather than for recreational use. There is some concern that the recent legalisation discussion in the UK and the confusion over medical vs recreational use might encourage the latter. Specifically caution needs to be taken when traveling and in possession of these products.

Cannabis use in Multiple Sclerosis

One in five people with MS who were surveyed by the MS Society in 2014 reported that they have used cannabis to help with their symptoms. They reported benefits with muscle spasms or stiffness (spasticity) and pain. More than half of those with MS say they would consider trying it if it was legal and there was more scientific data available.

Advocates of cannabis believe that its chemicals have powerful anti-inflammatory effects, that this unique neuro-transmitter helps neuro-genesis and regulates the immune system. They believe that it can be extremely effective in treating MS and its associated symptoms.

There is a large body of research looking at the use of cannabis and its products in MS but the results have been mixed. The role of cannabis for MS symptoms isn’t fully clear.

It is generally accepted that cannabis is effective in treating moderate-severe MS spasticity, but there is less agreement on the benefits for treating pain or other MS symptoms.

Spasticity and pain are common MS symptoms which can have a significant and serious impact on people’s mental health, wellbeing and quality of life. Approximately 10% of people with MS with spasticity and pain find little or no relief in the medicines currently available. These medicines can also have significant side effects. This has resulted in the need to explore alternative options in the medical management of MS.

In this group of people the use of cannabis can have positive benefits. There are many reports in the media of PwMS who reported dramatic positive effects on their quality of life following cannabis use.

The general consensus is that cannabinoids do not affect MS disease activity or disability accumulation. They are not useful as a disease modifying therapy (DMT) in MS and they should not replace your prescribed DMT.

Sativex spray is the only licensed cannabis product in the UK for MS medical use as an add-on treatment. It is used for symptom improvement in patients with moderate-severe spasticity who have not responded adequately to other anti-spasticity medication and who demonstrate clinically significant improvement in spasticity related symptoms during an initial trial of therapy. It is initially prescribed for a 4-week trial period and stopped if ineffective. Approximately 50% of patients respond to treatment.

Smoked cannabis continues to be not legal in the UK at present and is not available for medicinal use.

Smoked cannabis research studies have not produced enough evidence to assess its safety or effectiveness for treating MS symptoms including spasticity, pain, balance, posture and cognition changes. Smoking cannabis, especially if mixed with tobacco, has dual harmful effects to the health of PwMS.

People who don’t have MS (“normal brain”) are at risk of cognitive impairment when smoking Cannabis. Not surprisingly, the cognitive effect is more marked in people whose brain is already affected by MS.

  • Dizziness or faintness
  • Dry mouth
  • Difficulty with attention or concentration
  • Hallucinations
  • Loss of balance and falls
  • Depression or psychosis
  • Increase the risk for cardiovascular diseases

Availability of Cannabis in the NHS

Current NICE guidance (National Institute for Health and Care Excellence) which “instructs” NHS organisations found that Sativex was not a cost-effective treatment. It would be extremely difficult for doctors to prescribe within the NHS based on this recommendation. Contradictorily, in Wales Sativex can be prescribed in the NHS for use in moderate-severe MS spasticity!

In December 2018 a statement from the ABN (Association of British Neurologists) which guides UK neurologists mentioned the following:

  • There is considerable patient demand for cannabinoids because it is perceived as a natural and side-effect free way of treating troublesome multiple symptoms, such as pain and spasticity, and many patients will already have experience of non-prescription cannabis.
  • The ABN recognises that there are likely to be large numbers of MS patients who may potentially benefit from these drugs
  • All patients will need to be assessed within specialist clinics and subsequently reassessed for initial benefit as well as continuing benefit.
  • Cannabis-based products should be used only in PwMS who have had an unsatisfactory response to conventional spasticity drugs.
  • This statement did not comment on the use of cannabis for pain in PwMS.

Any prospect of change?

NICE have started consulting on long term guidelines for medicinal cannabis including its use in MS treatment. The MS charities, the ABN and many other organisations and individuals are involved in the consultation with a decision expected around October 2019. There is significant pressure on NICE to include pain in the recommendations for MS. The cost-effectiveness issue is the major hurdle to facilitate the use in the NHS.

My personal view:

  • Yes, it is true that medicinal cannabis, like many other medicines, can help many people with multiple sclerosis to control their difficult to manage symptoms.
  • It is also true that the complex sets of MS symptoms need to be managed not only by medications but through a holistic multi-professional management approach to improve wellbeing and quality of life. MS services need to improve to adapt this approach.
  • It is fair to expect that PwMS with uncontrolled symptoms who might benefit from these medications could have the chance to trial them in a controlled environment. The sufferings of many can be managed with a less restrictive attitude towards medicinal cannabis.
  • Medicinal cannabis is increasingly legalised and available in many advanced healthcare systems; it is time for the UK healthcare and political systems to adapt to people’s needs rather than awaiting the next media generated crisis
  • Recreational cannabis use is relatively common in PwMS. Their side effects are well known to most people but the most worrying are the behavioural and cumulative cognitive impairment.
  • MSologists (MS specialists) need to be more pro-active in helping to inform PwMS the potential risks and benefits of cannabis and in explaining the myths surrounding its use.
  • The Association of British Neurologists call to consider using medicinal cannabis through NHS specialist clinics and to create an environment for assessment, prescribing and monitoring response, is very welcome.
  • It is likely that the independent UK healthcare sector will take the initiative after the legalisation of medicinal cannabis and start delivering specialist clinics to people who can afford the cost as seen in other Western countries.
  • All concerned need to keep pressure on NICE & Pharma to come to cost agreement to facilitate the availability of these medications in the NHS.

Dr Adnan Al-Araji
Consultant MS Neurologist

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