Intractable Pain Advisory Panel
Meeting
October 6, 2015
Present: Orlando Charry, Amy Anderly-Dotson. Nancy Jaworski, Erin Krebs, Mary Pat
Noonan, Daniel Truax, Neal Walker, Arthur Wineman,
MDH Staff Present: Tom Arneson, Alison Bjork, Michelle Larson, Alix Noonan, Susan
Anderson, Deepa McGriff, Deputy Commissioner Dan Pollock
Facilitated by: Charlie Petersen, Management Analysis and Development
Introductions
Charlie Peterson welcomed the panel to its third meeting, led introductions, and reviewed the
agenda. Charlie noted that there will be no public comment at this and the next advisory panel
meeting.
Medical Cannabis for Non-cancer Chronic Pain:
Systematic Review
Mary Butler, PhD, University of Minnesota Evidence-based Practice Center
Discussion
Study authors did not specifically attend to addiction or habituation. This may be due to the
short duration of the studies.
Dr. Butler’s review excluded cancer-related pain. Had cancer-related pain been included, results
in the JAMA article remain fairly applicable.
When asked whether there was anything from Dr. Butler’s presentation they did not expect,
panel members identified:
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The paucity of studies in rest of world
The large number of studies that are funded by industry1
How little studies addressed pain-related function and longer term pain
Key points to keep in mind include:
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Lack of available data, particularly on largest cohort, musculoskeletal pain, and on most
concerning harm: addiction and dependence. .
Industry funders were the pharmaceutical companies selling either Sativex or Nabilone.
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In some cases, there was enough harm that patients stopped treatment, which not
evident in the anecdotal reports from public comment.
This study report will be available to panel members by end of day Friday.
Addiction Medicine and Pain Management
Dr. Charlie Reznikoff, Hennepin County Medical Center
Discussion
Dr. Reznikoff pointed out that if prescribed enough, medical cannabis—much like Vicodin—
will create some addictions. The advisory panel replied that that is something they would like
to avoid, if possible.
Medical Professionals
Physician systems are not ready for medical cannabis. Panel members mentioned doctors often
fear chronic pain patients are looking for a magic bullet to cure their pain, rather than following
a regimen or attending physical therapy. The medical industry is reeling with pain and its
associated psychological distress, social issues, sedentary lifestyle, etc.
In response to Dr. Reznikoff’s survey results that indicated doctors do not feel prepared or
knowledgeable enough to certify patients, panel members agreed that even if they could
request training for doctors, there is a paucity of trial data to give them.
Definitions
Some doctors have requested a narrow definition of intractable pain that qualifies for medical
cannabis. A panel member asked Dr. Reznikoff if a more restricted definition would do more
harm than good. Dr. Reznikoff replied that sending patients to pain clinics to get certified for
medical cannabis might not be a good solution because it could fill the waiting rooms in pain
clinics and create opportunities for unscrupulous certification practices.
Dr. Reznikoff recommended that the advisory panel construct definition language in a manner
helps doctors avoid uncomfortable conversations with patients for whom medical cannabis is
not an appropriate treatment. The panel discussed that this would reduce or eliminate the need
for multiple referrals that complicate access for rural and residents and those who cannot afford
multiple clinic visits.
Patient experience
A panel member asked whether cannabis causes psychosis or merely unmasks a predisposition
to schizophrenia. Some people have had building anxiety for years and have used drugs or
alcohol to mollify the anxiety. Others have a specific COMT gene variant that cannot take the
dopamine surge caused by cannabis.
Panel members discussed public testimony that said opioids were doing more harm than good,
and patients were turning to cannabis. Discussion included the following points:
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Some patients will use cannabis in addition to opioids. The degree to which use of
cannabis can result in decreased opioid use is not clear.
Panel members and certifiers cannot discount the importance of normalization.
Cannabis use for adolescents is more complicated due to increased risks, but for
adolescents whose development or quality of life is already low, it may be useful to
consider a risk-to-benefit ratio.
Panel members discussed the need to avoid or reduce addiction to cannabis if they were to
approve intractable pain as a qualifying condition. Several members commented that the
medical cannabis available in Minnesota is likely safer than street forms of cannabis, which may
contain unknown additives. If doctors know their patient is using street forms, the doctor must
then consider whether it would be safer to certify the patient.
There is currently no medical treatment for cannabis addiction. Addiction to cannabis is not as
common or “soul-crushing” as some other drugs. Cognitive behavioral intervention and
emotional interviewing sometimes work. Some are still unable to stop using cannabis.
Panel members expressed desire for the ability to monitor patients’ cannabis use, rather than
certifying a patient and not being able to follow up with them.
Email Dr. Reznikoff for similar data on opioids or visit monitoringthefuture.com
Intractable Pain Public Comments Update
Lisa Anderson provided update on public comments. A public comment synthesis report will
be available at the next Advisory Panel meeting.
Intractable Pain Advisory Panel Discussion
Charlie asked the advisory panel to reflect on the information and discussions they have had to
date and share one thing that surprised them or caught their attention, one thing they found
helpful, one thing that concerned them, and what they would like themselves and their
colleagues to keep in mind.
Things that were surprising or caught attention:
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The impacts allowing intractable pain as a qualifying condition would have on primary care
and how it may distract from other, proven treatment methods.
High level of concern about adult addiction to cannabis, given what we know about opioid
addiction.
Doctors are not prepared to certify for medical cannabis for intractable pain and think it will
take too much time to learn
How little information clinical trial is available (x2)
Correlation of reduced opioid overdose deaths in states that have medical cannabis
programs.
Agent could reduce hypersensitization to pain.
Medical cannabis may be beneficial for neuropathic pain
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Overwhelming anecdotal evidence of benefits of cannabis
Things that the advisory panel found helpful include:
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Information on contraindications, such as psychosis help to quantify and scope intractable
pain
Dr. Reznikoff’s reasoned approach, given the paucity of little scientific evidence of
effectiveness
Looking at the primary care crisis
Learning about the need for training by practitioners
Did not hear about fatal marijuana overdoses
Things that concern advisory panel members include:
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Inability to monitor the use of medical cannabis like doctors can monitor other legal drugs 2
The cost is so high, even if we recommend intractable pain as a qualifying condition, it
might be for naught
o May prevent the resale and abuse of medical cannabis
o Centers may be forced to close down if they don’t build an adequate patient base
If the panel allows expanded use of medical cannabis without pushing for research, the
research may never happen
o There are not adequate studies on vaping or the health effects of inhaling cannabis,
particularly on lungs
There has not been much observed pain benefit from Sativex, a 50/50 mix of THC and CBD
concentration
Key points to keep in mind
For selves
• Benefit to the patient is first and foremost
• Need for additional research
• Need to define patient or disease state(s) that are most likely to benefit and those that are
most at risk
• Patients haven’t exhausted all pain remedies but think they have
• Focus on the big picture, for the system and for the individual
• Look at all factors
For colleagues
• Lack of evidence and research
• Many questions that remain unanswered
• Physician resistance to becoming certifiers due to hassle factors
The Minnesota Medical Cannabis program registry allows health care practitioners to view
information about patients they certify: medical cannabis purchases, side effects, and symptom
status.
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Contraindications of medical cannabis
Opportunities and options for educating primary care clinicians
Advisory panel points of agreement
Focus on the big picture, for the system and for the individual
What is needed to build a holistic system
Other discussion
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The data is there, but it’s not empirical. There is some signal. This is more of a philosophic
argument than a scientific argument. With scientific evidence lacking on benefits, there is
also little evidence on harms and some anecdotal evidence that some people have found
relief using cannabis.
In 2014, there were 140 deaths attributed to opiates. How many of the same were there for
cannabis? I don’t think we’ll see the devastating numbers as we would with opiates and
continue that path.
There are strong arguments for allowing defined conditions, such as neuropathy or specific
causes of pain, rather than more abstract symptoms. One solution may be to limit the use of
medical cannabis to specific conditions, with inclusion or exclusion criteria, such as
psychosis. More work would need to be done to determine that criteria, especially for
adolescents.
Medical cannabis is not necessarily an alternative to opioids. Patients believe they have tried
everything to relieve pain, when there are often several options they have not tried. Many
people are lacking appropriate care. There is no evidence that this will cure opioid mess.
This is not a miracle cure.
One panel member stated they would rather forward certification duties to pain clinics
because there should be a multidisciplinary pain group that reviews cases for certification.
The panel member acknowledged that this may be more difficult for people in rural areas
and suggested they may have to do more networking.
Another panel member asked if a doctor could un-certify a patient for reasons other than
noncompliance with the program. Once a patient is certified, they remain certified for
twelve months. However a doctor can choose to not recertify after the twelve months.
Next Steps
Charlie gave instructions for completing the worksheet. The deadline for completing the
worksheet is Wednesday, October 14th at 12:00 pm.
The final advisory panel meeting will be Thursday, October 29th 1:00pm - 3:00pm at the Wilder
Center.
The Commissioner of Health is planning an additional public meeting to discuss the advisory
panel recommendations.
If Advisory Panel members have feedback about the process the Office of Medical Cannabis has
followed for determining whether to add intractable pain as a qualifying condition, please share
them with Tom Arneson.