Dr Andrew Agius, Medical Director at the Pain Clinic, speaks to HEQ about the benefits of cannabis in treating chronic pain.
Cannabis has been used to alleviate acute and chronic pain symptoms for more than 5,000 years, due to its capacity to relieve pain with minimal side effects – particularly in comparison with stronger pharmaceutical painkillers, which can lead to addiction and long-term physical damage.
With an increasing number of countries around the world moving to legalise the medical use of cannabis, and consumer demand rising as patients become more aware of the potential benefits of cannabis-based medicines, health, and care centres such as Malta’s Pain Clinic are turning to cannabis to meet the complex pain management needs of vulnerable patients. Dr Andrew Agius, Medical Director at the Pain Clinic, speaks to HEQ about the benefits of cannabis in treating pain.
What is the current legal and medical status of cannabis in Malta?
Medical cannabis has been legally available in Malta since the law was amended in February 2018. Prior to this, a previous law enacted in 2015 only allowed registered pharmaceutical products such as Sativex to be prescribed; and they could only be prescribed by oncologists, psychiatrists, neurologists, and anaesthetists. Sativex was not available in Malta and all the specialists who were able to prescribe it refused to do so.
Patients only began to be able to access medical cannabis when all doctors were permitted to prescribe it, and new products consisting of raw cannabis flowers manufactured under Good Manufacturing Practice (GMP) began to be imported around May 2018. Since then, hundreds of patients have been accessing medical cannabis through a small percentage of doctors, most of whom specialise in family medicine. Most doctors in Malta still refuse to prescribe medical cannabis; and some also advise patients against it.
Medical cannabis is mostly prescribed for chronic pain conditions like fibromyalgia where pharmaceutical medication has not been effective or has caused side effects. It is very often prescribed in cases of cancer, where it can help with appetite, pain and the side effects of chemotherapy. It can also be beneficial for other conditions, such as anxiety and insomnia, where many patients are prescribed medical cannabis because it provides relief with fewer side effects than pharmaceutical medication.
To access medical cannabis in Malta, a patient needs to be assessed by a doctor who is registered with the Medical Council. Medical cannabis can only be prescribed if the patient has a chronic medical condition for which conventional medication has been prescribed and this medication was not effective or caused debilitating side effects. If the patient is eligible, an application is made to the Superintendent of Public Health, where the doctor declares that they take full responsibility for the patient’s use of the medicine. After due diligence by the Superintendent and a background check to determine whether the patient has attended a drug detoxification programme in the past, patients are approved within two weeks and they are then allowed a 30-day trial of the medicine. If the trial goes well, the doctor can request a six-month approval from the Superintendent. Patients are then able to access medical cannabis from designated pharmacies with a 30-day prescription for narcotic and psychotropic drugs, a control card which is renewed yearly and a permit from the Superintendent which is renewed every six months.
If a cannabis user is not registered as a medical patient, the person may be fined between €50 and €100; and they may face more serious charges if they have more than 3.5g in their possession. If a person is caught cultivating one cannabis plant, they may be able to fight it in court on the grounds that it is for personal use; but more than that or any indication that the cannabis may not be solely for personal use could land the cultivator in jail.
Another law allowing the production and processing of medical cannabis in Malta, which was adopted later in 2018, will mean that very soon Malta will be importing raw medical cannabis, processing it locally, and then exporting it to the rest of Europe. The prices of medical cannabis products will surely go down as the choice of products increases, and patients will hopefully have easier and more affordable access to their medicine.
What benefits does medical cannabis offer in the treatment of chronic pain?
Chronic pain is a common disabling condition affecting 20% of the population in Europe, and the incidence of chronic pain is expected to increase following the COVID-19 pandemic. Unfortunately, there are very few pharmaceutical medications which can be used to relieve chronic pain effectively; and these also very often cause side effects which can compound the disability. Recent research shows that the endocannabinoid system is very much involved in the pathophysiology of chronic pain. Patients who develop chronic pain often have a genetic predisposition towards it, which could be related to a dysfunctional endocannabinoid system. Loss of homeostasis and imbalances in neurotransmitter levels often contribute to the symptoms of patients with chronic pain.
THC and CBD are two potent therapeutic substances in medical cannabis which can help to rebalance the endocannabinoid system and therefore improve symptoms of chronic pain. Full-spectrum medical cannabis preparations have more than just THC and CBD: they contain more than 140 therapeutic cannabinoids, as well as terpenoids and flavonoids which continue to add to the synergistic effect. This results in a potent therapeutic effect which cannot be wholly explained by the effects of the individual cannabinoids alone, and which is known as the entourage effect.
Medical cannabis is highly effective at reducing pain levels, improving mood, reducing anxiety and promoting restful sleep with very few to no unwanted side effects. Patients experience a remarkable improvement in their quality of life and most patients report feeling ‘reborn’ or that they have been ‘allowed another chance to enjoy life’. Medical cannabis literally gives these disabled patients their life back, by helping them manage their symptoms better than anything they would have tried before.
In what areas should additional research be conducted to support the role of cannabis in pain management?
We know that full-spectrum medical cannabis is much more effective at relieving chronic pain than single-molecule THC or CBD. This is because of the synergistic effect of the cannabinoids with the other therapeutic substances in the plant. Everyone responds differently and some patients respond better than others. We can see the incredible therapeutic potential of this plant, yet there is still so much that we do not know and so much we need to explore. It may take decades before we fully understand the different therapeutic substances in this plant.
THC has been extensively studied in chronic pain and we have strong evidence that supports its use. Additional research should investigate the role of CBD, CBG, CBC, CBN and other cannabinoids as treatment in chronic pain, both alone and in combination. Hopefully, the changing laws around the world will allow us better access and make this research easier.
What key factors should clinicians bear in mind when prescribing medical cannabis?
Medical cannabis is relatively safe compared with pharmaceutical medication, since it has fewer side effects and is better tolerated. However, there are contraindications when prescribing and clinicians should also be aware of possible drug interactions.
Since THC may cause psychosis in 1% of the population, clinicians should screen for a possible family history or any symptoms which could indicate an increased risk. Using strains or products with higher levels of CBD and lower levels of THC would reduce the risk of patients developing psychotic side effects, because CBD is an anti-psychotic. Medical cannabis with high levels of THC is also contraindicated in patients who are pregnant or breastfeeding, or who have unstable heart conditions.
Since patients respond differently, it is advisable to start with a low dose and tail up very slowly until a therapeutic effect is achieved. Patients are unlikely to experience side effects at these doses. Intoxication can occur with higher doses of THC, but these usually subside within a few hours without any long-term consequences.
How do you foresee the medical cannabis landscape in Malta evolving in the next year?
As the production of medical cannabis in Malta is projected to start later this year, we are expecting several new products to become available in pharmacies from the various companies that are slowly starting their operations in the next few months. Prices for medical cannabis products should drop dramatically (currently medical cannabis flowers sell for €16 per gram) and we are hoping to see a wide variety of CBD and THC products in various forms and preparations. Malta is expected to become one of the first countries in Europe to produce EU-GMP cannabis medicines which will then be available locally and exported to the rest of Europe.
Dr Andrew Agius MD MSc EDPM
The Pain Clinic