Every once in a while, Tom Huynh, pharmacy manager for Minnesota Medical Solutions, one of the state’s two registered medical cannabis manufacturers, is recognized by a patient.
Many people with severe, chronic pain have tried nearly every medical option to make their lives easier, so they’ve spent plenty of time in doctors’ offices and pharmacies. Before he began working for Minnesota Medical Solutions, Huynh was a pharmacy manager at a busy local pain clinic. Pain patients trying cannabis for the first time often end up in a Minnesota Medical Solutions dispensary — and they run into Huynh.
“I’ve had quite a few patients that I knew from my pain clinic pharmacy days come in here,” Huynh said. He’s not a celebrity or anything, but the experience demonstrates that the world of chronic pain is small; “They recognize me. They say, ‘Oh my gosh, Tom. Weren’t you at that pain clinic?’ And I’ll say, ‘Yeah. I was your pharmacist and I remember how I had to control your [opioid] prescription on a regular basis and you weren’t doing that great on it.’”
Huynh said that he’s seen many of his former pain clinic patients respond well to medical cannabis. So well, in fact, that he doesn’t always recognize them when they come in for a follow-up visit.
“I had a patient who came to his first appointment walking with a cane,” Huynh said. “I wasn’t sure if he could even make it across the lobby without assistance. About three or four weeks later, he came back for a consult and I didn’t recognize him.”
With the pain reduced, the patient was transformed, Huynh explained.
“When I finally realized who he was, I said, ‘You had a cane when I last saw you. You were in so much pain you could hardly walk.’ Now he was so much better that he was practically running into the room.”
In 2015, the Minnesota Legislature added intractable pain, or pain that is not treatable by traditional medical methods, to the list of conditions that qualify for medical cannabis.
In August 2016, patients certified by a registered clinician as having intractable pain became eligible to receive medical cannabis in the state. Since then, the number of Minnesotans using cannabis to treat their pain has been on the rise. Many use medical cannabis to treat end-of-life or cancer pain, but others use it for non life-limiting conditions, including migraines, endometriosis and a range of gastrointestinal disorders.
According to the Minnesota Department of Health, as of Dec. 31, 2018, 9,267 Minnesotans have been certified to use medical cannabis to treat their intractable pain. These people make up 64 percent of all patients registered in the state’s medical cannabis program.
Huynh said that his experience at the dispensary is in line with state statistics: People experiencing pain represent a majority of the patients he serves.
“On an average day,” he said, “about 70 percent of my daily new consults are for intractable pain.”
Huynh said he’s seen so many positive responses to medical cannabis for pain that he’d like to see practitioners offer the therapy to patients earlier in their treatment.
“Most patients, if it’s intractable pain, they’re here because it’s the last effort,” Huynh said. “I feel like that shouldn’t be the case. I feel like this should be first-line therapy. Right now most people are here because they’ve tried opiates, because they’re not working, because they are scared of developing an addiction and they want to try something else.”
Advocates see the steadily increasing interest in medical cannabis as a sign that many people who used to rely on opiate-based medications are now turning to a new, less addictive option to treat their pain.
But some members of the state’s addiction-treatment community express concern that the trend toward medical cannabis for pain relief is a step in the wrong direction. They worry that encouraging cannabis use, even for relief of pain, exploits a vulnerable population by offering easy access to a potentially addictive substance.
Marvin Seppala, chief medical officer for Hazelden Betty Ford Foundation, said that his organization does not encourage the use of medical cannabis for the relief of chronic or intractable pain. Anecdotal arguments in favor of this therapeutic approach are informative, he said, but they are not fully backed by medical research.
“As an organization we take a stance against the legalization of marijuana and cannabis,” Seppala said. “And because it is a potentially addictive substance, we don’t like the idea of people using medical cannabis for pain.”
Drew Horowitz, founder of Drew Horowitz and Associates, a St. Paul-based addiction treatment-and-recovery program, said that while he has reason to believe that cannabis may be helpful in treating some forms of pain, the potential for addiction, no matter how slight, leaves him conflicted about its use.
“Medical cannabis shouldn’t be the first alternative to manage pain,” Horowitz said. “It should be the third, fourth or fifth alternative. There are a lot of methods to apply first, which people don’t always want to try. They want the fastest option for pain relief, which is understandable.”
No matter how you look at it, marijuana is a mind-altering substance, Horowitz said. He is concerned that the excitement around legalization in the state means that people are forgetting about that reality.
“Marijuana shouldn’t be an immediate go-to for pain,” Horowitz said. “Anytime you put a mind- or mood-altering substance into your body you are at risk of altering your ability to function, and for a subset of people, over time you are at risk of becoming addicted.”
Cannabis proponents argue that the potential for cannabis addiction is low, especially when compared to opiate-based medications that are commonly used to treat pain. Joseph Westwater, an emergency medicine physician and CEO of Minnesota Medical Solutions, said that patients and practitioners should keep that in mind when they are considering options to treat pain.
“The addictive profile for cannabis is 9 to 11 percent of the general population,” Westwater said. “The withdrawal symptoms from cannabis are mild. You can’t overdose on it. The side effects are minimal.” These facts make cannabis a much better option for pain treatment than existing opiate-based medications, Westwater said. And in cases of severe pain, cannabis can safely be used in combination with opioids, helping patients reduce the amount of the drug they need to use to control their pain.
Medical cannabis ”is not the answer for everybody,” Westwater added. “I would never claim someone could just get by with cannabis for severe pain. But as an adjunct it allows people to minimize their use of other meds that may be effective for them.”
Seppala said it is important not to let societal enthusiasm about medical cannabis blind us to reality. While the percentage of people who may become addicted to marijuana sounds low in the scheme of things, the numbers still represent individuals who may one day struggle with addiction.
“That 8 to 10 percent of people who may become addicted tend to get ignored by the proponents of legalization,” Seppala said. And it’s not just the risk of addiction, he added: “Any problems with cannabis get ignored or neglected by that group.”
Westwater said that he thinks the benefits of medical cannabis for pain relief are too great to ignore.
“It’s pretty clear that patients get relief from their intractable pain in large numbers,” he said. “That was documented by the National Academy of Sciences in a report released in 2017. There is good evidence, maybe more than that, that medical cannabis truly works for pain.”
‘A lot of our patients are no longer on opiates at all’
Some medical professionals tout cannabis as a way to help people with chronic pain reduce — or even eliminate — their dependence on opioids and other potentially addictive medications.
Because it has been shown to reduce pain in many individuals, providers have tried using cannabis to taper patients off opioid-based drugs.
Through the supervised use of medical cannabis, “Many people find that they are able to reduce their reliance on opioids and benzodiazepines, and have a higher quality of life with less anxiety,” Westwater said. “We don’t say it works for everybody. We don’t say it is a miracle drug. But it has been quite helpful for many people.”
Huynh agrees. “It’s been amazing for some of our patients,” he said. “A lot are no longer on opiates at all, or if they are still on pain meds, they have greatly reduced the number they are taking, or reduced the number of times they are taking it in a day.”
That said, cannabis doesn’t always help everyone stop using other medications. “There is a small percentage that medical cannabis doesn’t help,” Huynh said. He and his colleagues understand that cannabis is not a miracle cure for everyone, so they always proceed with caution in cases when working with an individual who is attempting to taper.
“We never we never tell patients to stop opiates cold turkey,” he explained. “What if this doesn’t work for them? Then they are out high and dry.”
Seppala is suspect of claims that cannabis can help people end opioid addiction. “I haven’t seen proof of the ability of cannabis to provide a way to end opioid dependence for folks,” he said. “I’m not sure about that one.”
Could the current enthusiasm about medical cannabis as a cure-all be a health fad?
Westwater likes to step back and take what he sees as a rational approach.
“I don’t think it’s a fad,” he said, “but I’m old enough to realize that I don’t know enough to say for certain. If you go back 120 years, everybody thought cocaine was the answer for pain. If you go back how many years, morphine was the answer.” Westwater said that decades of medical experience have made him jaded enough to realize that the pendulum may one day swing in the other direction.
“We may go too far,” he continued, “but what convinces me that we might actually be heading in the right direction here is the drug’s safety profile. That’s the key of cannabis for pain. I haven’t seen anything better yet.”
A day in a dispensary
Minnesota Medical Solutions’ downtown Minneapolis dispensary mostly looks and feels like an ordinary doctor’s office, except for the fact that the door is locked, and visitors are buzzed in with a question: “Are you a registered patient?”
Only individuals listed on the state’s medical cannabis registry can visit the dispensary; once that hurdle is cleared, people are encouraged to make an appointment, but can also walk in, though they may have to wait for some time to see a pharmacist.
The dispensary is designed to feel like a typical medical clinic. There’s a sunny waiting room with chairs and slightly old magazines, and a play area with toys for children. There are no exam rooms, but there are two private consultation rooms where pharmacists like Huynh meet with patients to discuss their reasons for using medical cannabis, their medical history, their current medications and any concerns they may have about side effects.
On a recent weekday morning, the dispensary was quiet and calm, with steady trickle of patients being buzzed in and out. Settling into one of the consultation rooms, Huynh described a typical first visit.
“I talk to the patient about what their goals are, what they are looking to achieve,” he said. “I go through their medication list and see what it is that they are hoping to reduce and what they can tolerate. Some patients are very new to medical cannabis and marijuana in general. We have to make sure they understand THC and CBD and what each product can produce, whether it be side effects or positive effects.”
Minnesota Medical Solutions offers a variety of products to patients, including cannabis oils, tinctures, pre-filled vape pens, balms, capsules and bars that resemble deodorant sticks that can be rubbed into the skin. Huynh said he takes time to explain how each product works. The products are labeled by colors that signify strength and composition; Huynh and other pharmacists walk patients through the system and explain how the different delivery methods are used.
“During the consultation I get a feel for what the patient prefers,” Huynh said. “Some will say, adamantly, ‘Tom, I’m not going to vape. I have asthma. I have COPD. I used to be a smoker. I don’t want to get back into that.’ Some will say, ‘I’m not a capsule person.’ Some will say, ‘I want an oral solution or something fast, like a vape.’”
Huynh said that patients who came into the dispensary with one idea about the way they would like their cannabis delivered often leave with a variety of other options. He usually sends first-time patients home with a starter pack, which includes a range of products.
“I always say, ‘Be open-minded about it,’” he said. “’You should go home with multiple formulations because they all have their benefits.’”
Staff at Minnesota Medical Solutions explain to patients that it is OK to experiment with different formulations of their product because the side-effect profile for medical cannabis is low.
“If they are using THC specifically, some patients will describe dizziness, dry mouth, euphoria, sleepiness,” Huynh said. “That’s why some people take it for bedtime at night because they need sleep. Some people can get some nausea and vomiting, but that side effect is really rare. I always tell patients that medical cannabis is unlike other medications where the rules are hard and fast. You get more free rein with it.”
The safest way for patients to find the amount and kind of cannabis that works well for them is to experiment — with caution.
The guiding principle at the dispensary is “start low and go slow,” Huynh said.
After their first consultation, patients are expected to come back to the dispensary in a few weeks for a follow-up visit. Medical cannabis is not like other prescription medications, Westwater explains. It takes time to find out what formula and delivery method works best for each individual.
“It’s not a one-time, you’re in, you’re out deal. There’s a trial-and-error period. Everyone is different. Everyone’s endocannabinoid system is different. There is a little bit of self-directed trial and error until you get the best combination for you. Our pharmacists are there to help out.”
Huynh said he’s happy that he decided to work at the dispensary. The work feels more satisfying than his last job, where said he constantly had to monitor patients’ prescription levels and help them deal with the side taxing effects of their medications.
“The work environment here is quite rewarding,” Huynh said. “I’m constantly talking with patients and getting positive feedback about how medical cannabis has changed their life. And it’s especially satisfying that I can physically see the benefits from one person to the next.”