Dr Sunny Nayee Answers Patient Questions – Part 2
After a successful live session hosted on the 18th of March, we carry on looking at what Dr Sunny Nayee, Pain Consultant and Medical Director of TMCC had to say in response to some patient questions:
Can you give us an overview on how cannabis works to relieve pain versus opiates such as codeine?
OK, so one of the big problems in the UK, and certainly in the US, is this opioid epidemic. Part of the reluctance of some doctors to get involved in medical cannabis is the fact that they are a bit concerned that the opioid epidemic may end up being replaced with cannabis. The fact is, medical cannabis opens the door to two main types of cannabis receptors, CB1 and CB2. Essentially, a lot of the CB1 receptors are in the central part of your brain, and there’s also a place in the spine where the nerves from across your body to your arms and legs meet that has a high concentration of CB1 receptors, then there’s then the bigger nerve areas that I’m more distanced from which have the CB2 receptors.
So, medical cannabis can be split into two main components, CBD and THC. THC is mostly involved in modulating and affecting the CB1 receptors, with CBD then being the antagonist or whatnot. So, when compared to opioids, of which there are a lot of receptors out there, I believe that there’s evidence that the rate of things like addiction is higher with stronger opioids – even just after five days of using them. I think that’s awful, and cannabis isn’t necessarily a wonder drug in comparison but it has a much lower addictive effect if used effectively and safely.
When will medical cannabis be available on the NHS?
OK, this is a tough question that I get a lot of people asking me. The NHS, as you’re aware, provides care for points of needs – all treatments on the NHS have to be approved by NICE, which had its big review in 2018, in which it was not recommended to pay for medical cannabis. The two main things that it looks into is cost effectiveness and clinical effectiveness, and one of the main criticisms that NICE came up with against medical cannabis was that the studies and scientific data couldn’t convince them that it has a strong role for pain medicine.
Now, in terms of the evidence, I believe they failed to look at gold standard evidence or a randomised controlled trial. This would essentially involve a patient having an active drug as ‘Pill A’, and then ‘Pill B’ as a placebo. The problem is, it’s inherently impossible to do that in medical cannabis, partly because cannabis itself isn’t a drug talked about for CBD and THC, but also because there are lots of other properties or chemicals in cannabis, such as terpenes, flavonoids and cannabinoids. These all have different functions, and different effects on various different patients. When there are hundreds of drugs for a particular condition, you can see how a scientific like this would be hard to do.
In terms of if it will ever be available on the NHS, we’re looking to gather data from across the world – specifically with studies from Australia or Canada, and as time progresses there’ll hopefully be more data that we can pull to support it. Just this morning, the International Pain Society came up with another statement saying that they’ve looked at all the evidence and that they can’t make their mind up. However, when I’ve gone in and looked at some data, they’re looking at how medical cannabis can affect rats and their nerves and have looked into CBD and THC concentrations for how their behaviour changes and that’s not really applicable. I would say that real life data is key here, and I think that’s where 2021 in the UK will be strong, because we can create evidence based on real life with how our patients’ lives are being changed.
When will other strains be available?
I think this goes back to the fact that medical cannabis is still in its infancy. When I started seeing patients early last year, there were only a few oils, perhaps one or two flowers available for prescription in the UK. There’s been exponential growth between now and then, so I think there will be more and more strains becoming available on the market as more and more patients become involved in medical cannabis. It just takes time, especially with there being various regulatory terms that the pharmacy has to deal with when getting medication out to our patients.
Every few months, I’ve seen novel products and new formulations coming out and, certainly, I think that’s something that will be very important in reducing the stigma around using this medication. For example, there’s been companies who are thinking about bringing in wafers to the UK, which I think would create a smell that’s far more acceptable to an employer or a housemate. I’m quite confident that everyone in the wider medicinal cannabis industry is looking at different formulations and different products to make available, so more strains will become available as that happens.
Is there more that patients can do to substantiate the benefits of medical cannabis?
I think I’d encourage patients to complete their feedback forms. Patients, such as those on Project 21, have to fill in quite extensive questionnaires for the database. If these are filled out and feedback is given to your doctor, they can then see what’s working and what’s not working and use this for their scientific data. We then would get what you call a positive bias, showing that medical cannabis is really helping someone with their quality of life or reducing their pain, or helping their anxiety and depression. These patients quite often will come back and see their doctor to validate their own experience, but with more private medicine that’s more unusual in the UK, at least for the vast majority, this doesn’t tend to happen so much and could be the death of medical cannabis if it’s not shown to be helpful for the patient.
We look out for the patients who don’t come back for repeat prescriptions because it’s sometimes just as helpful and valuable to see that things aren’t working, so we can make sure we’re informed on both sides of the argument.
What are the best topical cannabis products and how can they compliment cannabis oil medication?
There are a lot of topical preparations out there for medical cannabis and, on the whole, the concept of there being different preparations is to try and avoid what we call the metabolism effect. If you eat cannabis, and it’s not being prepared in the correct way and then, unfortunately, your gut will absorb the supply and it then goes into your liver and eliminates most of the goodness from its work. This is why we have root suction, and the sublingual oil that goes under the tongue. Other countries have patches, or suppositories, that try to avoid this situation. I don’t know whether suppositories will be available on our market anytime soon, it’s certainly a very ‘watch this space’ topic.
What do you think the pros and cons are of telemedicine?
So, as some of you may know, we have rooms in Harley Street that we’ve operated out of. When the pandemic struck last year, we sought the CDC approval to do our consultations virtually. There are pros and cons to this, as it’s great to see people face to face but it’s also taking away the length of our patients having to travel into Central London. With a lot of our patients being disabled, I think they found it hard to navigate the building we have. So, in my opinion, there are some advantages to telemedicine – another one being that it’s good to see people in their own environments. This can be good for their anxiety, especially when they have family members with them. I think, as a doctor, it also gives a lot of insight into how patients live their real lives. I remember this one patient had lots of cats everywhere, which was quite amusing to see.
In this pandemic, telemedicine became a bit more prevailing, especially in my NHS practice where we’re still using it for follow up appointments. It’s changed things in terms of how medicinal care will work moving forwards, as I think patients should now be given a choice in terms of whether they want to come and see a doctor or talk remotely post lockdown. There’s definitely going to be more of a demand for people to get to wherever easier for them, and I think there will be people that prefer one side and people that would prefer the other – and we’ll do our best to accommodate both.
Is medical cannabis effective for treating lupus?
Lupus is an anti-inflammatory disease and we know that cannabis, particularly CBD, has an inflammatory role. When you have inflammatory conditions, I believe that cannabis can be very helpful to treat them. When it comes to evidence, it’s hard to say that there’s clear cut evidence but it’s definitely something that should be considered as a treatment. If you discuss the option with your rheumatologist, and we have rheumatologists working with TMCC if you don’t have one who would be more than happy to talk to you, they can then go through any particular concerns that you may have.
We hope that this session was beneficial to all that attended and hope to host more like it soon, but if you do have any other questions you’d like to ask in the meantime then please do get in contact and we’ll do our best to answer them. As Dr Sunny said himself:
“It’s an absolute pleasure dealing with the patients I see through TMCC. I think a lot of doctors that are involved in medical cannabis do it because they like to see the good feedback, so I just want to say thank you. Thank you for choosing us and for giving us this response. It’s important that you keep letting your doctors know how you’re doing, be it good or bad – I do tell my patients that medicinal cannabis isn’t a magic wand, it’s not a cure for all ills so please do let us know if it’s working or not working. We will always do our very best to help you.”