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Cannabis has been around as a medicine for centuries. Usually taken as an infusion, it has been used to treat a range of different problems. But it’s most common use is as a painkiller. This is not the same as the high created by the recreational form of the drug. The psychoactive chemicals come from a different part of the plant. In the West, cannabis arrived as a street drug and, once its qualities were recognized, illegal farms were set up to grow it. However, the strong Asian and African cultures for medicinal use was never completely ignored and, after some detailed research and a positive political campaign, sixteen US states have now legalized its use for medical purposes. This is controversial. The FDA warns the drug can be abused. Indeed, the recreational form is classified as a Schedule 1 drug. That’s the highest class, reflecting the perceived level of danger. So, even under medical supervision, the FDA does not permit the medical profession to use or recommend cannabis as a medicine. Nevertheless, seven states allow dispensaries to sell medical cannabis and collect sales tax. This generates several billion dollars in extra tax revenue at a time when the state deficits are growing.

At this point, we come to a grey area of policy and law. If you talk to the regulatory authorities and law enforcement agencies, cannabis remains a dangerous drug. Even though there are laws permitting its use by individual patients and caregivers, there’s considerable suspicion that morality and the law are being undermined. That said, states find their budgets under pressure and, when it comes to deciding priorities in enforcement, cannabis is low down on the list. The law enforcement agencies do not unnecessarily harass clinics and hospices where cannabis is routinely given to patients. We should also recognize an overall irony in all this. 

If you look at all the major drugs developed by the manufacturing industry, all the patents are or were held privately. The assumption has been that effective drugs can be exploited for profit by the large corporations. But, when it comes to medical cannabis, the federal government holds the patent. This has not prevented the for-profit sector trying to produce individual drugs based on cannabis. Indeed, in some countries, synthetic cannabinoids are available on prescription. So far, there are no signs the FDA will approve any of these drugs for distribution in the US. In the UK, for example, there’s a new spray being made available for pain relief. There’s no high associated with its use. It works by numbing the muscles and it’s being prescribed for use in treating multiple sclerosis and will soon be available in hospitals for end-of-life treatment in cancer wards. 

It’s fascinating to see a natural product slowly being accepted as medicinal despite the capacity to derive recreational versions. In a way, this is the same process Tramadol had to go through. No one wanted to create yet another addictive derivative from the poppy so, as a synthetic, Tramadol had to prove itself effective and not seriously addictive. Fortunately, prejudices were overcome and the drug is now the world’s top selling brand for pain relief. It will be interesting to see whether cannabis and its medicinal derivatives can also be accepted. 

The Institute of Medicine stands outside the government, offering independent advice to both the decision-makers in government and the public. As a nonprofit, its mission is to improve the quality of the healthcare services by providing detailed policy suggestions based on the best available evidence. This July, it published a highly critical report on the continuing refusal of the medical profession to accept comparative effectiveness research. This is work to discover which treatments are the most effective. At present, we are left to guess which treatments offer the best outcomes for each illness or disorder with little effort made to collect evidence on safety and quality. Hence, at one end of the scale, we can go years without knowing a particular drug or surgical procedure is ineffective. Or we can find ourselves participating in unofficial trials where doctors talk patients into off-label experiments with drugs.

Unfortunately, this is all part of the general lack of accountability within the healthcare services. The present culture allows the pharmaceutical industry and the doctors to dictate the treatment standards based on what generates the most profit for them. The idea such people would actively seek evidence to show whether their cherished treatments were medically effective is a nonstarter. There’s no willingness to engineer a learning environment where everyone tries to improve. Rather everyone wants to avoid any liability for errors of judgement and mistakes. Imagine the litigation if it emerged that doctors had for years been advising we agree to ineffective treatments.

Until there’s a major change in the culture, we will have to look with envy at the approach of the Europeans in the pain management field. As a symptom of our problems, the words “pain management clinic” in Florida and certain other states usually indicates a borderline illegal operation to sell pills. We should modify all aspects of the current service. The first reforms should affect the health insurance industry and the public bodies like Medicaid and Medicare. At present, these administrators and business people simply pay out on the bills submitted by the hospitals, clinics and doctors. Since the taxpayers fund the entitlement systems and the rest of us with money pay ever higher premiums, there’s no pressure on insurers to demand value for money. They are not there to guarantee good quality care for their insured. All they do is pay out on the bills and pocket the rest as profit.

At present, it suits everyone concerned with pain management to do as little as possible. That means the shortest possible consultations followed by the prescription of one of the standard drugs, the most effective being Tramadol. This gives everyone in the healthcare services industry the maximum possible profit with the least possible effort. If they were to adopt the European model of one-to-one treatment by physical therapists, cognitive behavioral therapists, and so on, the labor costs would rocket and profit would decline. So there’s no chance of a team-based, patient-centric approach in our great nation. Further, any evidence that might show the European approach to be more effective in medical terms must be suppressed. Everything possible must be done to reinforce the current practice standards. That means you take another Tramadol and accept second best.

Unlike Hollywood and the science fiction writers who invented telepathy years ago, real humans can’t tell what each other are thinking or feeling. So, at one end of the scale, this limits the experience of sex to whatever is going on in our own heads. At the other end of the scale, doctors have no way of knowing exactly how much pain is being experienced by their patients. All they can do is ask. But asking is where the real problems begin. As we grow up, we learn all about pain when we fall over or bump into furniture. Our parents and anyone else around us show us how we are supposed to respond. Boys may be encouraged to get up and fall over again. Girls may be cuddled until they stop crying. Stereotypes can be reinforced from the earliest of ages. So when we are all grown up, how do we react to pain? As men do we smile as if nothing has happened? If asked, do we deny feeling anything? As women, do we immediately admit pain, possibly shedding tears to prove the point? We may all have our own scale from 1 to 10 where ten is the worst pain we have ever felt. But how does that scale compare to your scale? If I say the level of pain I feel is a 5, is that a 3 or maybe even a 7 for you? So what dose of painkillers is the “right” dose? Well, modern technology is trying to produce a more scientific way of measuring pain using brain scans. If this research is a success, it should reduce overprescribing potentially addictive opiate drugs.

Although there are nerve endings all over the body, all the messages signaling pain are processed in the brain. That’s why painkillers target the neurotransmitters and block the messages before they reach the conscious levels of the brain. There’s a new technique using an MRI scan. It’s called arterial spin and it seems to show changes in brain activity associated with pain. Now comes the difficult part. The brain is like a computer with massive processing power and memory storage capacity. Scientists know roughly where different functions are carried out, but the effective use of this technology requires a precise map showing exactly which parts of the brain deal with pain messages from different parts of the body. So far, the researchers think they have found the bit that registers lower back pain. In a study involving 32 people, half of whom had chronic lower back pain, the participants were asked to move in the same way or were subjected to heat. The patients then assessed how much pain they felt and these subjective findings were matched to their brain scans. The results are encouraging and may lead to the development of a more objective method of measuring pain.

Future tests are being planned before and after treatment. So, for example, patients will be assessed before and after taking the Tramadol dosage suggested by the subjective reports of pain and body weight. If the level of blood flow and neuron activity changes as predicted, this will allow doctors to give individual dosages rather than dosages based on averages. Tramadol is a great drug so it’s only right you should get it in the best dosage.

In theory, everyone is the same except, obviously, they are not. Let’s start with age. Seniors may be physically active but, look inside, and you will find their liver and kidneys are not working as well as in days gone by. This means it takes longer for impurities to be filtered out of the blood. For these purposes, drugs are impurities. So, when an older person takes any medication, it’s processed through the stomach into the bloodstream and then circulates for longer. This means an older patient must either take a smaller dose or the time between doses must be longer. If such simple steps are not taken, it’s easy for older people to have peaks of drug concentration close to overdose levels. Adverse side effects are more common.

At the other end of the age scale, most drugs are not tested on children and young adults. It’s not considered ethical to expose underdeveloped human bodies to the risk of injury unless there’s a clearly identified need. As a result, doctors are often left guessing whether to risk prescribing drugs and opting for the lowest possible doses. Now we come to the politically incorrect question of body weight. Without getting into the speed of your body’s metabolism, thin people should receive smaller dose than those carrying more weight. Doctors often use a formula relating grams to pounds of weight.

A further difficulty is that pain is very subjective. Some people seem to be able to accept levels of discomfort that would have others rolling on the floor in agony. This is partly physical and partly psychological. As we grow up, we learn from our parents and peers how we are supposed to react when injured. Boys are supposed to be tough. It’s OK for girls to cry. Stereotypes are difficult to shake. This makes it very difficult to assess how much pain anyone is feeling. All a doctor can do is ask and try to place the answer on a scale of 1 to 10 where 10 is the worst pain imaginable. The louder the complaint, the higher the dose or the stronger the drug. For the doctor, it’s all trial and error until the patient admits to feeling less pain. Against this background, it’s interesting to see some new research into using a new technique on an MRI scanner to measure pain. Arterial spin seems to show changes in the parts of the brain associated with pain. If this research can map the brain to show more precisely which part of the brain to monitor, it may be possible to produce a more objective method for measuring pain.

This would have immediate benefits for the patient, always giving the right dose. It would also be good for society because it would reduce the risk of drug abuse. As it is, patients who are developing a dependence can exaggerate their reports of pain and get additional tablets to feed their habit. This is less of a problem for drugs like Tramadol which are significantly less addictive than the opiates. But even Tramadol can be abused if people take it for too long at too high a dosage. No matter what the diagnosis, it’s always better to have the right dosage for your age and physical size.

The European approach to pain management depends on a formalized team approach. It’s never assumed one person knows enough to guarantee the right answer for every patient every time. This more open-minded approach makes the patient the focus of interest. If the patient has been complaining of pain and there’s no clear explanation for its cause or the most obvious treatments have already been tried without success, pain specialists will be called in.

The new team then reviews the diagnosis and treatment to date. This is not to find fault or blame anyone for past failures. Everyone wants to learn and avoid repeating mistakes. So the fresh pairs of eyes start again, question the initial assumptions, and look for alternate explanations for the current problems. If further tests will help this differential diagnosis, they are done. This may include further surgical procedures to collect biopsies or a wider range of scans to look for possible causes. Only when the team is satisfied all treatment options for the underlying causes have been exhausted, do they move on to a formal pain management strategy. In other words, they first try for a full cure and, only if that proves impossible, do they accept the pain as a permanent feature of the patient’s life and begin the process of managing that pain.

The team now excludes the physical specialists and brings in specialists in psychiatry, physical therapy, counseling, and Cognitive Behavioral Therapy (CBT). This recognizes the real nature of the problem. The patient must accept the reality of long-term pain. Without the guidance of a psychiatrist and the allied counselors and therapists, the prospect of persistent pain would be a source of depression. If you are the patient, you must be shown how to have a more positive view of life. This is not just theoretical. It starts with the physical limitations affecting life and plans how to cope more effectively. In the home, there may be a need to redesign the use of space to make it easier to move around and get things done. In the workplace, it’s often helpful to look at how the work is done and suggest new ways in which the tasks can be performed. Most employers are sympathetic so long as the smooth flow of work is not disturbed for one person. Now come the physical therapists. If you have lost muscle tone or should develop more strength in some movements, they will design a specific exercise program for you to follow. It’s often challenging to maintain commitment to these exercise routines but, if you are to make the best of your life with the new physical limits, you should stay positive and keep working. In most cases, patients report a real improvement in the quality of life.

This marks the difference with our experience with doctors, clinics and hospitals. No one has any time to sit down and talk with us about our problems. Everyone is on the clock to see a given number of patients in the hour. So we go in, we pick up out prescription for Tramadol and go home. It’s a tragedy. Although Tramadol is an excellent painkiller, there’s so much more that can be done, but we are denied access to any of it.