"With cannabis we still have a rabbit in our hat"

Christiane Fux studied journalism and psychology in Hamburg. The experienced medical editor has been writing magazine articles, news and factual texts on all conceivable health topics since 2001. In addition to her work for, Christiane Fux is also active in prose. Her first crime novel was published in 2012, and she also writes, designs and publishes her own crime plays.

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Pain, intestinal inflammation, nausea, cancer: cannabis has an amazingly diverse effect. Pain specialist Prof. Sven Gottschling explains in a NetDoctor conversation why it is the way he uses the drug and why applying for therapy is still so laborious.

Prof. Dr. med. Sven Gottschling

The head physician at the Center for Palliative Medicine and Pediatric Pain Therapy at the Saarland University Hospital has already written several books on the subjects of palliative medicine and dying as well as pain therapy.

Prof. Gottschling, in your book “Who heals is right”, you provide impressive examples of patients whom you have been able to help with cannabis - and indeed with very different diseases. Is cannabis - or more precisely - its active ingredients, the cannabinoids, a kind of all-purpose miracle weapon?

Cannabinoids are not miracle drugs either. When the rainbow press reports about the incredible effects and insane effects of cannabis-based medicine, it is usually very exaggerated. However, it is correct: cannabis can actually help in many desperate cases in which we cannot make any progress with traditional therapies.

With the cannabinoids you have another completely new treatment option.

That's the way it is. In a sense, we're pulling a rabbit out of our hat! In this case, the placebo effect certainly also supports the effect, the hope that it will finally get better with a new approach.

When do you use cannabinoids?

In the beginning we mainly used cannabis as a reserve drug for cancer patients - if they suffered from severe nausea after chemotherapy or to stimulate appetite in the case of cachexia.

This is extreme, disease-related weight loss.

Right. Gradually, more and more indications have been added. For example, severe chronic pain, especially nerve pain, which is otherwise difficult to treat. Other possible uses are Tourette, arthritis, severe spasticity, for example in multiple sclerosis, but also severe cases of chronic intestinal inflammation. And of course in palliative medicine. Cannabis can do a lot of good here.

How can it be that a single active ingredient is effective against such different ailments?

That actually seems strange at first. But cannabis docks with receptors that are located in practically all body tissues - including the brain. That explains why the effect is so diverse. And it acts on receptor systems in the body that are not controlled by any other active ingredient.

This explains why cannabis helps when other drugs fail.

There is even a decisive advantage: Kindly, the respiratory and cardiovascular centers in particular have no cannabinoid receptors. This means that an overdose does not become life-threatening as quickly as can be the case with other drugs used in pain medicine. In fact, there is not a single documented death from medical cannabinoids in the world. That is a very safe class of substances.

One often reads that cannabis is also said to be effective against cancer. Is that true?

We still have to be careful! But yes, in fact, recent studies provide evidence that cannabis may have anti-tumor effects. And there are already ideas about how that works. One example is that cannabis supports the apoptosis of cancer cells. A program is started in the tumor cell that causes it to perish.

Other studies suggest that cannabinoids could potentiate the effects of cancer therapies.

That's the way it is. Cannabinoids can apparently affect so-called tumor escape phenomena. Some tumor cells simply pump the chemotherapy drugs that are supposed to kill them out of the cell interior. Cannabis can stop that, researchers have observed. At the moment, however, we have to say: We need more clinical studies, but the findings are pointing in the same direction.

Do you feel stoned all the time during the treatment?

No, we pay attention to that. We almost exclusively use drops or tablets. This enables us to achieve an even active ingredient level of around 10 nanograms per milliliter of THC in the blood, which is completely sufficient for the effect we want to achieve. But it is far below the so-called psychotropic level, so it does not trigger any intoxication.

That means, one cannot become psychologically dependent either.

Right, the psychological addiction that cannabis can cause is void at these doses. Nothing happens there. That’s why the drugs are not on the black market: everyone knows they’re not going to crack. Then nobody wants to buy them either.

What if you smoke medicinal cannabis in the form of flowers?

When used by inhalation, I achieve peak values ​​of 150 to 180 nanograms per milliliter in the blood plasma. It's really fun in the head. That is exactly what the recreational consumer is aiming for. But that is ultimately what can trigger the psychological dependency phenomena.

In spite of this, inhalation therapy is also used medically.

At least from my point of view, there are only isolated cases in which flower therapy can be medically useful. For example, if someone suffers from the worst spasticity that can shoot up very quickly. He then benefits from the rapid surge of effect. This takes longer with capsules or drops. Most patients get along with them just fine.

For which patients is cannabis unsuitable?

Of course, there are also contraindications. Cannabis is taboo during pregnancy and breastfeeding because deformities in the child are then possible. Even if a patient has already suffered from psychosis or has a family history of schizophrenia, one should be extremely cautious about it.

As a pediatric palliative medicine specialist, you also treat children and adolescents with cannabis. Is it risky?

Up to young adulthood you have to be extremely careful and knowledgeable about cannabis. At this age, brain development is not yet complete. You can possibly cause real damage with cannabinoid therapy that has not been used carefully and knowledgeably: cognitive disorders, learning difficulties, listlessness, for example. In addition, the risk of psychosis increases.

And all of this despite the low drug levels?

In fact, we only know of such long-term effects from examples when cannabis was abusively consumed in leisure time. We assume that this is related to these high active substance peaks in the blood. So far, none of this is known in the low-dose area of ​​medical application.

But it cannot be ruled out either.

No, that cannot be ruled out entirely. Nevertheless, I find the demand “just don't give it to children!” Exaggerated. I have treated hundreds of children over the years, even over several years or even decades. I simply don't see the negative effects of a low, sensibly medically controlled dose.

So: smoking weed, no - treating illnesses, yes?

At least that's true for younger people. If you smoke weed at the age of 15, the risk of creating a problem in your brain is high. Certainly, cannabis shouldn't be a fashion drug for every youngster dealing with a bit of ADHD and the occasional back pain. For seriously ill patients, however, cannabis can be of great help - even if they are still very young.

What do you think of a general legalization of cannabis?

As I said: cannabis can have significant long-term consequences with high active ingredient peaks. Therefore, I am not in favor of the demand for full legalization. Of course you can go and say: "Alcohol is much more dangerous!" Of course that's true. But the mere fact that we have even more dangerous substances available for sale cannot be the reason for making other potentially risky substances freely available. Most people just have little plans for what they might do with it.

Since 2017, cannabis can be prescribed by doctors of all specialties. A special permit is no longer necessary. Nevertheless, there is a problem in practice.

In fact, 40 percent of all applications are rejected, although according to the law this should only be possible in justified individual cases. This is a huge problem! The health insurance companies defend themselves with all means. For example, the doctors receive pages of questionnaires. The health insurers are very successful with this strategy of denial: Doctors who only try it once or twice are then sufficiently deterred. They say to themselves: "I'll never do that to myself again."

Why does it work like that? Are the drugs that expensive?

We're talking about monthly therapy costs between 300 and 1500 euros a month, that's a number. Compared to the total drug costs for the insured, these are absolute peanuts.

Why are the health insurances behaving so rebelliously?

The problem is: a precedent has been set here. For the first time, politicians have forced the health insurances by law to have to pay for a drug for which there is neither an approval status nor an indication restriction. The doctor can prescribe this as he likes. It is understandable that this is a perceived dam break, a horror scenario. Because they no longer have the opportunity to regulate.

Cannabis on prescription - the prerequisites

Since 2017, cannabis in the form of flowers, extracts and medicinal products with artificial cannabinoids can be prescribed by general practitioners and specialists using narcotics prescriptions. Approval from the health insurance company is required for the first prescription. The prerequisite for approval is that the patient suffers from a serious illness for the treatment of which no recognized medical therapy is available or, in the opinion of the doctor, the patient benefits particularly from the cannabis treatment. In addition, there must be a prospect of a timely, noticeable positive effect on the course of the disease or on serious symptoms.

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