IJMSC Insights: Drs Rainka, Aladeen, and Mattle on Medical Cannabis and MS

Michelle Rainka, PharmD, BCPP, CCRP

Image credit: Dent Neurologic Institute

It came as no surprise that an article on medical cannabis (MC) in the May/June 2023 issue of the International Journal of Multiple Sclerosis Care attracted a lot of attention. “Multiple Sclerosis and the Use of Medical Cannabis: A Retrospective Review of a Neurology Outpatient Population” suggests that MC may be a promising avenue for symptom management in individuals with multiple sclerosis (MS). Use of MC was effective in reducing pain, muscle spasticity, and sleep disturbances. The study also found it to be well tolerated by participants, many of whom were able to reduce their use of opioids while taking it. The authors underscored the need for further investigation into optimal dosing regimens and administration routes, along with the importance of individualized therapy plans. The paper also touches on the legal landscape of MC. While it is widely accessible in Canada and certain states in the United States, the US federal status and the evolving legal landscape across states underscore differences in access. As the debate surrounding the medical benefits of cannabis continues, legislative changes and evolving legal perspectives will continue to shape its availability for individuals with MS.

Traci Aladeen, PharmD, BCPP

Image credit: Dent Neurologic Institute

Michelle Rainka, PharmD, BCPP, CCRP; Traci Aladeen, Pharm D, BCCP; and Anna Mattle, PharmD, MS, are 3 of the paper’s authors. Dr Rainka teaches at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences and is a preceptor for pharmacy students from Albany College of Pharmacy and Health Sciences, D’Youville University School of Pharmacy, Lake Erie College of Osteopathic Medicine, and the University at Buffalo, as well as for pharmacy residents from the Buffalo Psychiatric Center. She has been an investigator on numerous clinical trials and sees patients for medication therapy management. Dr Aladeen specializes in medication therapy management for patients with psychiatric and neurological conditions and is actively engaged in phase II-IV multicenter clinical trials in psychiatry and neurology. She is also an instructor at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences. Dr Mattle coordinates and manages phase II-IV clinical trials, conducts comprehensive medication reviews, and leads investigator-initiated research. All 3 authors are neuropharmacologists with the DENT Neurologic Institute in Buffalo, New York, one of the largest outpatient neurology practices in the United States, which is invested in advancing patient care, research, and new medications. Drs Rainka, Aladeen, and Mattle joined IJMSC to talk about their research and MS care.

Anna Mattle, PharmD, MS

Image credit: Dent Neurologic Institute

IJMSC: Your article drew a lot of interest. Why do you think it was particularly appealing to multiple sclerosis (MS) clinicians?

Drs Rainka, Aladeen, and Mattle (RAM): We think this interest from clinicians is a reflection of the increasing interest that patients and the general public have [regarding] medical cannabis (MC) as a potential component of MS treatment. MS clinicians frequently get questions about MC, and it can be difficult to answer those questions due to the lack of published literature on this topic. We think clinicians are eager to learn more about what outcomes are being seen with MC treatment.

How does this paper impact clinical practice?

Clinicians may feel more comfortable recommending MC as an adjunctive treatment to appropriate patients based on our report, which showed that MC was generally well-tolerated (only 3% [of patients] discontinued [use of MC] due to adverse effects) and that most patients reported symptomatic benefit, particularly in terms of pain relief (72%), spasticity (48%), and [improved] sleep (40%). Additionally, the population of patients we studied were able to decrease their opioid pain medication use throughout the course of their medical cannabis treatment. In the context of the opioid epidemic, this finding is exciting; more research into MC and other potential alternatives to opioid pain medications is urgently needed.

What are the next steps for medical cannabis in MS care? What needs to be studied next? Are there aspects of the field that remain understudied? What about regulatory hurdles?

Because this is a retrospective study, it can’t answer all the questions we have about safety and effectiveness of MC in MS; for that, we need more prospective, randomized controlled trials (RCTs). Only a small number of RCTs have been conducted, and these trials have not assessed the variety of formulations and doses currently in use by patients enrolled in MC programs for MS treatment. We hope that our study can serve as a jumping-off point for further RCTs, providing direction as to which patients might benefit the most from MC, as well as which formulations and dosing strategies may be effective. Currently, the status of MC as a federal schedule I controlled substance that is not approved by the Food and Drug Administration for MS treatment limits its use in patients with MS and drastically restricts opportunities for controlled clinical trials.

What is the end goal of this research path? What’s your vision for the future?

Ideally, we would like to see legislation passed [that] would loosen restrictions on clinical research with MC. This would enable further exploration of the potential symptomatic benefits we saw in our study.

Can you give us the 10,000-foot view of how your research fits into the larger world of MS care?

With access to MC increasing in the United States, our research provides a look at how MC treatment in a “real-world” MS population is going so far. This study looked at MC as an adjunctive treatment, not a replacement for disease-modifying therapies (DMTs). Overall, adjunctive treatment with MC in our patients was well-tolerated, and most patients reported symptomatic benefits!

One of the pillars of IJMSC and CMSC is multidisciplinary care. As neuropharmacologists, what role do you see for yourselves on the MS care team? How can you influence/improve patient care?

Our neuropharmacology team serves a dual role of providing clinical pharmacy services and supporting research initiatives at our institution. Our research is focused on developing comprehensive, clinically relevant, and cost-effective solutions to complex neurological problems faced in our community. In the clinical realm, as specialized clinical pharmacists, we strengthen the treatment team by providing expertise in medication therapy to provide a holistic and integrative approach to wellness. This includes staying up-to-date on the latest scientific literature surrounding investigational, newly approved, and complementary and alternative medications. In neurology, clinical pharmacists can be particularly significant [members of the MS care team], as patients often present with highly complex health conditions and medication regimens.

How can neuropharmacologists and pharmacists guide individuals with MS through the process of developing a treatment plan?

Neuropharmacologists and clinical pharmacists can work directly with patients and providers to apply specialized knowledge of evidence-based use of medications. They can help patients understand their care plan and their medications, ensure their medication regimen is appropriate and optimal, identify and minimize [the adverse] effects [of] medications, and coordinate care with the rest of the treatment team. As MS care evolves with evermore complex therapies, roles for pharmacists and pharmacologists can only grow.

How can patients integrate medical cannabis into their treatment plans? How do you strike a balance between traditional MS DMTs and MC?

Currently, research primarily supports MC as an adjunctive or alternative treatment for MS, not a replacement for traditional DMTs. While disease-modifying effects of MC may be another area for future research, patients considering MC should understand that it may be a way to potentially augment their treatment plan for symptomatic benefit, [but] not [a replacement for] traditional treatments.

What role can clinicians play in addressing the stigma associated with medical cannabis?

We hope that clinicians will use the results of this study and others to enable effective conversations about MC with patients. Clinicians can familiarize themselves with current research and “stick to the facts” about what is known about MC, as they would any other treatment. Clinicians should also be prepared to discuss the differences between medical and recreational cannabis. Patients should understand that unlike recreational cannabis, MC treatment is carried out under supervision from a licensed treatment team, with careful monitoring of dosing, effectiveness, and adverse effects. Supporting MC research is also critical to addressing the stigma surrounding this treatment. Because this study largely gathered research from patients’ experiences with MC, we believe it highlights the importance of how clinicians continue to learn from their patients and the value of empathetic listening.