Dr. Michelle Weiner, DO, MPH

Dr. Michelle Weiner, DO, MPH

Dr. Michelle Weiner, is an Interventional Pain Management Physician board certified in Physical Medicine and Rehabilitation. She completed her residency and fellowship training at the University of Miami. Her specialty is focused on prevention, treatment, reversal of health deterioration, increasing function and managing pain. Dr. Weiner focuses on diagnosing and treating spine and musculoskeletal pain as well as chronic migraines at the Spine and Wellness Centers of America

Addictions and Cannabis

More than 23 million Americans age twelve and older are affected by substance abuse or dependence—that’s nearly one in ten Americans. Smoking is the number-one preventable cause of death. Alcohol abuse is the seventh most common preventable cause of death. About 62 percent of high-earning individuals in the U.S. work more than fifty hours a week, which is the criteria for addiction to work, 35 percent work more than sixty hours, and 10 percent work more than eighty hours.

Americans over-65 only account for 14 percent of the nation’s population, but they use more than 30 percent of all prescription drugs. Medicare saved more than $165 million in 2013 on prescription drugs in D.C. and 17 states that allowed cannabis to be used as medicine. If every state in the nation legalized medical marijuana, would save more than $468 million per year on pharmaceuticals for disabled Americans and those 65 and older. 

The Substitution effect using cannabis to treat pain, anxiety, depression has shown a 16% decrease in benzodiazepines, 12% decrease in antidepressants and 12% replaces cigarettes with cannabis. Cannabis is a potential treatment for opioid withdrawal. In 2015, a Canadian survey using 473 cannabis patients found more than 80% using cannabis substituted it for a prescription drug and has less risk of dependence. The International Journal of Drug policy stated 30% use marijuana as a substitute for opioids. Cannabis augments analgesic effect of opioids and widens the therapeutic window when used together. This combination may allow for opioid treatment at lower doses with fewer side effects (Powell, 2015). 

Donald Abrams treated 21 patients in a hospital setting using high doses opioids for chronic pain. He received cannabis from NIDA (3.56%). The patients vaporized cannabis three times per day and pain decreased by 27%. The Hebrew University, in 2016 found that cannabis is effective for treating chronic pain. They studied 176 participants, who had been previously unresponsive to conventional medicines and treatments, who inhaled a monthly amount of 20 grams of cannabis for six-months. Sixty six percent experienced improvement in their pain symptom scores after cannabis therapy, and most reported “robust” improvements in quality of life.’ Patients also reduced their consumption of opioids by 44 percent! Univ of Michigan studied 185 chronic pain patients and discovered a 64% reduction in opioid use after increasing their cannabis consumption. Patients also reported a 45% improvement in quality of life since using cannabis. A study published in the international Journal of Drug Policy from researchers at FIU found people are less likely to turn to opioids for pain relief in medical marijuana legal states.

Substance abuse treatments like suboxone and methadone exist however these options are more addictive. Cannabis can minimize withdrawal symptoms, reduce anxiety, agitation, improves sleep, normalize digestive tract, spasms, and sweating. When using cannabis with naltrexone for heroin addiction or cocaine addiction a higher treatment retention was seen. Cannabis prevents opioid tolerance and need for dose escalation.  

Scientists in China used a synthetic CBD, called JWH-133, to see how mice given regular doses of cocaine might respond. Cannabidiol (CBD), turns down a receptor in brain that is stimulated by cocaine (July 2011 Nature Neuroscience). Mice dramatically reduced their IV cocaine intake (60%) after given JWH-133. This would lead to new drug replacement therapies for cocaine addicts. Further evidence that marijuana is an “exit” drug, and anti-addiction therapy.    

Illicit cannabis use has been shown to cause dependence, but it is likely that appropriate medical use does not carry the same risk.  The Cannabis addiction rate is nine percent which is overinflated as this number stems from the alternative being incarceration as well as the fact most are self-medicating and the desire to continue treatment partly due to the increase in dopamine, desire and outcome. Cannabis use can also cause withdrawal symptoms when abruptly stopped. These symptoms emerge 1-2 days after cannabis cessation and resolve in 1-2 weeks.  Most patients compare the severity of cannabis withdrawal to caffeine withdrawal.

Harm reduction offers safer options. The success rate of rehabilitation is 30%.  A treatment center in California uses marijuana as a substitute for more potent dangerous drugs. This has shown to decrease relapse and readmissions and offers a sense of emotional control.

We are facing an opioid crisis, non-opioid alternatives are minimally effective adjuncts for chronic pain, no data supports safety or efficacy of long-term opioids for chronic noncancer pain and millions of people around the world are using cannabis for pain which is the top indication for cannabis usage.  CB1 receptors in the limbic system are responsible for the affective elements of pain perception helping bring the mind into the body. In 2017 the National Academics of Sciences, Engineering, and Medicine reported that there’s substantial evidence that cannabis is an effective treatment for chronic pain in adults.

For those concerned about the growing prevalence of mental illness, including addiction, as well as its associated human, social and economic costs, plant based and alternative options exist. Ongoing research and clinical trials are taking place with a number of psychedelic drugs and cannabis; perhaps the future of medicine. For example, In the past decade there’s been a renewed interest in “psychedelic medicine,” including MDMA, psilocybin and LSD especially at it relates to treatment-resistant forms of addiction, anxiety, post-traumatic stress-disorder (PTSD) and depression. The U.S. Food and Drug Administration (FDA) continues to approve studies and, in some cases, new drugs like Spravato, a ketamine like nasal spray for treatment-resistant depression. These options may be able to help with our opioid epidemic while treating chronic pain, depression, PTSD, addiction and helping us return to balance.

Dr. Michelle Weiner, is an Interventional Pain Management Physician board certified in Physical Medicine and Rehabilitation. She completed her residency and fellowship training at the University of Miami. Her specialty is focused on prevention, treatment, reversal of health deterioration, increasing function and managing pain. Dr. Weiner focuses on diagnosing and treating spine and musculoskeletal pain as well as chronic migraines.

SPINE AND WELLNESS CENTERS OF AMERICA

Original Article: HighLife Magazine

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Virtual Reality Effects on Pain Perception: Implications for Pain Management

Current Status: Pending

Literature suggests that the use of virtual reality distraction for adjunctive pain control has been successful. In clinical settings and experimental studies, participants immersed in a virtual reality experienced reduced levels of pain, general distress/unpleasantness and reported a desire to use virtual reality again during painful medical procedures.

There has been research into the use of virtual reality distraction for adjunctive pain control with significant success. There has been growing evidence for the use of EEG for the measurement of pain. It has also been suggested that virtual reality could be used an alternative to marijuana and opioids for pain management. Further implications have been seen specifically among chronic pain sufferers. This is especially interesting since there is a reduced risk of addiction as is seen associated with marijuana and opioid use. This study aims to investigate the effect of virtual reality distraction on pain perception.

Additionally, we intend to create a body of open source content for potential use by other investigators utilizing similar tools. 

The intervention has the potential to relieve chronic pain sufferers of their pain with a non-invasive mechanism and minimal risk. The participants may experience a temporary decrease in the perception of pain during the course of the experiment or a distraction from said pain.

Pending IRB approval at UM

Seniors Over 60 With Chronic Pain Using Medical Marijuana

Current Status: Active

 

The purpose of this study is to identify what is effective and safe for older adults with chronic pain to develop an understanding of what educational materials are required for facilitate access to appropriate products at medical marijuana treatment centers (MMTC). 

Survey older adults (> 50 years) with chronic pain who have MM access cards and receive their product from state-approved dispensaries to document: demographic/health data; patterns of use; product specifics; pain effects on daily life; pain-related medical conditions; education prior to MM purchase; helpful and problematic effects of MM use. 

The proportion of Florida’s population that is 60 and older is growing more rapidly than other components of the population. Musculoskeletal disorders with associated chronic pain are a common problem in later life. Symptom management in older adults, including chronic pain management can be challenging (Briscoe, 2018). Medications, especially opioids, can increase the risk of confusion, constipation, falls and injury (Briscoe,2018). Medical marijuana (MM) is often recommended by doctors in the treatment of these medical conditions, guided by state law that defines qualifying conditions.

Medical marijuana use among older adults is growing at a rate more rapid than younger age groups (Lum, et al, 2019). The 2016 National Survey on Drug Use and Health estimated a 2.9% prevalence of marijuana use among this older population. However, the survey did not ascertain if use was for medical or recreational purposes (Han et al., 2016). Older adults may have important differences in pathophysiology, pharmacological interaction of medications, comorbid conditions, and toxicological responses to cannabis.

There is little evidence to evaluate the differences associated with medical marijuana use among older adults, such as individual reasons for use and problems arising with use (Haug et al., 2017).

Chronic pain is a major public health problem. Approximately 178 million (41%) adults in the U.S. age 18 and older suffer from at least one painful health condition (Nahin, et al, 2019).

In Florida, there are 327,492 medical marijuana card holders and chronic non-malignant pain was the No. 1 diagnosis for which patients are registered (The Florida Department of Health, Office of Medical Marijuana Use, 2020). Yet, it is not a qualifying condition, creating challenges for physicians wishing to support patient use of MM for chronic pain.

Chronic pain accounted for nearly 34 percent of diagnoses at certified dispensaries (The Florida Department of Health, Office of Medical Marijuana Use, 2019).