Cannabis and Multiple Sclerosis: Help Spasticity

Cannabis and Multiple Sclerosis: Help Spasticity!

One of the strongest arguments for the use of medical cannabis in the treatment of any disease is that cannabinoids have been shown to be remarkably safe with little potential for overdose.  The chemicals extracted from the marijuana plant work to modulate how the neurons in the brain and spinal cord fire.  Cannabis - both THC and CBD - work on a number of levels within the nervous system, including anti-inflammatory actions, analgesia, anti-oxidative actions, neuroprotective effects, immunomodulatory actions, and the regulation of tumor growth. 



Multiple Sclerosis and the Nervous System


The symptoms of Multiple Sclerosis are insidious - meaning they start quietly, where they are felt by the body as it becomes inflamed on the inside before the symptoms are seen on the outside.  One of the hallmark symptoms of MS is spasticity of the muscles, where the muscles tighten and do not release, causing pain and immobility.


Jean-Martin Charcot, a neurologist from France, first classified multiple sclerosis as a disease in the mid- 1800’s, when he autopsies on patients he had been monitoring showed an association with the development of plaques within the brain. 


Multiple sclerosis is a malfunction of the immune system where the body’s own T-cells attack the patient’s own nerve cells.  Some dysregulation causes the T-cells to think the myelin sheaths that cover the neurons of the affected patient are from a foreign body - like a virus.  T-cells are programmed to attack anything they see as foreign within the body; however, in the case of multiple sclerosis the T-cells are mistakenly attacking their own host (the patient’s body). 


The result of the T-cells attack is to destroy the myelin sheaths - which leads to a breakdown of the neurons.  The myelin sheaths are similar to the rubber coatings that surround wires.  Myelin protects and nurtures the neurons in addition to speeding up electrical condition - which is how the neurons speak to one another to make the nervous system control the body.  As the myelin breaks down, nerve signals cannot conduct smoothly along the full length of the nerve, so patients develop symptoms such as brain fog, muscle spasms, muscle weakness, numbness, optic nerve damage, bowel issues and difficulty with walking and muscle coordination. MS is a progressive disease, and its cause remains unknown.


More than 2.3 million people are diagnosed with MS worldwide, but diagnostic challenges and a lack of a national registry make it difficult to have an accurate number of multiple sclerosis. patients.3 The progression of the disease is unpredictable, and some forms of MS are more aggressive than others. A lack of muscle control due to decreased nerve conduction leads to difficulty driving and the inability to work, which inevitably leads to additional financial and emotional strain. MS is typically diagnosed in patients between the ages of 20 and 40. The progression of the disease is unique to each patient. Prognosis may be influenced by diet, stress, pharmaceutical medications, alternative therapies, and genetics. I have met with dozens of MS patients; no two patients have the exact same symptoms. In this chapter we will discuss the pharmacology for treating MS and how cannabis can be used for symptom relief and to possibly affect underlying disease progression.



Patients often come to our clinic after having tried the usual cocktail of prescription medications used to treat spasticity:  drugs like Clonazepam, Tizanidine, and Baclofen.  These drugs are potent and can require high doses to have effect.  They are also addictive (Clonazepam) and must be monitored carefully when the patient decides to stop taking them.  Medications like Baclofen are only mildly effective when taken orally.  This particular medicine works best when it is injected straight into the ventricles of the brain via a surgically-implanted device.  Baclofen has many side effects including - nocturia (peeing in the night), disorientation, and constipation. 


In contrast, patients who choose to treat the spasticity and other symptoms of multiple sclerosis report more improvement in the loosening of the muscle tightness and pain in addition to reporting much fewer side effects. 



Prescription Drug Treatments for Multiple Sclerosis


There is a myriad of symptoms that accompany an MS diagnosis, but the most common type of MS, and the one that most MS specific prescription medications are designed for, is relapsing-remitting MS (RRMS). Patients with a RRMS diagnosis experience disease remission (a lessening of symptoms) followed by symptom “flares” that can last for weeks to months. Flares, also known as attacks or relapses, increase myelin damage leading to symptom progression and a permanent increase in the severity of symptoms. Flares are treated with high-dose corticosteroids such as prednisone and methylprednisolone. These drugs have powerful side effects, especially when taken for weeks or months at a time, a common occurrence during a flare.


Pharmacology focuses on decreasing the frequency of flares and slowing disease progression. The most commonly prescribed drugs are classified as Disease-Modifying Therapy. The goal of prescribing these drugs is to reduce the frequency and severity of relapses over time. Studies show that they are most effective when started immediately after diagnosis.


A 2016 report from Pennsylvania State University compared delayed therapy to continuing therapy of Copaxone, one of the first disease modifying therapy drugs to come to market in 1997. The report found Copaxone caused a shift from auto-aggressive pro-inflammatory Th1 cells to protective anti-inflammatory Th2 cells, which migrated into the central nervous system providing improved long-term benefits and significant decrease in disease progression. Patients may not see a benefit immediately, but studies such as these show DMT provides overall long-term benefits.


The biggest issue is that DMT is expensive. Very expensive. According to an analysis published in 2017 by the Institute for Clinical and Economic Review (ICER), the annual cost of medications for MS range from $63,000 to nearly $104,000, so the financial burden of an MS diagnosis is substantial.  A study on the pricing of DMT therapies found first generation DMT therapy that originally cost $8,000–$11,000 now cost over $60,000. Same medication, higher price every year. DMT medication prices have increased at a higher rate than any other class of medications on the market.


Along with disease-modifying drugs, patients with MS are given a long list of other medications medications on the market.  Along with disease-modifying drugs, patients with multiple sclerosis are given a long list of other medications to combat symptoms. Baclofen and other muscle relaxants are standard therapies for muscle spasms, along with neuropathic agents such as gabapentin and pregabalin (Lyrica). Opioids and non-steroidal anti-inflammatories (NSAIDs) are prescribed for additional pain, which, when mixed, can leave patients struggling with fatigue and over sedation. Along with the cocktail of meds to treat the symptoms of MS, side effects from DMT therapies can be difficult to manage. Anxiety, joint pain, muscle stiffness, and depression are common. Because the benefits of continuing therapies seem to outweigh the risks, patients are left overwhelmed by both the diagnosis and the treatments. It is at this time, when they are drowning in pills, that patients will turn to alternative treatments such as cannabis to help decrease side effects from their current drug profile and alleviate symptoms of the underlying disease.



Cannabis Treatments for Multiple Sclerosis


Cannabis is a medicine that’s known to treat multiple symptoms simultaneously. It can decrease muscle spasms while increasing muscle tone and bladder control, and can even help patients achieve a better sex life. With all we know about cannabis and the endocannabinoid system, is it possible that cannabis is helping with just the symptoms of MS, or can it actually be helping to slow the progression of the underlying disease by aligning an aspect of the endocannabinoid system that was once off-balance?


In 1994, researchers conducted an experiment in which guinea pigs were injected with experimental autoimmune encephalitis (EAE), which is used as a model for MS in a laboratory setting. All animals exposed to the disease and treated with a placebo developed the disease, and 98% died as a result. When animals were treated with D-9-THC, 95% survived and developed little to no symptoms, and on inspection their brain tissue was less inflamed.  As mentioned in the chapter on migraines, the Clinical Endocannabinoid Deficiency (CECD) hypothesis proposes that a lack of cannabinoids can lead to chronic and exacerbated disease, MS being one of them.  This approach could substantially change the way MS is treated from the day of diagnosis.


Cannabis for Combating MS Symptoms


Powerful corticosteroids are prescribed whenever we need to substantially decrease the body’s inflammatory response. From poison ivy to asthma to cancer, steroids have potent anti-inflammatory actions coupled with strong side effects. When used for under two weeks, steroids can cause weight gain, edema, agitation, and sleep disturbances, but are generally safe for most people. When steroids are prescribed during an MS flare, patients can remain on the drug for weeks to months at a time, and side effects can egregiously interfere with normal body functions.


Long-term use of steroids can lead to the development of diabetes, upset stomach and ulceration, glaucoma, nausea and vomiting, headache, insomnia, depression, and anxiety. If we could find another way to decrease chronic inflammation while preventing these nasty side effects, we would really be on to something.


If we look at CBD as a possible alternative, it possesses potent anti-inflammatory properties that may someday allow patients to decrease dosages of steroid treatments. The biggest downside of this therapy is the cost. CBD therapy currently costs much, much more than the average prescription for a corticosteroid.


Muscle spasms due to damaged and inflamed nerves can be severe in MS patients. Baclofen, a centrally acting muscle relaxant, is the most commonly prescribed medication to treat these painful muscle spasms. As is the case with many older pharmaceuticals, how baclofen works is not exactly understood, but the benefits are limited by dosage. Too high a dose and patients can experience muscle weakness and extreme dizziness, while too low a dose offers minimal spasm relief. By adding cannabis (THC and CBD) to an MS drug regimen, patients can often decrease baclofen dosages to more comfortable levels while still experiencing powerful relief.


Sativex is a plant-based 1:1 CBD:THC oral spray that is sold as an adjunct therapy for MS spasticity in Canada, the United Kingdom, Australia, and Spain. Each dose delivers about 2.5mg of THC and CBD. A double blind, placebo-controlled study found that “Sativex was significantly superior to placebo for spasm frequency and sleep disruption.”   It is a shame MS patients in the United States are unable to use this medication like the rest of the world due to federal scheduling of THC.


Strains of cannabis used to treat muscle spasms should include THC, an antispasmodic, but the freedom to choose the amount of THC lies with the patient. Indica-dominant hybrids or full indica strains to be most effective for muscle relaxation, but they do cause substantially more drowsiness and sedation than sativa-dominant strains. Patients can begin using a hybrid strain first, during the daytime, then move to a more sedating product if they need to relax their muscles more.


Patients who need to treat severe muscle spasms should look for products that combine CBD and THC in a 1:1, 2:1, or 3:1 CBD:THC ratio. Products can be chosen based on the immediate need to alleviate symptoms. Use more THC when spasms and pain increase and lower amounts of THC when symptoms subside.


For quick, on-demand relief, patients can use inhalation or sublingual dosing. Oral formulations should be dosed every 6–12 hours around the clock if being used for prevention, although some patients use edibles every 4 hours during a flare. High, frequent dosing of THC can lead to excessive drowsiness. Products for MS patients will ideally be low in sugar and gluten-free because some studies suggest both compounds exacerbate inflammation.


Nerve pain is most often treated with gabapentin, pregabalin (Lyrica) or duloxetine (Cymbalta). Because CBD is a potent anti-inflammatory and has been shown to be effective when treating nerve pain, it can be used synergistically to treat pain and reduce dosages of gabapentin and pregabalin (Lyrica), or as a total replacement for these medications if they are not well tolerated by patients.  CBD has the added benefit of reducing THC euphoria to make it more tolerable for daytime use.


Fatigue is a common complaint heard from MS patients, and the uplifting qualities of a wakeful sativa strain can help with both fatigue and depression. If a full sativa strain causes any anxiety, consider a sativa-dominant hybrid strain such as Jack Herrer or Blue Dream. These strains are wakeful but a bit more relaxing, so they are good for patients that deal with anxiety. Sativa strains such as MediHaze or Harlequin are rich in CBD and great for reducing pain and daytime fatigue while also reducing anxiety.


Injection site swelling from DMT medications can be treated with CBD+THC topical lotions. Use the strongest formulation you can find, and apply it as often as needed until the inflammation subsides.


For additional information on the best strains for your specific symptoms, I recommend using the Leafly app on your phone or the website.























Dr. Allison Kendrick

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