What are medicinal cannabis products and when can they be used – The cost of treatment is entirely borne by the patient, as the products belong to non-reimbursed medicines – What patients report
Anna, a mother of three who lives in Athens, will pass through the pharmacy door in the coming days to execute one of the first – probably the first prescription in our country, for the administration of cannabis for medical – pharmaceutical use. Anna Paga is 60 years old and received on February 15 – with great relief, as she tells APE – MPA, the message from the electronic prescription system, which concerned the medicinal cannabis preparation that her doctor prescribed for her with the aim of continuing treatment for the treatment of chronic pain due to psoriatic arthritis.
“What can I say about this day? A big thank you, relief, vindication, freedom to live. Yes, I was one of the first, maybe the first, when the prescription came to me with an intangible prescription and I didn’t expect it, I didn’t believe it. I started crying, I was holding my cell phone without being able to see anything from the emotion. No more risks and heart palpitations, I feel vindicated, I have written a book about it, NAAN is the mirror of ANNA and I speak openly about my story. When you have been through such an adventure, you have no right to keep it a secret. I had to say it so that I could help others. That was my bet, if even one person stops hurting and maybe even sleeps, I have won.”
The terrible pain and the other way
The story of Anna, who is a podiatrist by profession, is almost a novel. At the end of 2017, she was diagnosed with psoriatic arthritis and the disease turned her life upside down.
“Come on, kid, you can handle it,” you hear every day. And you can.! This mountain of steel, this machine that you always took for granted, that every morning with the turn of the starter started, creaked..Somehow I could handle it too… until one morning I collapsed.
I had unbearable pain in my bones to the point where I couldn’t sleep. I thought it would pass, that my doctor would give me a treatment and I would be like before again. I had my family, my three children to take care of, my job, my activities, a normal, beautiful life. I had to endure it”
After the initial shock, she enters treatment. Among other medications, she is given the first biological agent, but its side effects in this patient force her doctor to discontinue the treatment. He decides to give her another biological agent, but in this case too, the side effects, including the serious suspicion of breast carcinogenesis, throw the second treatment out of line.
“When my doctor changed my treatment regimen, my question was “when will the pain stop?”, I was on the verge of ending my life because I couldn’t take it anymore, I was exhausted. I started searching, reading, trying to find how I could help myself in another way. By chance on the internet I found my “angel” – because we all have angels willing to help us, as long as we ask for it. I met Ms. Poitras and MAMAKA (Moms for Cannabis), founded by mothers with children with autism, cerebral palsy, spasticity, epilepsy, where conventional medications had also failed. I trusted her and so I started with the 13-10-18 oils, which I had to procure from abroad, with all that that entails.
Medicinal cannabis now available in Greece but it is not a panacea
However, Anna no longer needs to risk the illegal procurement of her medicine from abroad, as the availability of final cannabis pharmaceutical products for medical purposes is a reality in our country as well. The doctors who prescribe them welcome the fact, but are quick to clarify emphatically that although many can benefit from this development with the right guidance from their doctor, cannabis as a pharmaceutical product is not a panacea and requires patience from the patient and doctor, in terms of finding it, the right dose and the results of the treatment.
“I don’t think there is a limit. Everyone can potentially benefit and everyone may see their expectations not be fulfilled,” says Ms. Chrysoula Karanastasi, anesthesiologist and president of the Hellenic Medical Society for Cannabinoids, who explains speaking to APE-MPE and Michalis Kefalogiannis: “Cannabinoids are a new group of pharmacologically active substances, which behave differently from the drugs available to date. I wouldn’t say that they fill a specific gap, rather they come to complement our therapeutic options.”
Anna Paga took a big risk as she continued her treatment for the last two years with the preparations she purchased from the Netherlands, without knowing whether the dosages of medicinal cannabis she was using were absolutely correct. She had relied on international recommendations, which were the result of recent studies.
“Back then, I didn’t have the luxury and security of having a specialized doctor like I do today. I had taken my health into my own hands. Not out of courage or magic, but out of despair…I was literally dying. I was one of the small number of patients who experienced extremely serious side effects from the use of biological agents. What could a desperate person think when they see their life being lost? What else could they fear?
All of this is already a thing of the past for Anna. Today in our country, the patient, after being evaluated by the specialist, will receive the relevant prescription – or since the therapist does not have the right to prescribe, he will refer them to the corresponding specialist, points out Ms. Karanastasi. “The prescription is issued at any private pharmacy, and as for the flowers – which to date is the only pharmaceutical form available in our country – it is accompanied by the purchase of a special approved medical device.”
The entire cost of the treatment is borne by the patient, as the final medicinal cannabis products are non-reimbursable medicines. “The dosing is done gradually – a process that we follow in several treatments and is called “titration”. However, the classic approach of dosing in grams, milligrams, units or something similar has no place here. Each patient has their own therapeutic dose and finding it will be done in collaboration with the therapist, which is why this collaboration is of key importance. Nor is there a maximum permitted daily dose, although in our country there is a relative limitation,” concludes Ms. Karanastasis.
What are the final medicinal cannabis products
Anna notices from the very first months of taking the medicinal cannabis preparation from abroad, a significant reduction in the inflammation caused by psoriatic arthritis in the body and a significant improvement in her clinical picture.
“I then announced to the rheumatologist who was treating me that I would stop taking conventional medications, I told him that I would not go so that my pain would go away and I would run away from something much worse. Then he tried to dissuade me, and he did well, telling me “Anna, now that we have reached the levels of the medication… you may sleep and the pain will go away, but it is a chronic inflammatory disease”.
My answer was “they told me that the inflammation will also go down”. I started the oils on 13-10-18 with blood tests that showed the inflammation index, CRP at 21.5 and without any medication for a month and a half, then it had gone down to 14.5.
But let’s clarify what we mean when we say medical or pharmaceutical cannabis. Ms. Karanastasi explains to APE – MPE: “The cannabis plant is one, Cannabis sativa L. Like all plants, it has various species, which have many common characteristics, but also several differences. Among the characteristics that differentiate them is the content of the flowers in the psychoactive substance Δ9-tetrahydrocannabinol, Δ9-THC. When we talk about medical or pharmaceutical cannabis, we mean products that come from plants with a Δ9-THC content in the flowers greater than 0.2%”
However, as she points out, in reality this is an oversimplification, since the plant contains an abundance of active substances – more than 140 that are chemically classified as cannabinoids, but also abundant terpenoids, flavonoids, etc.
“All of these substances are pharmacologically active, and consequently cannabis is a plant with many uses, including medicinal ones, and not a plant that can be medicinal or not. Hence the phrase “final medicinal cannabis products” and not “final medicinal cannabis products” concludes.
Anna sees the surprise on her doctor’s face when they discuss the results of her tests after the systematic use of medicinal cannabis and now begins to see life with the same optimism that she faced before she was faced with psoriatic arthritis.
“When I went to the rheumatologist for the tests, he looked at me, looked at the tests, looked at me again and said, ‘I know who you are, but I have a hard time believing it’.
This was my first victory, my first breath, my first hope for life.
Then, after about 8 months, my inflammation dropped to normal levels of 3-6 CRP. I should add here that at that time I was costing the Greek state around 3,000 euros a month in medicines and now I cost nothing.”
Where can medicinal cannabis treatments be applied
It is important to note that Anna’s case and that of each patient are unique and as such should be treated by the treating physician. It does not mean that what works for one works for everyone.
“There are patients who ask for cannabinoid treatment to be their first choice. However, because the more we study the plant and its products, the more we understand that we still know very little about its actions, cannabinoids are not first-line treatments. Experts disagree about the use of cannabinoids, mainly in terms of the way they modify our endocannabinoid system. Treatment with (phyto)cannabinoids can have a synergistic or antagonistic or additive or inhibitory effect when combined with other treatments, biological or not, regardless of the severity of the condition. Nor is it used only when other treatments have failed. It always needs to be individualized – not all diseases or all patients are the same”, explains Ms. Karanastasis.
Anna acknowledges that she was lucky in her misfortune, but she believes that the driving force for each of us is to stop being afraid of our fear.
“Medicinal cannabis may not be a panacea, but in this case it saved me, I was just lucky!
Let me close with the words of my surgeon who is no longer alive and to whom I dedicated my book. “You are very lucky that you discovered cannabis on your own and that it suited you as a treatment”
What do you mean, doctor? I said to him.
“Let me put it more simply. Imagine yourself in a bed paralyzed, writhing in the pain of psoriatic arthritis and we cannot give you medication because you will get cancer.” There I was!
Who can prescribe and for what indications
In our country, the right to initial prescription for medicinal cannabis is currently held by anesthesiologists, neurologists, pathologists-oncologists, pathologists-infectious disease specialists and pathologists-rheumatologists. The prescription can be repeated by a doctor of another specialty for 6 months, but then the treatment needs to be re-evaluated by a specialist. It is worth noting that prescribing medicinal cannabis is not a process that should be done lightly, as it requires the doctor to be very knowledgeable about the subject and trained in it.
“It should be noted once again that all of this concerns products containing Δ9-tetrahydrocannabinol in a percentage of more than 0.2%. However, we must remember that even products that contain a smaller amount, and do not require a prescription, are pharmacologically active, and therefore should not be taken without the supervision of a health professional with relevant training,” points out Ms. Karanastasi, who expresses the hope that criteria will be established in prescribing that will not allow for unreasonable use.
Regarding the internationally recognized indications for use that are also listed in the Greek “package insert” of Δ9-THC, these include:
1. Nausea and vomiting due to chemotherapy for cancer or HIV/AIDS.
2. Pain and spasticity in multiple sclerosis.
3. Intractable pain that does not respond to other available treatments or when available treatments are not well tolerated by the patient,
4. As an appetite stimulant in patients receiving end-of-life care (palliative/comfort care).
“However, patients receive cannabis for many other conditions, from cancer to post-traumatic stress disorder and rheumatic diseases to glaucoma. And of course they do not only receive what is called medical cannabis, namely Δ9-THC, but also other cannabinoids, such as cannabidiol (CBD), which is not classified as a controlled substance. And it should be noted here that different combinations of cannabinoids, as well as terpenoids and flavonoids, may have different effects on the body,” concludes Ms. Karanastasi.