Question & Answer with Dr. Boehnke

PPM: Why is cannabidiol a good candidate for potential treatment of chronic pain?

Dr. Boehnke: Cannabidiol, or CBD, has a lot of therapeutic potential for multiple reasons. The first is safety. CBD has no known abuse or addiction potential, and the side effect profile is remarkably safe. Obviously, anything that you put into your body can have negative side effects – and that is true of CBD. But those side effects tend to be remarkably minimal compared to other classes of pain medications.

Second, in non-human animal research, in addition to its analgesic effects, CBD shows very potent anti-inflammatory effects, and inflammation is often related to pain. There’s also some evidence that CBD may provide anxiety relief and be useful for sleep – both things that often go hand in hand with pain issues.

Dr. Boehnke: We will be sourcing our products from a DEA-licensed facility that will make CBD products for us. It will be an oral formulation, either a liquid or capsule.

We want to investigate many types of pain. So we’re doing a large study. Part of what we’re going to do in this clinical trial is look at the different underlying mechanisms of pain that people have. People can have the same diagnosis and yet have different contributions to their pain. Somebody who has pain in their low back, that could be because they have a bulging disc; they could also have a central nervous system sort of pain that is amplifying and maintaining the pain rather than the pain being caused by actual tissue damage or inflammation. So, what we’re going to do is try to understand what people’s underlying pain phenotype is, and then see who might respond to CBD based on the type of pain they have.

PPM: Veterans will be the primary subjects of this study. Can you share a little about that?

Also, the statute that allocated money for this research dedicated the money to addressing health conditions of veterans and to testing the therapeutic potential of cannabis and marijuana in this context, and ideally to reduce the risk of suicide among veterans.

PPM: Many people with chronic pain are already using CBD, without any medical guidance. What’s your take?

Dr. Boehnke: Yes. Studies that my colleagues and I, and many other people, have conducted throughout the country show that there’s a big disconnect between what people are doing and what their doctors know. A lot of physicians don’t want to engage with their patients about this, partly because cannabis is still a Schedule 1 drug. So there are concerns about legal issues. Also there’s a lack of education for many healthcare providers: Why would they have been taught about the therapeutic potential of a Schedule 1 drug? The policy is now far ahead of the science.

Dr. Boehnke: The first part of the study focuses on CBD. In the second part of the study, participants can choose to use CBD, THC, or both as they wish. We give people CBD or placebo first because we think of CBD is the lowest-risk cannabinoid. After that, they will get randomized to this behavioral intervention or weightless control, where they may, if they wish, add THC products. Employing this sort of stepped model aligns with what you typically see in clinical practice. You want to give people the lowest risk option first, and then slowly go up with the people who are not having a treatment response. We will help them optimize their use regardless.

Part of the importance of doing research like this is that if we want to understand the value of cannabis as medicine – and part of what we need to do is demystify it. There are people saying cannabis is good for everything, we should use it for everything. There are people who say cannabis is terrible. And others say, it’s just a drug of abuse, and nobody should touch it. We want to take very data-driven and thoughtful path to understand in whom cannabis may be helpful, when it is helpful, and how it is helpful.

Dr. Boehnke: Typically what happens when somebody is using medical cannabis – this is how it is in Michigan, for example,­ the physician signs a document that says this patient has a condition that under state law qualifies them to be a medical cannabis patient. Then the patient submits that paperwork to whatever state regulatory agency oversees the medical cannabis program. And that agency decides whether that person gets a license. If that person gets a license, then depending on what the law says, they might be able to grow their own plants; they might be able to purchase at dispensaries if there’s a legal marketplace; or they might be able to do both. That’s different than a physician saying, ‘Okay, we’re going to start you out on a prescription for a 1000 mg CBD tincture. Go get the prescription filled, and this is how much you should take.’

PPM: Will you be developing treatment guidelines?

Dr. Boehnke: I wouldn’t say we’re developing treatment guidelines. What we want to do is see if we can develop a behavioral intervention that we can test in a rigorous clinical trial to see whether we can help people optimize their cannabis use for chronic pain.

PPM: As you mentioned, healthcare providers have had little to no training on this. How will this study help physicians making treatment decisions for patients with chronic pain?