Some pain experts here though have expressed cautious support for Malaysia to allow the use of cannabis-based medicine to expand treatment options for chronic pain management. — Reuters pic

KUALA LUMPUR, June 12 — Mention marijuana to the average Malaysian and chances are high that he or she will not immediately associate it with chronic pain management even though medical marijuana is not new overseas.

Some pain experts here though have expressed cautious support for Malaysia to allow the use of cannabis-based medicine to expand treatment options for chronic pain management.

Dr Maya Nagaratnam, pain management and anaesthetic consultant with Pantai Hospital, said opioids are effective to treat pain only for 70 per cent of the population and that such painkillers have more side effects (e.g. nausea, vomiting and constipation) than medical marijuana as well as far higher tolerance and addiction levels. Chronic pain is pain that lasts for more than three months.

“Oral cannabinoids are not new; however they have become available and they’re FDA approved, and so, I think we should consider it in a repertoire of treatments for certain chronic conditions,” Dr Maya told Malay Mail Online in an interview here.

Dr Maya Nagaratnam speaks to Malay Mail Online on May 31, 2016, in Kuala Lumpur. — Picture by Choo Choy May

Dr Maya was referring to the medications approved by the US Food and Drug Administration (FDA) that contain chemicals in marijuana, called “cannabinoids”, in the form of pills, adding that the human body has cannabinoid receptors and produces its own cannabinoid chemicals.

“However, I’m not sure that that calls for any need for any kind of marijuana to be legalised, only to get federal approval for the use of these drugs on maybe a named patient basis under clear supervision,” she said.

A 2014 US-based survey by health site WebMD showed that the majority of doctors said medical marijuana should be legalised nationally, with the highest support coming from oncologists and haematologists, as it is typically used to treat chronic pain from illnesses like cancer, chemotherapy-related nausea and multiple sclerosis, besides seizure disorders.

Newswire Reuters reported that Ohio approved legislation last month that legalises medical cannabis use under certain circumstances, with some 24 states in the US and Washington DC allowing some form of medical marijuana use. Using marijuana, however, remains illegal in the US under federal law.

Malaysia has very strict drug laws. Section 6 of the Dangerous Drugs Act 1952 prohibits the possession of cannabis, an offence punishable with imprisonment of up to five years, or a fine not exceeding RM20,000. Under Section 39A, being found with over 50 grammes is punishable with a jail term of at least five years and at least 10 strokes of the rotan.

It’s unknown how many Malaysians use marijuana for medical purposes, since the FDA-approved cannabis-based pills and the cannabis-based mouth spray licenced in the UK, Canada, and several European countries are not registered here. However, Facebook page MalaysiaMedicalMarijuana currently has almost 19,000 likes since it was set up in 2011.

Dr Maya cited the 2004 UK Cannabinoids in Multiple Sclerosis (CAMS) study on the medical use of marijuana that showed a small treatment effect on reducing muscle spasticity in multiple sclerosis, a neurological condition where patients have stiff muscles and spasms.

She also pointed to the ‘2015 US Cannabinoids for Medical Use: A Systematic Review and Meta-analysis Study’ that showed “moderate-quality” evidence to support the use of medical marijuana to treat chronic pain and spasticity, as well as “low-quality” evidence that linked medical cannabis use to improvements in nausea and vomiting due to chemotherapy, weight gain in HIV infection, sleep disorders and Tourette’s syndrome.

Dr Maya cautioned that research has yet to be done on the long-term effects of medical marijuana use, noting that the side effects of taking too much cannabis are depression and paranoia.

“When you smoke it, you lose all the benefits and you gain all the adverse side effects of smoking,” said Dr Maya, as she warned people against smoking marijuana, like how it’s done recreationally, for medical use.

“You have to extract it in its purest form, which is the delta-9-tetrahydrocannabinol (THC),” she said, referring to marijuana’s main mind-altering chemical. “And then take it in a pill form or as a spray”.

Dr Mary Cardosa, consultant anaesthesiologist and pain specialist with Selayang Hospital, however, said she did not think it was essential to register cannabis-based medicine in Malaysia as she advocated non-drug alternatives for pain management.

“It’s looking for a quick fix. There’s no magic bullet,” Dr Cardosa told Malay Mail Online in an interview.

“You need to look at other methods of managing pain, along with appropriate medications. So I won’t push any company to bring the drug in because I don’t think it’s an essential drug; it may be a ‘nice to have’ drug but not a ‘must have’ drug,” she added.

Dr Mary Cardosa speaks to Malay Mail Online on June 4, 2016, in Kuala Lumpur. — Picture by Choo Choy May

Dr Cardosa, who is also president of the Malaysian Association for the Study of Pain, also said not enough research has been done on the effectiveness of using marijuana for medical purposes, noting that while it can play a role in reducing chronic pain, such as HIV-related pain, the long-term effects are unknown.

She said the problem is that people tend to treat pain only with drugs and to underestimate the role of other methods, especially for chronic non-cancer pain.

“We should use all kinds of modalities, not just drugs, but exercise, relaxation, changing our lifestyle, for example sitting and standing frequently if you have chronic back pain instead of just taking drugs.

“Analgesic medications (painkillers) — pills and injections — are the easiest way to relieve pain and therefore, many patients and doctors just focus on medications. While pain medications may be appropriate for treating acute pain, it certainly is not true for chronic pain,” said Dr Cardosa.

“A multimodal approach — using non-drug techniques including physical and psychological modalities (for example, exercise, relaxation) together with medications — has been shown to be the most effective in the management of chronic pain, but it takes a longer time to take effect and requires effort,” she added.

Then there are chronic pain sufferers like Siti (not her real name) who found that opioids simply did not work for her. She suffers from hypokalaemia, a condition where potassium levels in the bloodstream are too low and patients can suffer muscle cramps, and found marijuana has been effective in managing her pain.

Without access to cannabis-based pills or sprays, the 38-year-old Malaysian woman has been using marijuana for the past five years by smoking it; one joint before she goes to work, two more joints in the afternoon, and it’s “free flow” at night. This costs her about RM50 a week.

She does this without medical supervision but insists that before she started using marijuana, she would suffer total paralysis twice a year. She was diagnosed with hypokalaemia when she was 24 or 25, describing it as a condition in which her “whole body” was aching most of the time.

“My back, kidneys, until the tip of my toes, aching all the time. It’s a constant pain that won’t go away even in your sleep,” she said.

Siti told Malay Mail Online her doctors kept increasing the dosage of opioids but it still failed to treat the pain.

“When you take dihydrocodeine, everything you eat feels like paper. The pain doesn’t go away,” she said. “It increased to five pills at a time. One day, I needed to take it four to five times”.

“Now, everything’s back to normal,” she said.

While there is no conclusive proof that it is marijuana that helped Siti get her life back, there exists in Malaysia a segment of chronic pain sufferers like her who think Malaysia should legalise not just cannabis-based medicine but marijuana itself.