Cannabis for MS: the facts you should know

Introduction

Prevalence of Multiple Sclerosis (MS) Multiple Sclerosis (MS) continues to affect many individuals globally, with the prevalence rising from 2.3 million in 2013 to 2.9 million in 2023​¹. Around one million people in the United States live with this condition as of 2023​². The global prevalence rate in 2020 stood at 35.9 per 100,000 individuals, indicating a 30% increase when compared to the data from 2013​³.

Brief Mention of Common Treatments The treatment landscape for MS has been evolving, with Disease-Modifying Therapies (DMTs) becoming crucial in managing the disease. The World Health Organization recently added three DMTs for MS to its list of "Essential Medicines" in July 2023, marking a significant milestone in recognising MS treatments​⁴. Moreover, new treatment avenues are continuously being explored, including nasal sprays and drugs targeting the Epstein-Barr virus​⁵.

Introducing Cannabis as an Alternative Treatment Cannabis, with its rich historical backing as a medicinal herb, has resurfaced in contemporary discussions as an alternative treatment for MS. The scientific community and legislative bodies are exploring and acknowledging the potential benefits of cannabis-based therapies, particularly in alleviating spasticity and pain. This growing recognition has been facilitated by a shift in legal landscapes across various regions, paving the way for more comprehensive research and understanding of cannabis's therapeutic potential in MS management.

Significance of Understanding Cannabis Treatment Understanding the potential benefits and limitations of cannabis as a treatment for MS is crucial for patients, healthcare providers, and policymakers. It offers an alternative avenue for symptom management, potentially improving the quality of life for individuals living with MS. Moreover, a nuanced understanding of cannabis treatment could foster informed decisions, both on an individual and societal level, regarding integrating cannabis-based therapies in the broader MS treatment paradigm.

Historical Background of Cannabis Use in MS Treatment

Early Usage and Anecdotal Evidence Cannabis has been used in medicine for centuries, with its roots tracing back to ancient civilizations. The introduction of cannabinoids, the active compounds found in cannabis, to Western medicine occurred in 1838 by William O'Shaughnessy to treat many conditions, including rheumatic pain and epilepsy. However, due to political barriers and challenges in establishing quality control, using cannabinoids in clinical practice entered a period of dormancy​⁶​​⁷.

Despite these hurdles, the potential therapeutic benefits of cannabinoids for various ailments continued to garner attention. Especially in the context of Multiple Sclerosis (MS), numerous studies and systematic reviews have highlighted the efficacy of medical cannabis in relieving spasticity and pain, two common symptoms associated with MS​⁸​​⁹.

Progression in Legalisation and Research The legal landscape surrounding cannabis has significantly evolved, particularly in the last decade. This evolution has been pivotal in advancing research and understanding of cannabis as a potential treatment for MS. In the United Kingdom, for instance, the legal status of medicinal cannabis shifted on 1 November 2018, allowing specialist clinicians to prescribe cannabis-derived medicinal products to patients with exceptional clinical needs​¹⁰.

Similarly, in the United States and other parts of the world, there's been a trend towards legalizing cannabis, driven partly by shifts in public opinion. By early 2018, many regions, including twenty-nine states in the US, had adopted laws legalizing cannabis in some form. This legal evolution has created a more conducive environment for researching and understanding the potential benefits and risks of cannabis use in treating MS and other medical conditions​¹¹​​¹².

A significant milestone was the publication of a systematic review 2014 by the American Academy of Neurology, which found strong evidence supporting the use of cannabis-based treatments for alleviating MS-related muscle problems. Such findings have propelled further research and discussion within the medical community regarding the role of cannabis in managing MS symptoms​¹³.

Cannabis Treatments for MS in 2023

In recent years, cannabis and its derivatives have been increasingly recognized for their potential therapeutic benefits for individuals with Multiple Sclerosis (MS). The various forms of cannabis treatment, including Cannabidiol (CBD) supplementation, oral cannabis extracts, oromucosal sprays, and specific pharmaceutical preparations like Sativex (nabiximols), have been studied for their efficacy in managing common MS symptoms like spasticity, pain, muscle stiffness, and bladder issues.

1. CBD Supplementation:
   • CBD supplementation may aid in reducing fatigue, pain, and spasticity and improve mobility over time​¹⁴.
2. Oral Cannabis Extracts:
   • Oral cannabis extracts, often encapsulated, have shown promise in relieving muscle stiffness (spasticity) and spasms and may also alleviate pain​¹⁴.
   • A double-masked, placebo-controlled study involving 279 MS patients revealed that those in the cannabis group experienced significant relief in spasticity and pain​¹⁵.
3. Oromucosal Sprays:
   • Oromucosal sprays such as Sativex (nabiximols) have been effective as an add-on therapy for easing spasticity in adult MS patients, especially those who did not respond well to other treatments​¹⁶.
   • These sprays primarily target symptoms like spasticity and pain, with indications of a slight improvement in other MS symptoms, warranting further research​¹⁷.
4. Cannabis Oil or Tincture:
   • Nearly one-third of adults with MS report using cannabis oil or tincture for pain management, suggesting a significant user base finding relief through this form of cannabis administration​¹⁸.
5. Future Directions:
   • While the initial findings are promising, the call for additional, larger-scale clinical studies to confirm the benefits of cannabis and its derivatives for MS treatment is a consistent theme in the literature​¹⁴.

Cannabis Laws for MS patients in the UK

The legal landscape surrounding the use of cannabis for medical purposes, particularly for managing symptoms of Multiple Sclerosis (MS), has seen a shift in the UK over the past few years. Here's a detailed breakdown:

1. Legal Rescheduling:
   • On 1 November 2018, the UK government rescheduled cannabis-based medicinal products to make them legally prescribable. This change allowed specialist doctors like neurologists to prescribe unlicensed cannabis-based treatments grown to specific pharmaceutical standards. However, such prescriptions could only be made after exploring all licensed treatment options. General Practitioners (GPs) cannot prescribe cannabis but may refer patients to specialists​¹⁹.
2. Prescribing Guidance:
   • Post-rescheduling, the Department of Health requested the National Institute for Health and Clinical Excellence (NICE) to develop guidance on prescribing medical cannabis or cannabis-based products for medicinal use (CBPMs). The guidance NICE provided recommended using Sativex, a licensed cannabis-based treatment, for MS but did not recommend any unlicensed types of medical cannabis. The choice to prescribe medical cannabis ultimately rests with individual specialist doctors, notwithstanding the guidance​¹⁹.
3. Licensing and Approval:
   • Any cannabis-based products for medicinal use in humans (CBPM) supplied to a patient in the UK, be it oil, flower, or capsules, must be approved and licensed by the Medical Healthcare Agency (MHRA) and the Home Office​²⁰.
4. Classification under the Misuse of Drugs Act 1971:
   • Cannabis is a controlled drug under the Misuse of Drugs Act 1971. The classification broadly reflects the potential for harm and has legal implications, including penalties for inappropriate supply and possession. Cannabis and many cannabis-based products are assigned to Class B under this act​²¹.
5. Access Challenges:
   • Despite the legal provision for medicinal cannabis, a report by the MS Society highlighted that not nearly enough medical cannabis patients have been able to obtain medical cannabis through the National Health Service (NHS), underscoring a gap between policy and practical access for MS patients​²².
6. Sativex Availability:
   • Sativex, a cannabis-based oral spray, is approved for use in the UK for managing spasticity in MS patients. It was made available in England for 'moderate' or 'severe' spasticity after a price reduction by the manufacturer. The availability extended to Wales, Northern Ireland, and Scotland in subsequent years. However, obtaining Sativex on the NHS may still pose challenges as it depends on regional NHS agreements and local prescribers' decisions​¹⁹.

The laws and regulations surrounding cannabis use for MS in the UK reflect a cautious approach, with a clear preference for licensed cannabis-based medicinal products like Sativex over unlicensed varieties. The onus of prescribing such treatments rests with specialist doctors, who are guided yet not mandated by NICE guidelines. Despite the legal allowances, practical access to cannabis-based treatments through the NHS remains challenging, indicating a need for further policy refinement to bridge the gap between lawful provision and patient access.

Conclusion

The intersection of Multiple Sclerosis (MS), a debilitating neurological condition, with cannabis, an age-old yet controversial herb, presents a nuanced narrative. The rising prevalence of MS globally underscores the need for practical, versatile treatment regimens. While traditional Disease-Modifying Therapies (DMTs) have been cornerstones in managing MS, the quest for more patient-centric, holistic remedies has spotlighted cannabis. The historical tapestry of cannabis paints a picture of an ancient medicinal herb replete with a blend of societal acceptance and stigmatization. The modern-day narrative of cannabis, particularly in the context of MS, is gradually shifting from taboo to therapeutic, driven by evolving legal frameworks and burgeoning scientific evidence.

In 2023, the spectrum of cannabis-based treatments for MS is broad, encompassing CBD supplements, oral cannabis extracts, oromucosal sprays like Sativex, and more. These treatments, underscored by promising initial findings, aim at alleviating cardinal MS symptoms like spasticity and pain. However, the call for robust, large-scale clinical trials reverberates through the scientific community, highlighting a quest for unequivocal evidence on cannabis's efficacy and safety in MS management.

The legal narrative in the UK reflects a cautious yet progressive stance towards medicinal cannabis. The rescheduling of cannabis-based medicinal products in 2018 marked a significant stride, albeit with stringent prescribing guidelines. The provision for Sativex, a licensed cannabis-based treatment, reflects a preference for licensed over unlicensed cannabis products. Yet, the chasm between legal provision and practical access, primarily through the NHS, delineates an area ripe for policy refinement.

This unfolding narrative resonates beyond the shores of the UK, mirroring a global dialogue around cannabis, MS, and the broader realm of medicinal herbs. As legal landscapes morph and scientific inquiry deepens, the chapter on cannabis in MS treatment is far from closed, heralding a journey of exploration, acceptance, and, hopefully, healing.