A bottle of Care by Design medical cannabis on a table

Germany and the US have many apparent differences. However, the gap couldn’t be larger in terms of people discussing marijuana, especially for medical use. Uncountable patients that suffer from chronic pain live in Germany, and many of them do not have an adequate medication to relieve their pain. Even though medical marijuana has been accessible more easily since 2018, doctors hesitate to prescribe it. On the contrary, getting cannabis in CA is rather simple. But why do these vast differences regarding the treatment of pain all around the world exist, and what does this mean for German patients?

Strolling along a street in San Francisco in the morning, there is always a slight whiff of cannabis in the air – sometimes more prominent, on other days covered by a smell of urine – and almost every time someone igniting a joint is close by. San Francisco is not only known for its many tourist attractions, but also for its open-minded lifestyle. Whether it is the Mission district or the hip neighborhood Haight-Ashbury – the latter one was the starting point of the flower power movement in 1967 (“summer of love”) – there is no minute when one wouldn’t walk through a cloud of the medical product.

In March 2017, the laws regarding medical use of cannabis were loosened in Germany.

Especially chronically ill patients could have benefitted from these changes. However, medical professionals refused to prescribe it, or health insurances do not cover the costs. Their arguments are rooted in the missing long-term studies about the risks and benefits of medical marijuana intake. 

A never-ending fight between supporters and opposers began.

Cannabis supporters believe in studies that suggest more positive than adverse effects of cannabis, particularly on a few specific conditions. A review article [1], for example, shows reliable evidence that justifies cannabis usage to treat chronic pain, nausea (especially during chemotherapy), multiple sclerosis (muscle spasms and neuropathy), spinal cord damage, Tourette syndrome, and glaucoma. Scientist Amar states that for those illnesses mentioned above randomized, double-blind studies exist, and those count as the standard for clinical studies. Randomized, double-blind studies are designed, standardized programs in which the participant and the doctor do not know if the patient is in a group that takes a placebo or the actual drug. Furthermore, less substantial evidence suggests that cannabis might have positive effects on neuropathy [2], PTSD [3], anxiety disorders [4], and epilepsy [5]. It has also been noted that cannabis has anti-inflammatory components [6], which is why it has been proposed for the treatment of inflammatory conditions. Chronic pain seems to be one of the most and best-studied indications for medical marijuana intake [2, 7].

On the other side, contrasting studies do not see any advantages when comparing cannabis to a placebo (an inert medication without pharmaceutical components) [8]. Even as a pain medication, cannabis is still considered controversial, which adds to the uncertainty of medical professionals in Germany.

German doctors prefer to trust the familiar: opioids.

In Germany, significantly more opioids are prescribed than cannabis. The latter is just starting to become more popular,” Konstantin Dirr, who is a pharmacist based in Neumarkt, explains. Opioids, such as morphine, can cause addiction and/or dependence and might lead to potentially deadly side-effects. For example, they can slow down or even stop the breathing [9]. Nevertheless, several studies about long-term effects of opioids exist, and so they are prescribed before cannabinoids.

Denise knows what this means for chronic pain patients.

She lives with a rare, genetic condition called Ehlers-Danlos syndrome. The connective tissue that is supposed to hold her joints together isn’t built the right way, which leads to hypermobility and periodical dislocations of her hips, shoulders, or other joints. Walking became difficult for her. Despite using a wheelchair, she still suffers from severe pain for which she was advised to take opioids when she was only 30 years old. She took morphine without success. The pain did not reduce, and she developed a variety of adverse reactions, for instance, bloody diarrhea, nausea, and constipation, which are common when taking opioids. Besides morphine, there is barely a medication the 47-year-old hasn’t tried yet: acetaminophen, ibuprofen, tramadol, metamizole, piroxicam, meloxicam – drugs that could lead to severe side-effects as well. The group of nonsteroidal anti-inflammatory drugs (NSAID), to which ibuprofen counts, does not influence the chemistry of the brain, so they don’t cause adverse events related to opioids and don’t lead to addiction. But NSAIDs can harm the patient’s liver, kidney and partially the heart [10], and, if taken permanently, stomach bleeding might occur [10]. According to scientific publications, COX2-inhibitors, which are prescribed as a long-term alternative for ibuprofen, can damage the heart [11], and increase the risk to have a heart attack or stroke [12]. Reading the instruction leaflet might worry the patient, but most of the time, they have no choice but to take the prescribed medication.

Facts & Figures about Ehlers-Danlos syndrome



No drug available in Germany has helped Denise so far.

Denise’s quality of life did not significantly enhance by taking all those pills. Short distances become a major challenge for the Elmshorn resident. Walking causes her severe pain, due to her permanently damaged joints. She is a chronic pain patient – without any helpful medicine. Denise has reached a brick wall. Until recently, chronically ill people had no other option than to resort to the long-term established opiates.  The new German law gave many patients a new glimmer of hope.

Suddenly, an alternative arose: medical marijuana.

I have to emphasize that cannabis is no miracle drug. It is a normal medication with positive and negative effects, and it is not suitable for everyone,” Dirr states. Cannabis might cause dependence or addiction, but to a lesser degree than opioids, and the risk for overdosing marijuana is almost non-existing [13]. Most studies describe its side-effects as mild. The most commonly observed adverse reaction was dizziness [2]. Side-effects categorized as severe were, for example, vomiting and urinary tract infections [2]. One clear contraindication for medical cannabis that exists is using it during adolescence since this is associated with an increased risk to develop schizophrenia [2]. Death by marijuana overdosing is rare [14], and studies that researched cannabis as pain medication did not show severe adverse events [7].

Uncertainty dominates in doctors’ minds.

Cannabis’ potential medical benefit is largely ignored. Pharmacist Dirr affiliates this attitude with the lack of long-term studies. He additionally says that a lot of training is needed since those new regulations were rushed. “I am certain that over the next years many things will change in pain therapy, and cannabis can be a valid alternative for many indications.” Doctors and pharmacists will have to be more open regarding cannabis over time.

What can patients like Denise do until then?

She will have to go back to her non-effective drugs, while her doctors try to convince her to take opioids. When she asked a physician to prescribe medical cannabis for her, the doctor looked at her upset, and said: “We don’t support drug addicts in this office!” Denise was shocked by the unexpected reaction. Insecurely she adds: “But morphine is also a drug, right? Why are opioids better than at least trying cannabis for once?” Unwilling to give in, the doctor shook her head and stated that cannabis was not compatible with her ethics as a doctor, and she didn’t want to hear Denise asking for it ever again. Konstantin Dirr reflects on this opinion: “Even those who are skeptical  now will become more open about cannabis, but those developments need time.” And this time can mean great torments for pain patients.

Denise suffers from Ehlers-Danlos syndrome and daily, severe pain.
Denise lives with Ehlers-Danlos syndrome and daily, severe pain.

In California, on the other hand, medical marijuana is easily accessible.

The state even has a category of physicians who do nothing else than to issue or reject licenses for medical cannabis. A person only needs to prove he or she lives with a condition for which medical marijuana is permitted; these include, for example, chronic pain, inflammatory bowel disorders, cancer, sleep disorders, and many more. An appointment costs around 100 Dollars, which is affordable, and has to be paid out of pocket. If the doctor thinks the chronically ill patient could benefit from cannabis, he issues an ID that finds its way into the patient’s mailbox in less than seven days. With this white card, including a photo of the cardholder, the California bear, and lots of green cannabis flowers, the patient can now visit a dispensary – a pharmacy for marijuana products. Not only is the 70-year-old granny with arthritis that moves around with her walking aid, or the 30-year-old pain patient waiting here, people with all backgrounds search for relief in those institutions. Cannabis is even allowed as a first therapeutic measure. This means, chronically ill people do not have to unsuccessfully try the whole range of drugs which has been the case for patients in Germany so far.

Before March 2017, prescribing cannabis in Germany was even harder.

Back then, the patient needed the explicit permission of the Federal Institute for Drugs and Medical Devices,” Dirr explains. Today, at least every patient that relies on access to cannabis may go through the authorization procedure. Still, achieving a permission for medical marijuana as the first therapeutic approach is unlikely. In San Francisco, cannabis is a medication just like any other pain drug and is therefore seen as equivalent to ibuprofen and others.

Dispensaries resemble pharmacies in San Francisco.

If the patient opens the doors of a dispensary in San Francisco, he or she is greeted by a delicate, pleasant scent of cannabis, and the friendly staff at the registration counter checks the ID and escorts him or her to the waiting area. Chic leather armchairs and ornate decoration are reminiscent of a particularly upscale waiting room in a private doctor’s office in Germany. Behind elegant wooden counters stand the medical consultants, who, like doctor’s assistants, call up the patients and provide them with a menu card with possible consumable items. Pages full of long lists with an almost inextricable range of cannabis products in all concentrations, mixtures and dosage forms. Edibles – a medication that can be eaten and digested – like gummy bears or chocolate, over tinctures and liquids, to joints that can be smoked, everything is available. The selection creates confusion, and an inexperienced German quickly loses track over the variety of products. But the employees can help out by quoting studies. Everything is like in a German pharmacy, just for medical cannabis. Another medicine is not sold here. Moreover, cannabis is affordable in San Francisco. A bottle with 5 ml costs, for example, 30 Dollars and lasts for two weeks.

Do you want to hear more about this topic? Listen to this podcast in which I talk to Monica who lives with Ehlers-Danlos syndrome, a rare connective tissue disorder that leads to severe pain.

There is room for improvement in Germany.

So far, the selection of cannabis products is rather meager. According to Konstantin Dirr, right now, a spray, liquid, and about 10 – 15 different flowers are available. Regarding the flowers, the pharmacist is skeptical. “It remains to be seen if flowers will be part of cannabis therapy in the long run, or whether we move in the direction of extracts that are medically more accurate to dose. In terms of the flowers, correctly dosing is difficult.” Besides the dosage, medical marijuana leads to other problems: While medication such as ibuprofen is always covered by German insurance, so the patient does only have to pay the prescription cost of 5 Euro, the costs for medical marijuana do not automatically have to be paid by insurance. The patient needs an authorization for it. “It has never happened before that the pharmacy has to have a permit from the health insurance,” says Dirr. And those applications are often rejected by the insurance. If the patient decides to pay out-of-pocket for medical cannabis, it can quickly become expensive. “Medical marijuana is very individual to dose. Some patients use more, other less. 10 g flowers currently cost between 150 and 250 Euro. If the patient, for example, needs 80 – 100 g per month, because he inhales multiple times daily, it is expensive.” Such sums are simply not feasible for people living with chronic pain without the help of their insurance. “The patient has to be gone a long way and has to have unsuccessfully tried multiple drugs for their condition until they are authorized to try medical marijuana. And even if their insurance agrees to bear the costs, then mainly only for one specific product and not for all of them.”

Without the help of her insurance, cannabis would not be affordable for Denise. She lives from disability benefits and has only 600 Euro per month. If she had to pay for marijuana herself, she would reach her financial limits quickly.

So far, however, she does not have to worry about the costs, because all doctors refused her the prescription. “I just hope to find a drug that improves my quality of life. Maybe there is a drug that has fewer side-effects for me, and that I tolerate better.” For Denise, cannabis is not a drug, but a medication and her last option to decrease her pain.

Some fears are unfounded.

The worries of physicians that drug addicts might use the new law to obtain cannabis legally is unfounded. Pain patients are usually not interested in a “high” caused by THC, in contrast to people who use cannabis as an illegal drug. The latter are looking for a mood-altering effect, or even euphoria [15]. Denise, on the other hand, needs a functioning brain that is not clouded by daily pain. She also does not want to tolerate a high caused by cannabis – only the pain should decrease to a manageable level. Marijuana could be a valid option for Denise.

Is cannabis a substitute for opiates?

The hopes are high in chronic pain patients. Nevertheless, medical marijuana is not suitable or sufficient for every type of pain. “There are currently many expectations that may not be fulfilled. Cannabis is not a general substitute for opiates. Some types of pain, such as nerve pain, are more likely to respond to cannabis. Others might not at all,” Dirr explains.

However, if cannabis was available, a study [16] showed that the use of opiates and other potent drugs for anxiety or sleep disorders had been partially replaced by it. Furthermore, in US states with legal access to marijuana, there had been a decline in hospital treatment due to opiate dependence and a reduction in overdose deaths [17].

One can only wish that Denise and other pain patients who have already tried many painkillers can get help from their doctors, and that the remaining doubts of medical professionals in Germany can be eliminated by relevant data. Additionally, marijuana needs to be financially accessible. Therefore, the prices have to decline, and lastly and most importantly, patients need to find relief from their pain. This desire might not be fulfilled for some of those affected. After all, medical marijuana is not a miracle cure, and like any other medication, there are advantages and disadvantages that must be weighed up in cooperation between the doctor and the patient.

Sources:

[1] AMAR, Mohamed Ben. Cannabinoids in medicine: A review of their therapeutic potential. Journal of ethnopharmacology, 2006, 105. Jg., Nr. 1, S. 1-25.

[2] BORGELT, Laura M., et al. The pharmacologic and clinical effects of medical cannabis. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2013, 33. Jg., Nr. 2, S. 195-209.

[3] ZER-AVIV, Tomer Mizrachi; SEGEV, Amir; AKIRAV, Irit. Cannabinoids and post-traumatic stress disorder: clinical and preclinical evidence for treatment and prevention. Behavioural pharmacology, 2016, 27. Jg., Nr. 7, S. 561-569.

[4] BLESSING, Esther M., et al. Cannabidiol as a potential treatment for anxiety disorders. Neurotherapeutics, 2015, 12. Jg., Nr. 4, S. 825-836.

[5] IFFLAND, Kerstin; GROTENHERMEN, Franjo. An Update on Safety and Side Effects of Cannabidiol: A Review of Clinical Data and Relevant Animal Studies. Cannabis and Cannabinoid Research, 2017, 2. Jg., Nr. 1, S. 139-154.

[6] KLEIN, Thomas W. Cannabinoid-based drugs as anti-inflammatory therapeutics. Nature reviews. Immunology, 2005, 5. Jg., Nr. 5, S. 400.

[7] JENSEN, Bjorn, et al. Medical marijuana and chronic pain: a review of basic science and clinical evidence. Current pain and headache reports, 2015, 19. Jg., Nr. 10, S. 50.

[8] BOWEN, Lynneice L.; MCRAE‐CLARK, Aimee L. Therapeutic Benefit of Smoked Cannabis in Randomized Placebo‐Controlled Studies. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2017.

[9] RICARDO BUENAVENTURA, M.; RAJIVE ADLAKA, M.; NALINI SEHGAL, M. Opioid complications and side effects. Pain physician, 2008, 11. Jg., S. S105-S120.

[10] FANELLI, Andrea, et al. Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors: latest evidence and clinical implications. Therapeutic Advances in Drug Safety, 2017, S. 2042098617690485.

[11] RUSCHITZKA, Frank, et al. Differential blood pressure effects of ibuprofen, naproxen, and celecoxib in patients with arthritis: the PRECISION-ABPM (Prospective Randomized Evaluation of Celecoxib Integrated Safety Versus Ibuprofen or Naproxen Ambulatory Blood Pressure Measurement) Trial. European Heart Journal, 2017.

[12] MUKHERJEE, Debabrata; NISSEN, Steven E.; TOPOL, Eric J. Risk of cardiovascular events associated with selective COX-2 inhibitors. Jama, 2001, 286. Jg., Nr. 8, S. 954-959.

[13] HALL, Wayne; PACULA, Rosalie Liccardo. Cannabis use and dependence: public health and public policy. Cambridge university press, 2003.

[14] GABLE, Robert S. The toxicity of recreational drugs. American scientist, 2006, 94. Jg., Nr. 3, S. 206.

[15] GRUBER, Staci A., et al. Splendor in the grass? A pilot study assessing the impact of medical marijuana on executive function. Frontiers in pharmacology, 2016, 7. Jg.

[16] PIPER, Brian J., et al. Substitution of medical cannabis for pharmaceutical agents for pain, anxiety, and sleep. Journal of Psychopharmacology, 2017, 31. Jg., Nr. 5, S. 569-575.

[17] POWELL, David; PACULA, Rosalie Liccardo; JACOBSON, Mireille. Do medical marijuana laws reduce addictions and deaths related to pain killers?. National Bureau of Economic Research, 2015.

Want to read my personal experience with medical marijuana? Here is a Blog post for you.

Or listen to my experience on my podcast:

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