Vitamin D Supplementation Has No Impact on Cancer and Cardiovascular Disease

New NEJM Trial on Vitamin D

I am not sure if all of you saw the NEJM trial on the Vitamin D supplementation and the prevention of cancer and cardiovascular disease. In the VITAL study (funded by NIH in the United states) they looked at Vitamin D3 at 2000IU per day and marine Omega-3 fatty acids 1 gram per day for the prevention of cancer and cardiovascular disease in men 50 years of age or older and women 55 years of age or older in the United States. It randomized 25,871 patients including 5106 black.

Primary and Secondary End Points

Primary end points were invasive cancer of any type and major cardiovascular events (a composite of myocardial infarction, stroke, or death from cardiovascular causes).

Secondary end points included site-specific cancers, death from cancer, and additional cardiovascular events. This trial reports the results of the comparison of vitamin D with placebo for an average follow-up of 5.3 years.

No Impact on Cardiovascular Disease

Supplementation with vitamin D was not associated with a lower risk of cardiovascular disease. A major cardiovascular event occurred in 805 participants (396 in the vitamin D group and 409 in the placebo group; hazard ratio, 0.97; 95% CI, 0.85 to 1.12; P=0.69). The Odds Ratio (OR) of each of the major CV events were:

  • Cardiovascular events plus coronary revascularization, 0.96 (95% CI, 0.86 to 1.08)
  • Myocardial infarction, 0.96 (95% CI, 0.78 to 1.19)
  • Stroke, 0.95 (95% CI, 0.76 to 1.20)
  • Death from cardiovascular causes, 1.11 (95% CI, 0.88 to 1.40)

No Impact on Cancer Risk

Cancer was diagnosed in 1617 participants (793 in the vitamin D group and 824 in the placebo group; hazard ratio, 0.96; 95% confidence interval [CI], 0.88 to 1.06; P=0.47). In their analysis of cancer risk, they report OR of:

  • Death from cancer (341 deaths), 0.83 (95% CI, 0.67 to 1.02)
  • Breast cancer, 1.02 (95% CI, 0.79 to 1.31)
  • Prostate cancer, 0.88 (95% CI, 0.72 to 1.07)
  • Colorectal cancer, 1.09 (95% CI, 0.73 to 1.62)

No Impact on Death from Any Cause

In the analysis of death from any cause (978 deaths), the hazard ratio was 0.99 (95% CI, 0.87 to 1.12)


What Does this Mean for Practice?

This was a well-researched trial that was funded by the National Institute of Health in the US. I think that we have to be careful in what we recommend supplements for, based on this and other research. The good thing from this trial is the overall risk of adverse events was found to be the same as placebo.

I think we can continue to recommend the 400-1000IU daily of Vitamin D3 as recommended by the Osteoporosis Canada 2010 guidelines, but we should be cautious of stating that there are any other additional benefits for the heart or cancer risk.

References

Manson, JoAnn E., Nancy R. Cook, I-Min Lee, William Christen, Shari S. Bassuk, Samia Mora, Heike Gibson, et al. “Vitamin D Supplements and Prevention of Cancer and Cardiovascular Disease.” New England Journal of Medicine 380, no. 1 (January 3, 2019): 33–44. https://doi.org/10.1056/NEJMoa1809944.

Papaioannou, Alexandra, Suzanne Morin, Angela M. Cheung, Stephanie Atkinson, Jacques P. Brown, Sidney Feldman, David A. Hanley, et al. “2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada: Summary.” CMAJ 182, no. 17 (November 23, 2010): 1864–73. https://doi.org/10.1503/cmaj.100771.

Proposed New Cannabis Formats

Yesterday, Health Canada released proposed new formats for cannabis to be available next year.  If you are interested in seeing the full list and the restrictions on each, you can download it at:

These formats include:

  • Edibles (solid)
  • Edibles (beverages)
  • Cannabis extract (inhaled)
  • Cannabis extract (ingested)
  • Cannabis extract (concentrated THC)
  • Cannabis topical

Most of these products target the recreational market.  I like the idea of a topical cream.  There is limited data, on topical application of cannabis, but tremendous interest in the topical route for different diseases of the skin. 

The new cannabis extract could lead to the end of nabiximols (Sativex) in Canada. Likely a licensed producer’s extract would be significantly cheaper than Nabiximols and be available in a variety of strengths for patients. 

For people who want to share their thoughts on these dosage form with the government, they can submit them to:

Opioids or NSAIDs for Chronic Pain – Is One Superior to the Other?

Yesterday, Dr. Busse from the Michael G. DeGroote Institute for Pain Research and Care at McMaster University published in JAMA a Systematic review and Meta-analysis on Opioids for Chronic Pain. He was the lead author of the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain.

The authors reviewed 96 clinical trials with 26,169 patients with chronic non-cancer pain.  It had some interesting information on the efficacy of opioids for chronic pain and function.

Bottom Line: Opioids may not offer better pain relief and function than many non-opioid analgesics. 

Opioids for Pain Relief

They converted all the of the pain studies to using the same 10 cm visual analog scale.  They said that the minimally important difference was a 1 cm reduction on this scale.  They report:

  • Opioids led to a weighted mean difference of only -0.79 cm versus placebo [95%CI, -0.90 to -0.68 cm], p<0.001
  • Only 13.6% of patients achieved the minimally important difference compared to placebo

The longer the study the worse opioids did for pain relief.  For trials that followed up patients for 3 months or longer:

  • Opioids led to a weighted mean difference of only -0.69 cm versus placebo [95%CI, -0.82 to -0.56 cm], p<0.001
  • Only 11.9% of patients achieved the minimally important difference compared to placebo

Think about that for a second, the mean difference in pain scale for people using opioids for chronic pain was < 1 cm on a 10 cm point scale.  

Opioids for Physical Functioning

High quality evidence found that opioids were associated with a small improvement in physical functioning compared with placebo, but did not meet the criterion for the minimally important difference.

The change on the 100 point SF-36 physical component  score was 2.04 points [95%CI, 1.41-2.68], p<0.01.  This was lower than the minimally important difference of 5 points.

Opioids and Other Domains

Emotional functioning – Opioids were not significantly associated with emotional functioning compared with placebo.

Social functioning – High-quality evidence from 29 RCTs (7623 patients) showed an association of opioids with improved social functioning compared with placebo but did not meet the minimally important difference.

Sleep Quality – opioids were associated with a small improvement in sleep quality but did not meet the minimally important difference.  If therapy is > 3 months, the improvement was even less.

Adverse effects – At least 20 RCTs reported each of the following adverse events: nausea, constipation, dizziness, drowsiness, headache, pruritus, and dry mouth. Except for headache, opioid use was associated with a higher incidence of these adverse events compared with placebo

Opioids Versus NSAIDs

Moderate-quality evidence showed no difference in the association of opioids vs nonsteroidal anti-inflammatory drugs for pain relief and physical functioning. 

NSAIDs offered similar pain relief and physical functioning improvement as opioids.

Opioids Versus Tricyclic Antidepressants

Low-quality evidence suggested no difference in pain relief between opioids and nortriptyline.  Low-quality evidence suggested no difference in physical functioning.

TCAs offered similar pain relief and physical functioning improvement as opioids.

Opioids Versus Anticonvulsants

Moderate-quality evidence suggested opioids were associated with greater pain relief than anticonvulsants. Low-quality evidence suggested no difference in physical functioning.

Opioids Versus Nabilone

Low-quality evidence suggested no difference between opioids and nabilone for pain relief and physical functioning. 

Cannabinoids offered similar pain relief and physical functioning improvement as opioids.

Author’s Conclusion

Opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. Comparisons of opioids with non-opioid alternatives suggested that the benefit for pain and functioning may be similar.

Commonly Asked Question – What are the Drug Interactions with Cannabis?

I have been writing quite a few programs over the last few months on cannabis.  One of the most common questions that I get is on drug interactions with cannabis.

 The Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids developed by Health Canada is a great starting point if you have questions regarding pharmacology, potential indications, adverse effects, kinetics and methods of administration.  There is a large amount of great information in this publication.

What are the most concerning drug interactions with cannabis?

The drug interactions that are most concerning with cannabis are with medications that could cause sedation or cognitive impairment. These include alcohol, opioids, benzodiazepines, tricyclic antidepressants, and gabapentinoids. 

The key is when cannabis is going to be used with these medications, slow titration is recommended.  I would normally recommend starting on a lower dose of THC, and slow the titration.

What about CYP 450 enzyme interactions with cannabis? 

CYP 2C9, 2C19 & 3A4 inhibitors

Delta-9 THC is oxidized by the CYP isoenzymes 2C9, 2C19, and 3A4 into approximately 80 metabolites.  Substances that inhibit these CYP enzyme could increase the bioavailability of THC.  These include:

  • Antidepressants – fluoxetine, fluvoxamine, moclobemide
  • Proton pump inhibitors -omeprazole
  • Macrolides – azithromycin, erythromycin, clarithromycin
  • Azole antifungals – itraconazole, fluconazole, ketoconazole
  • Calcium channel blockers – diltiazem, verapamil
  • HIV protease inhibitor – ritonavir, indinavir, atazanavir, darunavir
  • Amiodarone
  • Ticlopidine
  • Grapefruit juice
  • Isoniazid

Additive tachycardia, hypertension, and drowsiness have been reported with THC and concomitant consumption of tricyclic antidepressants such as amytryptiline, and desipramine. Additive hypertension, tachycardia, and possible cardiotoxicity have been reported with THC and concomitant consumption of sympathomimetic agents such as amphetamines and cocaine. 

CBD is also metabolized by CYP 2C19 and CYP 3A4.  The bioavailability of CBD could potentially be increased by many of the same substances listed
for THC.

CYP 2C9 and 3A4 inducers

Medications that induce CYP 2C9 and 3A4 can accelerate delta9-THC and CBD metabolism.  These drugs include rifampin, carbamazepine, phenobarbital, phenytoin, primidone, and Saint John’s Wort.

Does smoking have an impact on drug interactions?

Smoking cannabis may induce CYP 1A1 and 1A2.  This could lead to a decrease in plasma levels of medications metabolized these isoenzymes (e.g. chlorpromazine, theophylline).

What about CBD and anti-convulsants?

There is also some evidence to suggest a potential interaction between CBD and phenytoin.  Patients taking CBD and anti-convulsants such as phenytoin should be monitored for increased blood levels of phenytoin, and doses of phenytoin should be adjusted accordingly to avoid the potential for excess blood levels of phenytoin and a phenytoin overdose. 

In the CBD in severe pediatric seizure (Lennox Gastaut Syndrome) trial, the clobazam levels increased significantly when CBD was used.  This is managed by a decrease in clobazam dose. 

What drug interactions are clinically significant?

The key cannabis drug interactions that are most concerning are those drugs that cause sedation (e.g. opioids, alcohol, benzodiazepines).  These drug interactions can be mitigated by starting on a low dose of cannabis and increasing slowly. 

The other drug interactions with the CYP isoenzymes are all generally mitigated by low dose and slow titration.  The key is that while the patient is on any CYP P450 metabolized drug that can interact with cannabis, he/she must be completely adherent to cannabis and the other medication otherwise the drug levels may increase or decrease significantly. 

For those patients with epilepsy, the interaction with CBD and clobazam is significant and may require dose adjustments. 

Commonly Asked Questions – Anti-Obesity Pharmacotherapy

Obesity is a Chronic Disease

Over the last year I have had the pleasure of working on a number of obesity programs.  Obesity is now viewed as a chronic, progressive disease state by most medical groups across the world.  Clinicians have to start to treat obesity as a chronic disease versus just a lack of willpower. 

There are currently three anti-obesity medications available in Canada and I thought I would do a quick review of the most commonly asked questions on these medications. 

Key point: The European Obesity Guidelines recommend that when starting a patient on an anti-obesity medication, clinicians should evaluate the efficacy in 3 months.  If the patient has lost 3-5% body weight, continue treatment (can be continued long-term), if not, consider stopping the medication as the patient is unlikely to respond.  

Why use medications when the patient can just eat less and exercise more?

There is the widely held belief that people with obesity should just simply have better lifestyle to control their weight.  In reality, very few people can achieve long-term weight control through just lifestyle changes alone.  The reason is our body has a feedback loop that controls both hunger and satiety (sense of fullness) that makes it difficult for the person with overweight or obesity to obtain long-term weight loss. 

When we start to lose weight, these signals will lead the body to increase hunger, decrease energy expenditure and reduce satiety.  This is why most people can lose weight short-term with a restrictive diet, but these changes can’t be maintained long-term for continuous weight loss.

Here is a quick review of the three anti-obesity pharmacotherapies. Before prescribing or dispensing these products, it is important to review their product monographs. 

Is 5-10% weight loss significant?

Although many people will like to lose large amounts of weight long-term, this is an unrealistic goal for many patients.  A 5-10% weight reduction is usually a reasonable goal for patients. 

Although it does not seem like a significant amount of weight loss, a review found that this amount of weight loss can lead to:

  • A reduction in the risk of developing type 2 diabetes
  • An improvement in blood pressure and dyslipidemia
  • An improvement in A1C in people with diabetes
  • An improvement in non-alcoholic fatty liver disease (NAFLD)
  • A reduction in obstructive sleep apnea symptoms
  • An improvement in osteoarthritis pain in weight bearing joints
  • A reduction of GERD
  • An improvement in polycystic ovary syndrome

What do I need to know about orlistat (Xenical)?

Orlistat is a lipase inhibitor in the GI tract.  By inhibiting lipase, it prevents triglycerides being broken down to free fatty acids and monoglycerides that can be absorbed by the body.  This translates to 30% reduction in the amount of fat being absorbed.  With less fat, we have less calories, and thus weight loss.

The Xendos study evaluated the efficacy of orlistat over 4 years.  It found that orlistat 120 mg 3/day was associated with a 5.8 kg weight reduction compared to 3.0 kg with placebo.  It also reduced the risk of type 2 diabetes development (6.4% orlistat, 9.0% placebo). The biggest issue with this study was a high drop-out rate.  Close to half of participants in both the orlistat and placebo groups dropped out. 

GI related adverse effects are very common with orlistat.  If a person eats too much fat, this will commonly lead to oily stools, diarrhea and abdominal discomfort.

Orlistat can impair the absorption of fat-soluble vitamins (A,D,E,K), so patients should be encouraged to take a multivitamin at bedtime.  It is associated with drug interactions with cyclosporine, warfarin and anti-epilepsy medications. 

The standard dose is 120 mg 3/day with each of the main meals.  This is to prevent the fact absorption with the meal. 

Bottom line: For some people orlistat is an option for weight reduction. Frequent dosing, adverse effects and lack of impact on the neurobiology of obesity translates to this option not being used as frequently as the other options. 

What do I need to know about liraglutide 3.0 mg (Saxenda)?

The GLP-1 receptor agonist liraglutide has been used for the management of type 2 diabetes for many years.  Liraglutide 3.0 mg (Saxenda) has been used for the last several years for the management of obesity. Liraglutide is very similar to endogenous GLP-1, but these small changes make it resistant to breakdown by the enzyme DPP-4. 

Liraglutide acts on the hunger center in the hypothalamus of the brain and interacts the underlying neurobiology associated with obesity.  GLP-1 has influence over the POMC pathway, which:

  • Increases satiety (sense of fullness)
  • Decreases appetite
  • Decreases hunger
  • Decreases energy intake
  • Decreases gastric emptying

These changes are associated with weight reduction in people with obesity.  The SCALE Obesity and Prediabetes trial assessed the efficacy of liraglutide 3.0 mg.  Two-thirds of people on liraglutide 3.0 mg lost at least 5% of body weight (27% with placebo) and one-third lost at least 10% body weight (10.6% with placebo).

The most common adverse effects with liraglutide are GI effects such as nausea and vomiting.  These are usually transient and can be mitigated with slowly titrating the dose.  Gall bladder disease can occur with liraglutide, but is also common with weight reduction. 

The dosing is 0.6 mg daily increasing by 0.6 mg each week until the dose of 3.0 mg daily is reached.  The injection is given in the abdomen, thigh or upper arm. 

Bottom line: Liraglutide 3.0 mg is an effective treatment for reducing a patient’s weight by 5-10%.  This treatment targets the underlying neurobiology of obesity.  Most adverse effects are mild and temporary.  The subcutaneous injection may be a barrier for some patients. 

What do I need to know about naltrexone/bupropion (Contrave)?

The newest anti-obesity agent in the Canadian market is Naltrexone/Bupropion (N/B).  Like liraglutide, this medication targets a component of the underlying obesity neurobiology.   It is thought that the bupropion has a dual mechanism of action.  It increases the level of dopamine in the reward pathway but also stimulates the release of alpha-MSH and B-endorphins in the POMC pathway in the hypothalamus.  Alpha-MSH promotes a decrease in food intake.  Naltrexone is thought to block the effect of B-endorphin, which stimulates feeding.  This combination of N/B is more effective than either agent alone. 

The COR-1 trial found that approximately two-thirds of people who completed the trial (56 weeks) lost at least 5% of body weight (versus 23% with placebo) and 34% lost at least 10% body weight (versus 11% with placebo).  Unfortunately, almost 40% of participants did not complete the trial.

The most common adverse effects are nausea, constipation, headache, vomiting, dizziness, insomnia and dry mouth.  It is contraindicated in people with seizure disorders and chronic opioid users.  Bupropion can interact with drugs metabolized by CYP 2D6 (metoprolol, SSRI’s, tricyclic antidepressants, risperidone, tamoxifen). 

The dosing is started at 1 tablet daily for 1 week, then 1 tablet 2/day for 1 week, then 2 tablets in the morning  and 1 tablet in the evening for a week, then 2 tablets 2/day. 

Bottom Line: Naltrexone/bupropion is an effective agent that targets the underlying neurobiology of obesity.  It will help some patients achieve the 5-10% weight reduction.  The adverse effects and drug interactions can be a concern in some patients. 

Image courtesy of the Obesity Canada Image Bank

Commonly Asked Questions – What do I have to know about Shingrix (Recombinant Zoster Vaccine)?

I have been presenting on vaccines for the last few weeks.  I had a few questions on Shingrix.  The updated NACI statement on herpes zoster was published earlier this year, and has been integrated into the Canadian Immunization Guide.  I thought I would review some of the questions I am commonly asked about Shingrix.

Should Shingrix be used at 50 years or 60 years?

Age is a major risk factor for the development of shingles.  This is mostly due to a decrease in antibodies and a decrease in immune system function as we age (immunosenescence)

In the past, Zostavax was recommended for all people 60 years of age and older, but could be considered in people starting at age 50 years.  The reason for this recommendation is that the shingles risk increases starting at age 50 years but significantly increases after the age of 60 years.  The antibodies to the live vaccine decreases with time, so if given too early it would not protect when the patient was at the highest risk. 

With Shingrix, the recommendation is to offer it to everyone 50 years of age and older.  The reason is we know that the immunogenicity last up to 9 years.  You should comfortably offer Shingrix to all your patients 50 years of age or older. 

What if the patient has never had chicken pox (varicella)?

Shingles is a reactivation of the chicken pox virus.  A question that comes up is if the person hasn’t had chicken pox, do they really need the shingles vaccine? 

Shingrix should be offered to everyone 50 years of age or older regardless of whether the person has a history of varicella infection.  Nearly all Canadians 50 years of age or older have had prior varicella exposure, even if a diagnosis of varicella cannot be recalled. 

What about the side effects with Shingrix, I heard they are severe?

Shingrix is a adjuvanted IM vaccine injection.  Local injection site reactions are more common with Shingrix compared to Zostavax.  Approximately 4 out of 5 people report injection site pain and 1 in 3 develop redness at the site of injection.  Systemic reactions such as fatigue and mylagia occur in up to 50% of people receiving Shingrix.  Up to 40% of people developed headache. Most of these events (>95%) were rated mild or moderate in intensity and lasting less than 2 days. 

I think it is crucial that clinicians discuss the risk of side effects with the patient.  I would fully expect any vaccine with an adjuvant to cause more local reactions.  Letting patients know that this is common, temporary and in most cases, mild, can put them at ease if they occur.  If you have a patient that is worried, consider administering on a Friday, so that if they have systemic effects, they are home. 

Can I give Shingrix with other vaccines?

Shingrix can be administered with any inactivated or live vaccines protecting against a different disease. 

If you have not administered multiple vaccines to a patient at the same visit, consider reviewing Concurrent Administration of Vaccines Section in the Canadian Immunization Guide.

Can I administer Shingrix to an immunocompromised patient?

Zostavax is a live-attenuated vaccine.  Since it is live, it is normally contraindicated in immunocompromised patients.  Shingrix is a non-live vaccine. 

The two key Shingrix trials,  ZOE 50 (Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults) and ZOE 70 (Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older) did not include patients who were immunocompromised. 

Immunocompromised patients are a high risk group of developing shingles and could benefit from herpes zoster protection.  NACI states that Shingrix could be used in people 50 years of age and older. 

Bottom line: we know Shingrix is safe to use in immunocompromised patients but we are not sure of how effective it is. 

Herpes zoster vaccines are not covered under the public program, do I really have to offer them?

A common concern from healthcare professionals is that they are unsure of their responsibility to recommend vaccines not covered under the public routine program of their province or territory. The Canadian Medical Protective Association (CMPA) published a review of a physician’s responsibilities with new vaccines in 2009. 

Bottom-line is these new vaccines are designed to protect your patients against a number of vaccine-preventable diseases.  My belief is that all healthcare professionals have an obligation to offer vaccines to candidates based on NACI recommendations regardless if they are free or the patient must purchase. Fundamentally, it is the patient’s right to choose what treatments they would like to receive, and by offering the choice, the patient can choose if he/she would like to receive this treatment. 

What is the administration schedule for Shingrix?

Shingrix requires two doses at days 0 and then days 60-180 (2-6 months).  NACI states that clinicians could consider administering the second dose 1 year later at the time of the influenza vaccine to improve adherence. 

Are boosters required for either shingles vaccine?

At this time, there is no recommendations for booster.  This may change as more research is done. 

Commonly Asked Questions – Asthma Control Assessment

Commonly Asked Questions – Asthma Control Assessment

I worked on an asthma program this last weekend.  I was reviewing the GINA asthma guidelines for this project.  They have simplified the assessment of asthma control and allow us to assess if the person with asthma is fully controlled, partially controlled or uncontrolled in a matter of a couple of minutes.

Each of the asthma assessment tools provided below can quickly assess asthma control of people with asthma.  By having patients complete these tools, clinicians can determine if the patient needs intensification in therapy.  I really like the GINA asthma symptom assessment tool as it is quick and can assess full, partial or poor control. 

30 Second Asthma Test

The 30 Second Asthma Test has been used in Canada for years.  It has 5 questions to assess if a person has his/her asthma under control.  If the person answers yes to any of these questions, this could indicate sub- optimal control. 

  1. Do you cough, wheeze, or have a tight chest because of your asthma? (3 or more times a week)
  2. Do coughing, wheezing, or chest tightness wake you at night? (1 or more times a week)
  3. Do you stop exercising because of your asthma (in the past 3 months)
  4. Do you ever miss work, school, social activities because of your asthma? (in the past 3 months
  5. Do you use your fast-acting reliever inhaler 4 or more times a week?

A key change is the doses of fast-acting reliever also include any dose given prior to exercise.

Asthma Control Test (ACT)

The Asthma Control Test (ACT) is a 5 question test that assesses asthma control over the last 4 weeks.  For each question, the patient scores 1 to 5 depending on the level of impairment or asthma symptoms.

The ACT score can range from 5-25.  The higher the score the better.

Level of asthma control is based on the score:

  1. Score 20-25 – is classified as well-controlled asthma
  2. Score 16-19 – is classified as partial control (or not well-controlled)
  3. Score 5-15 – is classified as very poorly controlled asthma

GINA Asthma Assessment Test

The 2018 GINA Asthma Guidelines have a very simple asthma assessment test. The four questions include:

  1. Daytime asthma symptoms more than twice/week?
  2. Any night waking due to asthma?
  3. Reliever needed for symptoms more than twice/week?
  4. Any activity limitation due to asthma?

Scoring of the GINA assessment test:

  • Well controlled – answer no to all of these questions
  • Partly controlled – Answer yes to 1 to 2 of these questions
  • Uncontrolled – Answer yes to 3 to 4 of these questions

Palliative Care Symptom Management Resources

Palliative Care and Primary Care Clinicians

I just finished a project on palliative care. Although I have had a few patients over the course of my career as a pharmacist, I never really felt that I was confident enough in helping to reduce the symptoms as these patients approached the end of their lives.

I think feel that every primary care clinician can play an active role in improving the quality of life of these patients.  We can do this by actively assessing and managing common symptoms seen in palliative patients.

I was so impressed with the incredible resources that are available to help manage the most common symptoms seen in palliative care patients, such as:

  • Pain
  • Depression
  • Anxiety
  • Confusion
  • Fatigue
  • Breathlessness
  • Insomnia
  • Nausea
  • Constipation
  • Diarrhea
  • Anorexia

By effectively managing these symptoms we can improve the quality of life and reduce the burden on both the patient and the family.

British Columbia Inter-Professional Palliative Symptom Management Guidelines

The BC Centre for Palliative Care has published a Palliative Symptom Management Guideline.  This is such a great tool for clinicians who are helping to manage a palliative patient in the community. It provides clear guidance on the assessment, interventions and different symptom management options. They provide an algorithm for each of the most common symptoms to help guide clinicians on the different treatment recommendations.

I would recommend that pharmacists and primary care clinicians download and keep it for when you need it.  This is important as the management strategies for these palliative symptoms can be very different than what we would do for a typical ‘healthier’ patient. Knowing these differences can have a dramatic impact on how well these symptoms are controlled.

Palliative Care Adult Network Guidelines Plus

The Palliative Care Guidelines Plus is a UK site that provides clinicians with up-to-date information on how to manage the most common palliative care symptoms.  It also provides some resources for the psychosocial and spiritual issues seen in palliative patients.  I found the site had a ton of highly practical information to help some of the key concerns expressed by patients and their families.  I would encourage you to bookmark it, so that you have it available when presented with a palliative patient in your practice.

Six Things Every Patient Should Know About Medical Cannabis

I am going to be on a medical cannabis panel in a few weeks. The audience is going to be the public. I thought I would write a quick post on six points that every patient should know about medical cannabis.  A couple of months ago, I wrote a post called Five Things You Should Know About Medical Cannabis which was for healthcare professionals. Hopefully this clears up some of the ‘smoke’ around medical cannabis.

1.      Cannabis is Not a ‘Magic Bullet’

If you read many of the cannabis sites online, you will think that cannabis can be used for almost every disease. People will say that it can cure many conditions. I have even read that there is a conspiracy to prevent the real benefits from cannabis from getting out to the public.

In reality, most people take cannabis to help with some of their

symptoms such as pain, anxiety, sleep, nausea and muscle spasms. It makes them feel better by lowering these symptoms. What I like about cannabis, is it works well for people with a number of these symptoms.  For example, a person with chronic pain and insomnia treated with cannabis can commonly see improvement in both his/her pain and sleep.

2.      Medical Users Don’t Need to Get High

Many critics of medical cannabis think that everyone just wants to get high.  Most medical users take only enough cannabis to lower symptoms and not enough to get high.  If a medical user is always getting high, we will normally need to adjust the cannabis strain to get rid of this.

3.      Cannabis Abuse is Less Than with Other Substances

One of the biggest criticisms of cannabis is that medical and recreational use will lead to a large number of cannabis addicts. Honestly, we don’t know how many people will have a problem when recreational cannabis is legalized in Canada. What we do know, is that 6.8% of Canadians who have used cannabis have reported a cannabis use disorder (also called an addiction to cannabis).  This is lower than with other medications such as opioids.

Cannabis is also not linked to overdose deaths that we see with other drugs like opioids.  What is very interesting is we have some early data showing that states that allowed medical cannabis have lower deaths from opioid overdoses.

4.      Buy Your Cannabis Through a Licensed Producer

I know I am going to get some flack for this one. Let me say there are many good dispensaries, but there are also some not so great ones. Licensed producers in Canada have strict rules in the way they can treat cannabis and you can be very comfortable that the cannabis will match what is on the label. Many people using cannabis are not in perfect health, and the products from licensed producers are likely a better choice for people with health conditions.

5.      Work with your Doctor and Other Healthcare Professionals

I am really worried about the stigma of cannabis use. I would tell every person that if you are using cannabis, whether you buy it illegally or get it through the medical system tell your doctor and pharmacist. We will want to have this on your chart and can caution you if you get a medication that can cause problems with cannabis.

6.      Cannabis is Not for Everyone

So many people think that because cannabis is natural it is safe.  There are some risks with using cannabis.  This is a real concern in young people and those people with serious medical and mental health conditions. We usually have different treatment options for most of these people that could be safer.

The NB College of Pharmacist is Wrong About Medical Cannabis

New Brunswick Pharmacists and Medical Cannabis

I was recently sent the position statement of the New Brunswick College of Pharmacists Position Statement on Cannabis for Medical and Non-Medical Purposes.  I would strongly encourage all pharmacists interested in medical cannabis to read this statement. The college firmly feels that there:

Currently available information does not support pharmacy distribution of cannabis.

This Position is Stigmatizing a Population of Patients

Like it or not, many patients throughout Canada are using cannabis for medical purposes.  The vast majority of these patients are using cannabis for the management of chronic pain.  Many find that it offers superior relief and improvement in outcomes than other analgesics. The use of medical cannabis for chronic pain is supported numerous trials and the National Academies of Sciences, Engineering, and Medicine’s systematic review in 2017 concluded that there is:

  • There is substantial evidence that cannabis is an effective treatment for chronic pain in adults

What bothers me about this position the most is the college is saying that patients using medical cannabis should be treated differently than other patients receiving other analgesics.  Some of these other analgesics also have limited long-term safety and efficacy data.

Regardless of the treatment, my belief is that patients should have:

  • Timely access to medications in the communities they live
  • Access to customized patient care and counselling based on their needs
  • Their complete medical record accessible at one pharmacy for both safety and monitoring

With the college’s position, the patient cannot access their medication by the healthcare professional with whom they have an established and trusted relationship.  This can also lead to delays in treatment initiation while the patient waits to have their cannabis shipped from a licensed producer.  This delay would not be tolerated for other medications in Canada.

For some reason, the New Brunswick College of Pharmacists feels that patients using medical cannabis should NOT receive the same expert counselling, education and guidance as other medications in Canada. 

Canada is one of the ONLY Countries Where Pharmacists Don’t Have a Major Role

I have had the pleasure of working on some medical cannabis projects in other parts of the world. I recently returned from South America, where medical cannabis legislation is currently being approved. Cannabis in Colombia will be treated like any other medication. The prescriber assesses the risk and benefits for the patient and then the prescription filled by a specially trained pharmacist.  This system allows patients to have the expert insight of two healthcare professionals providing education, counselling and monitoring.  This is also the same in other parts of the world like Israel.

I don’t understand why the college feels that the people of New Brunswick using medical cannabis cannot benefit from the care, guidance, education and monitoring of pharmacists in the province

Why Does Efficacy and Safety Only Apply to Cannabis?

One of the key concerns with the college is they state that:

  • “We must ensure that external pressures are not causing us to bypass normal checks and balances in the health care system”

My interpretation of this is there is a lack of safety and efficacy data with medical cannabis and thus we don’t feel pharmacists should be distributing it. 

I would be fine with this statement, if it held true for all products sold in pharmacies.  I also do a tremendous amount of work in the vaccine space. Currently, pharmacies across the country are selling nosodes. These are homeopathic vaccines. These nosodes are marketed online as alternative to routine immunizations. Having them for sale in pharmacies, legitimizes these as a safe and effective option for patients.  I would argue nosodes distributed through pharmacies can do much more harm to patients and public health than the expert care of patients with chronic pain requiring cannabis.

Even if a product is approved by Health Canada, there can be safety and efficacy concerns. 

Patients with Chronic Conditions Need Care and Support

This position from the New Brunswick College stigmatizes patients as they don’t feel the cannabis they are using is an legitimate treatment.  They also devalue the care provided by the pharmacists in the province by not allowing them to provide patient-centered care surrounding cannabis.

Bottom Line: I feel this position statement was very short-sighted.  There is an opportunity to improve the care provided to these patients and the college does not feel these patients can benefit from the expert care of pharmacists trained in cannabis.