A PAGE IN MY DIARY — Living with Multiple Sclerosis

Written by Faith Long, PharmD
Edited by Markita Wilburn, PharmD 

A PAGE IN MY DIARY — Living with Multiple Sclerosis

It’s 7 am, and my alarm's piercing sound jolts me awake from a restless slumber. The start of another day in the ongoing battle within my own body begins. With a deep breath, I brace myself for the war ahead, dragging my weary limbs out of bed. The weight of exhaustion hangs heavy on me, but I refuse to surrender to the invisible enemy that is Multiple Sclerosis.

As I reach for my arsenal of medications to fortify myself against further attack, I can’t help but acknowledge their limitations. While they offer temporary relief from the pain, their benefits force me to navigate a treacherous terrain of side effects. Yet, amidst the chaos, there is a glimmer of hope that has emerged – the possibility of relief with medical marijuana. 

This is the reality faced by over 2.8 million people worldwide, grappling with the debilitating symptoms of Multiple Sclerosis1, for which a cure remains undetermined and adequate symptom management is lacking.

WHAT IS MULTIPLE SCLEROSIS?

Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) that ravages crucial communication between the brain and the body. Specifically, the immune system attacks myelin sheath, the fatty tissue protecting nerve fibers, of the central nervous system. These attacks prevent transmission of electrical impulses across nerve cells that disrupt functionalities at random for unknown intervals. Constant destruction of myelin sheath leads to scar tissue formation, at which point communication between the brain and body can be permanently disrupted2,3. Neurodegeneration gives rise to various motor, sensory, and cognitive implications for which various symptoms present. 

SYMPTOMS OF MULTIPLE SCLEROSIS?

Patients with MS often present with episodic patterns of relapsing-remitting neurological attacks that are associated with highly variable symptoms:

Accumulation of lesions and ongoing neurodegeneration lead to functional decline and irreversible disability. The disease burden can be physically and emotionally taxing for patients with MS. Psychosocial problems, mental health concerns, and poor quality of life become increasingly prevalent as MS progresses. 50% of patients with MS develop depression and/or anxiety yet are often overlooked and left untreated, further disabling patients.4,5

MS is immune-regulated and progressively deteriorating, so symptoms will vary from person to person. No two people are the same, and one person’s symptoms can fluctuate and differ daily and even change or multiply over time. Common symptoms include anxiety, depression, bowel disruption, fatigue, muscle spasticity, heat sensitivity, pain, numbness, tingling, and slurred speech. 

BRIEF HISTORY OF MMJ USE IN MULTIPLE SCLEROSIS

Medical marijuana is no stranger to those inflicted by MS. Since its legalization for medical use in 1997, MS has been listed as one of the approved conditions due to its effectiveness in alleviating spasticity symptoms. Reduction of spasticity was further demonstrated in several randomized controlled trials leading to the approval of Nabiximols, a naturally derived cannabis product formulated as a 1:1 THC:CBD oromucosal spray in Europe.8 The success of Nabiximols as a tolerable add-on therapy for MS-related spasticity was just the beginning. Despite legal restrictions in the United States, the use of MMJ for MS has gained traction upon Nabiximols’ success. In 2014, the American Academy of Neurology recommended cannabis-based medicine for symptomatic management of MS-associated spasticity and pain.5

CURRENT TREATMENTS FOR MULTIPLE SCLEROSIS

Despite the availability of more than 20 FDA-approved “disease-modifying therapies” (DMT) aimed at reducing MS relapses and slowing disease progression, their efficacy often falls short, rendering many patients vulnerable to worsening stages of MS and disability.5 Furthermore, DMT often fail to relieve the symptomatic burden of MS, resulting in patients becoming increasingly desperate for relief.6,7 Anti-inflammatory-based treatments are available for symptomatic management; however, they’re frequently found ineffective, intolerable, and carry a significant risk for toxicity.7,2 In the relentless pursuit of effective symptom management, an increasing number of patients are turning to alternative therapies, including medical marijuana (MMJ).7,2

DOES MEDICAL MARIJUANA FILL THE GAPS IN MANAGING MS SYMPTOMS?

Cannabinoids exert anti-inflammatory effects that give rise to the relief of MS symptoms. The four primary cannabinoids, delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), cannabigerol (CBG), and cannabichromene (CBC), have proven to exert potent anti-inflammatory effects involved in many inflammatory-medicated degenerative diseases.9,10 THC provides the additional benefit of suppressing the overactive, inappropriate immune responses that characterize autoimmune disorders like MS.10

Although conventional treatments for MS symptoms are anti-inflammatory as well, they fail to adequately control common symptoms of MS.7,2 A possible explanation for this would be the theory of the “entourage effect” of cannabis compounds. This describes the synergy amongst cannabinoids, terpenes, and other components of the cannabis plant as they work together to produce an even greater effect than when used individually.10

Data spanning over 10 years offer cannabis-based medicine as a potential option for the improvement of other MS-related symptoms. In addition to reducing MS-related spasticity and pain, several studies found that cannabinoids also improved MS-associated sleep disturbances, urinary dysfunction, depression, and walking abilities.8

Disturbed sleep and urinary dysfunction burden the MS population and negatively impact patients’ quality of life. Recent studies found that MMJ use in MS provided statistically and clinically significant improvements in sleep disturbances and urinary dysfunction. 4,8,11 Improvements in urinary problems were secondary benefits in patients using MMJ to relieve spasticity.  Yet, it offers a solution for another debilitating symptom of MS, even in the absence of spasticity. 4,11

While this data may not be sufficient to conclude quite yet, these findings offer promising starting points that support the need for future research on using MMJ for MS symptoms.

MMJ + MULTIPLE SCLEROSIS 

People looking to mitigate symptoms of MS with MMJ should tailor choices specific to their symptoms. As MMJ may be a considerable alternative based on existing evidence, marijuana products are effective for treating symptoms of spasticity and pain but not effective for MS-related tremors or urinary incontinence. 

While there is no clear, evidence-based dosing recommendation, patients have found a range of 2.5mg to 10mg of THC to be effective for relief of spasticity and pain related to MS10, which is consistent with Nabiximols’ dosing.8 THC-dominant strains have demonstrated efficacy for MS-related pain and spasticity. For maximal benefit and greater entourage effects, it is recommended to utilize several different THC-dominant strains. Commonly blended strains include Blue Dream, Trainwreck, Bubba Kush, and OG Kush.10 When anti-inflammatory effects are desired, strains with high amounts of CBD are recommended, as well as those with relatively high amounts of limonene and myrcene.10

Another consideration to keep in mind when using MMJ for MS is the route of administration. Although orally ingested and inhaled forms of cannabis have been found effective, studies have determined that inhaled delivery of cannabis provides the greatest relief of spasticity. It has also been found that ingesting cannabis sublingually is more effective than other orally ingested cannabis.10

LIMITATIONS, but HOPE. 

Although marijuana has been used medicinally for thousands of years, the use of medical marijuana is mainly limited by a lack of high-quality evidence. Clinical cannabis research has been restricted, given its federal classification as a controlled substance. While clinical trial data for medicinal uses of marijuana may be scarce, there is still an abundance of evidence supporting the use of marijuana for a growing list of conditions.

As a precaution, patients with MS should be aware of potential adverse effects marijuana may present, including new or worsening cognitive symptoms, psychosis, tolerance and dependence, as well as drug-drug interactions. If you or someone you love may be looking to incorporate medical marijuana in your treatment plan, we welcome you to contact us for a consultation with a Maitri Pharmacist or visit your closet Maitri location for an in-person experience.

REFERENCES

1. Walton C, King R, Rechtman L, et al. Rising prevalence of multiple sclerosis worldwide: insights from the atlas of ms, third edition. Mult Scler. 2020;26(14):1816-1821. doi:10.1177/1352458520970841

2. Pryce G, Riddall DR, Selwood DL, Giovannoni G, Baker D. Neuroprotection in experimental autoimmune encephalomyelitis and progressive multiple sclerosis by cannabis-based cannabinoids. J Neuroimmune Pharmacol. 2015;10(2):281-292. doi:10.1007/s11481-014-9575-8

3. National Multiple Sclerosis Society. What is MS? Accessed March 6, 2024. Available at: https://www.nationalmssociety.org/What-is-MS.

4. Torri Clerici V, Brambilla L, Politi PL, et al. Nabiximols oromucosal spray in patients with multiple sclerosis-related bladder dysfunction: A prospective study. Mult Scler Relat Disord. 2023;74:104711. doi:10.1016/j.msard.2023.104711

5. Rice J, Cameron M. Cannabinoids for treatment of ms symptoms: State of the evidence. Curr Neurol Neurosci Rep. 2018;18(10):50. doi:10.1007/s11910-018-0859-x

6. Nouh RA, Kamal A, Oyewole O, et al. Unveiling the potential of cannabinoids in multiple sclerosis and the dawn of nano-cannabinoid medicine. Pharmaceutics. 2024; 16(2):241. https://doi.org/10.3390/pharmaceutics16020241

7. Sirbu CA, Georgescu R, Pleşa FC, et al. Cannabis and cannabinoids in multiple sclerosis: From experimental models to clinical practice-a review. Am J Ther. 2023;30(3):e220-e231. Published 2023 May 1. doi:10.1097/MJT.0000000000001568

8. Chan A, Silván CV. Evidence-based management of multiple sclerosis spasticity with nabiximols oromucosal spray in clinical practice: a 10-year recap. Neurodegener Dis Manag. 2022;12(3):141-154. doi:10.2217/nmt-2022-0002

9. Anil SM, Peeri H, Koltai H. Medical Cannabis Activity Against Inflammation: Active Compounds and Modes of Action. Front Pharmacol. 2022;13:908198. Published 2022 May 9. doi:10.3389/fphar.2022.908198

10. Cannabis Pharmacy : The Practical Guide to Medical Marijuana. First. Black Dog & Leventhal; 2014.

11. Kim-Fine S, Greenfield J, Chaput KH, Robert M, Metz LM. Cannabinoids and bladder symptoms in multiple sclerosis. Mult Scler Relat Disord. 2021;54:103105. doi:10.1016/j.msard.2021.103105