Introduction to Multiple Sclerosis (MS)

Multiple sclerosis (MS) is an inflammatory neurological disorder. It is an autoimmune disorder (i.e. when the body’s immune system works against itself) characterised by multiple lesions on the nerves that form the central nervous system. These lesions can lead to neurodegeneration, which can result in many neurological defects, both physical and cognitive.

Due to its unpredictable nature, MS can present itself in a multitude of ways. Symptoms depend on which nerve is being affected.

The most common symptoms of MS

• Sensory disturbances (such as numbness or tingling),
• Mobility issues (due to weakness, loss of balance, fatigue, etc.)
• Problems with vision 
• Dizziness
• Sexual problems
• Urinary issues
• Bowel issues
• Depression 
• Anxiety

Less common symptoms include problems with

• Breathing
• Hearing
• Swallowing
• Speech,
• Suffering from headaches or seizures¹

Overview of Cannabis

Despite the connotations surrounding cannabis, it has long been utilised for its medicinal properties. It is also known as hemp and marijuana. 

Cannabis is most commonly found in the plants Cannabis sativa, cannabis indica, and cannabis ruderalis. It has been used therapeutically for thousands of years and was officially recognised for this purpose in the US for over a century before being banned. 

In 1985, pharmaceutical companies received approval to start work with Δ9-tetrahydrocannabinol (THC), and in 2012, medicinal marijuana once again became legal in the US. 

In addition to THC, medicinal cannabis can also be consumed in the form of cannabidiol (CBD) and synthetic cannabinoids such as nabiximols. THC is the psychotropic agent of cannabis, which makes us feel “high”, whereas CBD is the non-psychotrophic agent.⁵ Cannabis has been used in the treatment of many conditions, including chronic pain, PTSD, nausea, Parkinson’s, epilepsy, IBS, cancer, and MS². 

Potential benefits of cannabis for MS

There has been evidence to suggest that cannabis can relieve the following symptoms:³

• Muscle spasticity: cannabis may help reduce muscle stiffness. Topical CBD is the best form for tackling MS-related muscle spasticity
• Chronic pain: there has been next to little development in finding therapeutic relief for MS pain, cannabis has been shown to have analgesic properties for MS-related pain relief
• Bladder dysfunction: Urinary issues are prevalent among MS patients, with 50-90% developing symptoms within 6 years of having the disease. Cannabis in the form of nabilone can improve bladder issues that arise due to MS
• Sleep disturbances: Cannabis may improve sleep quality. Cannabis in the form of dronabinol has shown significant improvement in MS-related sleep problems
• Fatigue: Cannabis in the form of CBD has been shown to improve MS-related fatigue
• Mental health: Cannabis in the form of CBD may alleviate symptoms of depression and anxiety

Mechanism of action

Cannabis works on the human body by affecting the endocannabinoid system (ECS). The ECS controls the stimulation of nerve cells for processes like pain, eating, processing memory, and anxiety. 

It is regulated by the receptors cannabinoid-1 (CB1) and cannabinoid-2 (CB2). CB1 receptors are found in nerve endings and block the release of neurotransmitters.CB2 receptors are found in immune cells where they regulate chemical production and work to move immune cells in and out of the central nervous system.⁴

Routes of administration

Inhalation

Cannabis can be consumed in many different ways. Cannabis is typically ingested via smoking, as this allows rapid absorption by the body to reach the brain and circulatory system; however, there is concern about carcinogens and other toxic substances reaching the lungs so this is not the preferred route of administration for medical purposes. 

By mouth

Cannabis can be taken by mouth via edibles, oils, or capsules. Cannabis, when taken orally, takes a longer time to show effect than inhalation, however, the therapeutic effects are long-lasting as the half-life of cannabis ranges from 20-30 hours. Cannabis levels in the blood are maximum at 6 hours post-ingestion. It can be mixed with food or consumed as tea. 

Topical 

Cannabis can also be applied topically, such as cream or skin patches, for relieving arthritic pain. Topical use provides localised pain relief with minimal effects on the rest of the body. 

Sublingual (under the tongue)

Finally, cannabis can also be ingested sublingually, such as via lozenges or sublingual tablets. This allows for quick absorption through the mucous membrane in the mouth. However, there is difficulty in getting precise dosing with this route of administration. 

There are specific doses for variations of cannabis such as cannabidiol, dronabinol, and nabilone depending on the route of administration and indication. ⁶ These should be carefully explained to patients before starting the course of medication. 

Safety and side effects

The common side effects of consistent marijuana use include:

• Dizziness
• Dry mouth
• Feeling drowsy
• Developing cognitive impairment

Those who utilise THC may also feel psychotropic effects such as 

• Euphoria
• Paranoia 
• Impaired judgement⁷

There is a chance patients could face dependence on the drug. Patients could also experience symptoms of withdrawal such as irritability or sleep issues when not using the drug.

It is important to note the medication history before commencing the cannabis course. Cannabis can interact with other medications especially central nervous system depressants. 

Specific populations of people should avoid using cannabis, even for medical reasons. Such populations include pregnant women, people with a known history of substance abuse, or those who suffer from any psychiatric conditions. 

Legal considerations and access

It is important to consider that medicinal cannabis laws vary from country to country. Laws may also vary from state to state in countries separated into states such as India or US.

Patients should be utilising cannabis for medical reasons under the supervision of a healthcare practitioner, not only for legal reasons but also for the safety of the patient. The healthcare practitioner can help monitor the patient for any adverse side effects and can also help provide the patient information on how to access legal sources of medicinal cannabis. 

Using healthcare provider-approved sources of cannabis is important for ensuring the quality of the cannabis being used which can prove paramount for patient safety.⁸

Patient-centered guidance

As stated above, it is important to keep honest and open communication with your healthcare provider when taking medical cannabis, as they can help keep an eye on any adverse side effects and work to keep you safe. Open communication is the key to developing a safe personalised treatment plan with your doctor.

The general rule of thumb with all medication is to start the dose low and slowly increase it as necessary. Doctors should encourage patients to keep a diary of symptoms to assess the effectiveness and tolerance of the cannabis. 

It is important to note that patients do not need to take cannabis even if recommended by a physician if they do not want to. It would be worth looking into alternatives such as traditional pharmacological treatments (e.g. pain killers, muscle relaxants) or non-pharmacological interventions such as physical therapy, occupational therapy, or mindfulness-based therapies. 

Summary 

In summary, cannabis has proven to be useful in managing the symptoms of MS. However, that is not to say that it doesn’t come with potential side effects such as dizziness, Dry mouth, feeling drowsy, and developing cognitive impairment. It can be administered through many routes such as oral, inhalation, topical, and sublingual, The inhalation route has the most rapid onset of action while the oral route has the longest duration of action. The pros and cons of cannabis use to treat MS should be carefully discussed with a doctor before commencing treatment so that the patient is fully informed of the journey they have ahead of them.