Last month, I talked about hepatitis C and pain, and presented information about over-the-counter and prescription pain medication. Nonsteroidal anti-inflammatory drugs (NSAIDS) and opioids are effective painkillers, but they are associated with the risk of medical complications. This month I focus on pain management techniques that have little or no risk of injuring the liver or other organs in the body. I start with the controversial one—marijuana.

Marijuana (Cannabis sativa) is slowly emerging from its status as the cause of “reefer madness” to a more reputable one showing potential medical benefits. However, before running out and buying some weed and a bag of Cheese Doodles, let’s explore these questions:

  • Is marijuana effective for reducing pain?
  • What is marijuana’s affect on the liver and hepatitis C?

First, let’s get one big frustrating fact out of the way: Marijuana is classified as a Schedule 1 drug. Drugs with a schedule 1 designation are deemed as having a high potential for abuse and no accepted medical use. Marijuana is tucked in there along with heroin, LSD, peyote, and ecstasy. Politicians determined this, not scientists. Because of this classification, marijuana is nearly impossible to obtain and test in clinical research. The bureaucracy is enormous, and permission is hard to get. In 2010, Time magazine summed it up this way, “Pot is listed as Schedule 1 because science hasn’t found an accepted medical use for it, but science can’t find a medical use for it because it is listed as Schedule 1.”

It is hard to imagine that marijuana is classified as a Schedule 1 drug when there has never been a reported death from marijuana overdose. Compare this to annual deaths from acetaminophen (300) or nonsteroidal anti-inflammatory drugs (7,000-10,000), and opioids (16,000). Compare marijuana’s zero deaths to those from legally obtainable substances, such as alcohol (88,000) or tobacco (480,000 including second-hand), and cannabis seems much safer.

This is not to say that marijuana isn’t without risk. In Colorado, two cannabis-related deaths are under investigation; one a suicide, the other a homicide in which other substances were involved. Also disturbing is the fact that the number of auto accidents have risen in Colorado since the legalization of pot.

These few deaths are hardly worth condemning pot for, especially since marijuana use may be causing a drop in the number of deaths from prescription opioids. States with liberal marijuana laws had a 25 percent reduction in opioid deaths. Cannabis is also associated with lower death rates in patients with traumatic injuries. That is just the beginning. The potential benefits are so many, that U.S. Surgeon General, Vivek Murthy said, “We have some preliminary data showing that for certain medical conditions and symptoms, marijuana can be helpful.”

Is marijuana effective for pain? Yes! I could write pages on this. The bottom line is that cannabinoids (a chemical compound found in a number of plants, including Cannabis sativa) interact with specific receptors in the brain. This appears to reduce pain and inflammation.

Will marijuana cause liver injury? It’s not well researched, but probably not. A Canadian study of 690 participants led by Laurence Brune and colleagues found, “Marijuana smoking does not accelerate progression of liver disease in HIV–Hepatitis C coinfection.” (Clinical Infectious Disease, Sep 2013). Previous studies have had mixed results.

What is marijuana’s effect on hepatitis C? The studies have been mixed. There is some research suggesting that marijuana may lower immune response. However, cannabis is being used in cancer studies with favorable results. In short, we don’t know.

What are the downsides of marijuana use? There are quite a few, such as risks of addiction, cognitive impairment, increased bleeding risks, etc. Frankly, we don’t know all the risks since marijuana has not been rigorously researched. I suspect that a day will come when marijuana will come with a paper insert that will list all the potential drug interactions, side effects, and warnings. Until then, keep this in mind: We don’t know if cannabis interacts with hepatitis C medications. Marijuana may interfere with drugs that are metabolized via the liver’s cytochrome P450 enzyme system. This may affect the dose of your hepatitis C medications. If you use marijuana, work with a doctor who will prescribe it, and show you how to use it medically and responsibly.

Note: If you are on or are being considered for liver transplantation, marijuana use can be a disqualifier. The state of California recently introduced legislation to prohibit marijuana use as a factor for disqualification for organ transplantation. Other states may follow suit, especially in the light of Congress’s latest legislation banning federal interference on state medical marijuana laws.

Some insurance companies and state Medicaid programs are requiring drug testing prior to approval of hepatitis C treatment. If your medical provider has prescribed treatment and you use pot, find out if there will be drug testing. If so, educate yourself about the washout period, or how to pass the test; it varies depending on how often you use marijuana.

Drug-Free Pain Control
Ideally, relieving pain without drugs is the safest approach. The trick is to work with a specialist who is trained in the art of introducing drug-free pain measures while slowly reducing pain medication. All sorts of drug-free techniques are used, such as acupuncture, massage, hypnosis. Below are three drug-free techniques worth considering.

  1. Exercise: I was surprised to learn that exercise topped the list of ways to reduce chronic pain, particularly arthritic and inflammatory pain. Exercise also helps fibromyalgia, migraine headaches and back pain. Aerobic exercise seems to be the best, and the intensity is determined by what you can tolerate. Walking is great exercise because it doesn’t require anything more than a good pair of shoes, sunscreen, and a safe place to walk. Gardening, dancing, bicycling, swimming, yoga, and tai chi are other fun ways to stay fit. If you are new to exercise, be sure to talk to your medical provider before starting. Start slow and only do what feels comfortable.
  2. Meditation: There are countless studies documenting meditation’s profound effect on reducing pain. Personally, I couldn’t imagine sitting still while relaxed, let alone in pain, so I had to experiment with this one myself. It works. It wasn’t as good as a spinal block or sedation, but it was free and without risk. There are many ways to meditate, but probably the most well-known in the U.S. is mindfulness-based stress reduction (MBSR) developed by Jon Kabat-Zinn. MBSR is taught in hospitals, clinics, and communities.
  3. Quitting Smoking: In “Prevalence and risk factors for patient-reported joint pain among patients with HIV/Hepatitis C coinfection, Hepatitis C monoinfection, and HIV monoinfection,” Alexis Ogdie and colleagues reported that hepatitis C patients who smoked, had higher levels of joint pain. (BMC Musculoskeletal Disorders 2015) (See review of this article by Alan Franciscus here.) Granted, the study did not show that tobacco cessation would reduce pain, but we all know that smoking presents huge health risks. If you do decide to quit, seek professional help. Perhaps MBSR and exercise will help.

Final Words
I have tried to simplify a very complicated subject. Pain management deserves more than I gave it here. In nursing, I learned that pain is the fifth vital sign. In short, pain should be taken seriously. However, the tragic reality is that pain is understudied and poorly misunderstood. Some physicians over-prescribe painkillers; some under-prescribe them. The bottom line is that if your pain is not well controlled, ask to see a pain specialist.

This article is reprinted from the HCV Advocate, July 2015. Copyright 2015 with permission from the HCV Advocate and Lucinda Porter.