Parkinson's Disease and Cannabis
Parkinson's Disease and Cannabis - Interview with Joseph Friedman, RPh
Every nine minutes someone is diagnosed with Parkinson's Disease. Approximately 900,000 people are living with Parkinson's in the United States and by 2030 that number is expected to reach 1.2 million.
In the passage of state legislation enabling the use of cannabis for palliative care stories of patients with diseases like Parkinson's were referenced frequently. In Oregon patients can qualify for the Oregon Medical Marijuana Program if they suffer from a "degenerative or pervasive neurological condition", which would include Parkinson's. It's been years since the OMMP program was created and included Parkinson's, so today we're going to fast forward and revisit this condition and review the latest research on cannabis for these patients. To help me with this, I have with me a fellow cannabis pharmacist, Joseph Friedman. Joseph is a pharmacist with decades of experience helping patients in both the community pharmacy setting and in dispensaries in his home state of Illinois.
Click below to listen to our interview or read on for the transcript.
More About Joseph Friedman, RPh
Joseph Friedman, R.Ph. MBA, is founding member and was a principal at Professional Dispensaries of Illinois, (PDI) Medical LLC. From the moment Illinois’ Medical Cannabis program was signed into law, he became deeply involved in the complex process of positioning himself as a medical expert on cannabis.
Through Friedman’s efforts, PDI Medical became the first accredited dispensary in the nation through Ohio based NMMAO (National Medical Marijuana Accreditation Organization). Friedman orchestrated the first ever pharmacy student clinical rotation at a medical cannabis dispensary in collaboration with Chicago’s Roosevelt University College of Pharmacy and Chicago State University College of Pharmacy.
Passionate about patients, pharmacy and pharmacy students Friedman works tirelessly to advance cannabis medicine research and education. Read more about Joseph and his work here or connect with him on LinkedIn.
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Full Interview Transcript
Hello and welcome to the latest installment of the Client Corner Blog. Today we have a research and condition focused conversation on the use of cannabis in Parkinson's disease. Parkinson's disease is a devastating degenerative neurological condition that eventually impacts almost every muscle in the body, leading to tremors, stiff limbs, difficulty walking and talking.
The Parkinson's foundation estimates that in 2020, over 900,000 people are living with Parkinson's and that by 2030, that number will climb to 1.2 million.
In the passage of state legislation enabling the use of cannabis for palliative care stories of patients with diseases like Parkinson's were referenced frequently. In Oregon patients can qualify for the Oregon Medical Marijuana Program if they suffer from a "degenerative or pervasive neurological condition", which would include Parkinson's. It's been years since the OMMP program was created and included Parkinson's. So today, we're going to fast forward and revisit this condition and review the latest research on cannabis for these patients. To help me with this, I have with me a fellow cannabis pharmacist, Joseph Friedman. Joseph is a pharmacist with decades of experience helping patients in both the community pharmacy setting and in dispensaries in his home state of Illinois. I'm so excited to have Joseph with us today. Joe, thank you so much for being with us.
Abby, it's wonderful to be here, and thank you.
Thank you! I think let's start off with a little bit about you so our readers can understand where you're coming from because the world of pharmacy is so vast.
You've had experience in many aspects of patient care, pharmacy, cannabis - so elaborate on that for me, and tell us about yourself and what you're working on today.
I will. Well, you know, I started in pharmacy many years ago, and I've probably done everything that you can do, or maybe not everything, but most things you can do in the profession of pharmacy, and that includes retail hospital, homecare, I mean, just have done a lot.
In 2013 I was in, I saw a segment on 60 minutes about the green rush in Colorado. And I thought okay, and I was aware that there was medical cannabis legislation coming to Illinois. And I thought, wow, that would be, you know, a pretty cool thing to get into, although I didn't know that much about it. And so I started doing the research in 2013. And, you know, by 2015, applications had come out. And I put together a group of some partners and together we wrote a 400 page application.
Yeah, it was it was huge! And, you know, we applied for three dispensary licenses in Illinois, with the idea that if we got one, we would consider that a success. And we did get one. And so we opened our doors on December 21, 2015 to help patients with medical cannabis.
Oh, that's, that is fantastic. I always - there are so many different types of consumers and provider groups in the cannabis industry that kind of take with them their own experience. And as a pharmacist, you know, I'm a little biased, but I love to see pharmacists in this space, and hear what they're doing, because I think they have such a unique community perspective.
So I think so to take us over to our discussion today on Parkinson's. Can you help us frame this discussion a bit just for readers who may not be familiar by giving us a global picture of Parkinson's disease? I talked about it a little bit at the top. But as a pharmacist, can you break it down for us in terms of what's happening in the body but also what does this mean for somebody living with Parkinson's? What does it mean for a typical patient and how it looks in their day to day?
Sure. And you know, and you did touch on this at the beginning, but I'll let you know, take it from there. You know, every nine minutes, a patient is diagnosed with Parkinson's disease in this country.
It's a type of movement disorder that can affect the ability to perform common daily activities. It's chronic and progressive, meaning that the symptoms become worse over time. And you know what - the drugs that are used for Parkinson's do work initially, but over time, the condition becomes worse and the drugs become less beneficial.
So Parkinson's is characterized by a common motor symptom, which is manifested by tremors. These tremors are in the form of rhythmic shaking. So Parkinson patients also experience a lot of stiffness, rigidity of the muscles, slowness of movement, called bradykinesia. But it can also manifest in non-motor symptoms that include issues with sleep, constipation, anxiety, depression and fatigue.
Though it's uncommon, Parkinson's can also affect young people. There's an estimated, you know, and I think Abby this is close to your number - 1 million people, right now, with Parkinson's living in the US. And more than 10 million people worldwide. Most people who develop the symptoms of Parkinson's disease do so sometime after the age of 50. But as I mentioned, it can affect younger people as well. So approximately 10% of Parkinson's diagnosis occur before the age of 50. And those diagnosis are called early onset or young onset.
And what makes Parkinson's disease distinctive from other movement disorders, is that cell loss occurs in a very specific region of the brain called the substantia nigra. These nerve cells or neurons in this region actually appear dark under a microscope. So that's the substantia nigra - it's Latin for 'black substance'.
So these dark neurons produce a specific type of neurotransmitter called dopamine. And I think you know, all of us are familiar, dopamine is sort of like the reward center, you know, in the brain. And that neurotransmitter dopamine also helps regulate movement. And so the loss of dopamine is the reason that many treatments in Parkinson's disease are intended to increase dopamine levels in the brain.
Future research will hopefully tell us more about alpha synuclein.
Can say that back one more time? Alpha synuclein?
Yeah - alpha synuclein. In addition to decreases in dopamine and the cells that make the dopamine, there is ongoing research about this alpha synuclein. We do not yet know what this protein does in the healthy brain. But in Parkinson's disease, it clumps up in what are called Lewy bodies, L-E-W-Y bodies. And you know, it's interesting what, you know, when I heard about Lewy bodies, I remember I had a patient with Lewy body dementia. And you know, this is this is a degenerative condition with many similarities to Alzheimer's disease, but it takes hold much more quickly. Dementia develops as nerve cells die or deteriorate, and doctors really don't know what the causes are. There's no cure for Lewy body dementia, but medications can help moderate some of the symptoms. It's difficult to identify, but a combination of symptoms can help can help doctors in their diagnosis.
I had this one patient with Lewy body dementia. And all we were able to do for him is really helped with some of the, you know, palliative of side of, of the symptoms he was experiencing, and he eventually passed away. So it was pretty sad.
So researchers believe that this alpha synuclein buildup contributes to the cause of Parkinson's disease, and that it may be possible to develop new treatments based on this idea.
Wow, thank you for that. That is really helpful. And yeah, when you were saying Lewy bodies, it's like, I think I've only heard of that in the context of dementia. I haven't heard that in the context of Parkinson's. So that's really helpful to know and a good point for me.
I really like what you said about the statistics of younger people getting Parkinson's and early onset, because I, I think that is a challenge for some folks living with these chronic conditions, especially who are younger. They are put in this group with, you know, the 65 plus or older people and I think kind of, you know, the MS patient advocates have done a lot of work around that of, you know, you see a lot of advocacy for younger people with MS. And so it's good to know that there's also this whole group of early onset patients. Since they are living with this disease, probably facing very different challenges than their older counterparts.
Putting cannabis aside for the moment - I think you mentioned in one of your, your earlier overviews - the traditional treatments for Parkinson's are highly individualized and include prescription drugs, but also a bigger picture of physical therapy, occupational therapy, even sometimes surgery with CNS stimulating devices. But the mainstay, gold standard for Parkinson's is a drug called levadopa. The Parkinson's foundation finds that almost 90% of patients will use levodopa at some point in their treatment. So can you tell us a little bit about what this drug does? How it works, how well it works, and what are some of the side effects with it?
Sure. Well, you know, let me just start sort of at the beginning - carbidopa is probably the oldest mainstay medication in Parkinson's.
Oh yes, start with that.
It's got to be taken together with the levodopa to be effective. Levadopa is the metabolic precursor of dopamine, you know the neurotransmitter that's gets depleted in Parkinson's disease. The use of lone carbidopa really has no effect on Parkinson's symptoms such as shakiness, stiffness, and difficulty moving.
So as I mentioned before, you know, Parkinson's disease is thought to be caused by too little of, you know, dopamine in the brain. And so levadopa is, you know, is that metabolic precursor and is converted to dopamine in the brain, helping to control you know, movement.
Carbidopa prevents the breakdown of the levadopa in the bloodstream, some more levodopa can enter the brain. Carbidopa can also reduce some of the levodopa side effects such as nausea and vomiting. Some patients may experience a weaning off or worsening of symptoms, before the next dose is due and this is called an on off effect, and that could occur in which sudden short periods of stiffness occur.
It's best to avoid a high protein diet, which could decrease the amount of levodopa that the body takes in during treatment. And it's always a good idea to separate the dose of this medication by as many hours as possible from any iron supplements or products containing iron such as multivitamins are minerals. So the patient may take iron, but you know, they have to take it at a time when they're not taking their drug.
In time, most if not all Parkinson's disease, patients will experience a worsening of symptoms that will not be addressed by increasing the dose of the carbidopa and levodopa. At that point other drugs will be added to address the worsening dyskinesia, which are which are the sudden uncontrolled movements. One drug to add is Gocorvi, which is meant to increase the effects of dopamine in the brain. Another drug that's out there is Kynmobi which is a sublingual medication that is a dopamine agonist indicated for acute intermittent treatment of 'on/off' episodes in patients with severe Parkinson's disease.
So I mentioned severe. So 'off' episodes are defined as patients experiencing hypomobility for an extended period of time such as an entire morning. And this can occur when standard Parkinson's disease medications are wearing off.
So it's a very fine balance between 'on' times and 'off' times, and I've heard patients describe it. As you know, they feel like a remote control when their medications are wearing off and they suddenly they're moving around moving around and then they can slowly get this hypomobility and then suddenly be frozen. Feeling like a remote control depending on how much dopamine is in their system.
Yeah, it's an on/off switch. Exactly. And that's what patients experience especially when their disease gets more serious.
So carbidopa/levodopa, is the mainstay - and then we have prescription drugs that kind of add in where carbidopa and levodopa is no longer effective.
Or in combination with carbidopa and levodopa.
Oh yes - or in combination. But eventually, as you say, this is unfortunately, a progressive degenerative disease. So now we have, of course, in the, in the bigger broader picture of you know, all of these states had medical cannabis programs, had medical cannabis legislation and those policymakers heard from patients with conditions like Parkinson's, about the palliative effects and about how cannabis was able to help them when even all this combination of prescription drugs and physical therapy and diet isn't enough.
So now of course to cannabis. I've got another statistic from you for the Parkinson's foundation. They surveyed physicians across 40, Parkinson's centers of excellence - these are the groups of doctors that routinely treat Parkinson's as their area of expertise. And 80% of physicians reported that their patients told them they were using cannabis, which that kind of blew me away. That's a lot.
So we definitely have a concentration of use and an interest here. So, in your experience, as a cannabis pharmacists working at your dispensary can you tell us a bit about your work with people living with Parkinson's? Where they were at, how they approached it, what their goals were with therapy, and you know, how they, how they approached it as part of their overall health and every day?
You know, with a with an array of motor and non motor symptoms, many people with Parkinson's disease have looked to medical cannabis, you know, to provide some kind of relief. And, you know, you said 80% of the patients that these doctors had were doing just that.
However, little is known about the effects of medical cannabis for Parkinson's symptoms, or the potential side effects and safety issues. To your point to address this, the Parkinson's foundation convened a group of experts and this was in early March 2019, in Denver to discuss available evidence for the use of cannabis for Parkinson's disease and the gaps in knowledge.
This group of more than 40 individuals that included physicians, basic scientists, a pharmacist of Parkinson's disease, Parkinson's disease nurse, industry members, nonprofit organizations, the PD community and foundation staff. So there was a lot of people that were there that were really had an interest in understanding this. The primary goal of these of this group getting together was to provide guidance to both people with Parkinson's and their physicians for the safe use of medical cannabis.
A secondary goal is to uncover gaps in knowledge that should be addressed through rigorous research studies. So regardless of whether a medical cannabis patient is approved for Parkinson's in the future, this will help to inform its use for Parkinson's disease so that is it is used in the safest most effective way possible.
The experts urged caution. You know, there's a lot of adverse effects, toxicity issues and drug to drug interactions, and they didn't fully know what this means for patients with PD, who are taking PD medications. The second top takeaway was given the lack of any clear data supporting the use of cannabis in PD, the foundation did not endorse its use for PD symptoms or to modify disease progression. So that's important because, you know, the lack of evidence, you know, just sort of says, this is a non-starter we need to do more research.
However, because they realize that people with PD are interested in trying cannabis products they provided guidance for both general safety as well as working with dispensaries. Some studies have suggested cannabis may be beneficial for non-motor symptoms such as sleep disturbances, pain, anxiety, and GI issues. However, these studies are generally small, uncontrolled, and are open label - meaning that both healthcare providers and patients are aware of the drug or treatment being given which could influence the results.
So more rigorous research is definitely needed to determine if there's any medical benefit. But the research itself has demonstrated some potential benefits such as reducing tremors plus reducing slow and an involuntary movements. Other benefits noted improvements in pain and sleep. However, there were potential side effects and safety issues on the lungs drug interactions as mentioned before, toxicity, dependency and addiction, plus other adverse effects such as fatigue, short term memory loss, dizziness, and behavioral and mood changes.
Cannabis can also cause anxiety and depression. So, you know, the lack of regulation made makes it very difficult to have consistency in products.
Yeah, definitely. And then I think that's a very important point that where the foundation is, and where that group is, is a place of acknowledging that there's a huge interest in this and the physicians acknowledging that this is being used by their patients, but they are not in the place of endorsement for it at all, so they are focused on the safety aspects around it. Is that fair?
Yeah, that's fair. It's just like, you know, you know, doctors that are involved with seizure disorders, you know, neurologists and such. You know, I mean, the cannabis is showing that it's reducing seizures in children, but you know, they're not going to go right out and endorse it because of all the potential side effects.
In your experience and community dispensaries how did you work with patients and what were their experiences with cannabis?
Well, you know, I had several Parkinson's patients, but this one, this one young patient really stuck out. She was getting, you know, her levodopa and carbidopa from a compounding pharmacy. And she was very exacting with everything that she was taking, she was, you know, the timing, the dosing, you know, the food that she eats, you know, she, she came out and she was very serious, she had all of these notes and records, and she wanted someone to tell her that you know, how to use cannabis that could help. And so I worked with her for several months, and, you know, she would make the long trip to our, to our dispensary, you know, to pick up particular products, and, you know, use them and then come back and we would discuss how it was helping her.
You know, unfortunately, you know, the, the symptoms got worse, and she had to increase her Parkinson's drugs. And, you know, the cannabis did help in some areas, but it really wasn't, you know, the, the silver bullet that that really made a big difference in her life.
Did it help her achieve, you know, any sort of treatment goals? Any functional goals that she had in terms of her sleep or her ability to, you know, work during the day or anything like that?
Well she was very active. She worked during the day, you know, and you know, but she was always very aware of the tremors coming and getting worse. And she was hoping that cannabis was going to help with that. Initially, it did. It did relax her and it did help with the tremors. But over time, you know, she had an up her doses of the PD medications. And, and then she stopped coming.
Yeah. Thank you for sharing that. That's, I think, actually kind of a perfect segue to our last question. So this is the crystal ball question. So this is Joseph's crystal ball. We don't hold you to any of these predictions. But we want to know - in the treatment guidelines for PD, where do you see cannabis medicine falling in those guidelines, you know, when the whole guideline body is updated - say 10 years from now.
There is this huge movement and all of the advocacy is trying to have cannabis fit somewhere - to have it not be a medicine of last resort. But like you said, it's not appropriate for the first line. So what's your what's your crystal ball telling you on where this might fit in the guidelines in for patients diagnosed with Parkinson's?
Well, well one of the things that cannabis does do is it activates dopamine. But if you have you know, if you don't have dopamine to activate, it's really not going to help.
So 10 years from now, what I envision I think there's going to be a lot more consistency of cannabis based products, you know, tablets and capsules and things that are going to be the same you know, batch after batch after batch - that doesn't exist necessarily today.
And so I so I believe 10 years from now we could see for Parkinson's patients - you know cannabis for symptoms cannabis for some of the non-motor type of symptoms. You know, the the sleep, the GI issues, things like that.
I don't believe it's going to be a mainstay to really help prevent the progression of the disease or the severity of it over time.
Okay - that sounds -
You know I would like to be wrong, I would like to be wrong.
You know I was going to say, I am always anxious to see research in this space. And I would also like you to be wrong, but based on, you know, the picture of research we have, which is limited, you know, that crystal ball look, sounds reasonable. It sounds reasonable. And, of course, we would like it to be more, but I can't disagree with your prediction today.
Well, you know, I don't want to be one of these, you know, cannabis advocates that say it's a cure all for everything. I don't think that's, that's just as bad as the opposition is who say it's the worst thing in the world. But I think somewhere in the middle with science behind it, it, you know, can be a drug that is used as as is either adjunct or mainstay for a lot of disease conditions going forward. We just need to get it legalized at the federal level.
Absolutely agree. Absolutely agree. And I think that is the perfect spot to end our interview today. Joseph, thank you so much for being on the Client Corner Blog. Thank you so much for your time. This conversation has been amazing and above and beyond where I had hoped to go today. So thank you so much!
Abby. It's been my pleasure.