The truth about treating epilepsy with medical marijuana- where do science and medicine stand as of today? Pediatric epileptologist, Dr. Eric Segal
Dr. Eric Segal was born and raised in New Jersey. He completed his Doctor of Medicine, at Albert Einstein College of Medicine, Yeshiva University, Bronx, NY. He completed his Pediatric Residency in The Children's Hospital at Montefiore - Bronx, NY, his Child Neurology Fellowship at Columbia University Medical Center - New York, NY, and his Clinical Neurophysiology training at Children's Hospital Boston - Boston, MA. He is Board Certified in Clinical Neurophysiology and the American Board of Psychiatry and Neurology - Special Certification in Child Neurology. His research interests include Metabolic Epilepsy and Epilepsy Surgery. In 2011, he was granted the American Epilepsy Society Young Investigator Award and in 2010 he was granted the Arnold P. Gold Foundation Gold DOC Award.
We asked Dr. Segal to talk to us about a topic that has been in the news recently on CNN and in many local newspapers. This is such a rapidly changing topic that in fact, while this newsletter was being edited, changes in the laws were happening overnight. On September 10, 2013, Governor Chris Christie signed into law that children with severe epilepsy syndromes in the state of New Jersey would now have access to medical marijuana. Dr. Eric Segal answered our questions about the usefulness of medical marijuana for treating epilepsy.
Is medical marijuana different than recreational marijuana:
Marijuana is derived from the Cannabis sativa herb. There are over 100 compounds within this plant (known as phytocannabiniods). Historically, the recreational and medicinal applications of C. sativa derivce from tetrahydrocannibinol (THC). THC is well known for its psychoactive properties and associated substrance abuse potential.
However, THC has also been used medicinally to treat pain, nausea, and appetite stimulation in cancer patients. This is the most common form of medical marijuana available.
However, recent attention has been given to a different phytocannabinioid known as cannabidiol (CBD). Unlike THC, CBD does not have psychotropic proprieterities and has a low toxicity and high tolerability in patients. This compound is now being given more attention as a possible anti-convulsant.
What research is there to support this or to disprove this?
Unfortunately, there are very few studies involving humans. Several different animal epilepsy models have demonstrated decreases in the most severe tonic-clonic seizures as well decreases in the high risk of death associated with seizures.
There have been several case reports and surveys attesting to a positive effect of either CBD or THC on seizure frequency. These case reports and surveys do suggest that C. sativa may be helpful in treating seizures.
However, there are only 4 randomized clinical trials in which patients were enrolled to determine if CBD is actually effective at reducing the number of seizures. By modern standards, these trials are low-quality. None of these trials measure seizure freedom at 12 months or seizure responder rate (how many patients had their seizure frequency cut by 50%) at 6 months. The largest study was of 15 patients. One of the studies was a "letter to the editor" and another was an abstract presented at a conference and was never published in a peer-reviewed journal.
Two of these trials demonstrated no benefit and 1 resulted in "some" reduction in seizure frequency. Two of these clinical trials test CBD for only short periods of time.
It should be noted that all of the studies demonstrated that CBD did not have any adverse side effects except for making 1 patient mildly drowsy.
What research is in the works?
Given the strict laws concerning C. sativa, it is very difficult to study different phytocannabinoids. However, GW Pharmaceuticals (UK) and Otsuka Pharmaceuticals (Japan) have funded CBD research since 2007 and will continue to until at least 2013. This research includes testing CBD compounds in patients with epilepsy as well as other neurological disorders such as multiple sclerosis.
How would a doctor go about prescribing medical marijuana as per New Jersey State law?
The law in New Jersey continues to change as new legislation is passed. As of now, the physician must be registered with NJ's medical marijuana program. The physician-patient relationship must exist of at least 1 year (at least 4 visits) and the patient must have a 'debilitating' illness. Medication-refractory epilepsy meets the State's criteria. Patients also must register with the State and have an active Registry Card.
The process for pediatric patients is much more involved and as of this interview may change based on new legislation passed by the State Assembly.
How would the dose and drug administration work? Is this smoked, taken as a pill, as a syrup?
The clinical trials mentioned earlier were tested in oral capsule form. However, NJ currently sells marijunana in bud or lozenge form. This may change with newly proposed legistation and include edible forms for the pediatric-age population.
Are there dangers in using medical marijuana and are there secondary negative side effects (cognitive or physiological)?
Unfortunately, the clinical trials we have discussed involve a small number of patients for a short period of time. While there were no clear adverse side effects beyond "mild" drowsiness, larger- longer-term studies are needed before this question can be answered confidently.
Do you think medical marijuana will become part of the armament epileptologists have at their disposal in the near future?
We are all looking for a treatment that has a low side effect profile that can eliminate seizures. With the lack of well-powered randomized studies (large number of patients, lack of bias, long study time), it is hard to say. There are clearly individual reports to suggest that CBD specifically may be an effective anti-convulsant for some patients. However, it is difficult to broadly apply this possibility to all patients with epilepsy. More studies need to be done and this can take some time to sort out.
Thank you, Dr. Segal for sitting down with us to talk about this very important and heated topic in a way that we can now all understand.
