By Jeffrey Fogel, MD, Member of the FPA Board of Directors

Dr. Jeffrey Fogel is an FPA Board Member and pediatrician who was diagnosed with trigeminal neuralgia (TN) in 2008 and geniculate neuralgia (GN) in 2013. He is the FPA Support Group Leader for the Geniculate Neuralgia Support Group and Co-leader of the Philadelphia Support Group. After 30 years in private pediatric practice in the Philadelphia suburbs, he had to stop practicing medicine in 2013 due to TN. He was active in the passage of Act 16 (2016), which legalized medical marijuana in the Commonwealth of Pennsylvania. He has spoken about medical marijuana at FPA conferences and hosted webinars on the topic.

It’s been nearly five years since the Facial Pain Association (FPA) published a Special Edition Quarterly journal (Summer 2019) that was devoted solely to medical marijuana. In that issue, we discussed the history and pharmacology of marijuana, the status of medical marijuana in the United States, travel restrictions, and three patients shared their experiences using marijuana for their neuropathic facial pain. Click here to read the Special Edition Quarterly.

Since that Special Edition Quarterly was published, the number of states that have initiated medical marijuana programs, as well as those approving recreational marijuana use, has increased significantly. 40 states and the District of Columbia now have some type of medical marijuana program. However, marijuana is still not approved for medical use in ten states: Idaho, Indiana, Kansas, Nebraska, North Carolina, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming.

The rules within the 40 states that permit medical marijuana vary greatly, including dosage of tetrahydrocannabinol (THC) permitted and medical indications for acceptance into a program. It is important to check with your individual state for more information about their particular program’s rules and regulations.

As someone who regularly receives questions on medical marijuana from fellow facial pain community members, I thought it might be helpful to answer the top three questions I get asked most often from others living with neuropathic facial pain.

What is the best form of marijuana to use?

To answer this question, one must consider three factors: onset, duration, and form. First, how quickly would you like the onset of pain relief to begin? Second, how long do you need the effect to last? Third, what form are you most comfortable taking and which one best suits your needs?

Let’s address the onset question first. There are three main delivery methods: inhalation, tincture, and edibles. Each has advantages and disadvantages.

Which form you should take depends on your need for immediate versus long-lasting relief. At one end of the spectrum, inhalation would be the best option for immediate relief, but you must first consider if you have any preexisting lung conditions, are in an environment where smoking is not permitted or appropriate, or simply just do not feel comfortable inhaling marijuana.

On the other end of the spectrum are edibles. They are best for those who have more chronic pain and are unable to dose medical marijuana throughout the day. However, because of the long latency and lack of a true peak-effectiveness, edibles are not considered a good choice for acute pain attacks.

Tincture products fall in the middle. They don’t provide the instantaneous relief that inhalation does, nor do they last as long as edibles. But they do provide an onset of pain relief much quicker than edibles and provide a nice peak, making them a good choice for acute pain episodes for those patients who are unwilling or unable to use the inhalation method.

I tried marijuana for facial pain and it didn’t work. Why?

The most common reason it didn’t work is because the product or dose was not correct for the individual. To better understand this, we need to recognize that marijuana is complex and not a uniform product.

To begin with, marijuana is composed of two main cannabinoids: tetrahydrocannabinol (THC) and Cannabidiol (CBD). THC is psychoactive and is composed of two different strains — Sativa or Indica. The Sativa strain makes you feel “high” or energetic. The Indica strain makes you feel mellow. A particular marijuana product can have one strain or the other. There is also a third option which is a hybrid of the two strains.

Then, there is the CBD component. CBD is not psychoactive, and while it has been shown to be helpful for conditions such as insomnia and anxiety, CBD alone has never been demonstrated to be an effective treatment for central neuropathic pain conditions, such as trigeminal neuralgia (TN). To treat a central neuropathic pain condition like TN, both THC and CBD are required. THC and CBD work in a synergistic manner, meaning they work better together.

Next, we must look at both the ratio and concentration of THC:CBD in the product. Taken together, these factors will impact both the efficacy as well as the side effects. To understand the difference between the ratio and concentration, think of a peanut butter and jelly sandwich. The ratio would be the amount of peanut butter there is compared to the amount of jelly. Is there the same amount (1:1) of each, or twice as much peanut butter as jelly (2:1)? Or five times as much (5:1)? A product with a lower THC:CBD ratio (such as 1:1) will have fewer side effects, but also may be less likely to provide pain relief than a product with a higher THC:CBD ratio (such as 5:1).

Lastly, we need to consider the concentration, which is the absolute amount of each component. Back to the PB&J sandwich analogy, did we make the sandwich with two tablespoons of peanut butter, or five, or ten? Obviously, the higher the dose, the greater the effect will be, but there is also the potential for increased side effects.

Now, with all these variables, it may be easier to understand that if one product didn’t work, you may need to adjust the strain of THC, the ratio of THC:CBD, or the concentration of the THC dose. Similar to the use of antibiotics for infections — just because one didn’t work doesn’t mean we avoid antibiotics altogether. Instead, a doctor will need to try something different to find the one that works for your particular situation.

The real advantage of having so many different dosing and delivery options is that it offers you the opportunity to tailor the product and dosing to meet your needs and lifestyle. For example, you could take one product during the day for acute pain episodes which allows you to work (e.g. tincture with Sativa), and a different one at night that lasts longer and helps you sleep (e.g. gummy with Indica). A gummy during the day could be ideal for chronic relief without the peaks and valleys that would be seen with the shorter acting products.

If I live in a state with recreational marijuana, why should I spend extra money for a marijuana card?

While on the surface it may seem unnecessary to spend extra money, there may be good reason to do so. If your state has a medical as well as a recreational marijuana component, check to see if they have kept the medical dispensaries separate from the recreational. As can be seen from the answers above, getting a product that works well for your particular type of facial pain can require dosing adjustments that may be beyond the ability of the typical recreational “budtenders” — dispensary staff members who can offer suggestions, answer customer questions, and handle and showcase marijuana products. There is a vast difference between using marijuana for its psychoactive effects versus using it to relieve intense pain while still allowing you to function and maintain your lifestyle. Medical marijuana programs are set up to provide you with the optimal product tailored for your condition and needs. In addition, some states permit those with medical marijuana cards to purchase and carry more product than recreational users.

Neuropathic facial pain is as complex as the options currently available to treat it, and medical marijuana is an option that has provided real relief for many people with facial pain. The FPA encourages you to be informed and armed with the tools needed to achieve pain-free days. Visit our library of medical marijuana resources.