New TMJ study may answer questions about pain

A new study about painful jaw problems could lead to a better understanding of chronic pain and pain disorders.

The results, recently published in the Journal of Pain, provide insights into potential causes of temporomandibular joint and muscle disorders, known as TMJ. Researchers believe their work, the first large scale study of its kind, could lead to new methods of diagnosing facial pain, predicting who is susceptible to them and new treatments.

TMJ is not a single condition, but rather a group of conditions, categorized by acute pain in the jaw joint and chronic pain in the facial area. This cluster of jaw problems is the second most common occurring musculoskeletal condition that can lead to disability, trailing only chronic lower back pain. TMJ radiates through the jaw and muscles, causing pain and tightness in the jaw, neck, and ear. Symptoms include aching facial pain, difficulty chewing, ear aches, pain and tenderness in the jaw, headache, jaw locking, and an uncomfortable or uneven bite.

Researchers with the Orofacial Pain Prospective Evaluation and Risk Assessment study (OPPERA) followed an initial group of 3,200 pain-free people, aged 18 to 44, between three and five years. They found that chronic pain TMJ increased with age in women but not in men. This finding overrode assumptions that pain was greatest in childbearing years for women but decreased with age. The study also found genetic factors that were linked to chronic TMJ. These genes were identified, resulting in the possibility of creating drugs for these and other chronic pain conditions that are related to TMJ.

“This novel study will also allow us to learn more about pain disorders in general, and will improve our ability to diagnose and treat chronic pain conditions across the board,” said Dr. William Maixner, program director for the study and director of the Center for Neurosensory Disorders at the University of North Carolina at Chapel Hill School of Dentistry. “OPPERA is allowing us to study potential biological, psychological and genetic risk factors over a longer period of time, so we will be able to better evaluate the association of these factors.”

While trauma is often the cause of TMJ, there are many times when the cause isn’t clear. The Mayo Clinic states that some of the reasons for jaw pain, tightness, and clicking include the disk eroding out of alignment, a damaged joint, arthritic damage to the cartilage of the joint and fatigued muscles that should be stabilizing the joint. Simply put, even every day occurrences such as grinding your teeth at night or clenching your jaw may lead to the condition.

Perhaps the most outstanding finding in the study was finding a range of biological and psychological factors that contribute to the pain of the condition. People with TMJ are more sensitive to pain, even just mildly painful stimulation, than those that do not have the condition. They have a higher heart rate that increases greater during stress. They are also more aware of their body’s sensations than those without TMJ. These findings may conclude that TMJ is partially connected to the ability to suppress pain and the perception of pain.

Why the focus on medical cannabis?

I know it seems like I've been posting a lot about medical cannabis lately, but there are several studies being publicized at this time.  I believe, if it works, it works, so I have no problem with publicizing these studies and writing about medical cannabis.  I will soon be focusing on other areas of treatment of chronic pain, and have in my past posts.  A number of topics can be found in the archives.

Cannabis and California’s Physicians: A New Perspective

The following statement appears in the December edition of San Francisco Medicine, the journal of the San Francisco Medical Society.

Time for New Perspectives

CANNABIS AND CALIFORNIA’S PHYSICIANS


Steve Heilig, George Fouras, Donald Abrams, and David Pating

There has long been a “drug war” surrounding marijuana, not only in terms of the plant’s legal status but also in words.  As the California Society of Addiction Medicine observes, “Reasonable dialogue regarding marijuana use has historically proven extraordinarily difficult.”  The result is a longstanding stalemate and various symptoms of “reefer madness,” but with a growing consensus that our nation’s marijuana policy has not served us much better than the failed experiment with alcohol prohibition many decades ago.

Most recently, there was this headline: “California Medical Association calls for legalization of marijuana.” It was a cover story in the Sunday Los Angeles Times in October. As the CMA is a large, mainstream medical society, this caused quite a stir.

The four authors of this article served as San Francisco’s representatives on the CMA’s “Technical Advisory Committee” (TAC) tasked with drafting “a comprehensive white paper recommending policy on marijuana legalization and appropriate regulation and taxation.”  The TAC was “selected to represent CMA in the areas of science, ethical affairs, public health, addiction medicine, and expertise in the use of cannabis.”  We met five times; the deliberations were sometimes contentious but each member agreed sufficiently to endorse a final report to the CMA board of trustees.

Our 14-page report, titled “Cannabis and the Regulatory Void”, was submitted to the CMA’s Board of Trustees and approved, unanimously, in October. Reactions from all sides were immediate.  The CMA was called “irresponsible” and at least one opponent utilized the cliché “What are they smoking?”  But there has also been much positive response as well, with editorials saying we took “a bold step” towards “a prescription for the medical pot mess” and that that the CMA’s “traditionally conservative doctors” are “simply acknowledging the obvious: Our current laws and the resulting war on drugs aren’t working.

“1. Impact on Cannabis use:  The primary concern regarding “legalization” or any lessening of legal penalties regarding cannabis is that it might increase use, particularly among teens.  We share such concerns, especially in light of growing evidence regarding negative effects on neurodevelopment.  But there is no good evidence that laws have much effect on use; in fact, long evidence is that our punitive approaches have little deterrent effect.  Thus we should seek approaches which maximize knowledge about the impacts of cannabis use, and which do not worsen the problem by criminalizing otherwise law-abiding people, kicking kids out of schools to no productive end, wasting resources, and hampering research.  Evidence-based drug education is difficult but likely to be at least as effective as legal approaches – and likely more so.

2. Resources and costs:  Enforcing largely futile laws is expensive, especially when prison is involved.  Appropriate treatment and education is far more cost-effective. While our report recommends an approach closer to that taken towards alcohol, at least for adults, we have no illusion that such an approach is easy or ideal, or that the taxation we endorse will be a simple matter or yield massive funding.  But we are confident that it will be more cost-effective than longtime, failed “drug war” or prohibition-type policies.  And very importantly, the funds saved and generated should be directed towards treatment of addiction.

3. Medical Marijuana: We join the many experts and organizations holding that cannabis be placed in a less restrictive category that would facilitate more research.  And while we support some legal medical use of cannabis such as allowed since 1996 in California, we note that a decriminalization approach would have the salubrious effect of lessening or even eliminating the need for physicians to serve in the oft-uncomfortable “middle man” role of “gatekeeper” for medical use of cannabis – and also allow for more rigorous regulation of questionable practices at “cannabis dispensaries.”

An ever-growing roster of medical, legal, political, and other authorities of all political stripes feel that the time has come for a serious change in our drug laws, especially with respect to cannabis.  We have joined them, as has the CMA.

Interestingly enough, another new CMA policy was independently adopted this year, which could have served as a preamble to our own report:

MEDICAL VS. LEGAL SOLUTIONS TO DRUG ABUSE: CMA encourages the federal government to re-examine the enforcement- based approach to illicit drug issues (“war on drugs”) and to prioritize and implement policies that treat drug abuse as a public health threat and drug addiction as a preventable and treatable disease.

We agree, and know that many others do as well.  We hope our elected leaders will listen.

***Steve Heilig is with the San Francisco Medical Society and editor of the Cambridge Quarterly of Healthcare Ethics.  George Fouras is a child and adolescent psychiatrist and President of the San Francisco Medical Society; Donald Abrams is chief of Hematology-Oncology at San Francisco General Hospital and a leading medical cannabis researcher at the University of California, San Francisco; David Pating is an addiction psychiatrist and past-president of the California Society of Addiction Medicine. Their opinions here are their own and not necessarily representative of their affiliated organizations.
For more information:
The California Society of Addiction Medicine:
http://www.csam-asam.org/

Speaking out against a stigma

Terry Bremner smokes his marijuana pipe in Halifax parking lots and quiet woods, even though he is legally allowed cannabis to dull the pain of fibromyalgia.

Until now, his two adult sons didn't know. Nor did his neighbours, or the parents of the preteen football players he coaches.

But he thinks it's time to speak up against the stigma that lumps medical users with recreational ones.
As president of the Chronic Pain Association of Canada, headquartered in Edmonton, Bremner, 50, visits chronic pain sufferers across the country talking about marijuana as a medical option, especially for those who experience side-effects from strong opioids.

"I was begging for pain meds," said Bremner, who was 34 and working in St. Albert when he was in a head-on collision in 1995. Doctors didn't diagnose him with a mild traumatic brain injury and fibromyalgia until two years later.

Bremner tried Tylenol 3s, morphine, Demerol and Prozac. A psychiatrist suggested shock treatment.
Instead, Bremner started sneaking off for a joint, which helped interrupt his fixated thoughts of pain, his worries about making ends meet and his fight for benefits.

When Bremner moved back to Nova Scotia in late 1997 with his wife and two children, he couldn't find a doctor willing to take on his complex needs. Initially he turned to the streets to get his small supply.
His supplier got busted.

Then, his wife found out. "She wasn't impressed," he said.

At least not until he discovered the compassion club in Halifaxthat sold marijuana illegally to people with documented health problems - and then only in clandestine handovers.

Bremner could only afford 10 grams a month, and would quickly run out. He enrolled in a two-year study to try the government's marijuana. "It was total garbage," he says, but it was free.

Eventually, Bremner got his federal licence to use the drug. He has been waiting two months for a renewal. Then he will once again order his supply from Victoriabased MedMe, a company that supplies multiple strains of marijuana.

Bremner looks for the right combination of Sativa strains, to boost energy, and Indica strains, to bring sleep and relaxation. Some types help with chronic pain; others work better for patients with cancer, HIV or other severe diseases. Health Canada's one-size-fitsall approach simply isn't adequate, Bremner said.
His wife now understands the medical need. Bremner plans to explain it soon to his two sons.

"I have been asked to be a voice" for chronic pain sufferers, Bremner said. "Maybe it will attract more attention to help more individuals, people like myself who need this medication."