Recently interviewed by MIDWEEK Magazine. Here is the complete interview.
What is your role/title?
I am a board certified pain medicine physician and owner of Hawaii Pacific Pain and Palliative Care. The focus of my practice is the care of patients with chronic pain. In addition, I have a strong interest in hospice and end-of-life care. This practice is done on a voluntary basis and is based in Waimanalo at the Native Hawaiian Model Agricultural Village called Pu’uhonua O Waimanalo. Nearly all fees generated by the advocacy and clinical practice for medical cannabis therapies are used for expenses and native Hawaiian programs.
Malama First Healthcare is a nonprofit initiative based in the village and its goals are to improve the health care of all Hawaiians worldwide. I serve as their chief medical officer on a voluntary basis under the CEO Dennis Kanahele. I have other businesses and sources of income, which allow me to be involved in these important projects. I feel very honored and privileged to be allowed to come into the village in Waimanalo as they have welcomed me into their Ohana.
Where did you receive your schooling/training?
I have been a medical physician for over 29 years since graduating from the University of Utah School of Medicine in 1984. My serendipitous life path to Hawaii has been quite unusual, full of unexpected twists and turns. I started medical school wanting to be a cardiologist and ended up applying to surgical residencies because I like surgeons better. I completed full training in general surgery in Los Angeles and plastic surgery in Utah. During my general surgery training I completed a one year plastic surgery research fellowship at the University of Southern California, after choosing it over a surgical oncology fellowship at the University of California at Los Angeles.
I had equal interest in both cancer surgery and plastic surgery but found dealing with patients with cancer too challenging at that time in my life. In Utah, I was able to train under internationally renowned hand surgeon Graham Lister. I finished my board certifications in both general surgery and plastic surgery and set up private plastic surgery practice in Las Vegas, Nevada. I practiced plastic and reconstructive surgery for six years until I underwent cervical spine surgery for herniated discs in the neck. The surgery left me with great neck pain and bodily muscle pain that prevented me from returning to the practice of surgery. After five years, I was well enough and fortunate to retrain in pain medicine at the University of Utah and in Salt Lake City with renowned pain medicine physicians, who have served as current and past presidents of the various prominent pain academies and societies in the United States. I feel quite fortunate to be friends with these distinguished individuals, as well as other equally prominent pain doctors in California.
I am a life member of the American Society of Plastic Surgeons. In addition, I hold current memberships in the American Academy of Pain Medicine, the International Cannabinoid Research Society, and the American Telemedicine Association. I was also a member of the United States Army Reserve Medical Corps during the 1990s serving as a surgeon in a combat support hospital unit, and received an honorable discharge at the rank of Major after my neck surgery. I feel a close affinity and responsibility toward those in the military when they separate from active duty, especially towards those with combat or service-connected injuries and conditions. My practice of medicine combines my extensive formal clinical training and life experiences with my personal experiences of learning to live with and overcome chronic pain. In fact, I would say that my personal experiences with pain have had a much more profound effect on the way I practice medicine than my formal training represented by the three board certifications.
How long have you been an advocate for medical marijuana?
I have been an advocate for the use of medical cannabis since 2008 when I was first exposed to a group of chronic pain patients on the Big Island of Hawaii who were using cannabis as their pain medication, either alone or in combination with pain pills. Having no personal experience with marijuana use, I found it quite fascinating that so many people found benefit and relief to their chronic pain conditions using cannabis. From there, my professional opinion evolved to the point of full political and medical advocacy. My training had taught me that marijuana was a gateway drug and had no medical use, which I learned to be completely false. In fact, during my training patients using cannabis were often denied opioid therapies and viewed as drug seekers and addicts.
During my training no one explained to me how it helped with the pain except one young man who suffered a severe neck injury in the Indonesian tsunami. Our addiction psychiatrists were forcing him to quit the use of cannabis before the group would prescribe opioids. Thankfully this is an out of date notion. These restrictions should never be forced upon any patients who suffer severe disabling pain. I am quite open-minded and a believer in the truth of patients’ experiences. As I interviewed more people, I became more convinced of its usefulness. I thought to myself that “thousands of Hawaiians can’t be wrong.” Patients were finding significant relief from chronic pain conditions and syndromes that otherwise have poor or no effective treatments. I then set off on an extensive endeavor to understand the medical science of cannabis, cannabinoid receptors, cannabinoid physiology, and cannabinoid therapies.
At first, I was shocked by the suppression of these safe and effective therapies because of irrational prejudices and political machinations. This was followed by professional and political disdain at government, politicians, entities, and corporations with ulterior motives who are willfully causing millions of people to endure greater suffering because of their direct interference in the practice of medicine and medical research, and their suppression and denial of these therapies. Thankfully, the Hawaii State legislature took a bold stand over a decade ago, in the face of great political pressure which still exists, and allowed for the legal use by chronically ill and disabled people. Although the program is not ideal, it does allow for its use in a legal sense.
Chronic pain is actually the number one medical condition in the United States with an estimated 75 to 100 million Americans living with it. At least 20 to 25 million Americans live with severe pain. In Hawaii, it is conservatively estimated that over 100 thousand Hawaiians live with moderate to severe pain from all causes including arthritic degeneration, trauma, metabolic such as diabetes, and cancer or its treatment. There would be greater than 100k “Blue Cards” in existence if all took advantage of the program.
There is a lot happening in the legislative arena regarding medical marijuana — where do things stand right now?
In 2013, two bills out of many were vetted in committee and passed by both the Hawaii State Senate and House of Representatives and are expected to be signed by Gov. Abercrombie. These bills dealt with the transfer of the program as well as improvements in the program as requested by patients statewide. The first and most important bill calls for the transfer of the medical cannabis program to the Department of Health. We hear that the governor supports this transfer and may have had a significant role in the matter beforehand. On behalf of my patients, I applaud him for that effort. Patients and physicians have requested this transfer for many years. It is more appropriate that a program for the health and medical welfare of patients be under the auspices of a health department and not law enforcement. These are health issues and not law enforcement issues.
More patients will participate in the program under the Department of Health. Many patients felt uncomfortable giving their personal information to the Department of Public Safety because of documented past leaks of confidential information. One can go through the testimony for these bills to understand the issues involved and the shortcomings of the Department of Public Safety.
My main criticism was their open and public disdain they demonstrated toward patients, physicians, the medical cannabis program, and the medicine itself. I resent their past attempts to criminalize the application process as well as any attempts by government to criminalize medicine and medical care. However, as far as I’m concerned it is “water under the bridge”, and in the spirit of aloha, we look forward to working with the Department of Health and to the significant improvements in the medical cannabis program.
The second bill attempted to improve significant shortcomings in the program itself. Safe access is our number one problem and concern. The state allows for the use of cannabis as a medicine but does not allow the access to a safe source of that medicine. Sadly, many of the improvements in this bill were taken away or diminished by people who ought to know better. I do not know what their ulterior motives are, but they seem to yet hold onto outdated biases and prejudice. I would think that when the Q Mark research polls show 80% of Hawaiians support the medical cannabis program AND a dispensary system, that our elected leaders would listen to the people and not their special interests, if they are interested in holding onto their jobs. From a medical point of view this is unconscionable. You would not make a diabetic grow and produce their own insulin or diabetes pills.
Currently, patients must obtain seeds, grow the plants, overcome the hostilities of growing by mold and bugs and then develop the yield that becomes their medicine. The majority of patients are not in a position to even get started. They don’t know how to grow. They don’t feel well enough to grow. They don’t have a place to grow. And there’s no guarantee that these efforts will result in an adequate medication supply. Most disparaging is the situation for cancer patients and anyone else that needs immediate access but is forced to procure through illegal channels the medicine that will be needed for chemotherapy or other treatments/medications with severe adverse systemic effects.
The use of cannabis is not an alternative to the use of traditional medications; it is a unique medication with unique medical effects, and mechanisms of action. It is not replaceable with anything else in existence. Immediate access can only be solved by a dispensary or retail outlet. We support legislation for a state run system. Hawaii can be put on the map as pioneering the most revolutionary dispensing system for medical cannabis by forming a state-run brokerage and clearing house. It could generate tax revenue, pay the local Hawaiian grower, and provide the medicine to patients all in the same day! The location and number of places for retail sale would be determined and limited by the Clearing House.
The other main issue is the failure to increase the qualifying diagnoses list, since cannabinoid therapy is uniquely helpful to a myriad of conditions. A large proportion of Hawaii’s cannabis users do use it for medical purposes in their lives but the law does not respect that and allow them to be legal because they are using it for unauthorized conditions not allowed by law. I personally feel that it is quite shameful that our combat soldiers are denied its legal use for PTSD after a decade of multiple deployments to the war zones of the last decade. They are not allowed to get Blue Cards for this difficult to treat condition, and are thereby denied an effective and safe treatment. Many feel it is superior to all other modalities in existence such as anti-depressants and anti-psychotics, which have questionable effectiveness and many adverse side effects.
Senator Espero has introduced bills to allow for PTSD but they have not made it through the legislative process. Again, we have politics interfering with medical science and medical care. I applaud Senator Espero for his efforts, and urge the rest of the legislature to give his bills the honest and sincere support that our soldiers deserve.
Where do things stand right now in the medical field?
Human cannabinoid receptors are found extensively in the brain, spinal cord, and peripheral nerves as well as on the cells of our immune system. Like opioid receptors, these cannabinoid receptors are involved with the suppression of pain signals to the brain and their modulation by the brain. The cannabinoids found uniquely in the cannabis plant are effective for the reduction of chronic pain and relatively safer than all other traditionally prescribed pain medicines. It is my opinion that within a span of a few short years, all chronic pain patients will be treated with a combination regimen of cannabinoid and opioid therapy because of its superior efficacy and safety. The medical research needs to be free from interference. Much more research needs to be done. This does not in any way mean that there is a lack of credible medical science and research literature. In fact, the International Cannabinoid Research Society provides much of this research leadership and provides an international platform for the free nonpolitical worldwide efforts in cannabinoid research.
Any physician who maintains that there is not enough credible research in existence for the medical use of cannabis is living in the medieval dark ages. I say wake-up! The earth goes around the sun! When Dr Raphael Mechoulam of Israel discovered many of these things in the early 1990’s, including the body's natural endocannabinoids, the entire field of cannabinoid medicine was changed. The identification of the cannabinoid CB1 receptor as a mediator of short and long-term synaptic transmission inhibition moved it away from predominance in the drug abuse field into the neuroscience mainstream where it has become a legitimate therapeutic target.
Further research has developed the physiological and behavioral tools that have provided important new insights into CB1 receptor function of mammals. This includes a role for learning and memory, analgesia, appetite regulation, and neuro–protection. Therapeutic agents are being developed as appetite stimulants, analgesics, anti-emetics, anti-diarrheals, antispasmodics, antitumor agents, anti-glaucoma agents, and agents for the treatment of diseases that are associated with inappropriate retention of aversive memories such as PTSD and phobias blocking. Other potential medications have even been proposed for such uses as appetite suppressants and agents that improve memory.
At the most recent meeting of the American Academy of Pain Medicine, Dr M. Moskowitz stated that “preclinical studies, surveys, case studies, and randomized double-blind placebo-controlled trials with cannabis have all shown its effectiveness in chronic pain conditions… cannabis works to settle down the processing of wind-up (or expanded pain processing in the brain) and is the only drug known to do so. It reduces inflammatory pain in the peripheral nerves, and has a unique mechanism for pain reduction unlike any other medicine. He concluded by saying that:
1. The scheduling of cannabis as a schedule one drug is a political decision, not a scientific one.
2. Marijuana research needs to be freely allowed by scientists studying all of its potential benefits,
3. It offers many potential alternatives to current medications for the control of neuropathic and non-neuropathic pain in malignant and non-malignant pain disorders, and called for more studies of both medical cannabis and pharmaceutical cannabinoids as pain medications and adjunctive medications.
4. Endocannabinoids and Cannabinoids are anti-nociceptive (anti-pain), anti-inflammatory, and anti-tumoral, and then asked the attendees ‘Why would we not study these things”?
5. The evidence for marijuana to have therapeutic utility for pain treatment is overwhelming,
6. NO DRUG has shown such broad utility yet been so sequestered from clinical availability because of politics.
What conditions/symptoms call for the use of medical marijuana?
There is a political answer and a medical answer to this question. I will first discuss the legal and politically determined diagnosis list. Hawaii is fairly restrictive in its use and number of diagnoses that qualify for a license by the state. In spite of all the medical evidence, the current legal diagnosis list is the same as it was in the late 90s when it was copied from the Oregon law. It covers the traditional illnesses, diagnoses, and conditions that were formulated by general patient experiences and limited to the most severe and disabling. These include cancer or malignant tumors, glaucoma, HIV and its effects and treatments, seizure disorders, and chronic conditions such as chronic disabling pain, cachexia or wasting, chronic nausea, and chronic muscle spasms, inflammatory bowel disorders, and multiple sclerosis.
The diagnosis of chronic disabling pain refers to pain of greater than 3 to 6 months duration and severe in nature, and this is not limited to any part of the body but includes everything from fibromyalgia, chronic migraine and headaches, chronic painful neuropathies, to failed surgeries of the spine and joints as well as to the various types of arthritis and joint destruction. It does not include acute pain from trauma and the healing process.
One of the legal qualifying hallmarks of pain is its disabling nature. This is a political overtone and makes no medical sense. In fact there have been attempts in the past by certain members of the legislature and law enforcement to criminalize the application process for this one unique medication that is certainly safer and more effective than many, if not all of the traditional medications. More shockingly, they attempted to increase the suffering and pain of a large proportion of Hawaii's population who are chronically disabled by pain by attempting to disallow the diagnosis of chronic pain. This would have disenfranchised thousands of legitimate chronic pain patients of their God-given naturally born rights to health and happiness by taking away their blue cards and forcing them to return to the illegal status. Again, this was purely political and made no medical sense. Within this decade, as traditional pharmacologic cannabinoid therapies come into being, the medieval mentality and folly of such an effort will be readily apparent and historically documented to the shame of those involved.
The medical indications for the use of medical cannabis are not limited to the above and should be greatly expanded. The most common indications medically indicated but not legally qualifying include sleep disturbances and insomnia as well as certain psychological diagnoses such as anxiety, depression, and PTSD. We also see requests for attention deficit disorder, bipolar disorder, and autism. These conditions can be mild to severe in nature.
How effective is medical marijuana compared with other painkillers?
The studies have shown that medical cannabis is as effective as opioid therapies. Many people are able to completely eliminate or significantly reduce their use of opioid pain pills. This eliminates or significantly reduces the numerous adverse side effects that opioids inflict. The major medical benefit to the withdrawal of opioids is the removal of the physical dependency, which patients and families fear and misunderstand. Most importantly, the mortal safety of the patient’s current opioid regimen is dramatically improved with the addition of medical cannabis by this reduction in opioid dosage.
Every day Americans are dying from the misuse and overdosing of opioid medications. Currently, there is an epidemic of prescribed opioid pill diversions which can lead to death or ongoing drug addiction. The use of cannabis in chronic pain also reduces the number of other types of medications needed for the coexisting sleep disorders, mood disorders, and myofascial spasms found in nearly all chronic pain patients. There are no other single medications in existence that can treat all these coexisting problems as well as the pain. The removal of these other medications also removes their inherent adverse side effects and any medications needed for adverse side effects, such as drowsiness, constipation or nausea.
Does this work for all patients?
That’s impossible to say because current patients are self-selected and only come to me usually after knowing that cannabis has worked for them. This is either from personal past use or by an offer from a compassionate family member or friend. However, there are patients who are new to cannabis and have no past recreational use. They are tired of their traditional medication regimens and the associated adverse side effects, or other treatments including surgery. They want to try something different and to see whether it works. Not one of these so-called newbies has reported to me that cannabis was not helpful. Some may prefer not to use medical cannabis due to uncomfortable feelings or dysphoria. Most only complain of access issues and not being able to grow an adequate supply. Not all pain conditions respond to opioid pain pills.
Chronic pain is distinctly different than acute pain, with which most people are familiar. They do not have the same etiology or cause, nor do they have the same mechanism of action. Most chronic pain conditions have a neuropathic component and increased processing of signals in the brain, or what is medically referred to as “wind up”. Cannabis or cannabinoid therapies are the only known medications to effectively treat “wind up”. Medical cannabis and cannabinoid therapies are uniquely suited to these conditions that do not have very good treatments otherwise.
Clinically I see excellent results with cannabis alone, as well as cannabis with opioids, taken either on a scheduled or as needed basis. Other conditions such as fibromyalgia, which is thought to be primarily a “windup” phenomenon, are uniquely treated with cannabis, and this is confirmed by dramatic improvements in their lives and well-being. There are other unique clinical situations where cannabis is particularly effective and superior to traditional medicines. I’ve personally seen patients with chronic pain and bipolar disorder show significant clinical improvement in both conditions with the use of medical cannabis. This is significant since traditional chronic pain opioid therapies are very problematic and only temporarily and partially effective in patients with bipolar or mood disorders.
Another unique clinical situation involves opioid withdrawal in patients with chronic pain. I have seen significant long-term improvement in patients with opioid misuse issues using a combination of Suboxone and cannabis. Finally, we find medical cannabis to be uniquely situated for the treatment of hospice and end-of-life terminal patients, regardless of the disease or condition.
Again, this single unique and safe medication replaces a handful of drugs that are commonly used in hospice patients. It treats their pain and sleeping problems, improves their appetite and strength, improves their mood, reduces anxiety, and reduces muscle tightness. It eliminates or significantly reduces the dosages of morphine and a patient’s subsequent narcotization until absolutely necessary. I will add that cannabinoid receptors are found in other areas extensively, such as in the large and small intestines. Edible cannabis-infused products, tinctures, and oils are ideal for diseases of the gut.
The main problem we face in Hawaii is that many of these products such as edibles and oils require more plant yield than what is allowed by law for one to grow and possess. Much of the discomfort in inflammatory bowel, irritable bowel syndrome, and celiac disease comes from uncontrolled spasm or irritability of the gut muscle by distention and inflammation. The intestinal paralyzing effect of opioids makes them very problematic in these conditions, yet cannabis is ideal. It can effectively treat the pain and spasm without incurring intestinal dysfunction and other adverse bowel effects as well as eliminating any habituation and physical dependency.
Why is medical marijuana so important in the healthcare field?
I think I have already answered question from a medical and scientific point of view. It is an effective and safe therapy that should not be denied to any human being. Government policies are directly interfering with medical science and research, along with clinical care. We are just beginning to unlock the secrets of cannabinoid physiology and potential therapies.
A critical mass of truth has been revealed and medical scientists and physicians are refusing to return to the dark ages of ignorance and prohibition. The prohibition of safe access is an ongoing major problem to patients in Hawaii and needs to be corrected by dynamic and “out-of-the-box” thinking. There are solutions to these issues. The concerns of cannabis habituation, dependency, and addiction, along with recreational or misuse in young people, are not valid reasons for the denial and suppression of these therapies for legitimate patients; otherwise no controlled substances would be allowed in clinical practice.
In addition, I have not dealt with the issues of legalization and decriminalization as they are outside the scope of this interview. They are equally important but too frequently, they are used politically as reasons to suppress the medical use of cannabis and its safe access. I confine my efforts and my activities solely to the advocacy of medical use. I hear very compelling life changing stories from patients almost daily.
Just today, a mother expressed her gratitude to us for helping her son, who was almost bedridden for two years, get his life back. She cried after he tried it, got up and out of bed and started running around. These are not isolated and rare occurrences. The other issue at hand is the epidemic of opioid deaths, abuses and misuses nationwide, which we discussed recently at the AAPM (American Academy of Pain Medicine) annual meeting in Florida.
Pain physicians are under severe government pressure and Drug Enforcement Agency scrutiny because of the level of pain prescriptions and dosages required for the most severe and challenging patients. However, pain medicine specialty physicians are relatively few in number and the majority of chronic pain care in the United States is managed by family practice physicians, physical medicine doctors and others who do the majority of the opioid prescriptions. This is especially true in Hawaii. The addition of medical cannabis as a replacement or adjuvant medication to the chronic pain patient’s medication regimen will greatly improve patient well-being and care, and provide increased patient safety.
Thank you,
David J Barton, M.D.