Interview with pharmacist Alexander Daske (Part 1)
Seriously ill people can benefit from Add-on therapy with cannabinoids: When concomitant symptoms improve, the quality of life of those affected increases. Some doctors have specialized in therapy with cannabinoids. But how do inexperienced physicians get started with this highly individualized therapy? What needs to be taken into account? We talked about this with Alexander Daske, cannabis expert and pharmacist at Collini Pharmacy in Mannheim. In the first part of our interview, we talk about the advantages of cannabinoids over guideline-based therapy, among other things.
Kalapa: Mr. Daske, how did you get interested in the topic of medical cannabis?
Alexander Daske: We got into cannabis therapy at Collini Pharmacy before 2017, before the official cannabis law allowed doctors to prescribe cannabis flowers, cannabis extracts or finished cannabis medicines. We had the first patients with an exemption before 2017 and have seen the extent to which their symptomatology has improved with the addition of cannabis. We are a pharmacy that specializes primarily in pain management and have been involved in SOPC – Specialized Outpatient Palliative Care – for years. We also work with additive cannabinoids in polytoxic patients and therefore have a high level of experience in this specific area. So it happened that a new therapeutic field opened up for us at that time.
“Medical cannabis therapy is highly individualized”
Kalapa: And what is special about this medicine for you?
Alexander Daske: Pain is the most evident area we currently have in cannabis therapy, although overall we still have little evidence for the different indications. But pain has been a key issue for us in pharmacy for a long time, and we have seen that cannabis can be a useful therapeutic approach as an adjunct to the guideline. Since 2017, we’ve seen with the many people we now serve with medical cannabis that targeted use and reduction of guideline therapeutics can add value to patients’ quality of life. For me, debates about evidence, especially in the area of SOPC, become secondary when I see how patients can benefit from the Add-on therapy with cannabis, also for their social environment.
Kalapa: How can an inexperienced doctor get started in therapy with cannabis? What are the most important points to consider?
Alexander Daske: First of all, it is important to know that medical cannabis therapy is very individual. We don’t have any other form of therapy that has such a high level of inter-individuality and heterogeneity of outcomes. So, it is a very specific form of therapy that is not easily transferable from patient to patient. It can also be observed that we have specialized centers in Germany: Specialized pharmacies, but also specialized doctors who have been working with cannabis therapy for a long time – the Collini Pharmacy is one of these centers. The therapy has also changed in recent years, we have more and more results and meanwhile we no longer speak of an indication-dependent use of cannabinoids, but really of a targeted symptom-dependent therapy. Especially in the area of SOPC, this is a very central issue. But it also makes therapy difficult.
“We have gotten a very complex, confusing market”
Alexander Daske: We should give support to new physicians in the initial phase of therapy. How do I start the therapy? How do I set the treatment goal? I start the treatment goal not according to the indication, but according to the symptoms. Usually, this is a symptom matrix – that is, different symptoms that combine to form a cycle – where we can achieve a targeted therapeutic effect in the patient through additional therapy with cannabinoids. Since the issues of dosage, dose finding, and dose-response curves are highly individualized, they must therefore be tailored precisely to the patient and the specific symptomatology.
On a daily basis, I speak on the phone with interested doctors who are new to this form of therapy, especially in the areas of pain management, multiple sclerosis and adjuvant therapy. We have had good experience with giving the physician a guideline on how to start the therapy. This means: using the medical history and the symptoms to be treated to determine the treatment goal, determine the dosage, find the right dosage form, and then select the right product from the dosage form. This guide is very important in therapy, because we have a very confusing market, with many flower varieties and extracts, and this market will become even more confusing in the future. Therefore, therapy with medical cannabis is becoming more and more difficult because many doctors simply have difficulties finding the right preparation for the patient. However, doctors should not be deterred by this great confusion in the flower and extract market but should seek support and obtain information from specialized places such as pharmacies or experienced physicians.
“The symptom-based therapeutic approach is central to cannabis therapy”
Kalapa: You have already mentioned the aspect of symptom-oriented therapy with cannabis. Can you elaborate on that a little bit?
Alexander Daske: In cannabis therapy, the symptom-oriented therapy approach is central – we don’t do causal therapy. We have data from other countries in certain therapy areas, where approaches for inflammatory diseases or immunologically triggered disease patterns are already presented causally. In Germany, however, we still treat symptom-oriented because of the limited data available. Legislation dictates that we do not consider cannabis as a first-line therapy, but as an add-on therapy. However, we see very good results with cannabis, especially in pain and in the area of palliative care – that is, the care of critically ill patients who are terminally ill – where we have a complex symptom picture. These patients don’t just have a single symptom like pain, nausea, or vomiting, but a combination of 5 to 10 or even more symptoms. This is where we can target cannabinoids to achieve a positive outcome. That is often not possible with guideline therapies, we have to be very clear about that.
Kalapa: What advantage do cannabinoids bring here compared to the mentioned guideline medications?
Alexander Daske: If we look at the WHO staging scheme for pain management and here opioids, we can successfully treat certain areas with them, such as pain intensity. But where we don’t see added value with guideline therapeutics like opioids, are symptoms like nausea and vomiting, improvement in quality of life and sleep, improvement in muscle tone, spasticity, tremor manifestations, muscle stiffness or uncontrolled myoclonias. These are all symptoms that can occur in a palliative patient and are not adequately treated with first-line medications. Here we try to break this symptom cycle by using cannabinoids to reduce the patient’s suffering.
In no other area of medicine do we have such a broad distribution of receptors in the body. When we look at the endocannabinoid system, we see that CB-1 and CB-2 receptors are ubiquitously distributed throughout the body – that is, in many places. We can take advantage of this and treat different symptom areas. That’s the crux of cannabinoid therapy.
“We need to provide evidence for cannabis therapy to be widely accepted”
Kalapa: In the accompanying BfArM survey, 70 percent of participating cannabis patients reported feeling an improvement in their quality of life. Somewhat more frequently, there was an improvement in symptoms.
Alexander Daske: The data from the accompanying survey were interesting for us to see what experiences have been made since 2017 in the field of treatment with cannabinoids. However, we do not have a study situation in the accompanying survey, i.e., no evident data, but observations that were reported by patients to the doctors and then forwarded. Accordingly, we have to deal with this data situation in a multilayered way and classify it correctly. Quality of life is not an evidence-based measure here. But of course, it’s quite important to generate data first, and that’s why real-word evidence such as observational studies are also quite important to even recognize how quality of life changes, what changes under add-on therapy. Based on the results of the observational study, we can already see that a key aspect of the therapy is the impact on quality of life. And we also see this in practice every day.
In the future, we should build on this to provide evidence and collect data on quality-of-life impairment so that cannabis therapy is also recognized as a broad-based therapy. This is a point that doctors in Germany should also bear in mind, because SOPC centers in particular often do not yet use cannabinoid therapy. Treatment is still strictly according to guidelines, which is of course completely correct, but one should not forget that the improvement of the quality of life should be in the foreground, especially for patients in the last phase of life. This is also important for the accompanying environment. Especially in the field of palliative care, we must consider the psycho-oncological and psychological effects. This is a central aspect, which is also based on the mood-lifting effect of cannabinoids. We should take advantage of this in the future and increasingly consider the use of cannabinoids as add-on therapy especially in this patient group – despite the low evidence.
Alexander Daske is a pharmacist at Collini Pharmacy in Mannheim, a pharmacy specializing in pain therapy and cannabis-based medicine. He has many years of experience in pain therapy, SOPC therapy and MS therapy. Alexander Daske is head of the pain department and active as a consultant and speaker in the field of cannabis as well as for associations such as the VCA (Association Of Pharmacies Supplying Cannabis)