Edited and translated by AI.
Welcome to the podcast “The Caregiver”. I’m Ronit Shamay Schwartz, editor and host. This time I interviewed Professor Eliad Davidson, a pain medicine specialist. I chose to interview him because I felt he looks at patients in a different way.
Professor Davidson came to Israel’s day hospitalization without knowing him beforehand, and examined him physically – something that hadn’t been done for a long time. He identified a sensitive spot that indicated a possible metastasis, which was a breakthrough in the treatment.
Professor Davidson introduces himself: “I manage the pain unit at Hadassah Hospital in Jerusalem, and have been involved in the field of pain for over 20 years. We treat acute pain after surgeries and injuries, chronic pain, and oncological pain.”
To my question about pain medicine, he explains: “Pain is a very common complaint, perhaps the most frequent one doctors encounter. Every doctor needs to understand a bit about it. Pain has two aspects – it can be a sign of another medical problem, or it can be the disease itself. Sometimes we know the cause of the pain, like after surgery or injury, and sometimes we don’t.”
Often, we don’t know the cause of pain, and that’s when it’s appropriate to seek help from people who have specialized and studied the medical field. In fact, every doctor needs to know how to approach pain issues because it’s such a common complaint. If you’re a surgeon, an orthopedist, or a doctor working in the emergency room, you must know how to help people, and you don’t need to be a pain specialist.
Pain specialization was recognized and began in Israel about 12-13 years ago. The entire modern world of pain and its development as a specialty started about 30-40 years ago in the late 90s of the previous century. That’s when they began to understand that doctors needed to be specially trained to deal with pain, recognizing that pain is a disease in itself.
Over the years, as time passes, we have a field that is expanding with a variety of options to help people and requires specialization. In the last 20 years, pain clinics have been established throughout the country, and every hospital has a pain clinic, unit, or department.
These clinics focus on the more severe pain problems that doctors in their fields aren’t so successful in solving. They have someone who understands the world of pain a bit better, the ways to cope and try to alleviate people’s suffering.
Pain medicine is a very multidisciplinary field, meaning it requires broad expertise in various areas. The approach to solving or alleviating pain is often complex and consists of several options. There are some pain problems that we can alleviate through interventions, interventional procedures such as certain injections.
For example, for a person with back pain radiating to the leg, we can give an injection of anesthetic and steroid. Or we may resort to more invasive procedures such as implanting stimulators in the spine to relieve pain through electrical stimulation. This is the aspect of interventional medicine, and for this field, certainly the background of the person who treats us is important.
Pain medicine is a subspecialty. This means one must complete residency in one of the clinical medical specialties, followed by a second specialized training. Therefore, it’s called a subspecialty, lasting two or two and a half years, during which time spent in a pain clinic exposes one to various treatment methods.
It’s clear that someone coming from a department with interventions like anesthesia, surgery, or orthopedics, who has honed their manual skills, has greater ability and experience and generally finds themselves more suited to interventional pain medicine. However, as mentioned earlier, the field of pain is not solely based on interventions. A significant part of pain management also involves rehabilitation, cognitive and psychological methods, and overcoming pain. Thus, a background in psychiatry, psychology, or rehabilitation is certainly an advantage, especially for chronic pain issues.
Individuals from a neurology department, for example, and we have two neurologists working in our clinic (and in any large standard clinic I assume there are neurologists), require a different specialization and the ability to help people with medications, for example.
Today’s pain world, and pain clinics in general, and our ability to help – if I need to emphasize it – are just like this microphone standing before me on three legs:
1. One leg is the world of interventional procedures. This can involve injecting a long-lasting nerve-damaging drug in an oncology patient, for example, or using alcohol or phenol to destroy nerves. For someone with abdominal pain, we can help with such procedures, or as mentioned, other procedures.
2. The second aspect is working with medications, which requires skill because there are many new medications today.
3. The third leg is integrative or complementary medicine, including assistance in rehabilitation and psychology.
A comprehensive pain clinic needs to offer this multidisciplinary approach. And again, I return to the fundamental basis of pain: pain is a very complex complaint. It’s not like a blood pressure problem that I can measure and see exactly, or like a blood test I do to detect if there’s an increase or decrease in blood sugar levels or any other blood test. The complaint of pain is inherently complex.
Every pain issue has both an emotional component and an organic component. The balance between these components is constantly changing. The old perception, where a doctor would look at an X-ray, and if there was no fracture or other visible problem, would tell the patient that there’s nothing wrong and it’s all in their head, is an outdated and archaic view. This perception has no place in medicine at all, especially not in the field of pain.
Every pain complaint contains both an emotional and an organic component, and the weight of these components varies. Clearly, someone who falls and breaks their arm will have a more significant organic component, but even in such cases, the emotional component plays a crucial role in the pain experience. If the patient is anxious, they will feel the pain much more intensely. Alleviating the anxiety with medications can reduce the pain. On the other hand, with pain complaints like fibromyalgia, the emotional component is much more significant, and the organic component is less so.
A physician specializing in pain management needs to be able to offer the patient a range of options according to their specific problem. Regarding the oncological aspect, which is the focus of this podcast episode, treating oncological patients is generally more complex than dealing with patients with specific issues.
Ronit:I have a few questions that came up along the way that I didn’t know…
I need to stop you for a moment before you ask and tell you something surprising. As a doctor who sees patients suffering from pain all the time, I actually find it easier to treat an oncological patient. This relates to what I mentioned earlier. The complexity of the pain…
Indeed, you see people in great distress, and both the emotional and organic aspects are present. In chronic pain issues, even if the pain’s source is clearly organic, over time, additional layers develop, making the pain more complex between the organic and the emotional.
A person coming for chronic pain treatment often comes with prolonged pain, lasting weeks or months. Additionally, there are elements of anxiety, depression, social isolation, and sometimes family difficulties. For example, people who struggle to function at work, and others don’t understand why, or even if they do, not entirely. In such cases, the treatment becomes more challenging and complex.
Chronic pain is more complex, and the solutions we offer are much more multidisciplinary. However, when someone comes with a background of an oncological disease, and their life expectancy is sometimes limited, the problems are clearer. Of course, there is also an emotional aspect to consider, but the problem itself is more straightforward and laid out clearly on the table.
As someone trying to offer a solution, it’s easier for me in this sense with oncological patients. I’m not talking about the emotional layers and the difficulty of facing people whose lives may be short, which, of course, creates a certain emotional burden. But on the other hand, everything is clearer and laid out on the table.
With chronic pain issues, things are not always clear, and the problem is not always clear to the patient. Sometimes it’s hard for them to hear that they also need emotional support. Many people, especially in this country, tend to resist seeing a psychologist or psychiatrist, thinking it means they are inventing the problem or that it’s all in their head.
People come because they are in pain and don’t understand what you are talking about when you suggest emotional treatment. An oncological patient, because they have been through so much, is much more open to listening. If the problem is focused, you can sometimes offer a focused solution. For example, if they have chest pain that radiates, and we see a tumor in the area, we can offer radiation therapy. In the meantime, until the radiation helps, we can offer an injection to relieve the pain. The treatment is much more focused.
With people who have a limited life expectancy, some of our solutions can provide temporary relief. On the other hand, in cases of chronic pain, like after a shingles attack when post-herpetic neuralgia develops, the pain can last for years. Even if we offer a local solution like an injection, its effect is usually limited to weeks or months. Sometimes the fact that the patient’s life expectancy is shorter allows for more effective temporary solutions.
Sometimes, the fact that the patient’s life expectancy is shorter allows me to offer solutions that can work for weeks or months, but beyond that, in normal life, they usually won’t last. For example, if I leave a patient with a catheter through which they can inject medication daily, we sometimes do that. It’s suitable for someone who needs to be sustained for several months, but it’s not feasible to have someone injecting through a catheter for years, even if they’re willing to do it physically.
There are technical issues like infections that can develop, so with a patient whose life expectancy is limited, I have more options to help them, and the success is clearer. They have pain, and we can help with that specific problem, as opposed to chronic pain issues which have many more layers and thus require a more complex approach to treatment.
Ronit: Now, there’s a topic we encounter often: palliative care. What’s the difference between palliative care and pain management?
It’s quite simple. When we talk about palliative care, it’s not about curing but improving the quality of life so that people can live better. In simple terms, we try to ease people’s suffering and improve their quality of life during the time they have left. The goal is not to extend life but to improve it. Pain management is part of palliative care.
For example, at Hadassah, we have a palliative care team established in recent years by the administration. This team includes psychologists, social workers, oncologists, rehabilitation physicians, and more. It’s a team that can address a variety of issues that may trouble a person with advanced disease, with pain being one of them. But there are also issues of functionality, mood, nausea, and vomiting.
Addressing all sorts of problems that arise along the way requires understanding that this is an entire field that demands attention. This has become a relatively new specialty established in recent years. Pain management is part of palliative care; it exists within it, but palliative care encompasses much more than just pain management.
Ronit: I also wanted to ask about the tools you use, and if they vary from doctor to doctor. I’ve often encountered medications like Oxycodone, Fentanyl, even Methadone which was less popular from what I understood. When do you use each type, and can any pain specialist use all of them, or are there other treatment methods? I’m not talking about psychology, but specifically about the pain itself.
Perhaps it’s also a point that there are methods that are more interventional. So, I’ll go back for a moment to things you touched on, but I think that a pain doctor – their training and the requirements from them are that a person who comes to them with a pain complaint has already undergone some investigation.
Usually, the people who come to us – we’re not the first line and not even the second line. The person usually first went to their family doctor. The family doctor will sometimes refer them to an orthopedist if it’s back pain, or to a urologist or any other doctor. When these doctors, who are supposed to give the first conventional treatments, don’t quite manage or think that better treatment can be given – the patient will come to us. So usually, they come to us after investigation.
A good pain clinic should contain a variety of treatment options that can be offered to deal with a specific problem. Pain clinics that stand only on one particular way, meaning only interventional medicine, or only through cognitive methods like biofeedback and such things, or only through local injections – they have a disadvantage.
Sometimes we find that even hospices that treat only through drug infusions have a certain lack, because they can’t offer the range of possibilities. I think the role of the pain clinic is to see things broadly, and to think together with the patient about what treatment will suit them best. Many times it’s a combination of treatments.
Again, often a large part of people’s frustration is that they run from place to place, from another doctor to another healer and so on. Many times when a person leaves a pain clinic, they need to feel that they’ve reached… I don’t like it when a patient comes in and says, but not infrequently, almost every day someone comes in and says, “You are my last stop.”
This is not a comfortable statement as a doctor, because your shoulders, as broad as they are, wear down over the years from such statements. It creates a burden on you. But there’s a lot of truth in it, because many times doctors in related fields, or in fields not from the world of pain, they try, try, don’t succeed, and then you, as the pain doctor, get to see them. And indeed, sometimes there’s no one after you, you have no one to refer people to.
And that’s why a good pain clinic needs to… and often people leave my visit, and I didn’t do anything for them, I didn’t give them medication or anything, but I explain to them, I stop their race after what they’re looking for, which isn’t always possible. But at least I set them on their feet with clear answers to their questions, tell them what to expect, what not to expect, what can be done, what can’t be done.
It brings some order to their chaos and unrest, stemming from the feeling that they’re chasing after some expert who will invent a solution for them. This actually puts them into a state of unrest and anxiety. The point is that you can tell them to stop for a moment, to say “What we can help you with in this matter is this and that. You don’t have to come to me, there are other clinics, there are other places that can help you.”
But these are the directions we need to think about, and many times they say that’s enough, that’s what helps them and they don’t want more than that. Often I tell them, “Look, we can help you with this, that, or the other. For example, we can offer you medication” and the person will say “No, if it’s just medication, I prefer to suffer a bit and not take the medication”. But at least now they know. Often I ask the patient who comes to me “Why did you come to me?”, understanding that part of the reasons people come to the clinic – they have a suspicion that maybe something is hiding behind this pain, and this doesn’t always come out in their visits to the many clinics they’ve been to or other doctors, other disciplines they’ve been through.
In fact, after a conversation, it turns out that they’re somehow willing to live with the pain, but they have some anxiety that maybe underneath this headache they have, or underneath this back pain, there’s something hiding that hasn’t been discovered yet. And in fact, this is mainly what bothers them. They say “I’m willing to live with the pain, and if you tell me there’s a medication that can ease it, I prefer not to take medication, but what bothers me is, maybe something was missed here.”
So one of your roles as a pain doctor is to be able to tell people, after you’ve really verified that they’ve gone through the tests they needed to do, “Listen, this is the situation. There’s nothing here, you don’t have a disease that needs to be treated, there’s no tumor or other problem hiding here. Your problem is a pain problem, and now let’s discuss how to deal with the pain. We can try this, we can try that, and we can try the other.”
And often people will leave my clinic with a smile and a statement that I helped them a lot even though they decided not to do anything, but just the fact that you stop this race after something that can’t be achieved, or you remove this concern they have – that’s what they want to hear and nothing more than that.
Ronit: Many times, people go for a second opinion. They go, I don’t know, it could be an oncologist, it could be another doctor for a second opinion. From your experience in pain, I don’t know,but I think it’s less popular than what I’ve experienced. Do many go for a second opinion to a pain control doctor. Do you think they should go?
Personally, I very much encourage people to go and hear a second opinion. I generally… It really bothers me about patients who come to me and I understand from them that not necessarily in the field of pain clinic, that people…They felt that their doctors were reserved, and if the doctor hears about it, he might view them differently. I think especially in the world of pain, which is such a complex world and allows for different approaches, and there are occasionally new things, new electrodes, etc., we ourselves sometimes refer people. Just as an example, there’s a new electrode that can be implanted for certain problems. We’ve been implanting electrodes in the spine for 30 years already.
But there are new developments that have come to market in the last year or two, and I know that in a certain clinic in Tel Hashomer, they’ve experimented with these electrodes, and we haven’t tried them yet. I definitely not only encourage people to get a second opinion, I’ll send them with a recommendation to another clinic that has more experience with this treatment. There’s another treatment that I know a doctor in Beilinson does many times. So not everyone needs to know how to do everything, right?
If there’s a clinic where someone, a doctor who has experienced a complex procedure and already has experience, and you in your clinic have less experience, I’m definitely in favor. In general, in medicine, to open up the issue of second opinions, and I really don’t… it bothers me to hear people, doctors, who don’t encourage this. And in pain medicine especially, because of the different approaches that can be offered in this matter, I think we should encourage people to go and hear a second opinion.
Ronit: By the way, how is the situation in Israel regarding pain control medicine? I mean, are there cases where they say, okay, there’s only one clinic in the United States that does this, or in Switzerland, or something like that? How are we in terms of all the innovations in science?
I don’t see a reason to send someone abroad to deal with a pain problem. We may have one area where we’re not good enough and it’s not developed in the country, that’s the field of pain rehabilitation. People, and there are places in the world that maybe do it better than us, this is a lack that exists in the country. People who suffer with a pain problem who have already entered into difficulties, inability to walk, inability to move, and need to start moving them. So we have clinics, and there are excellent rehabilitation hospitals in the country.
And the connection between the world of pain and the world of rehabilitation is a connection that needs to be tightened and produced in a better way. There’s still a problem also from the health funds to recognize this issue, and therefore this field is definitely developing in the country and there are rehabilitation hospitals that are developing the issue of pain, but maybe in exceptional cases there are certain medicines in this matter that maybe we can think about, but I can’t think of another field.
There is a reason to refer a person abroad for pain treatment. For medicine, pain medicine is a field that has seen many developments in recent years, in terms of new drugs, and more. I think in general, the world of medicine is not a world that develops from the explosion of some sensational discovery, except for exceptional things like the discovery of antibiotics, or things that suddenly advance the world of medicine.
The world of medicine progresses step by step, so there are always small developments that happen, we hear about them and don’t always read about them and it’s not some kind of news scoop. So there are always small developments in the direction of better means to perform all kinds of injections, all kinds of implants. Today, they’re developing better imaging tools, the ultrasound that has entered in the last decade allows us to reach more precisely places that in the past we had difficulty working with. It’s an available device that can be brought into the clinic, less radiation, it has its advantages, so this is a field that has developed in the last decade.
In the field of… simply not a breakthrough but there is constant development in the direction of electrodes, using electricity to treat pain. There are implants in the spine and implants near the nerves in the periphery and again improvement, improvement of the means. It’s not a breakthrough but we have better electrodes today and the ability to place them in all kinds of places. We have batteries where in the past we needed some external battery, today we implant. In the past we had to replace them every three to five years, today we can implant batteries that are rechargeable from the outside, a bit like how you can charge your mobile phone, so that’s another area.
There are always pharmaceutical developments, new things. For example, in oncological patients we’re talking about, in the past people with severe pain that require pain response, what we call acute pain. This is pain that most oncological patients, as the disease progresses, they are helped by strong drugs that belong to the group of drugs from the morphine family, we call them opioids. So we had a reasonable response to the persistent pain that a person has and we can give drugs that release the drug in a delayed manner, so whether it’s drugs given twice a day or patches that release the drug and need to be changed every three or seven days.
But there was no answer for acute pain, pain that comes suddenly, as happens to these patients usually several times a day, whether it’s because of movement they need to get out of bed, whether it’s because of evacuation, whether it’s because they need to swallow or eat. So in the hospital, it was always possible to help them by injecting morphine intravenously, and this is a drug that works within five minutes, but there was no oral medication that could be given.
In the last five years, new drugs have entered the market that can be taken orally, sublingually, or sprayed into the nose. These drugs are absorbed directly from the nasal cavity or oral mucosa and work within fifteen minutes, providing relief similar to an injection of morphine into a vein. These drugs are called Rapid Acting Fentanyl.
Yes, there are several such drugs like Abstral or Actiq and other medications that certainly allow us to help people at home who have suffered and until now had no effective solution. This is another example of a pharmaceutical development that definitely helps us. As I said, pain medicine is advancing step by step, with small developments, but medicine is moving forward.
Ronit: We won’t discuss cannabis now, as it’s a whole other world, and if we open that topic, we will finish all we have to say. But few words?
Even the world of cannabis, although it is a drug that has been used for thousands of years both for medicinal purposes and for pleasure, we are definitely learning more about it in recent years. We are learning how to improve the forms of administration and turn it from a plant into a medicine to help with a variety of issues, starting with pain, and continuing with other areas such as inflammation and additional fields we are discovering that cannabis can help with. So, this can also be added to the list.
Ronit: A statement that I think most of us have heard at least once in our lives is, “You don’t need to suffer from pain”. You go to the doctor, and he says you don’t need to suffer Is it really possible to reach a state where an oncological patient, specifically, has no physical pain?
I must respond to this because it bothers me. About ten years ago, Hadassah hung a sign at the hospital entrance that said, “Hadassah without pain.” I approached the management and told them, “You must remove this sign because it is lying to people.” Now I tell patients, whether they are oncological patients or others, “We can help you, we can alleviate your pain.”
But to tell people we are talking about a world without pain, and today how can it be, and I hear this statement from patients because they hear it in various media, “How can it be in the 21st century that there is still pain and you haven’t overcome it?” No, the world of pain exists, these complaints exist, we have a lot to do, a lot to alleviate it, but to tell people that it is possible to reach a state where you have no pain is an incorrect statement.
I often sit with oncology patients and hear this concern they have. They tell me, “I don’t care so much, I say, I’ll live less, I don’t want to live with what I have in suffering, and I’m most afraid that if you, what you give me now, now it will still help me, but when the disease progresses, I’ll lose control over it and I’ll be driven crazy by pain.” I tell these people clearly: “We will not let you suffer from pain that will drive you crazy, that you can’t cope with. We will always be in a position to give you something, and if you reach a state where you’re in your last days, we’ll make sure to give you so many medications that you’ll also be in a state of reduced consciousness, and what’s called sedation, medications that will slightly sedate your condition to the point where we’ll put you into a kind of coma.”
Again, we tell patients, and sometimes I get requests, people want us to shorten their lives, and I explain that I don’t think that’s my role as a doctor. And here I’m also a religious person, but that’s not the point. I think that even without relation to this side of me, I don’t think I want to do like there are countries today, people travel to Switzerland or all sorts of places where a person in full consciousness is connected to a drug and within an hour they end their life. I don’t think that’s our role. Yes, it is our role not to let a person, even in their last days or especially in their last days, suffer from unbearable pain, and if they reach such a situation, then we’ll make sure to sedate them.
We need to do this in coordination with them. Sometimes we need to sit with the family and explain and say that now they will receive so many medications and their connection with the family – they will no longer be able to communicate. So this is a process we do in situations where it’s necessary to do so. So I think this certainly also reassures the patient that they don’t need to be anxious that they might reach a state where they have such an amount of pain that they can’t cope with.
Now, regarding day-to-day life, not regarding our last moments, they’re ill, they’re ill with oncology for several years, because sometimes it’s also a chronic disease, we can give them medications, but without them sleeping half the day, because… So this is our big challenge, and I can tell you about quite a few patients we’re trying to cope with this. So often I’ll sit in front of a patient and we manage the conversation and I say “Some of our medications certainly cause side effects, drowsiness, nausea or constipation, and we manage a negotiation with side effects versus benefit” and it’s very personal. Yes, I don’t always know what will bother a person. Yes, we know in general but…
I often sit with oncology patients and hear their concerns. They tell me: “I don’t mind living less, but I don’t want to live in suffering. I’m most afraid that as the disease progresses, I’ll lose control and be driven mad by pain.” I clearly promise them: “We won’t let you suffer unbearable pain. We can always provide treatment, and in your final days, we’ll give you medications to reduce your awareness, including sedation, to the point of a near-coma state if necessary.”
Sometimes I’m asked to shorten lives. I explain that this isn’t my role as a doctor, regardless of my being religious. I don’t want to act like in countries where a fully conscious person is connected to a drug and ends their life within an hour. Our role is to prevent suffering, especially in the final days, and if needed, to sedate the patient with medications.
This is done in coordination with the patient and family, explaining that communication with the patient will be affected due to the medications. This reassures the patient about the fear of unbearable pain.
In daily life, when dealing with a prolonged illness, the challenge is to provide medications without causing excessive drowsiness. We negotiate between side effects and benefits, which is very personal. It’s not always possible to know in advance what will bother each individual.
Ronit: For a very long time. There was another phenomenon that I encountered because I needed to buy Fentanyl and all kinds of such heavy drugs, and I would arrive at the pharmacy and feel like a fugitive criminal. They treated me as a potential criminal who’s going to take all the Fentanyl he received or the Oxycodone, go sell it on the black market ..while the purpose was to give my husband a pain relief. Now it’s just a slightly uncomfortable feeling but you can overcome it, but is there anything that can be done about it in your opinion?
Well, I’ll go back for a moment because you asked me and I didn’t answer you at all about these drugs from the morphine families, you mentioned Oxycontin, Methadone, Fentanyl and all these drugs, I’ll say a word, because there’s a lot of noise around all these drugs and whoever reads the newspapers hears about the opioid crisis in the world, what’s happening in the United States and there…
They really avoid giving these drugs and it reaches absurd levels where even people who need these drugs don’t always manage today in the US and some states to get them, they limit the possibilities to give these drugs for chronic pain and certainly for acute pain and I even hear from colleagues in the US that sometimes there’s difficulty giving them because of regulations that are tightened due to the opioid crisis in the US and deaths from overdoses even for oncological patients.
So I’ll say that in Israel the problem is less prevalent, not that it doesn’t exist at all, but we certainly aren’t in the picture of the opioid crisis that exists in the United States. But I’m returning now to the specific question you just asked me, can something be done about it? So the problem with opioids is that there are people who become addicted to these drugs,
Whether they are drug addicts and looked for something in advance, or people who received these drugs and the drugs stuck to them, they became attached to the drug and became dependent on them, to the extent that they developed dependence and they become a kind of addict. Yes? So these are people who have become dependent on the drug and they’re looking not just for the pain-relieving effect, but already for the high maybe that they give
The moment the drug is taken from them they enter some kind of withdrawal syndrome and the way to solve it is to take drugs so they try to become addicts and this is what you describe about the pharmacies and the pharmacists who sometimes have to deal with people who come to them and sometime they pressure pharmacies to do this. So in the entire modern medical world, it’s a certain problem how to deal with it, because these drugs are also purchased for the purposes of drug addicts. So that’s why you get this feeling.
I think that It’s not appropriate and there needs to be awareness among pharmacists as well, and I assume many understand and are able to distinguish, but the suspicion that arises is because there’s leakage of these drugs to the free market. How to distinguish between these and those, I’ve never thought about how to do it.
For example if it was given through a hospital with prescriptions given in the hospital, that’s a solution to the problem with a hospital or a hospital’s doctor or even with a family doctor, the same patient who is known to the system, let’s say to the medical system. Then some kind of system could be created, and I know that the Ministry of Health has been trying especially in the last year or two to deal with this problem, on the one hand the desire to supply the drugs, on the other hand the awareness that there’s leakage to the free market, and the Ministry of Health recently even approached hospital managers, and the issue spilled over to me as well.
Ronit: How can you try and deal with this problem and suggest solutions?
So there’s definitely an understanding that there’s a certain problem here, and I hope people won’t have to deal with what you felt, but this phenomenon is understandable, exists, and definitely bothers some of the patients.
Ronit: A question regarding cannabis. What are your thoughts of that? Does it help? Because according to what I’ve encountered, there’s smoking, and there are drops.There are those who say it doesn’t help at all, those who say “wow how did I not take it?”
So as we’ve really said already, cannabis is a whole world and here, it’s a very special drug and different from all the other drugs we know, because usually how drugs enter the market, many of the drugs we use today, they really started from herbal medicines, drugs that progressed.
They knew them in the past in all kinds of companies and modern medicine came and managed to isolate the component and found from the flower used in the ancient world, they eventually understood what the active ingredient is that does this, if they took morphine for example then people understood that from the poppy plant it comes from, you can isolate the morphine itself from all the other components and so on regarding all kinds of drugs that entered the world.
So cannabis is very different in this matter because when cannabis, they started talking about cannabis in the fifties, they started identifying what the materials are, they already knew for thousands of years that cannabis has medicinal properties as well and in the fifties of the last century Professor Mechoulam and his colleagues started identifying what the active ingredients are
So they identified Tetrahydrocannabinol, what’s called THC or CBD cannabidiol, and they started to identify also the sensors, the receptors, on which they work inside the body, and that’s how the world of cannabis has certainly developed in recent decades, in a very significant way to identify the components, and then they thought that like cannabis you can start to isolate and find the active ingredient, and when they started to isolate with just one of these products,
It turned out that it doesn’t work as it should and today we understand in the world of cannabis that cannabis is actually in order to get the most good properties that exist in cannabis in the world of medicine you must refer to the “whole plant”. The “whole plant” contains cannabinoids, these are molecules that are all similar, they are similar to cannabis to tetrahydrocannabinoid and so on, there is a common denominator between them, there are over 100.
And there are additional materials, groups of additional materials that exist like terpenes and more. We’re talking about 500 active ingredients and we don’t know today which of them we need and how much and what are the relationships between them. What we have learned in the last decade, especially in Israel, from working with patients at the moment, I’m putting aside for now all the basic scientific work that is done in laboratories with rats and so on, Cannabis is not one drug and that’s what I tell patients, it’s a much more complex drug and in order to start enjoying cannabis often requires a lot of trial and error to find what composition you need.
So already the Ministry of Health recognized this and in recent years the prescribing doctor in the past had to prescribe only cannabis whether it’s flowers or oil and some dosage, today he already needs to prescribe which composition but in the composition of the Ministry of Health that today has about 20 compositions
There is reference only to two of the main components that we know about, and that’s THC and CBD. But we know today that we’ll take 20 materials that are on the shelf of THC and CBD that patients receive. Every patient will know to tell you, no, I, although they have the same concentration of THC and the same concentration of CBD, it’s better for me precisely from this company or precisely from another company, because… they’re not marked, but there are additional compositions here that are here.
That can affect. So this makes the treatment much more complex. Beyond that we know that more drug or less drug in cannabis can give opposite effects. If I take too much of the drug I’ll get too much pain, too little of the drug won’t affect, and if I take the right dose, boom, it might help. In addition to this there’s the complexity of how to take it. There are people who do better with oil, there are people who do better with smoking, there are people who do better with inhalation.
All these things turn it into some kind of equation with many unknowns that the average patient won’t know how to solve and a large part of people who come to the doctor and say I tried cannabis and after several times I threw it away or I got it from a friend and it didn’t suit me it doesn’t help as it should it’s required to try to even know if cannabis is suitable for you or not you need someone who will lead and guide and allow you to go through a method of trial and error in an orderly manner
in order to enjoy it. So this is one problem with cannabis, and it’s different and unique to cannabis compared to other drugs. Another problem that is very familiar to pain clinics in particular, is that there aren’t many drugs that people take for fun, for pleasure, for recreational use. But cannabis, unlike morphine for example, normative people who are not drug addicts, if they take morphine it won’t do them good.
Certainly other drugs, no one wants to take drugs for no reason, right? But cannabis, even normative people, and we know that the normative population uses cannabis. Today, on the order of 10-20% of the normative adult population in the Western world consume cannabis for fun, for pleasure, so-called. And it costs money. It costs money to use one joint of cannabis, it costs you about 100 shekels a day.
So multiply that, it costs 3000 shekels a month, so the Israeli is not a sucker, he says, wait, if I can get it from the Ministry of Health as a medication, then why not? So again, some of the referrals to pain clinics and other clinics on the matter, and it’s clear to us that today the licenses that the Ministry of Health issues over 120 thousand, 150 thousand, it’s growing all the time, some of them are people who take it for pleasure and not for healing purposes.
So this created a certain problem, and some of the clinics or some of the doctors don’t want to deal with this field at all, because it’s standing in front of people who many times you feel that they’re not exactly coming to be healed, but they’re coming to solve their problem which is justified or not, but the separation between cannabis for medical purposes and cannabis for pleasure purposes is very gray, and it’s problematic for the patients themselves,
Even people who take cannabis to relieve pain, many times will tell you that it doesn’t help the pain so much, but still the intensity of the pain remains, but the pain doesn’t bother them so much. I’m not talking about people who take cannabis to get high, to get drunk, people who function and stand in all this, but they will say, if the cannabis still hurts me, but the pain doesn’t bother me so much. That’s okay for me as a pain doctor, I have no problem with that. But here…
There is already some blurring between the world of pleasure and the world of healing, and there is certainly a certain difficulty that we as doctors are not used to dealing with. I’m not currently discussing my opinion on whether the State of Israel should give permission for the use of cannabis for recreational purposes or remove the approval for it altogether, that’s a different question.
But as a doctor who prescribes medication, I’m not interested in dealing with this whole issue, and it deters quite a few people from engaging in this field, and ultimately, unfortunately, patients are harmed – patients who could definitely have benefited from cannabis, etc. Many doctors don’t want to deal with it because of all the problems I just raised. So I really hope that in a joint meeting with the Ministry of Health and legislators, members of the Knesset,
it will be possible to create clearer guidelines on this matter and really benefit from this medicine which, although it is ancient and has been used for thousands of years, in recent years attempts have been made to turn it into a medication, and there’s no doubt that this is one of the breakthroughs of recent years. I’m talking about breakthroughs regarding something that has already been used for thousands of years. There’s a certain absurdity here, but I have no doubt that in this direction, with advancing research, it will be possible to better utilize cannabis for medical purposes.
Ronit: I want to conclude with this because I know you’re in a hurry, and I want to thank you. First of all, this was very significant for me, and I learned a lot from this conversation. I believe that many more people who will listen to this will learn a great deal from it, and this is despite the fact that for many years, unfortunately, I had been exposed to part of this field. I thank you from the bottom of my heart.
Thank you very much to Professor Eliad Davidson.