An interview with David Neubauer, Paediatrician and Child Neurologist at the University Children’s Hospital Ljubljana
Could you give our readers a little background on your professional life? When did you start to become interested in researching cannabis, and why? What type of patients can particularly benefit from medical application?
As a Child Neurologist, my primary interest was in neurometabolic and neurodegenerative diseases, neonatal neurology and epilepsies (incl. non-epileptic paroxysmal events) and movement disorders. Following on from this, I have become interested also in Ethical issues regarding children, especially with regard to neurological/developmental problems. The interest of cannabinoids came rather late (in 2014), when some of the parents of our children with severe, intractable epilepsies were approaching me – and some of my colleagues – to start treatment with cannabidiol and/or medical cannabis for their children. Not long afterwards, we were already treating nearly 70 children and adolescents with cannabidiol and experienced very good results; the results having been published (Neubauer D, Perković Benedik M, Osredkar D. Cannabidiol for treatment of refractory childhood epilepsies: Experience from a single tertiary epilepsy center in Slovenia. Epilepsy Behav. 2018 Apr;81:79-85). I still believe that the patients who particularly benefit from medical application of cannabis, are those with the most severe forms of epilepsy, so-called developmental and epileptic encephalopathies – DEE.
What’s the current state of play in Slovenia regarding medical cannabis access for patients? How is cannabis-derived treatment viewed by the general public?
Current state of play regarding medical cannabis products in Slovenia is still generally against it, especially from the administrative side, like JAZMP – Slovenian Agency for Medicines and Medical Products, and even the Ministry of Health and National Institute of Health. However, for children and adolescents we have succeeded to get natural cannabidiol (CBD) as a treatment (free of charge e.g. fully covered by national insurance) and even import medical cannabis products (e.g. Haleigh’s Hope) where insurance is covering all the expenses for it. The major problem in Slovenia is that the – previously mentioned – administrators are not allowing to use ‘domestic’ cannabis products which are of good quality, quite well controlled and appropriately certified as safe.
General public is very much accepting of these kind of treatments and frequently, even adult patients, with different kinds of diseases, especially neurological ones, like: multiple sclerosis, Parkinsonism, tics, depressive behaviour…etc are asking me to help and advise them about the products they have bought from the local farmers.
To start new cannabis-derived research projects, what steps do you – and fellow researchers – have to go through, to get these off the ground? Are their roadblocks that you have encountered and how can these be passed?
We are now looking forward to publishing our first experiences in treating patients with developmental and epileptic encephalopathy with artisanal products (home-made products) that parents have bought for their severely disabled children from the local farmers. However, this is just a retrospective study on around 30 children where we succeeded in collecting information on the analysis of the products, the outcome of such treatment on seizures, as well as, perhaps an even more important issue, the quality of life of these children. But we have planned a proper double blind, placebo controlled study, to detect how medical cannabis is useful in treating spasticity (in the most severe cases of cerebral palsy, there was only one study done in Israel until now), and we currently encounter many obstacles from the previously mentioned administrative bodies. We hope that in the near future, if we will be able to do this study, other possible benefits of cannabis for children with autism, tics, behavioural problems…etc can be further evaluated.
Are there any specific research projects and studies that you’ve seen from global peers that particularly interest you? If so, could you tell us about them?
There were studies performed (mainly in Israel, with some others in Canada and USA) using different cannabis products strengths (cultivars) – with differing CBD:THC ratios and mixtures of other natural cannabinoids, like CBDA, THCA, CBDV, CBC, CBN…etc – to see the effects of these for different symptoms, as well as for certain conditions (like disruptive behaviours in autism; Gilles de la Tourette symptoms in severe childhood tic conditions; spasticity in cerebral palsy; multiple sclerosis and neurodegenerative diseases; and of course, seizures and quality of life in epilepsies/encephalopathies). These are the main fields of interest of cannabis research in children today.
Much of your clinical work is around paediatrics. What’s your view on cannabis medicines for children? In what circumstances do you think it can be appropriate (and conversely, when should it not be considered as treatment for minors)?
I always say that cannabis is not for healthy people, which is even more true for children and adolescents. But when you have severely affected children – due to different causes and when it is clear that all the standard medicines/management previously used had not been effective – I do believe that parents have the right to ask their paediatricians/neurologist to advise them on how to try medicinal cannabis products. Mayo Clinic recently published recommendations (Mayo Clin Proc 2019;94(9): 1840-1851) where they first encourage physicians to not disregard patients’ interest in these therapies and to retain clinical curiosity, as well as healthy scepticism when new options are tried; above all, to advise and warn them that a careful selection of product is crucial for both safety and potential efficacy. Additionally. They need to know how to be sure that the product is not merely hemp seed oil. They also mentioned that it is up to the discretion (and I would add also up to experiences) of the physician whether to suggest a patient/parent/guardian just one molecular cannabinoid (such as cannabidiol) or ‘full spectrum’. For the time being, I would not recommend cannabis treatment as the first choice of treatment – for example, in easily treated epilepsies or other mild conditions where proven and good treatments already exist.
Beyond THC and CBD, what other compounds would you be interested in for future research, and why?
The compounds of the cannabis plant which could be of interest in near future, because of their potential beneficial effects, are: CBDV – cananabidivarin and CBG – cannabigerol for seizures and epilepsies; THCA and CBDA (acid – non psychotropic forms of THC and CBD) for antineoplastic, anticonvulsive and anti-emetic properties; CBC – canabichromene and CBN – cananbinol for cancer/pain treatment and epilepsy; and even non-cannabinoid compounds (that are present in high quantities in the cannabis plant) – like beta-caryophyllene, as a potent anti-inflammatory substance.
You can hear more from David Neubauer at the GCI Europe Virtual Summit.
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