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Wadsworth E, Hines LA, Hammond D. Legal status of recreational cannabis and self-reported substitution of cannabis for opioids or prescription pain medication in Canada and the United States. Subst Abus 2022; 43:943-948. [PMID: 35420977 PMCID: PMC7614954 DOI: 10.1080/08897077.2022.2060431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Aims: With increased liberalization of cannabis policies in North America, there is growing interest in the use of cannabis to manage pain instead of opioids. The objectives of the study were to (1) examine the use of cannabis for pain relief in Canada and the United States (US) in 2018 and 2019; (2) examine the association between recreational cannabis laws and changes in the use of cannabis for pain relief, instead of opioids or prescription pain medication. Methods: Repeat cross-sectional survey data were used from Wave 1 and Wave 2 of the International Cannabis Policy Study conducted in 2018 and 2019 in Canada and the US. Respondents were recruited through commercial panels, aged 16-65, and had ever tried cannabis (N = 44,119). Weighted binary logistic regression models examined the association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication (n = 15,092). Results: Between 14-33% of cannabis consumers in Canada and the US reported using cannabis to manage headaches or pain. Of these consumers, 79% and 78% respondents in Canada; 80% and 83% in US illegal states; and 83% and 84% in US legal states, in 2018 and 2019, respectively, reported cannabis use for pain relief instead of opioids or prescription pain medication. There was little evidence of an association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication, among Canadian (AOR = 0.98, 95% CI: 0.78, 1.22) and US respondents (AOR = 1.11, 95% CI: 0.96, 1.28). Conclusions: Although substitution of cannabis for opioids or prescription pain medication is common among those who use cannabis for pain, there does not seem to be a significant difference according to cannabis legality. Future research should examine cannabis and opioid substitution using different research designs and time frames.
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Affiliation(s)
- Elle Wadsworth
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
| | - Lindsey A Hines
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Integrative Epidemiology Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Hammond
- School of Public Health Sciences, University of Waterloo, Waterloo, Canada
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Lalsare S. Cannabinoids: Legal aspects, pharmacology, phytochemistry, probable targets from biological system, and therapeutic potential. ASIAN JOURNAL OF PHARMACEUTICAL RESEARCH AND HEALTH CARE 2022. [DOI: 10.4103/ajprhc.ajprhc_9_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pritchett CE, Flynn H, Wang Y, Polston JE. Medical Cannabis Patients Report Improvements in Health Functioning and Reductions in Opiate Use. Subst Use Misuse 2022; 57:1883-1892. [PMID: 36168127 DOI: 10.1080/10826084.2022.2107673] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Purpose: Opioid use rates have dropped as North American patients gain access to medical cannabis, indicating a harm reduction role, yet health outcomes remain mostly unexplored. This study presents self-reported medical cannabis use, perceptions of health functioning, and changes in opioid pain medication use in Florida medical cannabis patients.Methods: Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey (SF-36) to assess health functioning before and after cannabis initiation.Results: Most participants were between the ages of 20 and 70 years of age (95%), over 54% were female, 47% were employed, and most (85%) were white. Commonly reported ailment groups were Pain and Mental Health combined (47.92%), Mental Health (28.86%) or Pain (9.07%). Health domains of bodily pain, physical functioning, and social functioning improved while limitations due to physical and emotional problems were unchanged. Most patients rated medical cannabis as being important to their quality of life. Many (60.98%) reported using pain medications prior to medical cannabis, 93.36% of these reported a change in pain medication after medical cannabis. The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis and 11.47% described improved functioning.Conclusions: The findings suggest that some medical cannabis patients decreased opioid use without harming quality of life or health functioning, soon after the legalization of medical cannabis. The public health implications of medical cannabis as an alternative pain medication are discussed.
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Affiliation(s)
| | - Heather Flynn
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, USA
| | - Yuxia Wang
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida, USA
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Takakuwa KM, Schears RM. Emergency Medicine Physicians Would Prefer Using Cannabis Over Opioids for First-Line Treatment of a Medical Condition if Provided With Medical Evidence: A National Survey. Cureus 2021; 13:e19641. [PMID: 34926086 PMCID: PMC8673685 DOI: 10.7759/cureus.19641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: To determine emergency medicine (EM) physicians’ preferences for using medical cannabis versus opioids if medical cannabis was legalized. Methods: We surveyed US physicians at the largest national EM conference (American College of Emergency Physicians’ Annual Conference) held in San Diego, CA from October 1 to 4, 2018. Of the thousands of conference participants approached, 539 US physicians completed the anonymous written survey, which represented 15.2% of the US physicians attending the conference. Results: The mean age of the participants was 39.6 ± 10.9 years, men composed 57.5% of the participants, and whites made up 72.8% of the respondents. Participants practicing in medically legal (54.8%) and medically plus adult-use legal cannabis states (23.1%) totaled 77.9%. A majority (70.7%) of the participants believed that cannabis has medical value. EM physicians preferred cannabis over opioids as a first-line treatment addressing a medical condition provided that medical studies found that cannabis was equally effective (p < 0.001, X2 = 36.8 [95% CI 2, 415]), and overwhelmingly preferred cannabis over opioids if it were more effective (p < 0.001, X2 = 90.8 [95% CI 2, 415]). Physicians appeared to prefer opioids over cannabis if medical studies found that cannabis was less effective though it was not significant (p > 0.05). Subgroup analyses showed that belief in the medical value of cannabis significantly increased the odds ratio of choosing cannabis over opioids if cannabis was equally or more effective than opioids. Conclusion: Our study shows that EM physicians believe cannabis has medical value and would prefer using cannabis over opioids if provided with equivalent findings. We believe our findings reflect EM physicians’ experience of the opioid epidemic and suggest the need for further study of this potential therapeutic.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
| | - Raquel M Schears
- College of Medicine, University of Central Florida, Orlando, USA
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Bonomo Y, Norman A, Collins L, O'Neill H, Galettis P, Trinca J, Strauss N, Martin J, Castle D. Pharmacokinetics, Safety, and Tolerability of a Medicinal Cannabis Formulation in Patients with Chronic Non-cancer Pain on Long-Term High Dose Opioid Analgesia: A Pilot Study. Pain Ther 2021; 11:171-189. [PMID: 34921662 PMCID: PMC8861237 DOI: 10.1007/s40122-021-00344-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION This phase I open-label study examined pharmacokinetics, safety, and tolerability of escalating doses of a novel combination cannabinoid medication (1:1 tetrahydrocannabinol [THC]/cannabidiol [CBD]) in patients with chronic non-cancer pain (CNCP) on high dose opioid analgesia. METHODS Nine people with CNCP and oral morphine equivalent daily dose of 60 mg or higher were recruited. Blood concentrations of THC, 11-hydroxytetrahydrocannabinol (OH-THC), 11-nor-9-carboxy-tetrahydrocannabinol (COOH-THC), and CBD were assayed weekly. Concentrations were measured after a single dose of 2.5 mg THC/2.5 mg CBD on day 1, and daily escalating doses up to a single dose of 12.5 mg THC/12.5 mg CBD on day 29. Follow-up was on day 36 after a 7-day washout. Secondary outcome data encompassed pain, mood, and sleep parameters. RESULTS The parent compounds THC, and CBD, and metabolites OH-THC and COOH-THC were detected at most time points. In general, the concentration of all analytes increased until 2 h post-administration, decreasing to approximately pre-dose concentrations by 8 h. There was considerable inter- and intra-individual variability. The study medication was well tolerated. Eight participants reported at least one adverse event (AE), with a total of 62 AEs; most common were euphoric mood, headache, and agitation, none classified as severe. There was no significant change to pain severity self-ratings, nor use of pain medications. Improvements in pain interference scores, mood, and some sleep parameters were observed. CONCLUSION The THC/CBD formulation was tolerated well in a group of patients with CNCP. Between-participant variability supports personalized dosing and "start low-go slow" titration. To validate and quantify improvements in secondary efficacy outcomes a randomized placebo-controlled study is needed. TRIAL REGISTRATION Australian New Zealand Clinical Trials Register (CT-2019-CTN-01224-1).
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Affiliation(s)
- Yvonne Bonomo
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, University of Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia.
| | - Amanda Norman
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia
| | - Lisa Collins
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia
| | - Helen O'Neill
- Department of Addiction Medicine, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia
| | - Peter Galettis
- Clinical Pharmacology Laboratory, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Jane Trinca
- Barbara Walker Centre for Pain Management, St Vincent's Hospital Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia
| | - Nigel Strauss
- Millswyn Clinic, 466 Punt Road, South Yarra, VIC, 3141, Australia
| | - Jennifer Martin
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - David Castle
- Mental Health, St Vincent's Hospital Melbourne, University of Melbourne, P.O. Box 2900, Fitzroy, VIC, 3065, Australia
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Ward SJ, Lichtman AH, Piomelli D, Parker LA. Cannabinoids and Cancer Chemotherapy-Associated Adverse Effects. J Natl Cancer Inst Monogr 2021; 2021:78-85. [PMID: 34850893 DOI: 10.1093/jncimonographs/lgab007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
The use of cannabis is not unfamiliar to many cancer patients, as there is a long history of its use for cancer pain and/or pain, nausea, and cachexia induced by cancer treatment. To date, the US Food and Drug Administration has approved 2 cannabis-based pharmacotherapies for the treatment of cancer chemotherapy-associated adverse effects: dronabinol and nabilone. Over the proceeding decades, both research investigating and societal attitudes toward the potential utility of cannabinoids for a range of indications have progressed dramatically. The following monograph highlights recent preclinical research focusing on promising cannabinoid-based approaches for the treatment of the 2 most common adverse effects of cancer chemotherapy: chemotherapy-induced peripheral neuropathy and chemotherapy-induced nausea and vomiting. Both plant-derived and synthetic approaches are discussed, as is the potential relative safety and effectiveness of these approaches in relation to current treatment options, including opioid analgesics.
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Affiliation(s)
- Sara Jane Ward
- Department of Neural Sciences, Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Aron H Lichtman
- Department of Pharmacology and Toxicology, Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA, USA
| | - Daniele Piomelli
- Department of Anatomy and Neurobiology, Center for the Study of Cannabis, University of California, Irvine, CA, USA
| | - Linda A Parker
- Department of Psychology and Neuroscience, University of Guelph, Guelph, Ontario, Canada
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Sexton M, Garcia JM, Jatoi A, Clark CS, Wallace MS. The Management of Cancer Symptoms and Treatment-Induced Side Effects With Cannabis or Cannabinoids. J Natl Cancer Inst Monogr 2021; 2021:86-98. [PMID: 34850897 DOI: 10.1093/jncimonographs/lgab011] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 01/06/2023] Open
Abstract
Cannabis and cannabinoids are increasingly being accessed and used by patients with advanced cancer for various symptoms and general quality of life. Specific symptoms of pain, nausea and vomiting, loss of appetite and cachexia, anxiety, sleep disturbance, and medical trauma are among those that have prompted patients with cancer to use cannabis. This conference report from the National Cancer Institute's "Cannabis, Cannabinoid and Cancer Research Symposium" on the topic of "Cancer Symptom/Treatment Side Effect Management" is an expert perspective of cannabis intervention for cancer and cancer treatment-related symptoms. The purpose of the symposium was to identify research gaps, describe the need for high-quality randomized prospective studies of medical cannabis for palliative care in patients with cancer, and evaluate the impact of medical cannabis on cancer survivors' quality of life. Further, education of clinicians and affiliated health-care providers in guiding cancer patients in using cannabis for cancer care would benefit patients. Together, these steps will further aid in refining the use of cannabis and cannabinoids for symptom palliation and improve safety and efficacy for patients.
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Affiliation(s)
- Michelle Sexton
- Department of Anesthesiology, Division of Pain Management, University of California, San Diego, CA, USA
| | - Jose M Garcia
- Department of Medicine, Division of Geriatrics, University of Washington and Geriatric Research Education and Clinical Center, Puget Sound Veterans Administration Health Care System, Seattle, WA, USA
| | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Carey S Clark
- Department of Nursing, Pacific College of Health and Science, San Diego, CA, USA
| | - Mark S Wallace
- Department of Anesthesiology, Division of Pain Management, University of California, San Diego, CA, USA
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Hjorthøj C, La Cour P, Nordentoft M, Posselt CM. Cannabis-based medicines and medical cannabis for patients with neuropathic pain and other pain disorders: Nationwide register-based pharmacoepidemiologic comparison with propensity score matched controls. Eur J Pain 2021; 26:480-491. [PMID: 34624164 DOI: 10.1002/ejp.1874] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Neuropathic pain and other pain disorders have received attention as potential indications for use of cannabis-based medicines or medical cannabis (CBM/MC). Evidence regarding the efficacy and safety of CBM/MC for pain disorders is, however, insufficient. Denmark introduced a pilot programme of medical cannabis in January 2018. We aimed to evaluate efficacy, safety, and non-specific effects of CBM/MC used under the pilot programme compared with controls. METHODS We conducted a nationwide register-based cohort study in Denmark, identifying all individuals redeeming at least one prescription for CBM/MC for either neuropathic pain (n = 1817) or other and unspecified pain disorders (n = 924), and to match one control to each case using propensity score matching. RESULTS Among both patient groups, users of THC used more opioids during follow-up than controls. Among patients with neuropathic pain, however, users of either CBD, THC, or combined CBD + THC used less gabapentin than controls. Users of all three classes of CBM/MC were hospitalized fewer days than controls among neuropathic-pain patients but not among patients with other or unspecified pain disorders. CONCLUSIONS CBM/MC were generally safe and even displayed some positive effects among patients with neuropathic pain. We conclude that CBM/MC are safe and possibly efficacious for patients with neuropathic pain but not patients with other pain disorders. SIGNIFICANCE Patients with neuropathic pain may benefit from treatment with cannabis-based medicines or medical cannabis (CBM/MC), particularly in terms of reduced use of gabapentin and fewer days admitted to hospitals, compared with propensity score matched controls. CBM/MC did not, however, reduce the use of opioids. We did not find evidence that CBM/MC were effective for patients with other pain disorders.
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Affiliation(s)
- Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Peter La Cour
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christine Merrild Posselt
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Copenhagen University Hospital, Copenhagen, Denmark
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Perlman AI, McLeod HM, Ventresca EC, Salinas MG, Post PJ, Schuh MJ, Abu Dabrh AM. Medical Cannabis State and Federal Regulations: Implications for United States Health Care Entities. Mayo Clin Proc 2021; 96:2671-2681. [PMID: 34607636 DOI: 10.1016/j.mayocp.2021.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/16/2021] [Accepted: 05/11/2021] [Indexed: 10/20/2022]
Abstract
Thirty-six states and four territories in the United States have legalized cannabis for medical and/or recreational use. Marijuana, however, continues to be classified as a schedule I substance under the Federal Controlled Substance Act and remains illegal under US federal law. The incongruity between state and federal legislation creates various challenges for stakeholders: patients, medical trainees, providers, and health care institutions. This communication provides an overview of the major policies impacting Cannabis sativa use within the United States, various state and federal regulations, and highlights potential implications for health care institutions moving forward. Existing literature, regulations, and policies on medical marijuana (MMJ) use in health care settings were searched, reviewed, analyzed, and distilled. As a consequence of legislative inconsistencies, there is insufficient clarity and resultant challenges regarding MMJ usage, prescription, possession, education, and research-related policies for health care stakeholders across the United States. Coupled with limited scientific evidence on the clinical efficacy of MMJ, the needs of the patient and the quality of health care delivery may be affected as hospitals balance the competing risks of being legislatively compliant while protecting the rights of patients and health care employees. There is a recognized need to better define acceptable MMJ policies and regulations in health care settings that are evidence-based, legally compliant, and adequately address the needs of both patients and providers. Given the complexity of the legal and policy landscape, there are potential opportunities for improvement, including in medical education and training, research, and usage oversight of MMJ for stakeholders in the United States.
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Affiliation(s)
- Adam I Perlman
- Department of Integrative Health, Mayo Clinic, Jacksonville, FL.
| | - Heidi M McLeod
- Department of Integrative Health, Mayo Clinic, Jacksonville, FL
| | | | | | - Peter J Post
- Department of Pharmacy, Mayo Clinic, Rochester, NY
| | - Michael J Schuh
- Department of Family Medicine and Palliative Medicine and Pharmacy, Mayo Clinic, Jacksonville, FL
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Fowler C. The Use of Marijuana Derivatives in Primary Care: An Evidence-Based Approach to Cannabidiol. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lee JB, Ghanem G, Saadat S, Yanuck J, Yeung B, Chakravarthy B, Nelson A, Shah S. Positive Toxicology Results Are Not Associated with Emergency Physicians' Opioid Prescribing Behavior. West J Emerg Med 2021; 22:1067-1075. [PMID: 34546882 PMCID: PMC8463062 DOI: 10.5811/westjem.2021.5.52378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/21/2021] [Indexed: 11/12/2022] Open
Abstract
Introduction Given the general lack of literature on opioid and naloxone prescribing guidelines for patients with substance use disorder, we aimed to explore how a physician’s behavior and prescribing habits are altered by knowledge of the patient’s concomitant use of psychotropic compounds as evident on urine and serum toxicology screens. Methods We conducted a retrospective chart review study at a tertiary, academic, Level I trauma center between November 2017–October 2018 that included 358 patients who were discharged from the emergency department (ED) with a diagnosis of fracture, dislocation, or amputation and received an opioid prescription upon discharge. We extracted urine and serum toxicology results, number and amount of prescription opioids upon discharge, and the presence of a naloxone script. Results The study population was divided into five subgroups that included the following: negative urine and serum toxicology screen; depressants; stimulants; mixed; and no toxicology screens. When comparing the 103 patients in which toxicology screens were obtained to the 255 patients without toxicology screens, we found no statistically significant differences in the total prescribed morphine milligram equivalent (75.0 and 75.0, respectively) or in the number of pills prescribed (15.0 and 13.5, respectively). Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. Conclusion Our study found no association between positive urine toxicology results for psychotropically active substances and the rates of opioid prescribing within a single-center, academic ED. Notably, none of the 103 patients who had toxicology screens were prescribed naloxone upon discharge. More research on the associations between illicit drug use, opioids, and naloxone prescriptions is necessary to help establish guidelines for high-risk patients.
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Affiliation(s)
- Jonathan B Lee
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ghadi Ghanem
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Soheil Saadat
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Justin Yanuck
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Brent Yeung
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Bharath Chakravarthy
- University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Ariana Nelson
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
| | - Shalini Shah
- University of California, Irvine, Department of Anesthesiology & Perioperative Care, Orange, California
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Zhang N, Woldeamanuel YW. Medication overuse headache in patients with chronic migraine using cannabis: A case-referent study. Headache 2021; 61:1234-1244. [PMID: 34370866 DOI: 10.1111/head.14195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/17/2021] [Accepted: 06/02/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine whether cannabis use predicts medication overuse headache (MOH) in patients with chronic migraine (CM). METHODS Electronic chart review was conducted by combining the terms "CM," "medication overuse," "cannabis," "cannabidiol," and "tetrahydrocannabinol" for patients seen at our headache clinics from 2015 to 2019. Of 729 charts consecutively screened, 368 met our inclusion criteria, that is, adult patients with CM with ≥1-year CM duration. The following variables were extracted from the included patient charts: MOH diagnosis, age, sex, migraine frequency, current CM duration, current cannabis use duration, overused acute migraine medications, current MOH duration, and types of cannabis products used. Logistic regression was used to identify variables predicting MOH while controlling for remaining predictors. Agglomerative hierarchical clustering (AHC) was conducted to explore natural clusters using all predictor variables. RESULTS There were 212 patients with CM and MOH (cases; median age 43 years, interquartile range [IQR] 33-54; 177 [83%] females) and 156 patients with CM without MOH (referents; median age 40 years, IQR 31-49; 130 [83%] females). MOH was present in 81% (122/150) of current cannabis users compared with 41% (90/218) in those without cannabis use-adjusted odds ratio 6.3 (95% CI: 3.56 to 11.1, p < 0.0001). Current cannabis use was significantly associated with opioid use (Spearman's rho 0.26, p < 0.0001). Both current cannabis use (rho 0.40, p < 0.0001) and opioid use (rho 0.36, p < 0.0001) were significantly associated with MOH. Similarly, AHC revealed two major natural clusters. Cluster I patients featured 9.3 times higher current cannabis use, 9.2 times higher current opioid use, and 1.8 times higher MOH burden than those in Cluster II (p < 0.0001). CONCLUSION Cannabis use was significantly associated with increased prevalence of MOH in CM. Bidirectional cannabis-opioid association was observed-use of one was associated with use of the other. Advising patients with CM and MOH to reduce cannabis use may help treat MOH effectively.
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Affiliation(s)
- Niushen Zhang
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Yohannes W Woldeamanuel
- Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
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Sihota A, Smith BK, Ahmed S, Bell A, Blain A, Clarke H, Cooper ZD, Cyr C, Daeninck P, Deshpande A, Ethans K, Flusk D, Le Foll B, Milloy M, Moulin DE, Naidoo V, Ong M, Perez J, Rod K, Sealey R, Sulak D, Walsh Z, O’Connell C. Consensus-based recommendations for titrating cannabinoids and tapering opioids for chronic pain control. Int J Clin Pract 2021; 75:e13871. [PMID: 33249713 PMCID: PMC8365704 DOI: 10.1111/ijcp.13871] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/24/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. RESULTS In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events. CONCLUSIONS This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.
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Affiliation(s)
- Aaron Sihota
- Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBCCanada
| | | | - Sana‐Ara Ahmed
- Medical Director, Anesthesiology and Interventional Chronic PainAhmed Institute for Pain and Cannabinoid ResearchCalgaryABCanada
| | - Alan Bell
- Department of Family and Community MedicineUniversity of TorontoTorontoONCanada
| | - Allison Blain
- Department of AnesthesiaMichael G DeGroote Pain ClinicHamilton Health SciencesMcMaster UniversityHamiltonONCanada
| | - Hance Clarke
- Department of Anesthesia and Pain MedicineToronto General HospitalUniversity Health NetworkUniversity of TorontoTorontoONCanada
| | - Ziva D. Cooper
- Department of Psychiatry and Biobehavioral ScienceUCLA Cannabis Research InitiativeJane and Terry Semel Institute for Neuroscience and Human Behavior University of CaliforniaLos AngelesCAUSA
| | - Claude Cyr
- Department of Family MedicineMcGill UniversityMontrealQCCanada
| | - Paul Daeninck
- Max Rady College of MedicineRady Faculty of Health SciencesUniversity of Manitoba, and CancerCare ManitobaWinnipegMBCanada
| | - Amol Deshpande
- Comprehensive Interdisciplinary Pain ProgramDivision of Physical MedicineToronto Rehabilitation InstituteTorontoONCanada
| | - Karen Ethans
- Department of MedicineSection of Physical Medicine and RehabilitationUniversity of ManitobaWinnipegMBCanada
| | - David Flusk
- Faculty of MedicineMemorial University of NewfoundlandSt John’s NLCanada
| | - Bernard Le Foll
- Translational Addiction Research LaboratoryCentre for Addiction and Mental HealthTorontoONCanada
- Alcohol Research and Treatment ClinicAcute Care ProgramCentre for Addiction and Mental HealthTorontoONCanada
- Campbell Family Mental Health Research InstituteCentre for Addiction and Mental HealthTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
- Institute of Medical SciencesUniversity of TorontoTorontoONCanada
- British Columbia Centre on Substance UseVancouverBCCanada
| | - M‐J Milloy
- British Columbia Centre on Substance UseVancouverBCCanada
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Dwight E. Moulin
- Departments of Clinical Neurological Sciences and OncologyEarl Russell Chair in Pain MedicineWestern UniversityLondonONCanada
| | | | - May Ong
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Jordi Perez
- Department of AnesthesiaMcGill UniversityMontrealQCCanada
| | - Kevin Rod
- FCFP Director Toronto Poly ClinicLecturer DFCM University of TorontoTorontoONCanada
| | | | | | - Zachary Walsh
- Department of PsychologyUniversity of British ColumbiaVancouverBCCanada
| | - Colleen O’Connell
- Department of Physical Medicine and RehabilitationStan Cassidy Centre for RehabilitationFrederictonNBCanada
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Noori A, Miroshnychenko A, Shergill Y, Ashoorion V, Rehman Y, Couban RJ, Buckley DN, Thabane L, Bhandari M, Guyatt GH, Agoritsas T, Busse JW. Opioid-sparing effects of medical cannabis or cannabinoids for chronic pain: a systematic review and meta-analysis of randomised and observational studies. BMJ Open 2021; 11:e047717. [PMID: 34321302 PMCID: PMC8319983 DOI: 10.1136/bmjopen-2020-047717] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 07/05/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To assess the efficacy and harms of adding medical cannabis to prescription opioids among people living with chronic pain. DESIGN Systematic review. DATA SOURCES CENTRAL, EMBASE and MEDLINE. MAIN OUTCOMES AND MEASURES Opioid dose reduction, pain relief, sleep disturbance, physical and emotional functioning and adverse events. STUDY SELECTION CRITERIA AND METHODS We included studies that enrolled patients with chronic pain receiving prescription opioids and explored the impact of adding medical cannabis. We used Grading of Recommendations Assessment, Development and Evaluation to assess the certainty of evidence for each outcome. RESULTS Eligible studies included five randomised trials (all enrolling chronic cancer-pain patients) and 12 observational studies. All randomised trials instructed participants to maintain their opioid dose, which resulted in a very low certainty evidence that adding cannabis has little or no impact on opioid use (weighted mean difference (WMD) -3.4 milligram morphine equivalent (MME); 95% CI (CI) -12.7 to 5.8). Randomised trials provided high certainty evidence that cannabis addition had little or no effect on pain relief (WMD -0.18 cm; 95% CI -0.38 to 0.02; on a 10 cm Visual Analogue Scale (VAS) for pain) or sleep disturbance (WMD -0.22 cm; 95% CI -0.4 to -0.06; on a 10 cm VAS for sleep disturbance; minimally important difference is 1 cm) among chronic cancer pain patients. Addition of cannabis likely increases nausea (relative risk (RR) 1.43; 95% CI 1.04 to 1.96; risk difference (RD) 4%, 95% CI 0% to 7%) and vomiting (RR 1.5; 95% CI 1.01 to 2.24; RD 3%; 95% CI 0% to 6%) (both moderate certainty) and may have no effect on constipation (RR 0.85; 95% CI 0.54 to 1.35; RD -1%; 95% CI -4% to 2%) (low certainty). Eight observational studies provided very low certainty evidence that adding cannabis reduced opioid use (WMD -22.5 MME; 95% CI -43.06 to -1.97). CONCLUSION Opioid-sparing effects of medical cannabis for chronic pain remain uncertain due to very low certainty evidence.PROSPERO registration numberCRD42018091098.
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Affiliation(s)
- Atefeh Noori
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- The Michael G. DeGroote National Pain Center, McMaster University, Hamilton, Ontario, Canada
| | - Anna Miroshnychenko
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yaadwinder Shergill
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vahid Ashoorion
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yasir Rehman
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rachel J Couban
- The Michael G. DeGroote National Pain Center, McMaster University, Hamilton, Ontario, Canada
| | - D Norman Buckley
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of of General Internal Medicine, University of Geneva Faculty of Medicine, Geneve, Switzerland
| | - Jason W Busse
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- The Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada
- The Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada
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Chandiok K, Marathe S, Rooney M, Stocker J, Tellis B, Pit S. Cannabis and its therapeutic value in the ageing population: Attitudes of health-care providers. Australas J Ageing 2021; 40:261-274. [PMID: 34273232 DOI: 10.1111/ajag.12846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/09/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE(S) To explore the attitudes of health-care providers and the perceived barriers and facilitators regarding the use of cannabis-containing medicines (CCMs) in older patients. METHODS Semi-structured interviews with eleven health-care providers in rural New South Wales (NSW). A thematic analysis was performed. RESULTS Themes and recommendations include attitudes towards CCMs for therapeutic purposes, their perceived uses, side effects, barriers to use and prescription (stigma, regulation, access and driving), difficulties encountered with the Special Access Scheme (SAS) and the need for ongoing research and education. An ecological framework demonstrated the complex interactions between patients and health-care providers and their social, community and political environment. CONCLUSION Providers' attitudes towards CCM use in older patients are generally positive; however, there is a need for further high-quality evidence on efficacy and safety, alongside improved CCM education and training, to reduce barriers to their implementation. Barriers to prescription and access continue to evolve on personal, organisational and systemic levels.
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Affiliation(s)
- Karan Chandiok
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Shreeya Marathe
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Miranda Rooney
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Jess Stocker
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Bianca Tellis
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia
| | - Sabrina Pit
- School of Medicine, Western Sydney University, Sydney, NSW, Australia.,University Centre for Rural Health, Lismore, NSW, Australia.,The University of Sydney, Lismore, NSW, Australia
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66
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Kvamme SL, Pedersen MM, Rømer Thomsen K, Thylstrup B. Exploring the use of cannabis as a substitute for prescription drugs in a convenience sample. Harm Reduct J 2021; 18:72. [PMID: 34246279 PMCID: PMC8272272 DOI: 10.1186/s12954-021-00520-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 06/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The use of cannabis as medicine (CaM) both prescribed and non-prescribed has increased markedly in the last decade, mirrored in a global shift in cannabis policy towards a more permissive stance. There is some evidence that cannabis functions as a substitute for prescription drugs, particularly opioids; however, more knowledge is needed on the motives of substitution users, their patterns of use, and perceived effects of substitution use. AIMS To explore who substitutes prescription drugs with cannabis, the type of prescription drugs substituted and the type of cannabis used, and the impact that substitution with cannabis has on prescription drug use as well as the motives for substitution in terms of experienced effects and side effects. METHODS A self-selected convenience sample was recruited through social media, public media, and patient organizations to take part in an anonymous online survey. Inclusion criteria were 18 years or older and use of cannabis (prescribed or non-prescribed) with a medical purpose. RESULTS The final sample included 2.841 respondents of which the majority (91%) used non-prescribed cannabis, and more than half (54.6%) had used CaM with the purpose of replacing a prescribed drug. Compared to non-substitution users, substitution users were more likely to be women and to use CaM in the treatment of chronic pain and other somatic conditions. Pain medication (67.2%), antidepressants (24.5%), and arthritis medication (20.7%) were the most common types of drugs replaced with CaM. Among substitution users, 38.1% reported termination of prescription drug use, and 45.9% a substantial decrease in prescription drug use. The most frequent type of cannabis used as a substitute was CBD-oil (65.2%), followed by 'hash, pot or skunk' (36.6%). More than half (65.8%) found CaM much more effective compared to prescription drugs, and 85.5% that the side effects associated with prescription drug use were much worse compared to use of CaM. CONCLUSION CaM is frequently used as a substitute for prescription drugs, particularly opioids. More research is needed on the long-term consequences of use of CaM, including the impact from low and high THC cannabis products on specific somatic and mental health conditions.
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Affiliation(s)
- Sinikka L Kvamme
- Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Building 1322. Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Michael M Pedersen
- Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Building 1322. Bartholins Allé 10, 8000, Aarhus C, Denmark
| | - Kristine Rømer Thomsen
- Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Building 1322. Bartholins Allé 10, 8000, Aarhus C, Denmark
| | - Birgitte Thylstrup
- Center for Alcohol and Drug Research, Aarhus BSS, Aarhus University, Artillerivej 90, 2. Floor, 2300, Copenhagen S, Denmark
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Dunn KE, Bergeria CL, Huhn AS, Speed TJ, Mun CJ, Vandrey R, Campbell CM. Within-subject, double-blinded, randomized, and placebo-controlled evaluation of the combined effects of the cannabinoid dronabinol and the opioid hydromorphone in a human laboratory pain model. Neuropsychopharmacology 2021; 46:1451-1459. [PMID: 33879842 PMCID: PMC8055479 DOI: 10.1038/s41386-021-01007-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/04/2021] [Accepted: 03/24/2021] [Indexed: 02/02/2023]
Abstract
This Phase II study evaluated analgesia, abuse liability, and cognitive performance of hydromorphone and oral delta-9-tetrahydrocannabinol (THC; dronabinol) using a within-subject, double-blind, randomized, placebo-controlled, human laboratory trial. Healthy adults (N = 29) with no history of drug use disorder received combinations of placebo, hydromorphone (4 mg; oral), and dronabinol (2.5 mg, 5.0 mg, 10 mg; oral). Primary outcomes were quantitative sensory testing (QST) measures of acute (thermal, pressure pain; thermal, punctate probe temporal summation; cold pressor; conditioned pain modulation) and chronic pain (capsaicin 10% topical cream with thermal rekindling), measures of drug abuse liability, cognitive functioning, and adverse events. Subgroup analyses were conducted within opioid-responders (endorsed >20 on a Drug Effect visual analog scale during the hydromorphone-only condition) and nonresponders. A consistent dose-effect relationship of dronabinol on hydromorphone across all measures was not observed. Analgesia only improved in the hydromorphone + dronabinol 2.5 mg condition. Hydromorphone + dronabinol 2.5 mg showed the lowest and hydromorphone+dronabinol 5 mg showed the highest risk for abuse. Hydromorphone+dronabinol 10 mg produced a high rate of dysphoric effects, and hydromorphone+dronabinol 5 mg and hydromorphone + dronabinol 10 mg produced AEs. Subgroup analyses showed subjective effects and abuse risk was increased among opioid responders and largely absent among nonresponders. Overall, only hydromorphone+dronabinol 2.5 mg modestly enhanced hydromorphone-based analgesia and hydromorphone + dronabinol 5 mg and 10 mg increased risk for abuse and AEs. These data can help inform opioid-sparing efforts in clinical pain populations. Demonstration that potential opioid effects varied as a function of participant opioid sensitivity (e.g., responder status) is a novel finding that warrants additional research.
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Affiliation(s)
- Kelly E. Dunn
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Cecilia L. Bergeria
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Andrew S. Huhn
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Traci J. Speed
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Chung Jung Mun
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Ryan Vandrey
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Claudia M. Campbell
- grid.21107.350000 0001 2171 9311Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD USA
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Erwin LL, Nilges MR, Denys IB, Sutphen JC, Friend AJ, Kapusta DR, Winsauer PJ. Interactive effects of (±)-trans-U50488 and its stereoisomers with cannabinoids. Pharmacol Biochem Behav 2021; 207:173218. [PMID: 34118232 DOI: 10.1016/j.pbb.2021.173218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 04/08/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022]
Abstract
The adverse effects of mu opioid agonists have spurred a renewed interest in using kappa opioid receptor (KOR) agonists as analgesics. KOR agonists also have potential for development as diuretics for the treatment of edema and hypertension. Here, we evaluated the discriminative stimulus, antinociceptive, and diuretic effects of the kappa agonist (±)-trans-U-50488 and its stereoisomers (-)-(1S,2S)-U-50488 or (+)-(1R,2R)-U-50488) alone and in combination with the cannabinoid agonist (-)-CP 55,940. To establish (±)-U-50488 as a discriminative stimulus, rats (n = 12) were trained to discriminate intraperitoneal (i.p.) administration of 5.6 mg/kg of (±)-trans-U-50488 from saline under a fixed-ratio 20 (FR-20) schedule of food reinforcement. Then, antinociception was assessed using two procedures: warm water tail withdrawal and von Frey paw withdrawal. Diuretic effects were assessed in separate rats (n = 6/group). Doses of (±)-U-50488 and (-)-U-50488 that served as discriminative stimuli produced significant increases in urine output, but at lower doses than those that produced antinociception. In contrast, (+)-U-50488 alone had no discriminative stimulus or diuretic effects at the doses tested, but did produce antinociception in the von Frey assay. When three cannabinoids and morphine were tested in the (±)-U-50488 discrimination procedure to determine the similarity of these drugs' discriminative stimulus effects to those for (±)-U-50488, the rank order similarity was (-)-CP 55,940 > (-)-trans-THC > (+)-WIN 55,212-2 ≥ morphine. (-)-CP 55,940 alone (0.056 mg/kg) partially substituted for the discriminative stimulus effects of (±)-U-50488 and produced significant diuretic and antinociceptive effects. (-)-CP 55,940 in combination with (±)-U-50488 also produced a two-fold leftward shift in the discriminative stimulus curve for (±)-U-50488, and near-additive antinociception with (±)-U-50488 and (+)-U-50488. Further, the diuretic effect of (-)-CP 55,940 was enhanced by a dose of (+)-U50488, which itself did not alter urine output. These data together indicate that a combination of cannabinoid and kappa opioid agonists can enhance diuresis, but may have limited potential for serving as opioid-sparing pharmacotherapeutics for treatment of pain.
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Affiliation(s)
- Laura L Erwin
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA.
| | - Mark R Nilges
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Ian B Denys
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Jane C Sutphen
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Ashton J Friend
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Daniel R Kapusta
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
| | - Peter J Winsauer
- Department of Pharmacology and Experimental Therapeutics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; Alcohol and Drug Abuse Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
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Jugl S, Okpeku A, Costales B, Morris EJ, Alipour-Haris G, Hincapie-Castillo JM, Stetten NE, Sajdeya R, Keshwani S, Joseph V, Zhang Y, Shen Y, Adkins L, Winterstein AG, Goodin A. A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019. Med Cannabis Cannabinoids 2021; 4:21-42. [PMID: 34676348 PMCID: PMC8525213 DOI: 10.1159/000515069] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 02/03/2021] [Indexed: 12/15/2022] Open
Abstract
In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.
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Affiliation(s)
- Sebastian Jugl
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Aimalohi Okpeku
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Brianna Costales
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Earl J. Morris
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Golnoosh Alipour-Haris
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Juan M. Hincapie-Castillo
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | | | - Ruba Sajdeya
- Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Shailina Keshwani
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Verlin Joseph
- Epidemiology, University of Florida, Gainesville, Florida, USA
| | - Yahan Zhang
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Yun Shen
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Lauren Adkins
- Health Sciences Center Libraries, University of Florida, Gainesville, Florida, USA
| | - Almut G. Winterstein
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Amie Goodin
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
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Safakish R, Ko G, Salimpour V, Hendin B, Sohanpal I, Loheswaran G, Yoon SYR. Medical Cannabis for the Management of Pain and Quality of Life in Chronic Pain Patients: A Prospective Observational Study. PAIN MEDICINE 2021; 21:3073-3086. [PMID: 32556203 DOI: 10.1093/pm/pnaa163] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the short-term and long-term effects of plant-based medical cannabis in a chronic pain population over the course of one year. DESIGN A longitudinal, prospective, 12-month observational study. SETTING Patients were recruited and treated at a clinic specializing in medical cannabis care from October 2015 to March 2019. SUBJECTS A total of 751 chronic pain patients initiating medical cannabis treatment. METHODS Study participants completed the Brief Pain Inventory and the 12-item Short Form Survey (SF-12), as well as surveys on opioid medication use and adverse events, at baseline and once a month for 12 months. RESULTS Medical cannabis treatment was associated with improvements in pain severity and interference (P < 0.001) observed at one month and maintained over the 12-month observation period. Significant improvements were also observed in the SF-12 physical and mental health domains (P < 0.002) starting at three months. Significant decreases in headaches, fatigue, anxiety, and nausea were observed after initiation of treatment (P ≤ 0.002). In patients who reported opioid medication use at baseline, there were significant reductions in oral morphine equivalent doses (P < 0.0001), while correlates of pain were significantly improved by the end of the study observation period. CONCLUSIONS Taken together, the findings of this study add to the cumulative evidence in support of plant-based medical cannabis as a safe and effective treatment option and potential opioid medication substitute or augmentation therapy for the management of symptoms and quality of life in chronic pain patients.
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Affiliation(s)
| | - Gordon Ko
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Bryan Hendin
- Apollo Applied Research, Toronto, Ontario, Canada
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Substituting Cannabidiol for Opioids and Pain Medications Among Individuals With Fibromyalgia: A Large Online Survey. THE JOURNAL OF PAIN 2021; 22:1418-1428. [PMID: 33992787 DOI: 10.1016/j.jpain.2021.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 12/16/2022]
Abstract
People report substituting cannabis for pain medications, but whether cannabidiol (CBD) is used similarly remains unknown. CBD products can be CBD alone (isolate), hemp extract (containing <0.3% Δ-9-tetrahydrocannabinol [THC], other cannabinoids, and terpenes), or CBD-cannabis (containing >0.3% THC). In a secondary analysis from a cross-sectional survey, we examined substitution patterns among n = 878 individuals with fibromyalgia who currently used CBD. We sub-grouped participants by most commonly used CBD product (CBD isolate, hemp, CBD-cannabis, no preference) and whether they substituted CBD for medications. We investigated rationale for substituting, substitution-driven medication changes, CBD use patterns, and changes in pain-related symptoms (eg, sleep, anxiety). The study population was 93.6% female and 91.5% Caucasian, with an average age of 55.5 years. The majority (n = 632, 72.0%) reported substituting CBD products for medications, most commonly NSAIDs (59.0%), opioids (53.3%), gabapentanoids (35.0%), and benzodiazepines (23.1%). Most substituting participants reported decreasing or stopping use of these pain medications. The most common reasons for substitution were fewer side effects and better symptom management. Age, hemp products, past-year use of marijuana, and higher somatic burden were all associated with substituting (P's ≤ .05). Those who substituted reported larger improvements in health and pain than those who did not. Participants using CBD-cannabis reported significantly more substitutions than any other group (P's ≤ .001) and larger improvements in health, pain, memory, and sleep than other subgroups. This widespread naturalistic substitution for pain medications suggests the need for more rigorous study designs to examine this effect. PERSPECTIVE: This article shows that people with fibromyalgia are deliberately substituting CBD products for conventional pain medications despite the dearth of evidence suggesting CBD products may be helpful for fibromyalgia. CBD's medication-sparing and therapeutic potential should be examined in more rigorous study designs.
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Antinociceptive synergism upon the joint use of methadone and Phα1β in a model of cancer-related pain in C57BL/6J mice. Life Sci 2021; 278:119582. [PMID: 33961856 DOI: 10.1016/j.lfs.2021.119582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/16/2021] [Accepted: 04/25/2021] [Indexed: 01/07/2023]
Abstract
Opioids are the first-line treatment for cancer pain. Incomplete pain relief and the high rate of adverse effects of these compounds bring a need to combine them with other drugs acting on different targets. AIMS We here evaluate the antinociceptive interaction and adverse events of methadone combined with recombinant Phα1β, an analgesic toxin from Phoneutria nigriventer. MAIN METHODS Melanoma was produced by intraplantar inoculation of B16-F10 cells into the right paw. von Frey filaments measured the paw-withdrawal threshold after administration of methadone, Phα1β, and their combination. The degree of interaction was evaluated using isobolographic analysis. Spontaneous performance and forced motor performance were assessed with the open-field and rotarod tests, respectively. Intestinal function was evaluated by the distance traveled by charcoal and opioid tolerance was induced by daily morphine injections. KEY FINDINGS Co-administration of Phα1β with methadone synergistically reverses the melanoma-induced mechanical hypersensitivity. No motor alterations were observed but mild alterations on intestinal function after treatment with the combination that was also capable of restoring morphine analgesia in the tail-flick test after an opioid-induced tolerance. SIGNIFICANCE Combinatorial treatment with Phα1β and methadone produces synergistic analgesic potentiation with potential implications to pain treatment even under opioid tolerance conditions.
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73
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Lee C, Lin M, Martins KJB, Dyck JRB, Klarenbach S, Richer L, Jess E, Hanlon JG, Hyshka E, Eurich DT. Opioid use in medical cannabis authorization adult patients from 2013 to 2018: Alberta, Canada. BMC Public Health 2021; 21:843. [PMID: 33933061 PMCID: PMC8088205 DOI: 10.1186/s12889-021-10867-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/15/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The opioid overdose epidemic in Canada and the United States has become a public health crisis - with exponential increases in opioid-related morbidity and mortality. Recently, there has been an increasing body of evidence focusing on the opioid-sparing effects of medical cannabis use (reduction of opioid use and reliance), and medical cannabis as a potential alternative treatment for chronic pain. The objective of this study is to assess the effect of medical cannabis authorization on opioid use (oral morphine equivalent; OME) between 2013 and 2018 in Alberta, Canada. METHODS All adult patients defined as chronic opioid users who were authorized medical cannabis by their health care provider in Alberta, Canada from 2013 to 2018 were propensity score matched to non-authorized chronic opioid using controls. A total of 5373 medical cannabis patients were matched to controls, who were all chronic opioid users. The change in the weekly average OME of opioid drugs for medical cannabis patients relative to controls was measured. Interrupted time series (ITS) analyses was used to assess the trend change in OME during the 26 weeks (6 months) before and 52 weeks (1 year) after the authorization of medical cannabis among adult chronic opioid users. RESULTS Average age was 52 years and 54% were female. Patients on low dose opioids (< 50 OME) had an increase in their weekly OME per week (absolute increase of 112.1 OME, 95% CI: 104.1 to 120.3); whereas higher dose users (OME > 100), showed a significant decrease over 6 months (- 435.5, 95% CI: - 596.8 to - 274.2) compared to controls. CONCLUSIONS This short-term study found that medical cannabis authorization showed intermediate effects on opioid use, which was dependent on initial opioid use. Greater observations of changes in OME appear to be in those patients who were on a high dosage of opioids (OME > 100); however, continued surveillance of patients utilizing both opioids and medical cannabis is warranted by clinicians to understand the long-term potential benefits and any harms of ongoing use.
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Affiliation(s)
- Cerina Lee
- School of Public Health, 2-040 Li Ka Shing Centre for Health Research Innovation, University of Alberta, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Mu Lin
- SPOR (Strategy for Patient Oriented Research) Data Platform, Alberta Health Services, Edmonton, Alberta, Canada
| | - Karen J B Martins
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Scott Klarenbach
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Lawrence Richer
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Ed Jess
- College of Physicians & Surgeons of Alberta, Edmonton, Alberta, Canada
| | - John G Hanlon
- St. Michael's Hospital Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elaine Hyshka
- School of Public Health, 2-040 Li Ka Shing Centre for Health Research Innovation, University of Alberta, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada
| | - Dean T Eurich
- School of Public Health, 2-040 Li Ka Shing Centre for Health Research Innovation, University of Alberta, 11203-87 Avenue, Edmonton, AB, T6G 2E1, Canada.
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74
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MacCallum CA, Eadie L, Barr AM, Boivin M, Lu S. Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain. Front Pharmacol 2021; 12:633168. [PMID: 33995035 PMCID: PMC8120104 DOI: 10.3389/fphar.2021.633168] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Chronic non-cancer pain (CNCP) is estimated to affect 20% of the adult population. Current United States and Canadian Chronic non-cancer pain guidelines recommend careful reassessment of the risk-benefit ratio for doses greater than 90 mg morphine equivalent dose (MED), due to low evidence for improved pain efficacy at higher morphine equivalent dose and a significant increase in morbidity and mortality. There are a number of human studies demonstrating cannabis opioid synergy. This preliminary evidence suggests a potential role of cannabis as an adjunctive therapy with or without opioids to optimize pain control. Methods: In 2017, the Canadian Opioid Guidelines Clinical Tool was created to encourage judicious opioid prescribing for CNCP patients and to reevaluate those who have been chronically using high MED. Mirroring this approach, we draw on our clinical experiences and available evidence to create a clinical tool to serve as a foundational clinical guideline for the initiation of medical cannabis in the management of CNCP patients using chronic opioid therapy. Findings: Following principles of harm reduction and risk minimization, we suggest cannabis be introduced in appropriately selected CNCP patients, using a stepwise approach, with the intent of pain management optimization. We use a structured approach to focus on low dose cannabis (namely, THC) initiation, slow titration, dose optimization and frequent monitoring. Conclusion: When low dose THC is introduced as an adjunctive therapy, we observe better pain control clinically with lower doses of opioids, improved pain related outcomes and reduced opioid related harm.
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Affiliation(s)
- Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, BC, Canada.,Department of Medicine, Faculty of Medicine, Division of Palliative Care, UBC, Vancouver, BC, Canada.,Faculty of Pharmaceutical Sciences, UBC, Vancouver, BC, Canada
| | - Lauren Eadie
- Department of Medicine, Faculty of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, UBC, Vancouver, BC, Canada
| | | | - Shaohua Lu
- Department of Medicine, Faculty of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, BC, Canada
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75
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Raja SN, Ringkamp M, Guan Y, Campbell JN. John J. Bonica Award Lecture: Peripheral neuronal hyperexcitability: the "low-hanging" target for safe therapeutic strategies in neuropathic pain. Pain 2021; 161 Suppl 1:S14-S26. [PMID: 33090736 DOI: 10.1097/j.pain.0000000000001838] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Matthias Ringkamp
- Neurological Surgery, Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
| | - Yun Guan
- Departments of Anesthesiology and Critical Care Medicine and.,Neurological Surgery, Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
| | - James N Campbell
- Neurological Surgery, Department of Neurosurgery, Johns Hopkins University, School of Medicine, Baltimore, MD, United States
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76
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Laksmidewi AAAP, Soejitno A. Endocannabinoid and dopaminergic system: the pas de deux underlying human motivation and behaviors. J Neural Transm (Vienna) 2021; 128:615-630. [PMID: 33712975 PMCID: PMC8105194 DOI: 10.1007/s00702-021-02326-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/04/2021] [Indexed: 01/11/2023]
Abstract
Endocannabinoid system (ECS) has been identified ever since cannabinoid, an active substance of Cannabis, was known to interact with endogenous cannabinoid (endocannabinoid/eCB) receptors. It later turned out that eCB was more intricate than previously thought. It has a pervasive role and exerts a multitude of cellular signaling mechanisms, regulating various physiological neurotransmission pathways in the human brain, including the dopaminergic (DA) system. eCB roles toward DA system were robust, clearly delineated, and reproducible with respect to physiological as well as pathological neurochemical and neurobehavioral manifestations of DA system, particularly those involving the nigrostriatal and mesocorticolimbic pathways. The eCB–DA system regulates the basics in the Maslow’s pyramid of hierarchy of needs required for individual survival such as food and sexual activity for reproductive purpose to those of higher needs in the pyramid, including self-actualization behaviors leading to achievement and reward (e.g., academic- and/or work-related performance and achievements). It is, thus, interesting to specifically discuss the eCB–DA system, not only on the molecular level, but also its tremendous potential to be developed as a future therapeutic strategy for various neuropsychiatric problems, including obesity, drug addiction and withdrawal, pathological hypersexuality, or low motivation behaviors.
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Affiliation(s)
- A A A Putri Laksmidewi
- Neurobehavioral and Cognitive Division, Neurology Department, Faculty of Medicine, Udayana University/Sanglah Hospital, Denpasar, Bali, Indonesia.
| | - Andreas Soejitno
- Neurobehavioral and Cognitive Division, Neurology Department, Faculty of Medicine, Udayana University/Sanglah Hospital, Denpasar, Bali, Indonesia
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77
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Le Foll B. Opioid-sparing effects of cannabinoids: Myth or reality? Prog Neuropsychopharmacol Biol Psychiatry 2021; 106:110065. [PMID: 32828853 DOI: 10.1016/j.pnpbp.2020.110065] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/09/2020] [Accepted: 08/05/2020] [Indexed: 12/15/2022]
Abstract
A converging line of evidence is indicating that cannabinoids may have an opioid-sparing effect. This property, well validated in preclinical studies, allow when both drugs are co-administered to reduce the dose of opioids without loss of analgesic effects. A meta-analysis of pre-clinical studies indicated in 2017 that the median effective dose (ED50) of morphine administered in combination with delta-9-tetrahydrocannabinol (delta-9-THC) is 3.6 times lower than the ED50 of morphine alone (Nielsen et al., 2017). However, very few studies have been conducted in humans to validate this effect. This narrative review provides an update on whether or not cannabinoid drugs can be used to produce an opioid sparing effect. For this, various lines of evidence ranging from preclinical, epidemiological and human studies will be summarized. Overall, this review indicates that the preclinical results are strongly and consistently supportive of the presence of an opioid sparing effect of cannabinoid drugs. However, to date the clinical studies have been mostly negative; and, the evidence collected in humans so far is so limited that it is premature to conclude. Therefore, prospective high quality controlled clinical trials are still required to validate this. Priorities for future research are also discussed.
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Affiliation(s)
- Bernard Le Foll
- Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Division of Brain and Therapeutics, University of Toronto, Toronto, ON, Canada.; Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada.
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78
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Abstract
The medicolegal landscape of cannabis continues to change, and with ever increasing access there has been a concurrent proliferation of research seeking to understand the utility of cannabinoids in treating innumerable conditions with pain at the forefront. This article seeks to summarize clinically relevant findings in cannabinoid research to better prepare clinicians in the utility of cannabis in the treatment of pain.
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Affiliation(s)
- Oliver Hulland
- Department of Emergency Medicine, Yale-New Haven Hospital, Yale University, 464 Congress Avenue, New Haven, CT 06519, USA
| | - Jessica Oswald
- Center for Pain Medicine, Department of Anesthesiology, UC San Diego Health, La Jolla, CA, USA; Department of Emergency Medicine, UC San Diego Health, La Jolla, CA, USA.
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79
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Mechtler LL, Gengo FM, Bargnes VH. Cannabis and Migraine: It's Complicated. Curr Pain Headache Rep 2021; 25:16. [PMID: 33630181 DOI: 10.1007/s11916-020-00931-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The use of cannabis for the treatment of migraine has become an area of interest with the legalization of medical cannabis in the USA. Understanding the mechanisms of cannabinoids, available studies, and best clinical recommendations is crucial for headache providers to best serve patients. RECENT FINDINGS Patients utilizing medical cannabis for migraine have reported improvement in migraine profile and common comorbidities. Reduction in prescription medication is also common, especially opioids. Side effects exist, with the majority being mild. Not enough data is available for specific dose recommendations, but THC and CBD appear to mediate these observed effects. The purpose of this article is twofold: review the limited research surrounding cannabis for migraine disease and reflect on clinical management experiences to provide recommendations that best capture the potential use of cannabis for migraine.
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Affiliation(s)
- Laszlo L Mechtler
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 600, Amherst, NY, 14226, USA.
| | - Fran M Gengo
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 300, Amherst, NY, 14226, USA
| | - Vincent H Bargnes
- Dent Neurologic Institute, 3980 Sheridan Drive, Suite 600, Amherst, NY, 14226, USA
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80
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Chang Y, Zhu M, Vannabouathong C, Mundi R, Chou RS, Bhandari M. Medical Cannabis for Chronic Noncancer Pain: A Systematic Review of Health Care Recommendations. Pain Res Manag 2021; 2021:8857948. [PMID: 33613794 PMCID: PMC7878090 DOI: 10.1155/2021/8857948] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
Purpose Medical cannabis for patients with chronic noncancer pain (CNCP) has been the focus of numerous health care recommendations. We conducted a systematic review to identify and summarize the currently available evidence-based recommendations. Methods We searched MEDLINE, EMBASE, PsycINFO, the Cochrane database of systematic reviews, and websites for clinical guidelines and recommendations. We summarized the type of the publications, developers, approach of health care recommendation development, year and country of publication, and conditions that were addressed. We categorized the direction and strength of each recommendation. Results We identified 12 eligible publications. Publication years ranged from 2007 to 2019; four (33.3%) of them were published in 2018. Canada ranked first for the number of publications (n = 4, 33.3%). Most (n = 11, 92%) of the included recommendations were based on both a systematic review of the best evidence and expert consensus. All the included publications provided a recommendation supporting medical cannabis for CNCP in general and for the specific conditions of neuropathic pain, chronic pain in people living with Human Immunodeficiency Virus (HIV), and chronic abdominal pain, with detailed information sharing and comprehensive consideration of a patient's own values and preferences. Conclusion Clinicians can attend to the guidance currently offered, being aware that only weak recommendations are available for medical cannabis in patients with CNCP, as a third- or fourth-line therapy. Detailed discussions with patients regarding the benefits in reducing pain and potential adverse effects are required before its prescription.
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Affiliation(s)
- Yaping Chang
- OrthoEvidence Inc., Burlington, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Meng Zhu
- OrthoEvidence Inc., Burlington, ON, Canada
| | | | - Raman Mundi
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Sunnybrook Holland Orthopaedic and Arthritic Centre, Toronto, ON, Canada
| | - Roland S. Chou
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- OrthoEvidence Inc., Burlington, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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81
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Andrews NJ, Phillips AJ. Community nurses' support for patients with fibromyalgia who use cannabis to manage pain. Br J Community Nurs 2021; 26:92-98. [PMID: 33539238 DOI: 10.12968/bjcn.2021.26.2.92] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Supporting patients to manage chronic pain conditions, such as fibromyalgia (FM), remains a challenge for community nurses. Research suggests that despite the absence of a licensed cannabis-based product for medicinal use (CBPM) available for people with FM in the UK, there is an appetite for FM patients to use cannabis for pain management. Nurses have expressed anxieties when balancing tensions between helping patients and working within medical guidelines, as well as a need for further education about patient cannabis use. This article provides community nurses with insight into how cannabis use affects the pain experience for people living with FM. Despite potential harms, cannabis is perceived by users to have a positive impact on the lived experience of pain, and it may be preferred to prescribed opioid medication. This understanding can help to inform empathic practice and recommendations are made for reducing the risks of cannabis use to patient health.
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Affiliation(s)
- Natasha J Andrews
- Student in Health Studies, Canterbury Christ Church University, Kent
| | - Adele J Phillips
- Senior Lecturer in Health Promotion and Public Health, Canterbury Christ Church University, Kent
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82
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Ceasar RC, Kral AH, Simpson K, Wenger L, Goldshear JL, Bluthenthal RN. Factors associated with health-related cannabis use intentions among a community sample of people who inject drugs in Los Angeles and San Francisco, CA 2016 to 2018. Drug Alcohol Depend 2021; 219:108421. [PMID: 33301996 PMCID: PMC7856255 DOI: 10.1016/j.drugalcdep.2020.108421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Cannabis motivations have been studied extensively among patients of medicinal cannabis dispensaries, but less is known about motivations in community samples of opioid-using people who inject drugs. Our objective is to describe cannabis use motivations associated with self-treatment of physical pain, emotional issues, and as an opioid substitute. METHODS Data come from 6-month follow-up interviews with people who inject drugs who participated in a study on the efficacy of an injection initiation prevention intervention in Los Angeles and San Francisco, California from 2016-18. The analytic sample consists of 387 people who inject drugs who reported past-month cannabis use. We developed multivariable logistic regression models by reported cannabis use motivations: physical pain relief, emotional problems, and opioid substitute. RESULTS The most common cannabis use motivations reported by people who inject drugs was to "get high," relieve physical pain and emotional problems, and reduce opioid use. In separate multivariate models, using cannabis for physical pain relief was associated with higher odds of using cannabis as a substitute for opioids; cannabis for emotional problems was associated with being diagnosed with depression; and cannabis as a substitute for opioids was associated with non-prescribed, non-injection methadone use. CONCLUSION People who inject drugs reported using cannabis for health-related motivations. This motivation aligns with health needs and suggests the acceptability of cannabis use for health reasons in this population. Studies to determine the medical effectiveness of cannabis products for these common health and mental health needs among people who inject drugs are needed.
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Affiliation(s)
- Rachel Carmen Ceasar
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA.
| | - Alex H Kral
- Behavioral Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | - Kelsey Simpson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
| | - Lynn Wenger
- Behavioral Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA, 94704, USA
| | - Jesse L Goldshear
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
| | - Ricky N Bluthenthal
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, 2001 N. Soto Street, Los Angeles, CA, 90032, USA
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83
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Maida V, Biasi SA. "Less pain with more gain"-Managing wound-related pain with cannabis-based medicines. Wound Repair Regen 2021; 29:338-341. [PMID: 33455032 DOI: 10.1111/wrr.12895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/10/2020] [Accepted: 12/17/2020] [Indexed: 11/30/2022]
Abstract
Wound-related pain poses a serious challenge for patients and physicians. It is a complex pathophysiologic construct that may be stratified, from the patient's perspective, into baseline pain and breakthrough pain. The current paradigm for treating wound related pain involves the overuse of opioids and other co-analgesics with little regard for breakthrough pain. These standard medications have a propensity for deleterious side effects while some of them inhibit wound healing, effectively perpetuating the wound and the related pain. In particular, the overuse of opioids is a contributor to the global opioid crisis. It is evident that a new paradigm needs to be considered. Cannabis-based medicines are a prominent prospect under investigation for their potential to reduce dosages of status quo analgesics while effectively reducing pain. The authors propose a new paradigm that emphasizes the use of Cannabis-Based Medicines, delivered through multiple routes, while recommending the need for more foundational scientific investigation into mechanisms, and clinical controlled trials to determine optimal combinations, dosages, and protocols.
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Affiliation(s)
- Vincent Maida
- University of Toronto, Toronto, Ontario, Canada.,Hospice Vaughan, Vaughan, Ontario, Canada
| | - Stefano A Biasi
- Faculty of Science, McMaster University, Hamilton, Ontario, Canada
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84
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Abu-Amna M, Salti T, Khoury M, Cohen I, Bar-Sela G. Medical Cannabis in Oncology: a Valuable Unappreciated Remedy or an Undesirable Risk? Curr Treat Options Oncol 2021; 22:16. [PMID: 33439370 DOI: 10.1007/s11864-020-00811-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2020] [Indexed: 01/11/2023]
Abstract
OPINION STATEMENT The use of the cannabis plant by cancer patients has been rising significantly in the past few years worldwide, primarily driven by public demand. There is an obvious need for more reliable scientific data, pharmacology information, a better understanding of its mode of action, and available clinical evidence supporting its robust use. Physicians must complete a thorough medical assessment, screening for potential drugs, or treatment contraindications before allowing its consumption. In light of the growing popularity of cannabis usage, it is highly essential that, in the near future, the medical community will be able to provide practical recommendations and explicit guidelines, including doses, and that cannabinoid concentrations in the used products are defined regarding its prescription before any medical procedure involving its usage is authorized. Here, we review and describe the favorable outcomes demonstrating the benefits of cannabis as an adjunctive treatment to conventional medicines for chemotherapy-induced nausea, vomiting, and cancer-related pain (primarily refractory chronic or neuropathic pain). Although not yet substantial enough, the treatment of anorexia, insomnia, depression, and anxiety is also seemingly favorable. To date, reports regarding its anti-neoplastic effects or its potent immunosuppressive properties influencing response to immunotherapy are still very conflicting and controversial. Thus, with the current state of evidence, cannabis use is not advisable as initial treatment, as an adjunct or an advanced line of care. In the coming years, we expect that preclinical data and animal models will shift to the clinical arena, and more patients will be recruited for clinical trials, and their reports will advance the field. Thus, physicians should prescribe cannabis only if careful clarification and consideration is provided together with a follow-up response evaluation.
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Affiliation(s)
- Mahmoud Abu-Amna
- Cancer Center, Emek Medical Center, 21 Yitzhak Rabin Blvd, 1834111, Afula, Israel
| | - Talal Salti
- Cancer Center, Emek Medical Center, 21 Yitzhak Rabin Blvd, 1834111, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 320002, Haifa, Israel
| | - Mona Khoury
- Cancer Center, Emek Medical Center, 21 Yitzhak Rabin Blvd, 1834111, Afula, Israel.,Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 320002, Haifa, Israel
| | - Idan Cohen
- Cancer Center, Emek Medical Center, 21 Yitzhak Rabin Blvd, 1834111, Afula, Israel
| | - Gil Bar-Sela
- Cancer Center, Emek Medical Center, 21 Yitzhak Rabin Blvd, 1834111, Afula, Israel. .,Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 320002, Haifa, Israel.
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85
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Kim TE, Townsend RK, Branch CL, Romero-Sandoval EA, Hsu W. Cannabinoids in the Treatment of Back Pain. Neurosurgery 2021; 87:166-175. [PMID: 32097466 DOI: 10.1093/neuros/nyz573] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 11/30/2019] [Indexed: 01/17/2023] Open
Abstract
Marijuana is increasingly utilized for the treatment of multiple medical problems, including back pain, in the United States. Although there is strong preclinical evidence supporting the promise of cannabinoids in the treatment of back pain, there is a paucity of clinical data supporting their use in clinical practice. Opioids are an important medication for the treatment of acute and chronic back pain, but utilization of opioid-based regimens have likely contributed to the growing opioid epidemic. The significant risk of morbidity, mortality, and dependence secondary to opioid medications have increased the interest in nonopioid medications, including cannabinoid-based pain regimens, in treating back pain. This review will provide an overview on the pharmacology, drug delivery methods, clinical evidence, and safety considerations critical to understanding the potential role of cannabinoids in the treatment of back pain.
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Affiliation(s)
- Teddy E Kim
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Robert K Townsend
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Charles L Branch
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Edgar A Romero-Sandoval
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston Salem, North Carolina
| | - Wesley Hsu
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston Salem, North Carolina
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Eadie L, Lo LA, Christiansen A, Brubacher JR, Barr AM, Panenka WJ, MacCallum CA. Duration of Neurocognitive Impairment With Medical Cannabis Use: A Scoping Review. Front Psychiatry 2021; 12:638962. [PMID: 33790818 PMCID: PMC8006301 DOI: 10.3389/fpsyt.2021.638962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
While the recreational use of cannabis has well-established dose-dependent effects on neurocognitive and psychomotor functioning, there is little consensus on the degree and duration of impairment typically seen with medical marijuana use. Compared to recreational cannabis users, medical cannabis patients have distinct characteristics that may modify the presence and extent of impairment. The goal of this review was to determine the duration of acute neurocognitive impairment associated with medical cannabis use, and to identify differences between medical cannabis patients and recreational users. These findings are used to gain insight on how medical professionals can best advise medical cannabis patients with regards to automobile driving or safety-sensitive tasks at work. A systematic electronic search for English language randomized controlled trials (RCTs), clinical trials and systematic reviews (in order to capture any potentially missed RCTs) between 2000 and 2019 was conducted through Ovid MEDLINE and EMBASE electronic databases using MeSH terms. Articles were limited to medical cannabis patients using cannabis for chronic non-cancer pain or spasticity. After screening titles and abstracts, 37 relevant studies were subjected to full-text review. Overall, seven controlled trials met the inclusion/exclusion criteria and were included in the qualitative synthesis: six RCTs and one observational clinical trial. Neurocognitive testing varied significantly between all studies, including the specific tests administered and the timing of assessments post-cannabis consumption. In general, cognitive performance declined mostly in a THC dose-dependent manner, with steady resolution of impairment in the hours following THC administration. Doses of THC were lower than those typically reported in recreational cannabis studies. In all the studies, there was no difference between any of the THC groups and placebo on any neurocognitive measure after 4 h of recovery. Variability in the dose-dependent relationship raises the consideration that there are other important factors contributing to the duration of neurocognitive impairment besides the dose of THC ingested. These modifiable and non-modifiable factors are individually discussed.
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Affiliation(s)
- Lauren Eadie
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay A Lo
- Department of Psychology, Queens University, Kingston, ON, Canada
| | - April Christiansen
- Centre for Neuroscience Studies, Queens University, Kingston, ON, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Provincial Neuropsychiatry Program, Vancouver, BC, Canada
| | - Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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87
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Rogers JM, Epstein DH, Phillips K, Strickland JC, Preston KL. Exploring the Relationship Between Substance Use and Allostatic Load in a Treatment/Research Cohort and in a US Probability Sample (NHANES 2009-2016). Front Psychiatry 2021; 12:630195. [PMID: 34408672 PMCID: PMC8367194 DOI: 10.3389/fpsyt.2021.630195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 07/05/2021] [Indexed: 11/30/2022] Open
Abstract
Allostatic load, an operationalization for cumulative strain on physiology from adaptation (allostasis) to stress over a lifetime, can manifest as damage to cardiovascular, neuroendocrine, and metabolic systems. The concept of allostatic load may be particularly useful in research on substance-use disorders (SUDs) because SUD researchers have sought to better understand the relationship between chronic stressors and drug use. Theoretical models hold that SUDs can be conceptualized as a spiral toward a state of persistent allostasis (i.e., allostasis so persistent as to represent homeostasis at a new, unhealthy set point). Regardless of the extent to which those models are accurate, increased allostatic load could be a mechanism by which frequent drug administration increases risk for adverse outcomes. We conducted two secondary analyses to evaluate allostatic load in the context of drug use, including alcohol use, in a locally recruited sample with a high proportion of illicit substance use (N = 752) and in a nationally representative sample from the NHANES 2009-2016. We hypothesized that after controlling for age and other potential confounds, people with longer histories of drug use would have higher allostatic-load scores. Multiple regression was used to predict allostatic load from participants' drug-use histories while controlling for known confounds. In the locally recruited sample, we found that longer lifetime use of cocaine or opioids was related to increased allostatic load. In NHANES 2009-2016, we found few or no such associations. Lengthy histories of problematic non-medical substance use may facilitate more rapid increases in allostatic load than aging alone, and, together with findings from previous investigations, this finding suggests increased risk for chronic disease.
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Affiliation(s)
- Jeffrey M Rogers
- Behavioral Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, United States
| | - David H Epstein
- Behavioral Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, United States
| | - Karran Phillips
- Behavioral Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, United States
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenzie L Preston
- Behavioral Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD, United States
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88
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Mohammadkhani A, Borgland SL. Cellular and behavioral basis of cannabinioid and opioid interactions: Implications for opioid dependence and withdrawal. J Neurosci Res 2020; 100:278-296. [PMID: 33352618 DOI: 10.1002/jnr.24770] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 01/22/2023]
Abstract
The brain's endogenous opioid and endocannabinoid systems are neuromodulatory of synaptic transmission, and play key roles in pain, memory, reward, and addiction. Recent clinical and pre-clinical evidence suggests that opioid use may be reduced with cannabinoid intake. This suggests the presence of a functional interaction between these two systems. Emerging research indicates that cannabinoids and opioids can functionally interact at different levels. At the cellular level, opioid and cannabinoids can have direct receptor associations, alterations in endogenous opioid peptide or cannabinoid release, or post-receptor activation interactions via shared signal transduction pathways. At the systems level, the nature of cannabinoid and opioid interaction might differ in brain circuits underlying different behavioral phenomenon, including reward-seeking or antinociception. Given the rising use of opioid and cannabinoid drugs, a better understanding of how these endogenous signaling systems interact in the brain is of significant interest. This review focuses on the potential relationship of these neural systems in addiction-related processes.
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Affiliation(s)
- Aida Mohammadkhani
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, The University of Calgary, Calgary, AB, Canada
| | - Stephanie L Borgland
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, The University of Calgary, Calgary, AB, Canada
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89
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Muller C, Reggio PH. An Analysis of the Putative CBD Binding Site in the Ionotropic Cannabinoid Receptors. Front Cell Neurosci 2020; 14:615811. [PMID: 33362478 PMCID: PMC7755602 DOI: 10.3389/fncel.2020.615811] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/18/2020] [Indexed: 12/22/2022] Open
Abstract
Cannabinoids have been long studied for their therapeutic properties, particularly for their use in the treatment of pain. As new therapies are sought after to treat conditions of chronic pain, so is a better understanding of the ligands and their target receptors or channels. A recently published cryo-EM structure showed the putative binding location of a well-known cannabinoid ligand, cannabidiol (CBD), in TRPV2, a channel that has been implicated in inflammation and chronic pain. TRPV2, along with TRPV1, TRPV3, TRPV4, TRPA1, and TRPM8 all have the capability to be modulated by cannabinoid ligands and are located in the peripheral nervous system. Here, we analyze the putative CBD binding site in each of these channels and compare structural and sequential information with experimental data.
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Affiliation(s)
| | - Patricia H. Reggio
- Department of Chemistry and Biochemistry, University of North Carolina at Greensboro, Greensboro, NC, United States
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90
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Buck JS, Bloomer AK, Wally MK, Seymour RB, Hsu JR. The Current Evidence for Marijuana as Medical Treatment. J Bone Joint Surg Am 2020; 102:2096-2105. [PMID: 33264218 DOI: 10.2106/jbjs.20.00269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- J Stewart Buck
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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91
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Takakuwa KM, Sulak D. A Survey on the Effect That Medical Cannabis Has on Prescription Opioid Medication Usage for the Treatment of Chronic Pain at Three Medical Cannabis Practice Sites. Cureus 2020; 12:e11848. [PMID: 33409086 PMCID: PMC7781576 DOI: 10.7759/cureus.11848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective: The opioid epidemic continues to claim thousands of lives every year without an effective strategy useful in mitigating mortality. The use of medical cannabis has been proposed as a potential strategy to decrease opioid usage. The objective of this study was to determine how the use of medical cannabis affects prescribed opioid usage in chronic pain patients. Methods: We conducted an online convenience sample survey of patients from three medical cannabis practice sites who had reported using opioids. A total of 1181 patients responded, 656 were excluded for not using medical cannabis in combination with opioid use or not meeting the definition of chronic pain, leaving 525 patients who had used prescription opioid medications continuously for at least three months to treat chronic pain and were using medical cannabis in combination with their prescribed opioid use. Results: Overall, 40.4% (n=204) reported that they stopped all opioids, 45.2% (n=228) reported some decrease in their opioid usage, 13.3% (n=67) reported no change in opioid usage, and 1.1% (n=6) reported an increase in opioid usage. The majority (65.3%, n=299) reported that they sustained the opioid change for over a year. Almost half (48.2%, n=241) reported a 40-100% decrease in pain while 8.6% (n=43) had no change in pain and 2.6% (n=13) had worsening pain. The majority reported improved ability to function (80.0%, n=420) and improved quality of life (87.0%, n=457) with medical cannabis. The majority (62.8%, n=323) did not want to take opioids in the future. While the change in pain level was not affected by age and gender, the younger age group had improved ability to function compared with the middle and older age groups. Conclusions: Patients in this study reported that cannabis was a useful adjunct and substitute for prescription opioids in treating their chronic pain and had the added benefit of improving the ability to function and quality of life.
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Affiliation(s)
- Kevin M Takakuwa
- Emergency Medicine, Society of Cannabis Clinicians, Sebastopol, USA
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92
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Positive allosteric modulation of the cannabinoid type-1 receptor (CB1R) in periaqueductal gray (PAG) antagonizes anti-nociceptive and cellular effects of a mu-opioid receptor agonist in morphine-withdrawn rats. Psychopharmacology (Berl) 2020; 237:3729-3739. [PMID: 32857187 PMCID: PMC7687722 DOI: 10.1007/s00213-020-05650-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
Opioid drugs are a first-line treatment for severe acute pain and other chronic pain conditions, but long-term opioid drug use produces opioid-induced hyperalgesia (OIH). Co-administration of cannabinoids with opioid receptor agonists produce anti-nociceptive synergy, but cannabinoid receptor agonists may also produce undesirable side effects. Therefore, positive allosteric modulators (PAM) of cannabinoid type-1 receptors (CB1R) may provide an option reducing pain and/or enhancing the anti-hyperalgesic effects of opioids without the side effects, tolerance, and dependence observed with the use of ligands that target the orthosteric binding sites. This study tested GAT211, a PAM of cannabinoid type-1 receptors (CB1R), for its ability to enhance the anti-hyperalgesic effects of the mu-opioid receptor (MOR) agonist DAMGO in rats treated chronically with morphine (or saline) and tested during withdrawal. We tested the effects of intra-periaqueductal gray (PAG) injections of (1) DAMGO, (2) GAT211, or (3) DAMGO + GAT211 on thermal nociception in chronic morphine-treated rats that were hyperalgesic and also in saline-treated control rats. We used slice electrophysiology to test the effects of DAMGO/GAT211 bath application on synaptic transmission in the vlPAG. Intra-PAG DAMGO infusions dose-dependently reversed chronic morphine-induced hyperalgesia, but intra-PAG GAT211 did not alter nociception at the doses we tested. When co-administered into the PAG, GAT211 antagonized the anti-nociceptive effects of DAMGO in morphine-withdrawn rats. DAMGO suppressed synaptic inhibition in the vlPAG of brain slices taken from saline- and morphine-treated rats, and GAT211 attenuated DAMGO-induced suppression of synaptic inhibition in vlPAG neurons via actions at CB1R. These findings show that positive allosteric modulation of CB1R antagonizes the behavioral and cellular effects of a MOR agonist in the PAG of rats.
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93
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Zarrabi AJ, Morrison LJ, Reville BA, Hauser JM, DeSandre P, Joselow M, deLima Thomas J, Wood G. Museum-Based Education: A Novel Educational Approach for Hospice and Palliative Medicine Training Programs. J Palliat Med 2020; 23:1510-1514. [DOI: 10.1089/jpm.2019.0476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ali John Zarrabi
- Department of Family and Preventive Medicine, Division of Palliative Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura J. Morrison
- Geriatrics Section, Yale School of Medicine, New Haven, Connecticut, USA
| | - Barbara A. Reville
- Harvard Interprofessional Palliative Care Fellowship, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joshua M. Hauser
- Division of Palliative Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Paul DeSandre
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marsha Joselow
- Palliative Care Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jane deLima Thomas
- Harvard Interprofessional Palliative Care Fellowship, Dana-Farber Cancer Institute/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gordon Wood
- Division of Palliative Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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94
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Lee MT, Chen YH, Mackie K, Chiou LC. Median Nerve Stimulation as a Nonpharmacological Approach to Bypass Analgesic Tolerance to Morphine: A Proof-of-Concept Study in Mice. THE JOURNAL OF PAIN 2020; 22:300-312. [PMID: 33069869 DOI: 10.1016/j.jpain.2020.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023]
Abstract
Analgesic tolerance to opioids contributes to the opioid crisis by increasing the quantity of opioids prescribed and consumed. Thus, there is a need to develop non-opioid-based pain-relieving regimens as well as strategies to circumvent opioid tolerance. Previously, we revealed a non-opioid analgesic mechanism induced by median nerve electrostimulation at the overlaying PC6 (Neiguan) acupoint (MNS-PC6). Here, we further examined the efficacy of MNS-PC6 in morphine-tolerant mice with neuropathic pain induced by chronic constriction injury (CCI) of the sciatic nerve. Daily treatments of MNS-PC6 (2 Hz, 2 mA), but not electrostimulation at a nonmedian nerve-innervated location, for a week post-CCI induction significantly suppressed established mechanical allodynia in CCI-mice in an orexin-1 (OX1) and cannabinoid-1 (CB1) receptor-dependent fashion. This antiallodynic effect induced by repeated MNS-PC6 was comparable to that induced by repeated gabapentin (50 mg/kg, i.p.) or single morphine (10 mg/kg, i.p.) treatments, but without tolerance, unlike repeated morphine-induced analgesia. Furthermore, single and repeated MNS-PC6 treatments remained fully effective in morphine-tolerant CCI-mice, also in an OX1 and CB1 receptor-dependent fashion. In CCI-mice receiving escalating doses of morphine for 21 days (10, 20 and 50 mg/kg), single and repeated MNS-PC6 treatments remained fully effective. Therefore, repeated MNS-PC6 treatments induce analgesia without tolerance, and retain efficacy in opioid-tolerant mice via a mechanism that involves OX1 and CB1 receptors. This study suggests that MNS-PC6 is an alternative pain management strategy that maybe useful for combatting the opioid epidemic, and opioid-tolerant patients receiving palliative care. PERSPECTIVE: Median nerve stimulation relieves neuropathic pain in mice without tolerance and retains efficacy even in mice with analgesic tolerance to escalating doses of morphine, via an opioid-independent, orexin-endocannabinoid-mediated mechanism. This study provides a proof of concept for utilizing peripheral nerve stimulating devices for pain management in opioid-tolerant patients.
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Affiliation(s)
- Ming Tatt Lee
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Faculty of Pharmaceutical Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Yi-Hung Chen
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan; Chinese Medicine Research Center, China Medical University, Taichung, Taiwan
| | - Ken Mackie
- Gill Center for Biomolecular Research, Indiana University, Bloomington, Indiana; Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Lih-Chu Chiou
- Graduate Institute of Pharmacology, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Acupuncture Science, China Medical University, Taichung, Taiwan.
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95
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Abstract
ZusammenfassungSchmerz als Hauptsymptom vieler chronisch-entzündlicher Erkrankungen stellt für den Patienten, aber auch für den behandelnden Arzt besonders in seiner chronifizierten Form eine große Herausforderung dar. Es gibt leider keine „Wunderpille“ mit der man Schmerzen für jeden gleich zuverlässig beseitigen kann. Es gibt aber viele Ansätze pharmakologischer als auch nicht-pharmakologischer Art und deren Kombination, um für den einzelnen Patienten wirksame Behandlungsstrategien zu finden. Um diese Strategien für jeden Patienten individuell optimal festzulegen, bedarf es zum einen eines fundamentierten Wissens über das Spektrum zur Verfügung stehender Mittel, zum anderen aber auch Erkenntnis darüber, wie diese sinnvoll nach Art der vorliegenden Schmerzformen einzusetzen sind. In dieser Übersicht wird beides behandelt, mit einem Fokus auf die medikamentöse Therapie von Schmerzen bei entzündlich-rheumatischen Erkrankungen. Dabei wird herausgearbeitet, dass es für die in diesem Zusammenhang relevantesten Formen des Schmerzes, akut-entzündlich nozizeptiv, neuropathisch und durch periphere und zentrale Sensibilisierung chronifizierte Schmerzen, jeweils andere wirksame Konzepte gibt.
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Affiliation(s)
- Georg Pongratz
- Poliklinik, Funktionsbereich und Hiller Forschungszentrum für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf
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96
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Maurer GE, Mathews NM, Schleich KT, Slayman TG, Marcussen BL. Understanding Cannabis-Based Therapeutics in Sports Medicine. Sports Health 2020; 12:540-546. [PMID: 32936058 DOI: 10.1177/1941738120956604] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
CONTEXT With increased use of cannabis-based products by the public for both recreational and medical use, sports medicine clinicians should be informed of historical context, current legal considerations, and existing evidence with regard to efficacy, safety, and risks in the athletic community. EVIDENCE ACQUISITION A review of ClinicalTrials.gov, MEDLINE, and CINAHL from 2015 to present was conducted with emphasis on the most recent literature using search terms, cannabis, nabiximols, cannabinoids, pain management, THC, CBD, and marijuana. Bibliographies based on original search were utilized to pursue further literature search. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 3. RESULTS At present, limited high-quality studies exist for use of cannabinoids for acute pain, chronic pain, or concussion. None of the trials involving cannabinoids included the athletic population. Thus, results from this clinical review are extrapolated to conditions of the sports medicine population. For acute pain, 2 small-randomized double-blinded crossover trials concluded no immediate effect of cannabinoid therapy. More robust evidence exists for treatment of chronic pain conditions through meta-analysis and systemic reviews. Cannabinoid therapy exhibits moderate efficacy as a treatment for some chronic pain conditions. Investigations included a broad spectrum of chronic pain conditions, including neuropathic, musculoskeletal, inflammatory, and central pain conditions, and reveal reduction in pain and improvement of quality of life with limited adverse effects. For concussion, evidence is based on preclinical in vitro and animal models revealing possible neuroprotective effects as well as 2 clinical studies involving the presence of cannabinoids for concussion (some sports-related), but there are no high-quality trials evaluating efficacy for treatment with cannabinoids at this time. CONCLUSION Although various biochemical explanations exist on the use of cannabinoid therapy through modulation of the endocannabinoid system for several medical issues affecting athletes, recommendations from clinicians must be extrapolated from a majority of research done in the nonathletic population. Lack of strong-quality clinical evidence, coupled with inconsistent federal and state law as well as purity issues with cannabis-based products, make it difficult for the sports medicine clinician to widely recommend cannabinoid therapeutics at present. Future larger, higher quality clinical research studies with standardized pure extracts will better guide appropriate medical use going forward. At present, evidence for a multitude of therapeutic applications is emerging for cannabinoid treatment approaches. With emphasis placed on patient-centered clinical decisions, cannabinoids hold promise of treatment for athletes with chronic pain conditions. Clinicians who treat the athletic community must consider legal and ethical issues when discussing and recommending the use of cannabinoids, with acknowledgment of inconsistencies in purity of various formulations and concerns of drug testing.
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Affiliation(s)
| | | | | | - Tyler G Slayman
- Carver College of Medicine, University of Iowa, Iowa City, Iowa
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97
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Abbasi-Habashi S, Ghasemzadeh Z, Rezayof A. Morphine improved stress-induced amnesia and anxiety through interacting with the ventral hippocampal endocannabinoid system in rats. Brain Res Bull 2020; 164:407-414. [PMID: 32937186 DOI: 10.1016/j.brainresbull.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/28/2020] [Accepted: 09/06/2020] [Indexed: 12/15/2022]
Abstract
The present study aimed to investigate the possible role of the ventral hippocampal (VH) cannabinoid CB1 receptors in the improving effect of morphine on stress-induced memory formation impairment and anxiety. A step-through type passive avoidance task and a hole-board test were used to measure memory formation and anxiety-like exploratory behavior, respectively. The results showed that the exposure to 10-min stress immediately after the successful training phase impaired memory formation and also produced anxiogenic-like exploratory behaviour in adult male Wistar rats. Moreover, morphine administration before stress exposure improved the adverse effects of stress on memory formation and exploratory behaviour. After training, intra-VH microinjection of cannabinoid CB1/CB2 receptor agonist, WIN 55,212-2 (0.01-0.05 μg/rat) enhanced the response of an ineffective dose of morphine (0.5 mg/kg for memory; 5 mg/kg for anxiety, i.p.) on memory impairment and anxiogenic-like exploratory behaviour induced by acute stress. Intra-VH microinjection of the higher dose of WIN 55,212-2 alone impaired memory formation. Post-training microinjection of a cannabinoid CB1 receptor antagonist/inverse agonist, AM-251 (100-150 ng/rat) into the VH attenuated the response of an effective dose of morphine (5 mg/kg for memory; 6 mg/kg for anxiety, i.p.) in stress-exposed rats. Taken together, the present results showed that morphine administration could improve stress-induced memory impairment and anxiety in the rats exposed to the inescapable acute stress. Interestingly, the improving effect of morphine on the adverse effect of stress on memory formation and anxiety-like exploratory behaviour may be mediated through the VH endocannabinoid CB1/CB2 receptors mechanism.
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Affiliation(s)
- Sima Abbasi-Habashi
- Department of Animal Biology, School of Biology, College of Science, University of Tehran, Tehran, Iran
| | - Zahra Ghasemzadeh
- Department of Animal Biology, School of Biology, College of Science, University of Tehran, Tehran, Iran
| | - Ameneh Rezayof
- Department of Animal Biology, School of Biology, College of Science, University of Tehran, Tehran, Iran.
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98
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Takakuwa KM, Hergenrather JY, Shofer FS, Schears RM. The Impact of Medical Cannabis on Intermittent and Chronic Opioid Users with Back Pain: How Cannabis Diminished Prescription Opioid Usage. Cannabis Cannabinoid Res 2020; 5:263-270. [PMID: 32923663 DOI: 10.1089/can.2019.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: To determine if cannabis may be used as an alternative or adjunct treatment for intermittent and chronic prescription opioid users. Design: Retrospective cohort study. Setting: A single-center cannabis medical practice site in California. Patients: A total of 180 patients who had a chief complaint of low back pain were identified (International Classification of Diseases, 10th Revision, code M54.5). Sixty-one patients who used prescription opioids were analyzed. Interventions: Cannabis recommendations were provided to patients as a way to mitigate their low back pain. Outcome Measures: Number of patients who stopped opioids and change in morphine equivalents. Results: There were no between-group differences based on demographic, experiential, or attitudinal variables. We found that 50.8% were able to stop all opioid usage, which took a median of 6.4 years (IQR=1.75-11 years) after excluding two patients who transitioned off opioids by utilizing opioid agonists. For those 29 patients (47.5%) who did not stop opioids, 9 (31%) were able to reduce opioid use, 3 (10%) held the same baseline, and 17 (59%) increased their usage. Forty-eight percent of patients subjectively felt like cannabis helped them mitigate their opioid intake but this sentiment did not predict who actually stopped opioid usage. There were no variables that predicted who stopped opioids, except that those who used higher doses of cannabis were more likely to stop, which suggests that some patients might be able to stop opioids by using cannabis, particularly those who are dosed at higher levels. Conclusions: In this long-term observational study, cannabis use worked as an alternative to prescription opioids in just over half of patients with low back pain and as an adjunct to diminish use in some chronic opioid users.
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Affiliation(s)
| | | | - Frances S Shofer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raquel M Schears
- Department of Emergency Medicine, University of Central Florida, Orlando, Florida
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99
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Babalonis S, Walsh SL. Therapeutic potential of opioid/cannabinoid combinations in humans: Review of the evidence. Eur Neuropsychopharmacol 2020; 36:206-216. [PMID: 32273144 PMCID: PMC7338254 DOI: 10.1016/j.euroneuro.2020.03.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/12/2020] [Accepted: 03/06/2020] [Indexed: 02/05/2023]
Abstract
The endogenous opioid and cannabinoid receptor systems are widely distributed and co-localized throughout central and peripheral nervous system regions. A large body of preclinical evidence suggests that there are functional interactions between these two systems that may be leveraged to address various health conditions. Numerous animal studies have shown that cannabinoid agonists (e.g., delta-9-tetrahydrocannabinol [Δ9-THC]) enhance the analgesic effects of µ-opioid analgesics as evidenced by decreasing the opioid dose required for analgesia (i.e., opioid sparing) and extending the duration of the opioid analgesia. In contrast, controlled human laboratory studies and clinical trials have not demonstrated robust analgesic or opioid-sparing effects from opioid-cannabinoid combinations. Meta-analyses of the literature (clinical trials, controlled laboratory studies; some non-controlled studies/case reports) have examined the effects of cannabis/cannabinoids for pain relief in those taking a wide variety of analgesics, including prescription opioid medications. These data do not strongly support the use of cannabinoids for chronic pain nor do prospective studies demonstrate significant cannabinoid-mediated opioid-sparing effects. Preclinical studies have also suggested a role for cannabinoids for the treatment of opioid withdrawal. Controlled laboratory and clinical studies suggest that there may be a modest signal for Δ9-THC to suppress some opioid signs and symptoms but they are not completely ameliorated and there may also be concerns around safety of Δ9-THC administration in a state of heightened autonomic arousal as occurs with opioid withdrawal. Despite anecdotal and correlational reports suggesting a benefit of cannabis on reducing opioid overdose, there is no strong data supporting this contention and emerging reports have conflicting results. In summary, there is a groundswell of public advocacy supporting the use of cannabis and cannabinoids to replace opioid analgesics or to reduce opioid use; however, the extant controlled clinical data do not support the role of cannabinoids for opioid replacement or opioid-sparing effects when treating opioid use disorder or chronic pain.
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Affiliation(s)
- Shanna Babalonis
- Department of Behavioral Science, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States; Department of the Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY 40508, United States
| | - Sharon L Walsh
- Department of Behavioral Science, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States; Department of Pharmacology, University of Kentucky, Lexington, KY 40508, United States; Department of Pharmaceutical Sciences, University of Kentucky, Lexington, KY 40508, United States; Department of Psychiatry, University of Kentucky, Lexington, KY 40508, United States; Department of the Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY 40508, United States.
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Wolf J, Urits I, Orhurhu V, Peck J, Orhurhu MS, Giacomazzi S, Smoots D, Piermarini C, Manchikanti L, Kaye AD, Kaye RJ, Viswanath O. The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications. Curr Pain Headache Rep 2020; 24:35. [PMID: 32506272 DOI: 10.1007/s11916-020-00873-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia. RECENT FINDINGS Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB1) and type 2 (CB2) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB2 receptor is located primarily in the immune system. CB1 receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.
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Affiliation(s)
- John Wolf
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jacquelin Peck
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami Beach, FL, USA
| | - Mariam Salisu Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Daniel Smoots
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | | | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA.,Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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