Medical use of cannabis products

Patient out-of-pocket costs for cannabis use during cancer treatment

BACKGROUND

We assessed patient costs associated with cannabis use during cancer treatment.

METHODS

Adults treated for cancer at a large, comprehensive center completed an anonymous survey regarding their thoughts and experiences with cannabis and cancer. Bivariate and weighted multivariable logistic regression assessed clinical and sociodemographic factors associated with patient-reported out-of-pocket costs for cannabis products.

RESULTS

Overall, 248 cannabis users provided data on cost and were analyzed. Median monthly out-of-pocket cost for cannabis was $80 (interquartile range = $25-$150). On regression analysis, male gender (odds ratio = 2.5, 95% confidence interval = 1.2 to 5.5, P = .026) and being 45 years of age or older (odds ratio = 7.5, 95% confidence interval = 1.9 to 30.0, P = .0042) were associated with spending $100 a month or more on cannabis. Of the 166 patients who stopped using cannabis early or used less than preferred, 28% attributed it to cost and 26% to lack of insurance coverage.

CONCLUSION

Cannabis use during cancer treatment may contribute to significant out-of-pocket costs, with men and younger patients more likely to pay higher costs.

Clinical Benefits and Safety of Medical Cannabis Products: A Narrative Review on Natural Extracts

Interest in medical cannabis and cannabis-based medicinal products (CBMPs) has increased greatly in recent years. Two cannabinoids are of principal importance; delta-9-tetrahydrocannabinol (∆9-THC), the primary psychoactive component, and also cannabidiol (CBD), considered non-intoxicating. Each has distinct mechanisms of action and different therapeutic potentials. CBMPs differ in their ∆9-THC and CBD components; predominantly ∆9-THC, balanced formulations with equivalent ∆9-THC and CBD elements, and CBD-predominant products. In this narrative review, we evaluate the published evidence for the clinical benefits of CBMPs and overall benefits in well-being. We also review the overall safety profile and discuss the potential for dependence with CBMPs. Evidence can be drawn from a wide range of randomized and other controlled studies and from observational real-world studies. Most data from observational registry studies are supportive of ∆9-THC-based products (∆9-THC-predominant or balanced CBMPs) in the management of chronic neuropathic pain. Balanced products are also effective in reducing spasticity in multiple sclerosis. Most CBMPs show benefit in providing symptomatic benefits in reducing anxiety, nausea, and in improving sleep, but the place of specific products is more subtle, and choice guided by specific circumstances. Symptomatic improvements are accompanied by improved quality of life and well-being. Safety data indicate that CBMPs are generally well tolerated in most patients without specific contraindications. The majority of adverse effects are non-serious, and transient; most are principally associated with ∆9-THC and are dose-dependent. In contrast to recreational cannabis use, there is little evidence from clinical studies that CBMPs have any potential for dependence.

Prevalence of cannabidiol (CBD) consumption and cancer patients' expectations in one oncology day-hospital: A cross-sectional study and questionnaire validation

INTRODUCTION

The growing interest of cannabidiol (CBD) in medical care prompted French health authorities to explore the potential of CBD in cancer-related severe symptoms. This study aimed to assess the prevalence of CBD use among cancer patients with potential associated factors and to measure the cancer patient's health literacy (HL) on CBD consumption.

METHODS

In a prospective study in oncology day-care hospital including patients from 29 October to 20 December 2021, we collected demographic, biological, and oncological characteristics. Patient CBD HL was measured by the hetero-questionnaire 8-item-CBD HL scale (HLS-8-CBD) whose conception has been validated by a psychometric analysis.

RESULTS

Among 363 participants, 20 patients (5.5%) reported CBD use. Factors associated with CBD use were: age <60 years (odd ratio = 7.80[1.36-13.32], p < 10^-4 versus ≥60 years), smoking history (OR = 5.53[1.81-16.88], p < 0.01), and no smoking cessation (OR = 5.07[1.66-15.46], p < 0.01). CBD use was also associated with a better CBD total HL score than non-users (p-value = 0.02).

CONCLUSION

Identification of factors associated with CBD use and a relatively high patient CBD HL in CBD users showed that CBD use in cancer patients care represented a new concern and should enhance health professionals to consider CBD with its associated drug-related problems.

Cannabinoids versus placebo for pain: A systematic review with meta-analysis and Trial Sequential Analysis

OBJECTIVES

To assess the benefits and harms of cannabinoids in participants with pain.

DESIGN

Systematic review of randomised clinical trials with meta-analysis, Trial Sequential Analysis, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

The Cochrane Library, MEDLINE, Embase, Science Citation Index, and BIOSIS.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Published and unpublished randomised clinical trials comparing cannabinoids versus placebo in participants with any type of pain.

MAIN OUTCOME MEASURES

All-cause mortality, pain, adverse events, quality of life, cannabinoid dependence, psychosis, and quality of sleep.

RESULTS

We included 65 randomised placebo-controlled clinical trials enrolling 7017 participants. Fifty-nine of the trials and all outcome results were at high risk of bias. Meta-analysis and Trial Sequential Analysis showed no evidence of a difference between cannabinoids versus placebo on all-cause mortality (RR 1.20; 98% CI 0.85 to 1.67; P = 0.22). Meta-analyses and Trial Sequential Analysis showed that cannabinoids neither reduced acute pain (mean difference numerical rating scale (NRS) 0.52; 98% CI -0.40 to 1.43; P = 0.19) or cancer pain (mean difference NRS -0.13; 98% CI -0.33 to 0.06; P = 0.1) nor improved quality of life (mean difference -1.38; 98% CI -11.81 to 9.04; P = 0.33). Meta-analyses and Trial Sequential Analysis showed that cannabinoids reduced chronic pain (mean difference NRS -0.43; 98% CI -0.72 to -0.15; P = 0.0004) and improved quality of sleep (mean difference -0.42; 95% CI -0.65 to -0.20; P = 0.0003). However, both effect sizes were below our predefined minimal important differences. Meta-analysis and Trial Sequential Analysis indicated that cannabinoids increased the risk of non-serious adverse events (RR 1.20; 95% CI 1.15 to 1.25; P < 0.001) but not serious adverse events (RR 1.18; 98% CI 0.95 to 1.45; P = 0.07). None of the included trials reported on cannabinoid dependence or psychosis.

CONCLUSIONS

Cannabinoids reduced chronic pain and improved quality of sleep, but the effect sizes are of questionable importance. Cannabinoids had no effects on acute pain or cancer pain and increased the risks of non-serious adverse events. The harmful effects of cannabinoids for pain seem to outweigh the potential benefits.

El uso terapéutico del cannabis y los cannabinoides

Los cannabinoides se dirigen principalmente al sistema endocannabinoide (ECS), que surge como un objetivo terapéutico potencialmente interesante debido a su importante papel en la modulación de procesos biológicos clave en todo el organismo. Como tal, los cannabinoides ya se han propuesto como, por ejemplo, antieméticos, agentes antiespásticos, estimulantes del apetito, antiepilépticos, analgésicos, depresores de la presión intraocular o como agentes para controlar los trastornos del movimiento en el síndrome de Tourette. Aquí revisamos las pruebas de investigación disponibles sobre el uso del cannabis y los cannabinoides para un conjunto de aplicaciones terapéuticas sugeridas, y abordamos algunos de los riesgos a corto y largo plazo que se han correlacionado con el uso de estas sustancias. Encontramos escasas pruebas científicas que apoyen el uso de productos basados en el cannabis para la mayoría de las aplicaciones sugeridas, así como ninguna necesidad médica no satisfecha que no esté ya abordada por los medicamentos existentes (algunos basados en cannabinoides) en el mercado. En este escenario, los riesgos potenciales asociados al uso crónico de estas sustancias pueden disuadir su uso médico.

Surveying Canadian Pain Physicians' Attitudes and Beliefs Regarding Medical Cannabis for Chronic Noncancer Pain: A Qualitative Study

BACKGROUND

Medical cannabis is commonly and increasingly used by Canadians to manage chronic pain. As of March 2021, Health Canada reported that approximately 300,000 Canadians who were authorized to access medical cannabis, which is more than a 1000% increase from the 24,000 registered in 2015. Physicians, however, receive limited information on therapeutic cannabis during their training, and their perceptions regarding this therapeutic option are uncertain. This study focused on exploring attitudes and beliefs of pain physicians regarding medical cannabis for the management of chronic noncancer pain.

METHODS

This study utilized a focused ethnography approach. Pain management clinicians within the Greater Toronto and Hamilton Area were recruited through snowball sampling methods, and individually interviewed. We applied thematic analysis to interview transcripts and identified representative quotes. The Hamilton Integrated Research Ethics Board reviewed and approved this project.

RESULTS

Thirteen physicians who focused their clinical practice on pain management agreed to be interviewed, and three themes regarding medical cannabis emerged: 1) evidence regarding medical cannabis, 2) medical cannabis as first-line therapy for chronic pain, and 3) barriers to accessing medical cannabis. Subthemes of the last theme included out-of-pocket costs, stigma by society and healthcare providers, and lack of knowledge among physicians.

CONCLUSION

Despite increasing use of medical cannabis for chronic pain among Canadians, pain physicians in our study expressed concerns regarding the evidence to support this therapy and acknowledged important barriers to access.

Use of Cannabis Does Not Decrease Opioid Consumption in Patients Who Underwent Total Joint Arthroplasty

Background

The primary purpose of this study was to determine if cannabis use decreases narcotic consumption in patients undergoing total joint arthroplasty (TJA).

Material and methods

Forty-six patients undergoing a primary unilateral TJA, who self-reported the use of cannabis, were prospectively enrolled and completed this study between July 2015 and November 2019. This cohort was prospectively matched to patients who did not report cannabis use. Morphine equivalents (MEs) were averaged and recorded at 1 and 2 weeks postoperatively. Secondary outcomes and complications were recorded and reported.

Results

There were no differences noted in ME during the hospitalization between the user (78.7 ± 58.5) and nonusers (70.4 ± 46.3), P = .455. ME daily average did not differ between the cohorts (user [36.8 ± 30.7] and nonuser [31.7 ± 25.6] at 1 week (P = .389) or user [22.5 ± 26.3] and nonusers [15.9 ± 18.3] at 2 weeks, P = .164, postoperatively). The total ME at 2 weeks did not differ between the user and nonuser groups (415 ± 375 vs 333 ± 275, P = .235). Pain scores at 1 week were significantly higher in patients who used cannabis (4.1 ± 1.9 vs 3.4 ± 1.6, P = .05). No differences in pain were noted during the patient's hospitalization or at 2- (P = .071) or 6-week (P = .111) follow-up. No differences in secondary outcomes or complications were noted.

Conclusion

We were unable to show a decrease in narcotic consumption in patients who use cannabis undergoing primary unilateral joint replacement. These findings do not support the routine use of cannabis to decrease or supplement narcotic use after primary TJA.

Level of evidence

Level II therapeutic.

Cannabis for Medical Use: Analysis of Recent Clinical Trials in View of Current Legislation

Cannabis has long been regarded as a recreational substance in the Western world. The recent marketing authorization of some medicinal products of industrial origin and the introduction onto the market of inflorescences for medical use mean that medical doctors can now prescribe Cannabis-based medicines in those countries which allow it. Nevertheless, there is still considerable controversy on this topic in the scientific community. In particular, this controversy concerns: the plant species to be used; the pathologies that can be treated and consequently the efficacy and safety of use; the routes of administration; the methods of preparation; the type and dosage of cannabinoids to be used; and, the active molecules of interest. As such, although medical Cannabis has been historically used, the results of currently completed and internationally published studies are inconclusive and often discordant. In light of these considerations, the aim of this work is to analyse the current legislation in countries that allow the use of medical Cannabis, in relation to the impact that this legislation has had on clinical trials. First of all, a literature search has been performed (PubMed and SciFinder) on clinical trials which involved the administration of Cannabis for medical use over the last 3 years. Of the numerous studies extrapolated from the literature, only about 43 reported data on clinical trials on medical Cannabis, with these mainly being performed in Australia, Brazil, Canada, Denmark, Germany, Israel, Netherlands, Switzerland, the United Kingdom and the United States of America. Once the reference countries were identified, an evaluation of the legislation in relation to Cannabis for medical use in each was carried out via the consultation of the pertinent scientific literature, but also of official government documentation and that of local regulatory authorities. This analysis provided us with an overview of the different legislation in these countries and, consequently, allowed us to analyse, with greater awareness, the results of the clinical trials published in the last 3 years in order to obtain general interest indications in the prosecution of scientific research in this area.

Physicians' experiences, attitudes, and beliefs towards medical cannabis: a systematic literature review

Background

An increasing number of countries legalise the use of medical cannabis or allow it for a narrow range of medical conditions. Physicians, and often the patients’ general practitioner, play a major role in implementing this policy. Many of them, however, perceive a lack of evidence-based knowledge and are not confident with providing patients with medical cannabis. The objectives of this review are to synthesise findings about hospital physicians’ and GPs’ experiences, attitudes, and beliefs towards the use of medical cannabis with the purpose of identifying barriers and facilitators towards providing it to their patients.

Methods

Peer-reviewed articles addressing hospital physicians’ and GPs’ experiences, attitudes, and beliefs towards the use of medical cannabis were searched systematically in PubMed, Scopus, EMBASE, and the Cochrane Library.

Results

Twenty-one articles were included from five different countries in which the medical cannabis laws varied. The studied physicians experienced frequent inquiries about medical cannabis from their patients (49–95%), and between 10 and 95% of the physicians were willing to prescribe and/or provide it to the patients, depending on setting, specialty and experience among the physicians. This review found that physicians experienced in prescribing medical cannabis were more convinced of its benefits and less worried about adverse effects than non-experienced physicians. However, physicians specialized in addiction treatment and certain relevant indication areas seemed more sceptical compared to physicians in general. Nevertheless, physicians generally experienced a lack of knowledge of clinical effects including both beneficial and adverse effects.

Conclusion

This review indicates that GPs and hospital physicians from various specialties frequently experience patient demands for medical cannabis and to some degree show openness to using it, although there was a wide gap between studies in terms of willingness to provide. Hospital physicians and GPs’ experienced in prescribing are more convinced of effects and less worried of adverse effects. However, most physicians experience a lack of knowledge of beneficial effects, adverse effects and of how to advise patients, which may comprise barriers towards prescribing. More research, including larger studies with cohort designs and qualitative studies, is needed to further examine facilitators and barriers to physicians’ prescribing practices.

Facilitators and barriers to the regulation of medical cannabis: a scoping review of the peer-reviewed literature

Background

In recent decades, several political, legislative, judicial, consumer, and commercial processes around the world have advanced legalization efforts for the use of medical cannabis (MC). As the use of MC evolves through legislative reform, with an increase in public acceptance and therapeutic potential, a need exists to further investigate the facilitators and barriers to MC regulation.

Methods

A scoping review was conducted to identify the facilitators and barriers associated with the implementation of MC regulations. MEDLINE, EMBASE, AMED and PsycINFO databases were systematically searched; no restrictions were placed on geographic location/jurisdiction. Eligible articles included those that evaluated the MC regulatory framework of one or more countries.

Results

Twenty-two articles were deemed eligible and included in this review. Themes identified include: (1) effects of conflicts, mindset, and ideology of state population, (2) the use of comparisons to analyze MC regulation, and (3) the need for more knowledge, advice, and empirical/clinical evidence to inform future MC policies.

Conclusion

Policymakers should be aware of facilitators to the MC regulation implementation process, such as the influence of state and federal congruence, increased transparency, and the incorporation of stakeholder concerns, in order to effectively respond to a growing societal acceptance of MC and its use among patients. Given a comprehensive understanding of these influential factors, policymakers may be better equipped to meet the consumer and commercial demands of a rapidly evolving MC regulatory environment.

Risk and benefit of cannabis prescription for chronic non-cancer pain

OBJECTIVES

We investigated whether cannabis usage was associated with reduced opioid usage, and the rates of opioid and cannabis use disorders among chronic pain patients who had been prescribed medical cannabis.

METHODS

A random sample of chronic pain patients who had license for cannabis use were interviewed by telephone about their lifetime opioid and cannabis usage. Cannabis and opioid use disorders were assessed with Portenoy's criteria.

RESULTS

Of the 100 participants aged 18-70 years (compliance 67% (aged >40) and 33% (aged ≤ 40y)), 76 ever used opioids. Of them, 93% decreased or stopped opioids following cannabis initiation. Ten patients (10%), 17.4% of the ≤40 y age group, met the criteria for cannabis use disorder. Compared to those who did not meet the criteria, their lifetime depression was higher (80% vs. 43.2%, respectively, P=.042), and they were less educated (12.2 ± 0.6y vs. 13.5 ± 2.1y, p = 0.05).

CONCLUSIONS

Cannabis usage was associated with reduced opioid usage. The prevalence of cannabis use disorder was high among the younger participants who also had a lower study compliance rate, suggesting the higher actual prevalence of cannabis use disorder. While medical cannabis may help reduce opioid use in chronic non-cancer pain patients, younger age, depression, and other risk factors should be carefully evaluated before cannabis is prescribed.

Cannabis use and cannabis use disorder

Cannabis use disorder (CUD) is an underappreciated risk of using cannabis that affects ~10% of the 193 million cannabis users worldwide. The individual and public health burdens are less than those of other forms of drug use, but CUD accounts for a substantial proportion of persons seeking treatment for drug use disorders owing to the high global prevalence of cannabis use. Cognitive behavioural therapy, motivational enhancement therapy and contingency management can substantially reduce cannabis use and cannabis-related problems, but enduring abstinence is not a common outcome. No pharmacotherapies have been approved for cannabis use or CUD, although a number of drug classes (such as cannabinoid agonists) have shown promise and require more rigorous evaluation. Treatment of cannabis use and CUD is often complicated by comorbid mental health and other substance use disorders. The legalization of non-medical cannabis use in some high-income countries may increase the prevalence of CUD by making more potent cannabis products more readily available at a lower price. States that legalize medical and non-medical cannabis use should inform users about the risks of CUD and provide information on how to obtain assistance if they develop cannabis-related mental and/or physical health problems.

From community of practice to epistemic community - law, discipline and security in the battle for the legalisation of medical cannabis in Poland

Although public debates on cannabis are ongoing in many countries, there are currently no EU-wide rules for either medical or recreational use of cannabis. Numerous studies have illustrated that creating such rules is a complex challenge. The battle over the legalisation of medical use of cannabis in Poland is a good example for analysing the mutual impact of the social practices that various actors perform through and by the discourses in the field of health care: how they discursively create their own roles and take positions and how they shape the coalitions and opposition in trying to achieve their strategic goals. This article aims to reconstruct and explain how different types of knowledge are discursively used to sustain or question power relations in the healthcare field. The dispersed knowledge-power influences social actors, who try to define or redefine social practices and aspire to guide them in the healthcare field. The presented approach allows authors to go beyond the social actors' perception vs institutional regulations and to analyse discursive actions as elements of the complex networks of meanings activating various type of resources. Those dynamic networks, involving the different (and sometimes the same) actors in the different actions, open the new fields of rationality. Starting by identifying the crucial actors and their discursive actions visible in the mainstream press discourse, we will reconstruct three types of groups related to medical cannabis. We will then investigate three types of dispositives - law, discipline and security - to investigate the relations between discursive and non-discursive elements. The proposed analysis belongs to the Critical Discourse Analysis (CDA) paradigm and includes investigation of the media discourses and in-depth interviews with the identified actors.

Medical Cannabis Use and Pain: An Experience Sampling Study

Background: Little research has tested associations of pain and MC use after long-term treatment and through methods that have external validity outside experimental settings. The study examined associations of pain, associated painful experiences, and long-term medical cannabis (MC) use in chronic pain (CP) patients using a naturalistic daily diary study that provided novel and externally valid data. Methods: Data were obtained from 78 MC users with CP three times daily over a 10-day period (n_observations = 1,688). Mixed-effects models were used to test the associations between MC use and momentary experiences of pain, affect, and fatigue. Results: Within persons, elevated experiences of pain intensity were associated with greater intention to use MC within the next hour. No evidence was found that the time lapse since last MC use was associated with pain levels, negative affect, or fatigue. Conclusions: The results imply that after long-term use, CP patients intend to use MC in response to pain experiences. Yet, they may not actually achieve the pain relief. More research is needed to examine whether continued MC use despite lack of pain relief is related to relief of other symptoms (e.g., dependence, withdrawal) or positive benefits (e.g., general sense of well-being) or tolerance.

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): consensus recommendations for perioperative management of cannabis and cannabinoid-based medicine users by a modified Delphi process

In many countries, liberalisation of the legislation regulating the use of cannabis has outpaced rigorous scientific studies, and a growing number of patients presenting for surgery consume cannabis regularly. Research to date suggests that cannabis can impact perioperative outcomes. We present recommendations obtained using a modified Delphi method for the perioperative care of cannabis-using patients. A steering committee was formed and a review of medical literature with respect to perioperative cannabis use was conducted. This was followed by the recruitment of a panel of 17 experts on the care of cannabis-consuming patients. Panellists were blinded to each other's participation and were provided with rater forms exploring the appropriateness of specific perioperative care elements. The completed rater forms were analysed for consensus. The expert panel was then unblinded and met to discuss the rater form analyses. Draft recommendations were then created and returned to the expert panel for further comment. The draft recommendations were also sent to four independent reviewers (a surgeon, a nurse practitioner, and two patients). The collected feedback was used to finalise the recommendations. The major recommendations obtained included emphasising the importance of eliciting a history of cannabis use, quantifying it, and ensuring contact with a cannabis authoriser (if one exists). Recommendations also included the consideration of perioperative cannabis weaning, additional postoperative nausea and vomiting prophylaxis, and additional attention to monitoring and maintaining anaesthetic depth. Postoperative recommendations included anticipating increased postoperative analgesic requirements and maintaining vigilance for cannabis withdrawal syndrome.

The trajectory of "medical cannabis" in Israel: Driving medicalization in different directions

BACKGROUND

Although researchers, laypersons and policymakers have been debating about the "medicalization of cannabis" for years, few have attempted to unpack this phrase and clarify what it actually means. The present qualitative research addresses this issue by tracing the trajectory of "medical cannabis" (MC) in Israel.

METHODS

This article draws on multiple sources, including in-depth interviews, parliamentary protocols, conference observations, policy documents, and media coverage.

RESULTS

The analysis shows that while patients, growers, and certain physicians advocated for a more inclusive type of cannabis medicalization, other physicians and sick funds strove to curtail this medicalization; for its part, the Ministry of Health (MoH) attempted to find a pathway that would bridge their conflicting standpoints. In the first phase of medicalization patients' and regulators' trajectories coincided; however, they diverged in the second phase as regulators sought to transform MC into a standardized medication in line with the biomedical model. Patients and physicians criticized the new policy reform and highlighted some of its negative effects on patient care. The trajectories of patients and regulators then intersected in a way that led to some alterations in the MC trajectory.

CONCLUSION

This study enhances our understanding of how MC was, and is still being, incorporated into medicine in Israel. The study illuminates the plurality of meanings that have been assigned to the concept of medicalization and the contingent nature of MC. Additionally, this study sheds light on the under-investigated role of regulators as drivers of the medicalization of "solutions," and it shows how different engines of medicalization may drive the process in diverging directions.

Cannabis and Pain Treatment-A Review of the Clinical Utility and a Practical Approach in Light of Uncertainty

Over the past decade the phenomenon of cannabis as a legitimate form of treatment for pain has overwhelmed the medical community, especially in the field of pain. From a status of a schedule 1 substance having no currently accepted medical use and being considered to have high potential for abuse, its use has mushroomed to over 50,000 legal medical users per year in Israel alone. There appear to be many reasons behind this phenomenon-medical, sociological, and economical. Thus, what is cannabis? An abusive substance or a medication? Should it be incorporated into current biomedical practice, and how should it be administered? Finally, what is the evidence for the beneficial and detrimental effects of cannabis? This article reviews and discusses the current literature regarding the beneficial and the detrimental effects of medical cannabis in the treatment of pain. We further discuss the problems and challenges facing the medical community in this domain and offer a practical approach to deal with these challenges.

Public health implications of legalising the production and sale of cannabis for medicinal and recreational use

We assess the current and describe possible future public health impacts of the legalisation of cannabis production, sale, and use in the Americas. First, we describe global patterns of cannabis use and their most probable adverse health effects. Second, we summarise evidence regarding the effectiveness of cannabinoids for medicinal use and describe approaches that have been used to regulate the use of medicinal cannabis and how these approaches might have affected medicinal and recreational use and harms (eg, road crashes). Third, we describe how jurisdictions that have legalised recreational use have regulated production and sale of cannabis. Fourth, we evaluate the effects of cannabis legalisation on cannabis use and harms and on the use of alcohol, tobacco, and other drugs. Fifth, we use alcohol and tobacco policy examples to identify possible long-term public health effects of cannabis legalisation. Finally, we outline policy approaches that could minimise harms to public health arising from the legalisation of a commercial cannabis industry.

Cannabis Use Does Not Affect Outcomes After Total Knee Arthroplasty

BACKGROUND

The self-reported use of cannabis has increased since its recent legalization in several states. The primary purpose of this study is to report total knee arthroplasty (TKA) outcomes in patients using cannabis.

METHODS

Seventy-one patients who underwent a primary unilateral TKA with minimum 1-year follow-up, who self-reported cannabis use, were retrospectively reviewed. The study period was from January 2014 to February 2018 at a single institution. Patients with a history of opioid consumption, alcohol abuse, tobacco, or illicit drug use were excluded. A matched control was conducted based on age, body mass index, gender, smoking status, and insurance type (surrogate of socioeconomic status) in patients with a unilateral TKA who did not report cannabis use. Outcome measures included Knee Society Scores (KSS), range of motion, Veterans RAND-12 mental and physical component scores. No preoperative differences were noted with these measures. Postoperative complications were recorded and reported.

RESULTS

No difference in length of stay was noted between the users (46.9 hours ± 15.7) and nonusers (49.3 hours ± 20.4) (P = .464). In-hospital total morphine equivalents did not differ between the 2 groups (user = 137 ± 104 mg, nonuser = 146 ± 117 mg, P = .634). Postoperative range of motion did not differ between users (128.4° ± 10.4°) and nonusers (126.9° ± 7.5°) (P = .346). No mean differences in follow-up KSS (user = 180.1 ± 24.9, nonuser = 172.0 ± 33.9, P = .106) or total change (user = 61.7 ± 32.8, nonuser = 62.7 ± 30.7, P = .852) in KSS were noted. Likewise, no significant mean differences in Veterans RAND-12 (mental component scores: user = 54.8 ± 9.3, nonuser = 55.9 ± 8.79, P = .472; physical component scores: user = 48.3 ± 9.9, nonuser = 45.8 ± 10.1, P = .145) scores were demonstrated. There were no differences in readmissions (user = 5, nonuser = 4, P = .730) or reoperations (user = 5, nonuser = 2, P = .238).

CONCLUSION

Cannabis use does not appear to influence (adverse or beneficial) short-term outcomes in patients undergoing a primary TKA. Further studies are warranted to determine the efficacy and safety of cannabis as a constituent of multimodal pain management following TKA before endorsements can be made by orthopedic surgeons.

Evidence for the use of cannabinoids in Parkinson's disease

Cannabis and synthetic cannabinoid formulations have now been legally approved in several countries for treatment of patients with Parkinson's disease (PD). Hence, PD patients consult physicians more frequently for prescription of cannabinoids to alleviate symptoms that might not respond well to dopaminergic treatment. Despite the increasing volume of research generated in the field of cannabinoids and their effect on Parkinson's disease, there is still paucity of sufficient clinical data about the efficacy and safety in PD patients. There is increasing understanding of the endocannabinoid system, and the distribution of cannabinoid receptors in basal ganglia structures might suggest potential benefit on parkinsonian symptoms. Concerning clinical research, only one of to date four conducted randomized placebo-controlled trials showed an effect on motor symptoms with alleviation of levodopa-induced dyskinesia. There are a growing number of uncontrolled trials and case reports that suggest beneficial effects of cannabinoids in PD patients. However, the variety of substances investigated, the varying routes of intake, differing doses and time courses make it difficult to compare data. We here provide an overview of the current literature in this field and discuss a pragmatic approach for the clinical use of cannabinoids in PD.

The Role of Cannabis in the Management of Inflammatory Bowel Disease: A Review of Clinical, Scientific, and Regulatory Information

There is significant interest among patients and providers in using cannabis (marijuana) and its derivatives to treat a number of chronic illnesses, including inflammatory bowel disease. Despite the Schedule I classification of cannabis by the federal government, state governments have sought ways to make cannabis available for specific medical conditions, and some states have legalized cannabis outright. This white paper summarizes the preclinical data, clinical data, safety data, and the regulatory landscape as they apply to medical cannabis use in inflammatory bowel disease. Animal models of cannabinoid chemistry and physiology give evidence of anti-inflammatory, antidiarrheal, and nociceptive-limiting properties. Human studies have found benefit in controlling symptoms and improving quality of life, but no studies have established true disease modification given the absent improvement in biomarker profiles or endoscopic healing. Finally, this review describes the legal, regulatory, and practical hurdles to studying the risks and benefits of medical cannabis in the United States. 10.1093/ibd/izy319_video1 izy319.video1 5852852028001.

The Prevalence of Nonprescription Cannabinoid-Based Medicines in British Children's Hospices: Results of a National Survey

Background: Almost 50,000 children and young people are affected by life-limiting conditions in the United Kingdom, around a third of which use children's hospices. Anecdotal evidence suggests that cannabinoid-based medicines (CBMs), specifically cannabis oil (CO), are being used by families with increasing frequency to manage distressing symptoms. The use of most nonprescription CBMs in the United Kingdom remains illegal. Objective: The objective of the study was to identify the prevalence of CO use by families who use children's hospices in the United Kingdom, and the approaches taken by those services to manage it. Design: An electronic survey was sent to each of the 54 children's hospices in the United Kingdom between May and July 2018, comprising 10 questions. Results: Forty children's hospices from across the four countries of the United Kingdom responded to the survey, representing 74% of British children's hospices. About 87.5% of hospices knew of children who use CO therapeutically. Sixty-nine percent of those hospices have received requests to administer CO during an episode of care. Approaches by organizations around CO management varied across the sectors, including arrangements for storage, administration, and recording of its use. Hospices highlighted how the lack of available guidance made decision making more challenging. Only a third of responding organizations routinely questioned families about the use of cannabis when prescribing medicines. Conclusion: CO is used extensively by children who use children's hospices. Despite recognizing the use of CO, many hospices are unable to support it. There is a need for clear guidelines on how hospices should approach the care needs of children, allowing hospices to meet the needs of children who use CO, and families in a safe, consistent, and relevant way, safeguarding all children, families, and professionals within the organization.

Has Self-reported Marijuana Use Changed in Patients Undergoing Total Joint Arthroplasty After the Legalization of Marijuana?

BACKGROUND

Marijuana use has become more accessible since its recent legalization in several states. However, its use in a total joint arthroplasty population to our knowledge has not been reported, and the implications of its use in this setting remain unclear.

QUESTIONS/PURPOSES

We report (1) the self-reported use of marijuana in patients undergoing total joint arthroplasty both before and after its legalization; and (2) clinical and demographic factors associated with marijuana use in patients undergoing total joint arthroplasty.

METHODS

One thousand records of patients undergoing primary total joint arthroplasty (500 consecutive before and 500 consecutive after the legalization of the commercial sale of marijuana in Colorado) were included for analysis. Preoperative medical history and physicals were retrospectively reviewed for self-reported and reasons (medicinal versus recreational) for use. Additionally, patient records were used to determine insurance type, age, gender, smoking status, history of substance abuse, preoperative narcotic use, alcohol intake, and the type of arthroplasty performed.

RESULTS

Self-reported use after legalization dramatically increased from 1% (four of 500) to 11% (55 of 500) (odds ratio [OR], 15.3 [95% confidence interval, 5.5-42.6]; p < 0.001) after legalization. For those reporting use after legalization, 46% (25 of 55) of patients reported recreational use, 26% (14 of 55) medicinal use, 27% (15 of 55) did not report a reason for use, and 2% (one of 55) reported both recreational and medicinal use. Factors associated with use included younger age (with a 10-year mean difference between the groups [p < 0.001]), male gender (36 of 59 users [61%] versus 411 of 941 nonusers [44%]; OR, 2.02; p < 0.01), current smokers (22 of 59 users [37%] versus 54 of 941 [6%] nonusers; OR, 0.09; p < 0.01), a history of substance abuse (eight of 59 users [14%] versus 18 of 941 nonusers [2%]; OR, 8.04; p < 0.001), insurance type (Medicaid only, 28 of 59 [48%] users versus 56 of 941 [6%] nonusers; OR, 20.45; p < 0.01), and preoperative narcotic use (eight of 59 users [14%] versus 17 of 941 nonusers [2%]; OR, 2.4; p < 0.001). We did not find differences with regard to alcohol use, amount of alcohol consumption, or insurance types other than Medicaid.

CONCLUSIONS

These results suggest the legalization of marijuana has led to either more users or more patients who are willing to report its use given the lack of legal ramifications. Despite these findings, the evidence to date precludes the use of marijuana postoperatively in patients undergoing total joint arthroplasty. Further investigation, ideally in a prospective randomized manner, should focus on opioid consumption, nausea, sleep patterns, and outcomes in patients using marijuana who are undergoing total joint arthroplasty before recommendations can be made for its use.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Chronic pain patients' perspectives of medical cannabis

Medical cannabis (MC) is used for a variety of conditions including chronic pain. The goal of this report was to provide an in-depth qualitative exploration of patient perspectives on the strengths and limitations of MC. Members of MC dispensaries (N = 984) in New England including two-thirds with a history of chronic pain completed an online survey. In response to "How effective is medical cannabis in treating your symptoms or conditions?," with options of 0% "no relief" to 100% "complete relief," the average was 74.6% ± 0.6. The average amount spent on MC each year was $3064.47 ± 117.60, median = $2320.23, range = $52.14 to $52,140.00. Open-ended responses were coded into themes and subthemes. Analysis of answers to "What is it that you like most about MC?" (N = 2592 responses) identified 10 themes, including health benefits (36.0% of responses, eg, "Changes perception and experience of my chronic pain."), the product (14.2%, eg, "Knowing exactly what strain you are getting"), nonhealth benefits (14.1%), general considerations (10.3%), and medications (7.1%). Responses (N = 1678) to "What is it that you like least about MC?" identified 12 themes, including money (28.4%, eg, "The cost is expensive for someone on a fixed income"), effects (21.7%, eg, "The effects on my lungs"), the view of others (11.4%), access (8.2%), and method of administration (7.1%). These findings provide a patient-centered view on the advantages (eg, efficacy in pain treatment, reduced use of other medications) and disadvantages (eg, economic and stigma) of MC.

Cannabis-based medicines for chronic neuropathic pain in adults

BACKGROUND

This review is one of a series on drugs used to treat chronic neuropathic pain. Estimates of the population prevalence of chronic pain with neuropathic components range between 6% and 10%. Current pharmacological treatment options for neuropathic pain afford substantial benefit for only a few people, often with adverse effects that outweigh the benefits. There is a need to explore other treatment options, with different mechanisms of action for treatment of conditions with chronic neuropathic pain. Cannabis has been used for millennia to reduce pain. Herbal cannabis is currently strongly promoted by some patients and their advocates to treat any type of chronic pain.

OBJECTIVES

To assess the efficacy, tolerability, and safety of cannabis-based medicines (herbal, plant-derived, synthetic) compared to placebo or conventional drugs for conditions with chronic neuropathic pain in adults.

SEARCH METHODS

In November 2017 we searched CENTRAL, MEDLINE, Embase, and two trials registries for published and ongoing trials, and examined the reference lists of reviewed articles.

SELECTION CRITERIA

We selected randomised, double-blind controlled trials of medical cannabis, plant-derived and synthetic cannabis-based medicines against placebo or any other active treatment of conditions with chronic neuropathic pain in adults, with a treatment duration of at least two weeks and at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data of study characteristics and outcomes of efficacy, tolerability and safety, examined issues of study quality, and assessed risk of bias. We resolved discrepancies by discussion. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 30% and 50% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardised mean differences for pain intensity, sleep problems, health-related quality of life (HRQoL), and psychological distress. For tolerability, we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawal due to adverse events and specific adverse events, nervous system disorders and psychiatric disorders. For safety, we calculated NNTH for serious adverse events. Meta-analysis was undertaken using a random-effects model. We assessed the quality of evidence using GRADE and created a 'Summary of findings' table.

MAIN RESULTS

We included 16 studies with 1750 participants. The studies were 2 to 26 weeks long and compared an oromucosal spray with a plant-derived combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (10 studies), a synthetic cannabinoid mimicking THC (nabilone) (two studies), inhaled herbal cannabis (two studies) and plant-derived THC (dronabinol) (two studies) against placebo (15 studies) and an analgesic (dihydrocodeine) (one study). We used the Cochrane 'Risk of bias' tool to assess study quality. We defined studies with zero to two unclear or high risks of bias judgements to be high-quality studies, with three to five unclear or high risks of bias to be moderate-quality studies, and with six to eight unclear or high risks of bias to be low-quality studies. Study quality was low in two studies, moderate in 12 studies and high in two studies. Nine studies were at high risk of bias for study size. We rated the quality of the evidence according to GRADE as very low to moderate.Primary outcomesCannabis-based medicines may increase the number of people achieving 50% or greater pain relief compared with placebo (21% versus 17%; risk difference (RD) 0.05 (95% confidence interval (CI) 0.00 to 0.09); NNTB 20 (95% CI 11 to 100); 1001 participants, eight studies, low-quality evidence). We rated the evidence for improvement in Patient Global Impression of Change (PGIC) with cannabis to be of very low quality (26% versus 21%;RD 0.09 (95% CI 0.01 to 0.17); NNTB 11 (95% CI 6 to 100); 1092 participants, six studies). More participants withdrew from the studies due to adverse events with cannabis-based medicines (10% of participants) than with placebo (5% of participants) (RD 0.04 (95% CI 0.02 to 0.07); NNTH 25 (95% CI 16 to 50); 1848 participants, 13 studies, moderate-quality evidence). We did not have enough evidence to determine if cannabis-based medicines increase the frequency of serious adverse events compared with placebo (RD 0.01 (95% CI -0.01 to 0.03); 1876 participants, 13 studies, low-quality evidence).Secondary outcomesCannabis-based medicines probably increase the number of people achieving pain relief of 30% or greater compared with placebo (39% versus 33%; RD 0.09 (95% CI 0.03 to 0.15); NNTB 11 (95% CI 7 to 33); 1586 participants, 10 studies, moderate quality evidence). Cannabis-based medicines may increase nervous system adverse events compared with placebo (61% versus 29%; RD 0.38 (95% CI 0.18 to 0.58); NNTH 3 (95% CI 2 to 6); 1304 participants, nine studies, low-quality evidence). Psychiatric disorders occurred in 17% of participants using cannabis-based medicines and in 5% using placebo (RD 0.10 (95% CI 0.06 to 0.15); NNTH 10 (95% CI 7 to 16); 1314 participants, nine studies, low-quality evidence).We found no information about long-term risks in the studies analysed.Subgroup analysesWe are uncertain whether herbal cannabis reduces mean pain intensity (very low-quality evidence). Herbal cannabis and placebo did not differ in tolerability (very low-quality evidence).

AUTHORS' CONCLUSIONS

The potential benefits of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD oromucosal spray) in chronic neuropathic pain might be outweighed by their potential harms. The quality of evidence for pain relief outcomes reflects the exclusion of participants with a history of substance abuse and other significant comorbidities from the studies, together with their small sample sizes.

Medical use of cannabis and cannabinoids containing products - Regulations in Europe and North America

In 1937, the United States of America criminalized the use of cannabis and as a result its use decreased rapidly. In recent decades, there is a growing interest in the wide range of medical uses of cannabis and its constituents; however, the laws and regulations are substantially different between countries. Laws differentiate between raw herbal cannabis, cannabis extracts, and cannabinoid-based medicines. Both the European Medicines Agency (EMA) and the United States Food and Drug Administration (FDA) do not approve the use of herbal cannabis or its extracts. The FDA approved several cannabinoid-based medicines, so did 23 European countries and Canada. However, only four of the reviewed countries have fully authorized the medical use of herbal cannabis - Canada, Germany, Israel and the Netherlands, together with more than 50% of the states in the United States. Most of the regulators allow the physicians to decide what specific indications they will prescribe cannabis for, but some regulators dictate only specific indications. The aim of this article is to review the current (as of November 2017) regulations of medical cannabis use in Europe and North America.

The effect of dronabinol in a male patient with anorexia nervosa suffering from severe acute urge to be physically active

OBJECTIVE

A 27-year-old male suffering from chronic anorexia nervosa was admitted for inpatient psychotherapy suffering from severe urge to be physically active.

METHODS

An off-label treatment with dronabinol was initiated, to reduce his symptoms related to that urge. Several attempts to reduce symptoms including intensive psychotherapy and several psychopharmacological agents had failed in the past.

RESULTS

Following treatment with 7.5 mg dronabinol twice a day, the patient reported a significant reduction in his acute urge to be physically active. Also eating disorder-specific cognitions and compulsive behaviors remitted.

DISCUSSION

Previous studies have applied much lower doses and showed no effect of dronabinol upon the urge to be physically active. Up to date, the patient reported no side effects, especially no psychotropic effects. Implications of this case report are discussed.

Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation

BACKGROUND

There is considerable public and political interest in the use of cannabis products for medical purposes.

METHODS

The task force of the European Pain Federation (EFIC) conducted a survey with its national chapters representatives on the status of approval of all types of cannabis-based medicines, the covering of costs and the availability of a position paper of a national medical association on the use of medical cannabis for chronic pain and for symptom control in palliative/supportive care.

RESULTS

Thirty-one out of 37 contacted councillors responded. Plant-derived tetrahydrocannabinol/cannabidiol (THC/CBD) oromucosal spray is approved for spasticity in multiple sclerosis refractory to conventional treatment in 21 EFIC chapters. Plant-derived THC (dronabinol) is approved for some palliative care conditions in four EFIC chapters. Synthetic THC analogue (nabilone) is approved for chemotherapy-associated nausea and vomiting refractory to conventional treatment in four EFIC chapters'. Eight EFIC chapters' countries have an exceptional and six chapters an expanded access programme for medical cannabis. German and Israeli pain societies recommend the use of cannabis-based medicines as third-line drug therapies for chronic pain within a multicomponent approach. Conversely, the German medical association and a team of finish experts and officials do not recommend the prescription of medical cannabis due to the lack of high-quality evidence of efficacy and the potential harms.

CONCLUSIONS

There are marked differences between the countries represented in EFIC in the approval and availability of cannabis-based products for medical use. EFIC countries are encouraged to collaborate with the European Medicines Agency to publish a common document on cannabis-based medicines.

SIGNIFICANCE

There are striking differences between European countries in the availability of plant-derived and synthetic cannabinoids and of medical cannabis for pain management and for symptom control in palliative care and in the covering of costs by health insurance companies or state social security systems.

Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management - An overview of systematic reviews

Medicinal cannabis has already entered mainstream medicine in some countries. This systematic review (SR) aimed at evaluating the efficacy, acceptability and safety of cannabis-based medicines for chronic pain management. Qualitative systematic review of SRs of randomized controlled trials with cannabis-based medicines for chronic pain management. The Cochrane databases of SRs, Database of Abstracts of Reviews of Effects and PubMed were searched for SR published in the period January 2009 to January 2017. Assessment of the methodological quality of SR was performed by the AMSTAR checklist. Out of 748 papers identified, 10 SRs met the inclusion criteria. The methodological quality was high in four and moderate in six SRs. There were inconsistent findings of four SRs on the efficacy of cannabis-based medicines in neuropathic pain and of one SR for painful spasms in multiple sclerosis. There were consistent results that there was insufficient evidence of any cannabis-based medicine for pain management in patients with rheumatic diseases (three SRs) and in cancer pain (two SRs). Cannabis-based medicines undoubtedly enrich the possibilities of drug treatment of chronic pain conditions. It remains the responsibility of the health care community to continue to pursue rigorous study of cannabis-based medicines to provide evidence that meets the standard of 21st century clinical care.

SIGNIFICANCE

We provide an overview of systematic reviews on the efficacy, tolerability and safety of cannabis-based medicines for chronic pain management. There are inconsistent findings of the efficacy of cannabinoids in neuropathic pain and painful spasms in multiple sclerosis. There are inconsistent results on tolerability and safety of cannabis-based medicines for any chronic pain.

Marijuana use and inpatient outcomes among hospitalized patients: analysis of the nationwide inpatient sample database

The purpose of this paper is to examine the relationship between marijuana use and health outcomes among hospitalized patients, including those hospitalized with a diagnosis of cancer. A total of 387,608 current marijuana users were identified based on ICD‐9 codes for marijuana use among hospitalized patients in the Nationwide Inpatient Sample database between 2007 and 2011. Logistic regression analysis was performed to determine the association between marijuana use and heart failure, cardiac disease, stroke, and in‐hospital mortality. All models were adjusted for age, gender, race, residential income, insurance, residential region, pain, and number of comorbidities. Among hospitalized patients, marijuana use was associated with a 60% increased odds of stroke (OR: 1.60, 95% CI: 1.44–1.77) compared with non‐users, but significantly reduced odds of heart failure (OR: 0.78, 95% CI: 0.75–0.82), cardiac disease (OR: 0.86, 95% CI: 0.82–0.91), or in‐hospital mortality (OR: 0.41, 95% CI: 0.38–0.44). Among cancer patients, odds of in‐hospital mortality was significantly reduced among marijuana users compared with non‐users (OR: 0.44, 95% CI: 0.35–0.55). Hospitalized marijuana users were more likely to experience a stroke compared with non‐users, but less likely to experience in‐hospital mortality. Prospective studies will be needed to better characterize the health effects of marijuana use, especially among older, sicker, and/or hospitalized patients. In the meantime, conversations regarding marijuana use/misuse may be warranted in the clinical setting in order for patients and healthcare providers to adequately weigh the anticipated benefits of marijuana use with potentially significant health risks.