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Guy D, Wootten JC, Wong M, Turski D, Lukewich M, Alboog A, Kandasamy AR, Gregory J, Poolacherla R. Pharmacodynamic effects following co-administration of cannabinoids and opioids: a scoping review of human experimental studies. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:423-434. [PMID: 38561178 DOI: 10.1093/pm/pnae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/29/2023] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Cannabinoids are increasingly used in the management of chronic pain. Although analgesic potential has been demonstrated, cannabinoids interact with a range of bodily functions that are also influenced by chronic pain medications, including opioids. OBJECTIVE We performed a scoping review of literature on the pharmacodynamic effects following the co-administration of cannabinoids and opioids. METHODS We systematically searched EMBASE, PubMed, and PsycINFO for studies that experimentally investigated the co-effects of cannabinoids and opioids in human subjects. Available evidence was summarized by clinical population and organ system. A risk of bias assessment was performed. RESULTS A total of 16 studies met the inclusion criteria. Study populations included patients with chronic non-cancer and cancer pain on long-term opioid regimens and healthy young adults without prior exposure to opioids who were subject to experimental nociceptive stimuli. Commonly administered cannabinoid agents included Δ9-tetrahydrocannabinol and/or cannabidiol. Co-administration of cannabinoids and opioids did not consistently improve pain outcomes; however, sleep and mood benefits were observed in chronic pain patients. Increased somnolence, memory and attention impairment, dizziness, gait disturbance, and nauseousness and vomiting were noted with co-administration of cannabinoids and opioids. Cardiorespiratory effects following co-administration appeared to vary according to duration of exposure, population type, and prior exposure to cannabinoids and opioids. CONCLUSIONS The available evidence directly investigating the pharmacodynamic effects following co-administration of cannabinoids and opioids for non-analgesic outcomes is scarce and suffers from a lack of methodological reporting. As such, further research in this area with comprehensive methodologic reporting is warranted.
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Affiliation(s)
- David Guy
- Department of Anesthesiology, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Jared C Wootten
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael Wong
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel Turski
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mark Lukewich
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Abdulrahman Alboog
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Anesthesia and ICU, University of Jeddah, College of Medicine Jeddah, Saudi Arabia
| | - Abirami R Kandasamy
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Hospital-London's Health Science Center, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Jonathan Gregory
- First Episode Mood & Anxiety Program, Emergency Diversion Clinic for Children's Hospital, and Ambulatory Child & Adolescent Mental Health Care Program, London, ON, Canada
| | - Raju Poolacherla
- Pediatric Chronic Pain Program, London Health Sciences Centre, London, ON, Canada
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Tarlovski S, Bar Kadmon A, Goldberg E, Segal D, Gavish D, Stepensky D. Comparative Pharmacokinetic Assessment of Innovative Sublingual, Rectal and Vaporizer Cannabis Products Versus Approved Cannabis Products in Healthy Volunteers. Cannabis Cannabinoid Res 2024. [PMID: 38656906 DOI: 10.1089/can.2023.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Background: Over the last years, there is a dramatic increase in the use of medical cannabis products for an expanding range of clinical indications. The type of the drug product and its administration route affect substantially the rate and the extent of absorption of cannabinoids and the effects induced by them in the patients. The current challenge for the cannabis pharmaceutical industry is to develop formulations that allow predictable and stable absorption of cannabinoids. This article reports the results of the clinical trial that investigated the pharmacokinetics (PKs) of innovative cannabis products in healthy volunteers. Materials and Methods: This was a single-center study with a single-dose, randomized, crossover, partially blinded controlled design. Each of the 12 healthy volunteers received 8 different products, of the 10 products that were assessed in this trial: novel sublingual (SL) tablet, vaporizer, and rectal products, comparator products (Sativex® and oil-based oromucosal products), and placebo products. Serial blood samples were collected, plasma concentrations of the THC, 11-OH-THC, and CBD were quantified and subjected to noncompartmental PK analysis. Results: Novel medical cannabis products that were investigated in the study induced substantial exposure of the volunteers to the active ingredients, had more rapid absorption, and in some cases also less variable absorption of THC and CBD, in comparison with the approved comparison products. The bioavailability of the novel SL tablet-based and suppositories products was somewhat lower than that of the oromucosal products. The vaporizer provided immediate systemic absorption with highest maximal concentration. The safety profile of the novel cannabis products, namely vaporizer, SL tablets, and suppositories, was not inferior to the Sativex and oil-based oromucosal formulations. Conclusions: The novel cannabis products that were assessed in this study have PK properties that may be advantageous for management of specific medical conditions or in specific subgroups of patients that are prescribed medical cannabis.
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Affiliation(s)
| | | | | | - Dadi Segal
- Panaxia Pharmaceutical Industries Ltd., Lod, Israel
| | - Dov Gavish
- Department of Medicine, Edith Wolfson Medical Center, Holon, Israel, Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - David Stepensky
- Department of Clinical Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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El-Mourad J, Lunghi C, Herrera NP, Zongo A. Dosing of Cannabinoids Associated with an Opioid-Sparing Effect: A Systematic Review of Longitudinal Studies. Pain Manag Nurs 2024; 25:e8-e20. [PMID: 37689509 DOI: 10.1016/j.pmn.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/31/2023] [Accepted: 08/12/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVE To assess cannabinoid dosing that could be associated with a reduction in opioid use. DESIGN Systematic review conducted according to the PRISMA statement. DATA SOURCES PubMed, Embase, Web of Science, and PsycINFO were searched up to December 10, 2022. REVIEW/ANALYSIS METHODS We included randomized controlled trials (RCT) and longitudinal observational studies assessing cannabinoids effect on opioid use in patients with acute or chronic pain. Two reviewers independently assessed the studies for inclusion and extracted the data. Tetrahydrocannabinol (THC), Cannabidiol (CBD), and other cannabinoids with dosing were the exposures. Change in opioid doses and opioid discontinuation were the outcomes. RESULTS Fifteen studies (including seven RCTs) were included. Eight studies (six observational and two RCTs) were conducted among patients with chronic pain including three with cancer-related pain. Seven studies involved patients with acute pain (five RCTs).In chronic non-cancer pain patients, two observational studies that assessed THC and CBD in combination (average daily dose 17mg/15mg), and one that assessed a CBD-rich extract (31.4 mg/day), showed a significant reduction in opioid use. Of the three studies conducted on patients with cancer, only the observational study that assessed nabilone (average 1.7 mg/day) showed a significant reduction in opioid use. In patients with acute pain, only two observational studies that assessed dronabinol (5mg and 5-10 mg/day for four days) showed a significant reduction in opioid use. CONCLUSION The opioid-sparing effect of cannabinoids remains uncertain based on current evidence. However, attention could be paid to cannabinoid doses associated with opioid reduction in included observational studies.
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Affiliation(s)
- Jihane El-Mourad
- Faculty of Pharmacy, Université Laval, Québec, Canada; Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec, Canada
| | - Carlotta Lunghi
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec, Canada; Department of Health Sciences, Université du Québec à Rimouski, Québec, Canada; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Norma Perez Herrera
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec, Canada
| | - Arsène Zongo
- Faculty of Pharmacy, Université Laval, Québec, Canada; Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec, Canada.
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Barkholtz H, Bates M. Measuring the diversity gap of cannabis clinical trial participants compared to people who report using cannabis. Sci Rep 2023; 13:9787. [PMID: 37328519 PMCID: PMC10276002 DOI: 10.1038/s41598-023-36770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/09/2023] [Indexed: 06/18/2023] Open
Abstract
Little is known about the demographics of people who use cannabis, including how use trends within population subgroups have evolved over time. It is therefore challenging to know if the demographics of participants enrolled in cannabis clinical trials are representative of those who use cannabis. To fill this knowledge gap, data from the National Survey on Drug Use and Health (NSDUH) on "past-month" cannabis use across various population subgroups in the United States was examined from 2002 to 2021. The most notable increases in "past-month" cannabis use prevalence occurred in those aged 65 and older (2,066.1%) and 50-64-year-olds (472.4%). In 2021, people reporting "past-month" cannabis use were 56.6% male and 43.4% female. Distribution across self-reported race and ethnicity was 64.1% White, 14.3% Black, 14.1% Hispanic, and 3.1% more than one race. And many ages were represented as 24.4% were 26-34, 24.1% were 35-49, 22.4% were 18-25, and 17.6% were 50-64 years old. To understand if these population subgroups are represented in cannabis clinical trials, participant demographics were extracted from peer-reviewed clinical trials reporting on pharmacokinetic and/or pharmacodynamic models of cannabis or cannabinoids. Literature was grouped by publication year (2000-2014 and 2015-2022) and participant prior exposure to cannabis. Results identified that cannabis clinical trial participants are skewed toward overrepresentation by White males in their 20s and 30s. This represents structural discrimination in the research landscape that perpetuates social and health inequities.
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Affiliation(s)
- Heather Barkholtz
- Forensic Toxicology, Environmental Health Division, Wisconsin State Laboratory of Hygiene, 2601 Agriculture Dr., Madison, WI, 53718, USA.
- Pharmaceutical Sciences, School of Pharmacy, University of Wisconsin-Madison, 777 Highland Ave., Madison, WI, 53705, USA.
| | - Maia Bates
- Forensic Toxicology, Environmental Health Division, Wisconsin State Laboratory of Hygiene, 2601 Agriculture Dr., Madison, WI, 53718, USA
- Department of Chemistry, College of Letters of Science, University of Wisconsin-Madison, 1101 University Ave., Madison, WI, 53706, USA
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Batinic A, Sutlović D, Kuret S, Matana A, Kumric M, Bozic J, Dujic Z. Trial of a Novel Oral Cannabinoid Formulation in Patients with Hypertension: A Double-Blind, Placebo-Controlled Pharmacogenetic Study. Pharmaceuticals (Basel) 2023; 16:ph16050645. [PMID: 37242428 DOI: 10.3390/ph16050645] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 05/28/2023] Open
Abstract
Cannabidiol (CBD) is a non-psychoactive cannabinoid, and available evidence suggests potential efficacy in the treatment of many disorders. DehydraTECH™2.0 CBD is a patented capsule formulation that improves the bioabsorption of CBD. We sought to compare the effects of CBD and DehydraTECH™2.0 CBD based on polymorphisms in CYP P450 genes and investigate the effects of a single CBD dose on blood pressure. In a randomized and double-blinded order, 12 females and 12 males with reported hypertension were given either placebo capsules or DehydraTECH™2.0 CBD (300 mg of CBD, each). Blood pressure and heart rate were measured during 3 h, and blood and urine samples were collected. In the first 20 min following the dose, there was a greater reduction in diastolic blood pressure (p = 0.025) and mean arterial pressure MAP (p = 0.056) with DehydraTECH™2.0 CBD, which was probably due to its greater CBD bioavailability. In the CYP2C9*2*3 enzyme, subjects with the poor metabolizer (PM) phenotype had higher plasma CBD concentrations. Both CYP2C19*2 (p = 0.037) and CYP2C19*17 (p = 0.022) were negatively associated with urinary CBD levels (beta = -0.489 for CYP2C19*2 and beta = -0.494 for CYP2C19*17). Further research is required to establish the impact of CYP P450 enzymes and the identification of metabolizer phenotype for the optimization of CBD formulations.
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Affiliation(s)
- Ana Batinic
- Pharmacy of Split-Dalmatia County, 21000 Split, Croatia
| | - Davorka Sutlović
- University Department of Health Studies, University of Split, 21000 Split, Croatia
- Department of Toxicology and Pharmacogenetics, School of Medicine, University of Split, 21000 Split, Croatia
| | - Sendi Kuret
- University Department of Health Studies, University of Split, 21000 Split, Croatia
| | - Antonela Matana
- University Department of Health Studies, University of Split, 21000 Split, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Zeljko Dujic
- Department of Integrative Physiology, School of Medicine, University of Split, 21000 Split, Croatia
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Bodnar RJ. Endogenous opiates and behavior: 2021. Peptides 2023; 164:171004. [PMID: 36990387 DOI: 10.1016/j.peptides.2023.171004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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Velez-Santiago A, Alvarez-Torres E, Martinez-Rodriguez R, Candal-Rivera E, Muniz-Camacho L, Ramos-Burgos L, Torres EA. A Survey of Cannabis Use among Patients with Inflammatory Bowel Disease (IBD). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5129. [PMID: 36982049 PMCID: PMC10049263 DOI: 10.3390/ijerph20065129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/20/2023] [Accepted: 03/02/2023] [Indexed: 06/18/2023]
Abstract
Inflammatory bowel diseases (IBDs) are chronic conditions of unknown cause or cure. Treatment seeks to reduce symptoms and induce and maintain remission. Many patients have turned to alternatives, such as cannabis, to alleviate living with IBD. This study reports the demographics, prevalence, and perception on cannabis use of patients attending an IBD clinic. Patients agreed to participate and completed an anonymous survey during their visit or online. Descriptive analysis, Fisher's exact test, and Wilcoxon-Mann-Whitney rank-sum test were used. One hundred and sixty-two adults (85 males, 77 with CD) completed the survey. Sixty (37%) reported use of cannabis, of which 38 (63%) used it to relieve their IBD. A value of 77% reported low to moderate knowledge about cannabis, and 15% reported little to no knowledge. Among cannabis users, 48% had discussed use with their physician, but 88% said they would feel comfortable discussing medical cannabis for IBD. Most saw improvement of their symptoms (85.7%). A considerable number of patients with IBD use medical cannabis for their disease, unknown to their physician. The study reinforces the importance that physicians understand the role of cannabis in the treatment of IBD in order to appropriately counsel patients.
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Affiliation(s)
- Alondra Velez-Santiago
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus, PR Medical Center, San Juan, PR 00935, USA; (A.V.-S.); (E.A.-T.); (R.M.-R.)
| | - Edwin Alvarez-Torres
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus, PR Medical Center, San Juan, PR 00935, USA; (A.V.-S.); (E.A.-T.); (R.M.-R.)
| | - Ricardo Martinez-Rodriguez
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus, PR Medical Center, San Juan, PR 00935, USA; (A.V.-S.); (E.A.-T.); (R.M.-R.)
| | - Emmanuel Candal-Rivera
- Veterans Affairs Caribbean Health System, 10 Calle Casia, San Juan, PR 00921-3201, USA; (E.C.-R.); (L.M.-C.)
| | - Luis Muniz-Camacho
- Veterans Affairs Caribbean Health System, 10 Calle Casia, San Juan, PR 00921-3201, USA; (E.C.-R.); (L.M.-C.)
| | - Luis Ramos-Burgos
- Massachussetts General Hospital, 55 Fruit St., Boston, MA 02114, USA;
| | - Esther A. Torres
- Department of Medicine, School of Medicine, University of Puerto Rico Medical Sciences Campus, PR Medical Center, San Juan, PR 00935, USA; (A.V.-S.); (E.A.-T.); (R.M.-R.)
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Narayan AJ, Downey LA, Manning B, Hayley AC. Cannabinoid treatments for anxiety: A systematic review and consideration of the impact of sleep disturbance. Neurosci Biobehav Rev 2022. [DOI: https:/doi.org.ezproxy.mnsu.edu/10.1016/j.neubiorev.2022.104941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
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Narayan A, Downey LA, Manning B, Hayley AC. Cannabinoid Treatments for Anxiety: A Systematic Review and Consideration of the Impact of Sleep Disturbance. Neurosci Biobehav Rev 2022; 143:104941. [DOI: 10.1016/j.neubiorev.2022.104941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/13/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
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