High-Frequency Medical Cannabis Use Is Associated With Worse Pain Among Individuals With Chronic Pain

Thoughtfully Integrating Cannabis Products Into Chronic Pain Treatment

Cannabis products (CPs) and cannabis-based medicines (CBMs) are becoming increasingly available and are commonly used for pain management. The growing societal acceptance of cannabis and liberalization of cannabis laws allows patients to access CPs with minimal clinical oversight. While there is mechanistic plausibility that CPs and CBMs may be useful for pain management, the clinical trial literature is limited and does not refute or support the use of CBMs for pain management. Complicating matters, a large and growing body of observational literature shows that many people use CPs for pain management and in place of other medications. However, products and dosing regimens in existing trials are not generalizable to the current cannabis market, making it difficult to compare and reconcile these 2 bodies of literature. Given this complexity, clinicians need clear, pragmatic guidance on how to appropriately educate and work with patients who are using CBMs for pain management. In this review, we narratively synthesize the evidence to enable a clear view of current landscape and provide pragmatic advice for clinicians to use when working with patients. This advice revolves around 3 principles: (1) maintaining the therapeutic alliance; (2) harm reduction and benefit maximization; and (3) pragmatism, principles of patient-centered care, and use of best clinical judgment in the face of uncertainty. Despite the lack of certainty CPs and chronic pain management use, we believe that following these principles can make most of the clinical opportunity presented by discussions around CPs and also enhance the likelihood of clinical benefit from CPs.

Pain is associated with exclusive use and co-use of tobacco and cannabis: Findings from Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health Study

INTRODUCTION

Rates of tobacco and cannabis use are disproportionately high among individuals with pain, and evidence suggests that pain may engender greater likelihood of substance co-use, yielding additive risk. This study examined national associations of pain with past-month tobacco use, cannabis use, and co-use of tobacco and cannabis.

METHODS

Data came from a nationally representative US sample of adults in Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health study (N = 32,014). The sample included civilian, non-institutionalized people who use tobacco and people who do not use tobacco. Past-week pain intensity (0-10) was dichotomized (0-4 no/low pain; 5-10 moderate/severe pain). Multinomial models adjusted for demographics examined substance use category membership (no tobacco or cannabis use, exclusive cannabis use, exclusive tobacco use, co-use) as a function of pain status.

RESULTS

Moderate/severe pain was associated with increased relative risk of exclusive tobacco use (RRR [CI] 2.26 [2.05, 2.49], p <.001), exclusive cannabis use (1.49 [1.22, 1.82], p <.001), and co-use of tobacco and cannabis (2.79 [2.51, 3.10], p <.001), in comparison to no tobacco or cannabis use. Additionally, moderate/severe pain was associated with increased risk of co-use compared to exclusive tobacco use (1.23 [1.11, 1.37], p <.001) and exclusive cannabis use (1.88 [1.54, 2.29], p <.001).

DISCUSSION

Findings suggest that not only is pain independently associated with greater risk of exclusively using tobacco or cannabis, but pain is also associated with heightened risk of co-using both products. Future work should examine the dynamic and potentially bidirectional relationships between pain and use of cannabis and tobacco.

Experiences and Perceptions of Medical Cannabis among People Living with Chronic Pain and Community Pharmacists: A Qualitative Study in Canada

Background

The use of cannabis to treat chronic pain is under debate despite high expectations from patients. Qualitative data obtained by exploring both patients' and health professionals' perspectives are scarce.

Aims

This study aimed to understand the experiences and perceptions of people living with chronic pain and community pharmacists regarding the role of cannabis in chronic pain treatment in the Canadian context where both medical and recreational cannabis are legal.

Methods

We conducted 12 online focus groups (July 2020-February 2021) with 26 patients and 19 community pharmacists using semistructured discussion guides. All discussions were audio recorded and transcribed verbatim were analyzed using a reflexive thematic approach.

Results

We developed three themes related to patients' perspectives and three themes related to pharmacists' perspectives. Patients' perspectives included (1) cannabis as an alternative to other pain medications, (2) a new treatment with potential health-related risks, and (3) a therapy rather than a recreational drug. Pharmacists' perspectives included (1) challenges in monitoring drug interactions with cannabis in the context of scarce research data, (2) informing and treating patients self-medicating with cannabis amid its growing popularity, and (3) financial costs and legal constraints for patients.

Conclusions

This study highlights patients' and pharmacists' urgent need for reliable information regarding the benefits and risks of cannabis. Training tailored to pharmacists' needs and evidence-based information for patients should be developed to support pharmacists' practice, improve patients' experiences, and promote safe cannabis use.

The relationship between cannabis use, schizophrenia, and bipolar disorder: a genetically informed study

BACKGROUND

The relationship between psychotic disorders and cannabis use is heavily debated. Shared underlying genetic risk is one potential explanation. We investigated the genetic association between psychotic disorders (schizophrenia and bipolar disorder) and cannabis phenotypes (lifetime cannabis use and cannabis use disorder).

METHODS

We used genome-wide association summary statistics from individuals with European ancestry from the Psychiatric Genomics Consortium, UK Biobank, and International Cannabis Consortium. We estimated heritability, polygenicity, and discoverability of each phenotype. We performed genome-wide and local genetic correlations. Shared loci were identified and mapped to genes, which were tested for functional enrichment. Shared genetic liabilities to psychotic disorders and cannabis phenotypes were explored using causal analyses and polygenic scores, using the Norwegian Thematically Organized Psychosis cohort.

FINDINGS

Psychotic disorders were more heritable than cannabis phenotypes and more polygenic than cannabis use disorder. We observed positive genome-wide genetic correlations between psychotic disorders and cannabis phenotypes (range 0·22-0·35) with a mixture of positive and negative local genetic correlations. Three to 27 shared loci were identified for the psychotic disorder and cannabis phenotype pairs. Enrichment of mapped genes implicated neuronal and olfactory cells as well as drug-gene targets for nicotine, alcohol, and duloxetine. Psychotic disorders showed a causal effect on cannabis phenotypes, and lifetime cannabis use had a causal effect on bipolar disorder. Of 2181 European participants from the Norwegian Thematically Organized Psychosis cohort applied in polygenic risk score analyses, 1060 (48·6%) were females and 1121 (51·4%) were males (mean age 33·1 years [SD 11·8]). 400 participants had bipolar disorder, 697 had schizophrenia, and 1044 were healthy controls. Within this sample, polygenic scores for cannabis phenotypes predicted psychotic disorders independently and improved prediction beyond the polygenic score for the psychotic disorders.

INTERPRETATION

A subgroup of individuals might have a high genetic risk of developing a psychotic disorder and using cannabis. This finding supports public health efforts to reduce cannabis use, particularly in individuals at high risk or patients with psychotic disorders. Identified shared loci and their functional implications could facilitate development of novel treatments.

FUNDING

US National Institutes of Health, the Research Council Norway, the South-East Regional Health Authority, Stiftelsen Kristian Gerhard Jebsen, EEA-RO-NO-2018-0535, European Union's Horizon 2020 Research and Innovation Programme, the Marie Skłodowska-Curie Actions, and University of Oslo Life Science.

Using Medical Cannabis for Chronic Pain: A Social-Ecological Framework

Early studies suggest medical cannabis (MC) has the potential to benefit people who suffer from chronic pain by offering a less addictive alternative to opioids; however, most investigators agree more research is indicated. Today, in 2023, cannabis remains a Schedule I drug and is an illegal substance in the United States under the Controlled Substances Act of 1970. Despite this designation, as of February 2022, 37 states, three territories, and the District of Columbia allowed using cannabis products to treat certain painful medical conditions. The contradictory status of federal and state legislation regarding cannabis use has resulted in delays and restrictions on relevant research. As a result, an inadequate foundation of knowledge exists needed to inform policy, program, and practice decisions concerning MC to treat pain. Implementing and controlling access to MC is influenced by overlapping individual, interpersonal, community, and organizational influences that all fall under the umbrella of federal and state policies. Increasingly, the legalization and expanded access to MC necessitates the integration of evidence, policy, and social-ecological reality. To adequately delineate these complex factors to anticipate and plan future interventions at multiple levels, we propose a social-ecological framework (SEF) for using MC to treat pain. This SEF assumes the transactional relationship between the individual and the environment and that no single factor can predict behavior or health outcomes. Our framework illustrates five dynamic levels of analysis that interact between dimensions. Key elements and intersections are discussed at the intrapersonal, interpersonal, institutional, community, and policy levels.

Medical Cannabis for Chronic Nonmalignant Pain Management

PURPOSE OF REVIEW

Cannabis has been used since ancient times for medical and recreational research. This review article will document the validity of how medical cannabis can be utilized for chronic nonmalignant pain management.

RECENT FINDINGS

Current cannabis research has shown that medical cannabis is indicated for symptom management for many conditions not limited to cancer, chronic pain, headaches, migraines, and psychological disorders (anxiety and post-traumatic stress disorder). Δ9-Tetrahydrocannabinol (THC) and cannabidiol (CBD) are active ingredients in cannabis that modulate a patient's symptoms. These compounds work to decrease nociception and symptom frequency via the endocannabinoid system. Research regarding pain management is limited within the USA as the Drug Enforcement Agency (DEA) classifies it as a schedule one drug. Few studies have found a limited relationship between chronic pain and medical cannabis use. A total of 77 articles were selected after a thorough screening process using PubMed and Google Scholar. This paper demonstrates that medical cannabis use provides adequate pain management. Patients suffering from chronic nonmalignant pain may benefit from medical cannabis due to its convenience and efficacy.

Predictors of Pain Reduction Among Fibromyalgia Patients Using Medical Cannabis: A Long-Term Prospective Cohort Study

OBJECTIVE

Many patients with fibromyalgia (FM) report using cannabis as a strategy to improve pain. Given that pain often co-occurs with symptoms of anxiety and depression (i.e., negative affect) and sleep problems among patients with FM, improvements in these symptoms might indirectly contribute to reductions in pain intensity following cannabis use. The main objective of the study was to examine whether changes in pain intensity following initiation of medical cannabis among patients with FM could be attributed to concurrent changes (i.e., reductions) in negative affect and sleep problems.

METHODS

This was a 12-month prospective cohort study among patients with FM (n = 323) initiating medical cannabis under the care of physicians. Patients were assessed at baseline, and follow-up assessment visits occurred every 3 months after initiation of medical cannabis. Patients' levels of pain intensity, negative affect, and sleep problems were assessed across all visits.

RESULTS

Multilevel mediation analyses indicated that reductions in patients' levels of pain intensity were partly explained by concurrent reductions in sleep problems and negative affect (both P < 0.001). This remained significant even when accounting for patients' baseline characteristics or changes in medical cannabis directives over time (all P > 0.05).

CONCLUSION

Our findings provide preliminary insight into the potential mechanisms of action underlying pain reductions among patients with FM who are using medical cannabis. Given the high attrition rate (i.e., 75%) observed in the present study at 12 months, our findings cannot be generalized to all patients with FM who are using medical cannabis.

Potency and Therapeutic THC and CBD Ratios: U.S. Cannabis Markets Overshoot

Background and aims: The effects exuded by cannabis are a result of the cannabinoids trans-Δ⁹-tetrahydrocannabinol (THC) and cannabidiol (CBD), and is dependent upon their pharmacological interaction and linked to the two cannabinoids’ concentrations and ratios. Based on current literature and trends of increasing cannabis potency, we postulate that most medical cannabis products with THC and CBD have ratios capable of producing significant acute intoxication and are similar to recreational products. We will test this by organizing products into clinically distinct categories according to TCH:CBD ratios, evaluating the data in terms of therapeutic potential, and comparing the data obtained from medical and recreational programs and from states with differing market policies.

Methods: We utilized data encompassing online herbal dispensary product offerings from nine U.S. states. The products were analyzed after being divided into four clinically significant THC:CBD ratio categories identified based on the literature: CBD can enhance THC effects (THC:CBD ratios ≥1:1), CBD has no significant effect on THC effects (ratios ∼ 1:2), CBD can either have no effect or can mitigate THC effects (ratios 1:>2 < 6), or CBD is protective against THC effects (ratios ≤1:6).

Results: A significant number of products (58.5%) did not contain any information on CBD content. Across all states sampled, the majority (72–100%) of both medical and recreational products with CBD (>0%) fall into the most intoxicating ratio category (≥1:1 THC:CBD), with CBD likely enhancing THC’s acute effects. The least intoxicating categories (1:>2 < 6 and ≤1:6 THC:CBD) provided the smallest number of products. Similarly, the majority of products without CBD (0%) contained highly potent amounts of THC (>15%). These results were consistent, regardless of differing market policies in place.

Conclusions: Despite the distinct goals of medical and recreational cannabis users, medical and recreational program product offerings are nearly identical. Patients seeking therapeutic benefits from herbal cannabis products are therefore at a substantial risk of unwanted side effects, regardless of whether they obtain products from medical or recreational programs. Efforts are needed to better inform patients of the risks associated with high potency cannabis and the interaction between THC and CBD, and to help shape policies that promote more therapeutic options.

Medical Cannabis Use Reduces Opioid Prescriptions in Patients With Osteoarthritis

Background

Osteoarthritis (OA) can result in significant pain, requiring pain management with opioids. Medical cannabis (MC) has the potential to be an alternative to opioids for chronic pain conditions. This study investigates whether MC used in the management of OA-related chronic pain can reduce opioid utilization.

Methods

Forty patients with chronic OA pain were certified for MC. Average morphine milligram equivalents (MME) per day of opioid prescriptions filled within the six months prior to MC certification was compared to that of the six months after. Visual analog scale (VAS) for pain and Global Health scores were measured at baseline, three, and six months post MC certification.

Results

Average MME/day decreased from 18.2 to 9.8 (n=40, p<0.05). The percentage of patients who dropped to 0 MME/day was 37.5%. VAS scores decreased significantly at three and six months, and Global Physical Health score increased significantly by three months.

Conclusions

MC reduces opioid prescription for patients with chronic OA pain and improves pain and quality of life.

Medical Cannabis Use Reduces Opioid Prescriptions in Patients With Chronic Back Pain

Background

This study investigates whether the use of medical cannabis (MC) in patients with chronic back pain is associated with a decreased opioid prescription.

Methods

The study included 186 patients with chronic back pain who were certified for MC use. The average morphine milligram equivalent (MME)/day of opioid prescriptions filled within the six months prior to MC certification was compared to that of six months after. Pain and disability questionnaires were distributed at three, six, and nine months post-certification.

Results

Patients who started at less than 15 MME/day and patients who started at greater than 15 MME/day decreased from 15.1 to 11.0 (n = 186, p < 0.01), 3.5 to 2­­­.1 (n = 134, p < 0.01), and 44.9 to 33.9 (n = 52, p < 0.01), respectively. Pain and disability scores were improved at follow-up as well.

Conclusion

MC use reduces opioid prescription for patients with chronic back pain and improves pain and disability scores.

Cannabinoids and chronic pelvic pain in women: Focus on endometriosis

Chronic pelvic pain in women is common and frequently difficult to treat. Chronic pelvic pain often develops in the setting of endometriosis, interstitial cystitis/bladder pain syndrome, and vulvodynia. Cannabinoids are a promising treatment modality for non-cancer chronic pain, but have not been studied in women with chronic pelvic pain nor in specific chronic pelvic pain conditions. This review focuses on the interaction of the endocannabinoid system with the menstrual cycles, with endometriotic lesions, and within the bladder. Furthermore, it provides a brief overview of existing literature of the effects of endocannabinoids on chronic pain generally, with a focus on neuropathic pain. Finally, it discusses limited data available regarding the use of cannabinoids in women with chronic pelvic pain conditions. In the opinion of the authors, cannabinoids are a reasonable treatment modality for refractory chronic pelvic pain, especially if a neuropathic component is suspected. Practitioners should expect a modest effect on pain levels with an acceptable safety profile.

Cannabis based medicines and cannabis dependence: A critical review of issues and evidence

Cannabis has been legalised for medical use in an ever-increasing number of countries. A growing body of scientific evidence supports the use of medical cannabis for a range of therapeutic indications. In parallel with these developments, concerns have been expressed by many prescribers that increased use will lead to patients developing cannabis use disorder. Cannabis use disorder has been widely studied in recreational users, and these findings have often been projected onto patients using medical cannabis. However, studies exploring medical cannabis dependence are scarce and the appropriate methodology to measure this construct is uncertain. This article provides a narrative review of the current research to discern if, how and to what extent, concerns about problems of dependence in recreational cannabis users apply to prescribed medical users. We focus on the main issues related to medical cannabis and dependence, including the importance of dose, potency, cannabinoid content, pharmacokinetics and route of administration, frequency of use, as well as set and setting. Medical and recreational cannabis use differs in significant ways, highlighting the challenges of extrapolating findings from the recreational cannabis literature. There are many questions about the potential for medical cannabis use to lead to dependence. It is therefore imperative to address these questions in order to be able to minimise harms of medical cannabis use. We draw out seven recommendations for increasing the safety of medical cannabis prescribing. We hope that the present review contributes to answering some of the key questions surrounding medical cannabis dependence.

Pain Profiles among Young Adult Cannabis Users: An Analysis of Antecedent Factors and Distal Outcomes

BACKGROUND

Pain is a primary reason for medical cannabis use among young adults, however little is known about the patterns of pain in this group. This study identified pain profiles among young adult cannabis users and examined related antecedents and distal outcomes.

METHODS

Past 30-day cannabis users aged 18-26, both medical cannabis patients and non-patients, were enrolled in Los Angeles in 2014-2015. A latent class analysis was used to identify pain classes based on history of chronic pain conditions and recent non-minor pain. The study assessed the predictors of membership in pain classes and examined the association of classes with recent mental health characteristics, cannabis use motives and practices.

RESULTS

Three classes were identified: Low pain (56.3%), Multiple pain (27.3%), and Nonspecific pain (16.4%). In adjusted models, lifetime insomnia was associated with membership in Multiple pain and Nonspecific pain classes versus the Low pain class. Medical cannabis patients and Hispanics/Latinos were more likely to belong to the Multiple pain class than the other classes. Regarding recent outcomes, the Multiple pain and Nonspecific pain classes were more likely than the Low pain class to use cannabis to relieve physical pain. Additionally, the Multiple pain class had a higher probability of psychological distress, self-reported medical cannabis use, consuming edibles, and using cannabis to sleep compared to one or both other classes.

CONCLUSION

Findings suggest that young adult cannabis users can be separated into distinct groups with different pain profiles. The Multiple pain profile was associated with medically-oriented cannabis use motives and practices.

Practical Considerations of Hypotheses and Evidence in Cannabis Pharmacotherapy: Refining Expectations of Clinical Endocannabinoid Deficiency

An Industry founded on the promotion of presumed health and wellness benefits of cannabis use continues to grow in the United States, despite the lack of substantial evidence in support of the many claims being made. Several hypotheses exist regarding the role of endocannabinoids in human health and the pertinence of phytocannabinoids as pharmacotherapies for addressing their dysregulation. An opinion is offered regarding the tenuous nature of these assumptions and questions are raised regarding how best to interpret the complex metabolic interplay of the still vaguely defined endocannabinoid system.