Topical Medical Cannabis: A New Treatment for Wound Pain-Three Cases of Pyoderma Gangrenosum

Cannabidiol-A friend or a foe?

Cannabidiol (CBD), one of the main actives from Cannabis sativa has been perpetually explored lately for its therapeutic effects. Its main attributes, such as anti-inflammatory and antioxidant effects, snowball into pain management, epilepsy and seizure alleviation, anxiety relief, as well as numerous other implications through the entire metabolism. However, conventional administration routes challenge its therapeutic potential, with reported poor water solubility, hepatic degradation, gastric instability and erratic bioavailability observed in oral administration. As a result, the transdermal delivery systems have emerged as a promising alternative to oral or inhaled routes, offering improved bioavailability and targeted effects. The medical use of CBD throughout Europe, UK, USA or Australia is extensive and usually represented by pharmaceutical preparations recommended after conventional treatment routs fail. The non-medical use is limited by each country's own legislation, a wider range of products being available, but the irregular regulatory landscape coupled with the growing market of cannabinoid-infused products, emphasizes the need for standardized formulations and further clinical research. The present work critically examines the transdermal administration of cannabidiol, explores the skin's potential as a route and the strategies involved in using it for systemic targeting. We highlighted key challenges and provided insights into CBD`s variable bioavailability based on different administration routes and methods, thus compiling a literature-based absorption, distribution, metabolism, and excretion (ADME) study. We also explore the role of the endocannabinoid system, its function in various medical conditions, and the therapeutic effects associated with CBD, particularly in light of the varying legislation across countries. While the breadth of potential benefits is compelling, it is essential to emphasize the ongoing nature of CBD research as individual responses to it can vary significantly.

Updates in innovation of the treatment of pyoderma gangrenosum

INTRODUCTION

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis characterized by rapidly enlarging, painful ulcers with undermined borders. The management of PG is challenging due to the lack of standardized evidence-based treatments.

AREAS COVERED

This review examines recent efforts to establish standardized outcomes for clinical trials to facilitate the drug development process for PG. It explores new therapeutics in development and evaluates advanced options for wound and pain management. Literature available on the pathogenesis, treatment, and pain management of PG from database inception to April 2024 was searched in PubMed, Embase, and Cochrane. ClinicalTrials.gov and the EU Clinical Trials Register were searched for clinical trials on PG.

EXPERT OPINION

New therapeutics such as interleukin 36 inhibitor and complement component C5a inhibitor more specifically target key pathways in the pathogenesis of PG have shown promise and can greatly benefit patients with PG, which still lacks an FDA-approved treatment. In addition to systemic therapy, local wound care and pain management should be carried out simultaneously to achieve successful wound healing.

The Potential Role of Cannabidiol in Cosmetic Dermatology: A Literature Review

Cannabidiol (CBD) is a non-psychotropic cannabinoid with multiple pharmacological properties. Cannabidiol has attracted growing attention in the cosmetic industry, with an increasing number of CBD-containing skincare products on the market in recent years. The aim of this review is to evaluate the current evidence on the use of CBD for cosmetic purposes. Following an overview of CBD and the endocannabinoid system in the skin, we summarize pre-clinical and clinical studies that address the potential of CBD in cosmetic dermatology. Available in vitro and in vivo evidence suggests that CBD has anti-oxidant, anti-inflammatory, moisturizing, anti-acne, wound-healing, and anti-aging properties. However, only a few clinical studies have been conducted on the use of CBD in the skin. In addition, there is a critical need to develop an efficient drug-delivery system for topical/transdermal application of CBD. Further research, including clinical and pharmacokinetic studies, are needed to fully evaluate the role of CBD in cosmetic dermatology.

Making Sense of Topical Pain Relief Options: Comparing Topical Analgesics in Efficacy and Safety

CONTEXT

In patients with musculoskeletal (MSK) conditions, pain is the leading contributor to disability and significantly limits mobility and dexterity. This narrative review describes the efficacy and safety of topical analgesics in common use today.

EVIDENCE ACQUISITION

Secondary literature gained via a literature search using PubMed.gov and the Cochrane library were used.

STUDY DESIGN

Recent literature (2000-2023) on several major classes of topical analgesics and topical delivery systems were reviewed to provide strength of recommendation taxonomy (SORT) levels. A total of 86 articles were reviewed.

LEVEL OF EVIDENCE

Level 2.

RESULTS

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) and cabbage leaf wraps (CLW) appear to be best suited for multiple types of acute MSK pain, and topical nitroglycerin is helpful when used specifically for rotator cuff pain in patients seeking relief while performing activities of daily living and willing to treat for long periods of time. For compounded topical formulations, it may be better to offer single agent creams based on patient preferences. Little data support the use of cryotherapy. Traumeel could be a promising natural analgesic that compares with diclofenac. Topical lidocaine appears best suited for postherpetic neuropathic pain. O24 is a reasonable alternative with a low risk profile to treat pain in patients with fibromyalgia syndrome.

CONCLUSION

Choice of topical agents should be guided by current evidence accounting for type of pain, medication side effects, patient comorbidities, as well as patient preference, convenience, and cost.

STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT)

Of the topical analgesics and modalities reviewed, SORT level A evidence was found for topical NSAID use in decreasing MSK pain, topical lidocaine for postherpetic neuralgia, and nitroglycerin patches for treating rotator cuff pain if used for prolonged periods of time. Alternative treatments such as CLW and Traumeel show promising results (SORT level B).

Cannabinoids in Integumentary Wound Care: A Systematic Review of Emerging Preclinical and Clinical Evidence

This systematic review critically evaluates preclinical and clinical data on the antibacterial and wound healing properties of cannabinoids in integument wounds. Comprehensive searches were conducted across multiple databases, including CINAHL, Cochrane library, Medline, Embase, PubMed, Web of Science, and LILACS, encompassing records up to May 22, 2024. Eighteen studies met the inclusion criteria. Eleven were animal studies, predominantly utilizing murine models (n = 10) and one equine model, involving 437 animals. The seven human studies ranged from case reports to randomized controlled trials, encompassing 92 participants aged six months to ninety years, with sample sizes varying from 1 to 69 patients. The studies examined the effects of various cannabinoid formulations, including combinations with other plant extracts, crude extracts, and purified and synthetic cannabis-based medications administered topically, intraperitoneally, orally, or sublingually. Four animal and three human studies reported complete wound closure. Hemp fruit oil extract, cannabidiol (CBD), and GP1a resulted in complete wound closure in twenty-three (range: 5-84) days with a healing rate of 66-86% within ten days in animal studies. One human study documented a wound healing rate of 3.3 cm2 over 30 days, while three studies on chronic, non-healing wounds reported an average healing time of 54 (21-150) days for 17 patients by oral oils with tetrahydrocannabinol (THC) and CBD and topical gels with THC, CBD, and terpenes. CBD and tetrahydrocannabidiol demonstrated significant potential in reducing bacterial loads in murine models. However, further high-quality research is imperative to fully elucidate the therapeutic potential of cannabinoids in the treatment of bacterial skin infections and wounds. Additionally, it is crucial to delineate the impact of medicinal cannabis on the various phases of wound healing. This study was registered in PROSPERO (CRD42021255413).

Evidence of Cannabidiol Effectiveness Associated or Not with Tetrahydrocannabinol in Topical Administration: A Scope Review

Cannabis sativa is a plant of the Cannabaceae family, whose molecular composition is known for its vast pharmacological properties. Cannabinoids are the molecules responsible for Cannabis sativa potential effects, especially tetrahydrocannabinol and cannabidiol. Scientific development has shown interest in the potential of cannabidiol in various health conditions, as it has demonstrated lower adverse events and great pharmacological potential, especially when administered topically. The present study aims to carry out a scoping review, focusing on the use of cannabidiol, in vivo models, for topical administration. Thus, the methodological approach used by the Joanna Briggs Institute was applied, and the studies were selected based on previously established inclusion criteria. Even though more information regarding the dose to achieve pharmacological potential is still needed, cannabidiol demonstrated potential in treating and preventing different conditions, such as glaucoma, atopic dermatitis, epidermolysis bullosa, and pyoderma gangrenosum.

Assessment of Wound-Related Pain Experiences of Patients With Chronic Wounds: A Multicenter Cross-Sectional Study in Eastern China

PURPOSE

The primary aims of this study were to evaluate the prevalence of wound-related pain (WRP) in patients with chronic wounds and assess the use of pain relief measures.

DESIGN

A cross-sectional study.

SUBJECTS AND SETTING

A convenience sample of patients with chronic wounds was recruited from outpatient clinics of 12 hospitals covering 7 of 13 cities in the Jiangsu province located in eastern China from July 10 to August 25, 2020. The sample comprised 451 respondents, and their mean age was 54.85 (SD 19.16) years; 56.1% (253/451) patients were male.

METHODS

An investigator-designed questionnaire was used to collect pain-related information from patients. The questionnaire consisted of 4 parts: (1) basic demographic and clinical information (patient and wound characteristics); (2) wound baseline pain; (3) wound-related procedural pain and pain relief method; and (4) the effect of WRP on the patient. Pain was assessed using the Numerical Rating Scale (NRS) scored from 0 (no pain) to 10 (worst pain). Severity of pain was based on NRS scores' classification as mild (1-3), moderate (4-6), and severe (7-10). The survey was conducted from July 10 to August 25, 2020. Participants were instructed on use of the NRS and then completed the questionnaire following dressing change independently.

RESULTS

The 3 most common types of chronic wounds were traumatic ulcers, surgical wounds, and venous leg ulcers. The 3 most prevalent locations were lower limbs, feet, and thorax/abdomen. Of all patients, 62.5% (282/451) and 93.8% (423/451) patients experienced wound baseline pain and wound-related procedural pain, respectively. The mean score of wound baseline pain was 3.76 (SD 1.60) indicating moderate pain. During wound management, the highest pain score was 6.45 (SD 2.75) indicating severe pain; the most severe pain scores were associated with debridement. The use of drugs to relieve wound pain was low, while the use of nondrug-based analgesia was relatively high. Because of WRP, patients with chronic wounds feared dressing changes, hesitated to move, and showed a decline in sleep quality.

CONCLUSIONS

Wound baseline pain and wound-related procedural pain were very common in patients with chronic wounds. In the future, targeted intervention plans should be developed by combining drug-based and nondrug-based analgesia according to pain severity.

Analgesic Efficacy of Oxycodone in Postoperative Dressings after Surgical Treatment of Burn Wounds: A Randomised Controlled Trial

INTRODUCTION

This study aimed to assess the analgesic efficacy of oxycodone at doses of 10 mg and 20 mg in dressings after surgery of burn wounds.

MATERIAL AND METHODS

Twenty adult patients who underwent surgical treatment of third-degree burn wounds under general anaesthesia were included. Burn wounds were treated with dressings, to which oxycodone was added at 20 mg in Group 1 and 10 mg in Group 2. After the surgery, plasma oxycodone and noroxycodone concentrations were assayed, and pain intensity was assessed with Numerical Rating Scale (NRS).

RESULTS

In Group 1, no patient reported pain; in Group 2, four patients reported pain. The pain intensity, according to NRS, was 1-8. Plasma concentration of oxycodone in the blood serum was in the range of 1.24-3.15 ng/mL and 1.09-1.28 ng/mL in Group 1 and Group 2, respectively. Noroxycodone was not detected in the plasma. Adverse effects were not observed in any of the treated patients.

CONCLUSIONS

Oxycodone in dressings provides patients with adequate and safe analgesia.

Leishmania mexicana promotes pain-reducing metabolomic reprogramming in cutaneous lesions

Cutaneous leishmaniasis (CL) is characterized by extensive skin lesions, which are usually painless despite being associated with extensive inflammation. The molecular mechanisms responsible for this analgesia have not been identified. Through untargeted metabolomics, we found enriched anti-nociceptive metabolic pathways in L. mexicana-infected mice. Purines were elevated in infected macrophages and at the lesion site during chronic infection. These purines have anti-inflammatory and analgesic properties by acting through adenosine receptors, inhibiting TRPV1 channels, and promoting IL-10 production. We also found arachidonic acid (AA) metabolism enriched in the ear lesions compared to the non-infected controls. AA is a metabolite of anandamide (AEA) and 2-arachidonoylglycerol (2-AG). These endocannabinoids act on cannabinoid receptors 1 and 2 and TRPV1 channels to exert anti-inflammatory and analgesic effects. Our study provides evidence of metabolic pathways upregulated during L. mexicana infection that may mediate anti-nociceptive effects experienced by CL patients and identifies macrophages as a source of these metabolites.

Chronic wound-related pain, wound healing and the therapeutic potential of cannabinoids and endocannabinoid system modulation

Chronic wounds represent a significant burden on the individual, and the healthcare system. Individuals with chronic wounds report pain to be the most challenging aspect of living with a chronic wound, with current therapeutic options deemed insufficient. The cutaneous endocannabinoid system is an important regulator of skin homeostasis, with evidence of system dysregulation in several cutaneous disorders. Herein, we describe the cutaneous endocannabinoid system, chronic wound-related pain, and comorbidities, and review preclinical and clinical evidence investigating endocannabinoid system modulation for wound-related pain and wound healing. Based on the current literature, there is some evidence to suggest efficacy of endocannabinoid system modulation for promotion of wound healing, attenuation of cutaneous disorder-related inflammation, and for the management of chronic wound-related pain. However, there is 1) a paucity of preclinical studies using validated models, specific for the study of chronic wound-related pain and 2) a lack of randomised control trials and strong clinical evidence relating to endocannabinoid system modulation for wound-related pain. In conclusion, while there is some limited evidence of benefit of endocannabinoid system modulation in wound healing and wound-related pain management, further research is required to better realise the potential of targeting the endocannabinoid system for these therapeutic applications.

Patients 'acceptance' of chronic wound-associated pain - A qualitative descriptive study

Chronic wound-associated pain negatively impacts the quality of life of individuals and their families. To date, little research exists that has explored collectively how individuals describe wound pain, strategies they use to manage pain, and the perceived effectiveness of such strategies. Therefore, qualitative, semi-structured interviews were carried out between June and August 2021 with 13 individuals to gain a deeper understand of the experience and impact of chronic wound-associated pain in this population. Data were analyzed following Braun and Clarke's approach for reflexive thematic analysis using MAXQdA®. Two themes and subthemes were identified. Theme 1 reflects participants' characterization of pain and how wound-associated pain affected their daily life and how they learned to accept it. Participants felt functionally impaired. In theme 2, participants described how they accepted to live with such a pain even though they received support to manage their chronic wound-associated pain, especially during the dressing-changes. Patients depended on their health care professionals and family support networks to cope with the pain. Coping with pain is exhausting contributing to poorer quality of life. Health care professionals should be aware of wound-associated pain during dressing changes. Patients recommended the need for further research on dressings and not drugs to manage pain.

Physician Trainees' Perception of Cannabidiol Use in Medicine: A Survey Study

PURPOSE

Given the ongoing national opiate crisis, physicians have been challenged with mitigating the risk of opiate dependence in their patients. With current physician efforts to mitigate the risks of treating pain with opioid prescriptions, this study evaluates medical students' and residents' understanding and perceptions regarding cannabidiol (CBD) in current medical care and their future medical practice.

METHODS

Orthopedic residents from all American programs and medical students from 50 medical schools, regardless of training year or future specialty plans, were eligible to participate in this survey-based study administered from December 2022 to March 2023. The surveys ask questions about demographic information, what education they receive on CBD utilization in medicine, thoughts on CBD effectiveness in pain control, and future plans on utilizing CBD.

RESULTS

A total of 55 residents (1.4%) and 53 medical students (5.1%) responded. Trainees in CBD-legal states were more likely to work with physicians who use CBD in their practice. Most trainees, regardless of location, believe CBD use has a stigma attached to it. Many responders were concerned about the role of CBD in pain control. Finally, most trainees believed that CBD is easy to access if desired and is affordable to purchase.

CONCLUSION

The trajectory of CBD use in the United States indicates that the therapeutic benefits of CBD will be targeted, and future physicians are not always provided adequate educational opportunities to learn about its potential medical uses. Continued training as well as interactions with patients may help decrease the stigma surrounding medical CBD use and help solidify its therapeutic use in pain control.

Systematic review of topical interventions for the management of pain in chronic wounds

Chronic wounds adversely affect quality of life. Pain is associated with chronic wounds, and its impact can vary according to wound aetiology, condition, and patient factors. This systematic review examined the effectiveness of topical interventions in the management chronic wound-related pain guided by PRISMA recommendations of randomised controlled trials (RCTs) where pain reduction is the primary outcome. Inclusion criteria were adults (older than 18 years) with chronic venous, arterial, diabetic, or pressure ulcers where pain has been managed through topical administration of pharmacological/nonpharmacological agents. Searches were conducted in Ovid Embase, Ovid MEDLINE, EBSCOhost, CINAHL, CENTRAL, PubMed, Web of Science, and Scopus. Studies were screened for eligibility; risk of bias and data were extracted by 2 independent assessors. Searches retrieved 10,327 titles and abstracts (7760 after deduplication). Nine full texts (1323 participants) examining ibuprofen (n = 4), morphine (n = 2), BWD + PHMB [polihexanide-containing biocellulose wound dressing] (n = 1), and EMLA (n = 2) were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. Meta-analysis was not possible, but initial exploration suggests improved outcomes (reduced pain) for ibuprofen when compared with controls. Two studies involving morphine showed conflicting findings. Included studies often had small samples, and considering confounding factors (eg, comorbidities), the results should be interpreted with caution. Review of included studies suggests that topical interventions may provide pain relief in individuals with chronic wounds. Further adequately powered RCTs are recommended to assess the efficacy of topical interventions for the management of chronic wound-related pain.

The dual role of cannabidiol on monocyte-derived dendritic cell differentiation and maturation

Introduction

Extracts and compounds isolated from hemp (Cannabis sativa) are increasingly gaining popularity in the treatment of a number of diseases, with topical formulations for dermatological conditions leading the way. Phytocannabinoids such as ( )-cannabidiol, ( )-cannabinol and ( )-Δ9-tetrahydrocannabivarin (CBD, CBN, and THCV, respectively), are present in variable amounts in the plant, and have been shown to have mostly anti-inflammatory effects both in vitro and in vivo, albeit dominantly in murine models. The role of phytocannabinoids in regulating responses of dendritic cells (DCs) remains unclear.

Methods

Our research aimed to investigate the effects of CBD, CBN, and THCV on human DCs differentiated from monocytes (moDCs). moDCs were treated with up to 10 μM of each phytocannabinoid, and their effects on viability, differentiation, and maturation were assessed both alone, and in conjunction with TLR agonists. The effects of CBD on cytokine production, T cell activation and polarization as well as the transcriptome of moDCs was also determined.

Results

Phytocannabinoids did not influence the viability of moDCs up to 10 μM, and only CBD had effects on maturational markers of moDCs, and neither compound influenced LPS-induced activation at 10 μM. Since only CBD had measurable effects on moDCs, in our subsequent experiments we tested the effect only of that pCB. On moDCs differentiated in the presence of CBD subsequent activation by LPS induced a markedly different, much more tolerogenic response. CBD-treated moDCs also produced significantly more interleukin (IL)-6, TNFα and, importantly, IL-10 in response to LPS, which shows a shift toward anti-inflammatory signaling, as well as a more robust secretory response in general. To rule out the possibility that these effects of CBD are specific to TLR4 signaling, we determined the effect of CBD on TLR7/8-induced maturation as well, and saw similar, although less marked responses. CBD-treated moDCs were also less efficient at activating naïve T cells after LPS stimulation, further supporting the tolerogenic effect of this phytocannabinoid on moDCs. Reactome pathway analysis showed an inflammatory response to LPS in moDCs, and to a lesser extent to CBD as well. In contrast CBD-treated moDCs responded to LPS with a shift towards a more tolerogenic phenotype, as IL-10 signaling was the most prominently induced pathway in this group.

Discussion

Our results show that CBD achieves an anti-inflammatory effect on adaptive immune responses only in the presence of an activating stimuli on moDCs by reprogramming cells during long-term treatment, and not through acute, short-term effects.

Topical Cannabidiol in the Treatment of Digital Ulcers in Patients with Scleroderma: Comparative Analysis and Literature Review

OBJECTIVE

To explore the effect of topical cannabidiol (CBD) in treating digital ulcers in patients with systemic sclerosis (SSc).

METHODS

In total, 45 patients with SSc who had digital ulcers were consecutively enrolled between January 2019 and December 2019. Of the participants, 25 were treated with CBD during surgical debridement and 20 were treated with standard local therapy. A numeric rating scale for pain and Health Assessment Questionnaire Disability Index were administered at the baseline and at the end of treatment.

RESULTS

Local treatment with CBD was significantly associated with lower pain scores, higher health assessment scores, and an increase in participants' total hours of sleep. Patients in the control group more frequently required additional analgesic therapy.

CONCLUSIONS

Topical CBD may be a valuable tool to treat pain related to digital ulcers in patients with SSc.

Cannabinoid Compounds as a Pharmacotherapeutic Option for the Treatment of Non-Cancer Skin Diseases

The endocannabinoid system has been shown to be involved in various skin functions, such as melanogenesis and the maintenance of redox balance in skin cells exposed to UV radiation, as well as barrier functions, sebaceous gland activity, wound healing and the skin's immune response. In addition to the potential use of cannabinoids in the treatment and prevention of skin cancer, cannabinoid compounds and derivatives are of interest as potential systemic and topical applications for the treatment of various inflammatory, fibrotic and pruritic skin conditions. In this context, cannabinoid compounds have been successfully tested as a therapeutic option for the treatment of androgenetic alopecia, atopic and seborrhoeic dermatitis, dermatomyositis, asteatotic and atopic eczema, uraemic pruritis, scalp psoriasis, systemic sclerosis and venous leg ulcers. This review provides an insight into the current literature on cannabinoid compounds as potential medicines for the treatment of skin diseases.

Opioid-sparing effect of cannabinoids for analgesia: an updated systematic review and meta-analysis of preclinical and clinical studies

Cannabinoid co-administration may enable reduced opioid doses for analgesia. This updated systematic review on the opioid-sparing effects of cannabinoids considered preclinical and clinical studies where the outcome was analgesia or opioid dose requirements. We searched Scopus, Cochrane Central Registry of Controlled Trials, Medline, and Embase (2016 onwards). Ninety-two studies met the search criteria including 15 ongoing trials. Meta-analysis of seven preclinical studies found the median effective dose (ED₅₀) of morphine administered with delta-9-tetrahydrocannabinol was 3.5 times lower (95% CI 2.04, 6.03) than the ED₅₀ of morphine alone. Six preclinical studies found no evidence of increased opioid abuse liability with cannabinoid administration. Of five healthy-volunteer experimental pain studies, two found increased pain, two found decreased pain and one found reduced pain bothersomeness with cannabinoid administration; three demonstrated that cannabinoid co-administration may increase opioid abuse liability. Three randomized controlled trials (RCTs) found no evidence of opioid-sparing effects of cannabinoids in acute pain. Meta-analysis of four RCTs in patients with cancer pain found no effect of cannabinoid administration on opioid dose (mean difference -3.8 mg, 95% CI -10.97, 3.37) or percentage change in pain scores (mean difference 1.84, 95% CI -2.05, 5.72); five studies found more adverse events with cannabinoids compared with placebo (risk ratio 1.13, 95% CI 1.03, 1.24). Of five controlled chronic non-cancer pain trials; one low-quality study with no control arm, and one single-dose study reported reduced pain scores with cannabinoids. Three RCTs found no treatment effect of dronabinol. Meta-analyses of observational studies found 39% reported opioid cessation (95% CI 0.15, 0.64, I² 95.5%, eight studies), and 85% reported reduction (95% CI 0.64, 0.99, I² 92.8%, seven studies). In summary, preclinical and observational studies demonstrate the potential opioid-sparing effects of cannabinoids in the context of analgesia, in contrast to higher-quality RCTs that did not provide evidence of opioid-sparing effects.

Evidence-based Potential Therapeutic Applications of Cannabinoids in Wound Management

BACKGROUND

Although wound management is a major component of all domains of healthcare, conventional therapeutics have numerous limitations. The endocannabinoid system of the skin, one of the major endogenous systems, has recently been connected to wound healing. Cannabinoids and their interactions with the endogenous chemical signaling system may be a promising therapeutic option because they address some of the fundamental pathways for physiologic derangement that underpin chronic integumentary wounds.

RECENT ADVANCES

The therapeutic applications of cannabinoids are increasing because of their legalization and resulting market expansion. Recently, their immunosuppressive and anti-inflammatory properties have been explored for the treatment of wounds that are not effectively managed by conventional medicines.

CRITICAL ISSUES

Failure to manage wounds effectively is associated with reduced quality of life, disability, mortality, and increased healthcare expenditures. Therapeutic options that can manage wounds effectively and efficiently are needed. In this review, the authors summarize recent advances on the use of cannabinoids to treat skin disorders with an emphasis on wound management.

FUTURE DIRECTIONS

Effective wound management requires medicines with good therapeutic outcomes and minimal adverse effects. Despite the promising results of cannabinoids in wound management, further controlled clinical studies are required to establish the definitive role of these compounds in the pathophysiology of wounds and their usefulness in the clinical setting.

Cannabinoids: Therapeutic Use in Clinical Practice

Medical case reports suggest that cannabinoids extracted from Cannabis sativa have therapeutic effects; however, the therapeutic employment is limited due to the psychotropic effect of its major component, Δ9-tetrahydrocannabinol (THC). The new scientific discoveries related to the endocannabinoid system, including new receptors, ligands, and mediators, allowed the development of new therapeutic targets for the treatment of several pathological disorders minimizing the undesirable psychotropic effects of some constituents of this plant. Today, FDA-approved drugs, such as nabiximols (a mixture of THC and non-psychoactive cannabidiol (CBD)), are employed in alleviating pain and spasticity in multiple sclerosis. Dronabinol and nabilone are used for the treatment of chemotherapy-induced nausea and vomiting in cancer patients. Dronabinol was approved for the treatment of anorexia in patients with AIDS (acquired immune deficiency syndrome). In this review, we highlighted the potential therapeutic efficacy of natural and synthetic cannabinoids and their clinical relevance in cancer, neurodegenerative and dermatological diseases, and viral infections.

Cannabinoids for the Treatment of Dermatologic Conditions

In recent years, cannabinoid (CB) products have gained popularity among the public. The anti-inflammatory properties of CBs have piqued the interest of researchers and clinicians because they represent promising avenues for the treatment of autoimmune and inflammatory skin disorders that may be refractory to conventional therapy. The objective of this study was to review the existing literature regarding CBs for dermatologic conditions. A primary literature search was conducted in October 2020, using the PubMed and Embase databases, for all articles published from 1965 to October 2020. Review articles, studies using animal models, and nondermatologic and pharmacologic studies were excluded. From 248 nonduplicated studies, 26 articles were included. There were 13 articles on systemic CBs and 14 reports on topical CBs. Selective CB receptor type 2 agonists were found to be effective in treating diffuse cutaneous systemic sclerosis and dermatomyositis. Dronabinol showed efficacy for trichotillomania. Sublingual cannabidiol and Δ-9-tetrahydrocannabinol were successful in treating the pain associated with epidermolysis bullosa. Available evidence suggests that CBs may be effective for the treatment of various inflammatory skin disorders. Although promising, additional research is necessary to evaluate efficacy and to determine dosing, safety, and long-term treatment guidelines.

Efficacy of topical cannabinoids in the management of pain: a systematic review and meta-analysis of animal studies

BACKGROUND/IMPORTANCE

Cannabinoids are emerging as an alternative pain management option, preliminarily supported by preclinical and clinical studies. Unwanted side effects from oral or inhaled cannabinoids remain, however, a major barrier to widespread use. Peripherally acting cannabinoids (eg, topically applied) may circumvent these side effects while providing localized pain management.

OBJECTIVE

Our purpose was to systematically review the literature on the effectiveness of peripherally acting cannabinoids for pain management.

EVIDENCE REVIEW

We searched MEDLINE, EMBASE, CENTRAL, CINAHL, and PubMed databases. Included studies examined the effect of topical/peripherally administered cannabinoids on pain ratings in humans, as well as pain-related outcomes in animals (eg, paw withdrawal). Due to a lack of trials, human studies were summarized in a narrative synthesis. Separate meta-analyses were performed for animal studies using radiant tail flick or paw withdrawal outcomes.

FINDINGS

Our search yielded 1182 studies following removal of duplicates, with 46 studies (6 human, 40 animal) included. Human studies (one randomized controlled trial and five case studies/series) reported no adverse events to topical cannabinoids and preliminary evidence of decreased pain ratings. Animal studies reporting tail flick (5) (2.81, 95% CI 1.93 to 3.69, p<0.001) and mechanical withdrawal (11) (2.74, 95% CI 1.82 to 3.67, p<0.001) reported prolonged responses (analgesia) in peripheral cannabinoid groups compared with controls.

CONCLUSIONS

Preclinical animal studies provided low-quality evidence for peripherally administered cannabinoids to provide regional, antinociceptive effects. The scarcity of high-quality human studies underscores the need to translate preclinical evidence into well-controlled human trials.

The Transdermal Delivery of Therapeutic Cannabinoids

Recently, several studies have indicated an increased interest in the scientific community regarding the application of Cannabis sativa plants, and their extracts, for medicinal purposes. This plant of enormous medicinal potential has been legalised in an increasing number of countries globally. Due to the recent changes in therapeutic and recreational legislation, cannabis and cannabinoids are now frequently permitted for use in clinical settings. However, with their highly lipophilic features and very low aqueous solubility, cannabinoids are prone to degradation, specifically in solution, as they are light-, temperature-, and auto-oxidation-sensitive. Thus, plant-derived cannabinoids have been developed for oral, nasal-inhalation, intranasal, mucosal (sublingual and buccal), transcutaneous (transdermal), local (topical), and parenteral deliveries. Among these administrations routes, topical and transdermal products usually have a higher bioavailability rate with a prolonged steady-state plasma concentration. Additionally, these administrations have the potential to eliminate the psychotropic impacts of the drug by its diffusion into a nonreactive, dead stratum corneum. This modality avoids oral administration and, thus, the first-pass metabolism, leading to constant cannabinoid plasma levels. This review article investigates the practicality of delivering therapeutic cannabinoids via skin in accordance with existing literature.

Cannabis and the Cancer Patient

Session 2 of the National Cancer Institute's Cannabis, Cannabinoids, and Cancer Research Workshop opened with testimony from a lymphoma survivor who detailed medicinal cannabis-related improvements in nausea, low appetite, insomnia, and mental health and the limited clinical counsel she received regarding cannabis use. Discussion next turned to the evolution of the legal landscape of cannabis in the United States, one in which state and federal laws frequently conflict and the Controlled Substance Act renders cannabis Schedule I. This legal climate creates conundrums for US medicinal cannabis researchers who contend with limited funding opportunities, avenues to source trial drug, and procedural red tape and for oncology clinicians who recommend medicinal cannabis to patients with some frequency while perceiving themselves as ill equipped to make such clinical recommendations. Ultimately, it creates challenges for cancer patients who find themselves turning to nonmedical and anecdotal information sources. The risks of cannabis use by the cancer patient were discussed next. These include infection, pharmacodynamic and pharmacokinetic drug-botanical interactions, cyclic nausea and vomiting, e-cigarette or vaping product use-associated illness, legal issues, and high cost. The session concluded with a broad survey of the research supporting oncologic cannabinoid use, conclusive evidence for chemotherapy-induced nausea and vomiting, and suggestive evidence for cancer-related pain.

Cannabis and the skin

The public and health care providers are increasingly curious about the potential medical benefits of Cannabis. In vitro and in vivo studies of Cannabis have suggested it has favorable effects on regulating pain, pruritus, and inflammation, making it a potentially attractive therapeutic agent for many dermatologic conditions. The body of literature reporting on the role of cannabinoids in dermatology is in its infancy but growing. We review the current research, possible cutaneous adverse effects, and future directions for cannabinoids and their use in skin cancer, acne, psoriasis, pruritus, dermatitis, scleroderma, dermatomyositis, cutaneous lupus erythematous, epidermolysis bullosa, pain, and wound healing.

Genetic deletion of the cannabinoid receptors CB1 and CB2 enhances inflammation with diverging effects on skin wound healing in mice

AIMS

Inflammation during wound healing is both essential and critical for restoring tissue integrity. Participating cells secrete soluble factors to regulate the inflammatory phase and to induce the adjacent regenerative processes. If pro-inflammatory signals are overexpressed, the wound stagnates in the inflammatory phase, which decelerates regular wound healing. The endocannabinoid system is ascribed great significance in maintenance of tissue homeostasis. It mediates several effects through the cannabinoid receptors CB1 and CB2.

MAIN METHODS

In order to clarify the role of these receptors in wound healing, excisional wounds were created on wildtype and CB1 and CB2 knockout mice. The wound closure was analyzed over a period of 14 days, and cytokine concentrations of tissue homogenisates were measured by ELISA. MSCs were isolated from the animals' subcutaneous adipose tissue and analyzed for viability and differentiation capacity, in vitro.

KEY FINDINGS

Deletion of CB2 increased Interleukin (IL)-6 and tumor necrosis factor (TNF)-α but did not affect tissue regeneration. In CB1-deficient animals, wound closure was delayed during early phases of healing, which was accompanied by increased concentrations of monocyte chemoattractant protein (MCP)-1 and TNF-α. CB1 and CB2 knockout MSCs presented altered viability and differentiation capacity compared to wildtype MSCs. The CB1-deficient MSCs released high levels of MCP-1 upon stimulation with TNF-α and IL-1β.

SIGNIFICANCE

The data indicate that both cannabinoid receptors regulate inflammation, and this study emphasizes the important role of CB1 in wound repair. Furthermore, our findings suggest that the secretome of CB1-deficient MSCs may contribute to the wound healing delay, in vivo.

Cannabis, a Miracle Drug with Polyvalent Therapeutic Utility: Preclinical and Clinical-Based Evidence

Cannabis sativa L. is an annual herbaceous dioecious plant which was first cultivated by agricultural human societies in Asia. Over the period of time, various parts of the plant like leaf, flower, and seed were used for recreational as well as therapeutic purposes. The main chemical components of Cannabis sativa are termed as cannabinoids, among them the key psychoactive constituent is Δ-9-tetrahydrocannabinol and cannabidiol (CBD) as active nonpsychotic constituent. Upon doing extensive literature review, it was found that cannabis has been widely studied for a number of disorders. Very recently, a pure CBD formulation, named Epidiolex, got a green flag from both United States Food and Drug Administration and Drug Enforcement Administration for 2 rare types of epilepsies. This laid a milestone in medical cannabis research. This review intends to give a basic and extensive assessment, from past till present, of the ethnological, plant, chemical, pharmacological, and legal aspects of C. sativa. Further, this review contemplates the evidence the studies obtained of cannabis components on Alzheimer's, Parkinson's, amyotrophic lateral sclerosis, multiple sclerosis, emesis, epilepsy, chronic pain, and cancer as a cytotoxic agent as well as a palliative therapy. The assessment in this study was done by reviewing in extensive details from studies on historical importance, ethnopharmacological aspects, and legal grounds of C. sativa from extensive literature available on the scientific databases, with a vision for elevating further pharmaceutical research to investigate its total potential as a therapeutic agent.

Scoping Review of Off-Label Topical Analgesia in Palliative, Hospice and Cancer Care: Towards Flexibility in Evidence-Based Medicine

PURPOSE

Scoping reviews address the nature of the literature per se rather than inferring evidence-based treatment guidelines. Scoping reviews of the published literature are intended to describe the aggregated nature of the evidence surrounding some agent or intervention, in contrast to systematic reviews that seek when possible to guide clinical practice. We conducted a scoping review to identify reports of potential clinical utility of off-label topical analgesics and adjuvants when FDA-approved treatments have proven inadequate.

METHODS

We performed a comprehensive search of three databases (PubMed, Web of Science and Embase) for articles dating from 1947 to the present. Mindful that FDA-approved and WHO-recommended analgesic medications often prove inadequate for individual patients in extremis with palliative, hospice or cancer pain, we used broad, structured inclusion criteria to retrieve articles.

RESULTS

We retrieved 12,100 articles; after screening, we had 39 reports addressing 19 different topical agents out of the 32 chemical entities. Our scoping review disclosed evidence about agents that might not have met inclusion criteria for clinical practice guidelines.

DISCUSSION

Although generally considered lower quality evidence, case reports or series present suggestions for diverse topical medications to manage pain in challenging circumstances when high-quality evidence for agents and routes of administration is lacking.

CONCLUSION

Patients with the greatest need for evidence to identify and guide lesser-used agents during aggressive pain management are the most difficult to enroll and follow in standardized, controlled and/or blinded clinical trials. This scoping review identifies medications, dosages, and routes of topical agents reported to be effective in these often-challenging circumstances. Until larger and higher quality studies are completed, we must rely on the best available evidence even if of lower quality.

Cannabinoid Formulations and Delivery Systems: Current and Future Options to Treat Pain

The field of Cannabis sativa L. research for medical purposes has been rapidly advancing in recent decades and a growing body of evidence suggests that phytocannabinoids are beneficial for a range of conditions. At the same time impressing development has been observed for formulations and delivery systems expanding the potential use of cannabinoids as an effective medical therapy. The objective of this review is to present the most recent results from pharmaceutical companies and research groups investigating methods to improve cannabinoid bioavailability and to clearly establish its therapeutic efficacy, dose ranges, safety and also improve the patient compliance. Particular focus is the application of cannabinoids in pain treatment, describing the principal cannabinoids employed, the most promising delivery systems for each administration routes and updating the clinical evaluations. To offer the reader a wider view, this review discusses the formulation starting from galenic preparation up to nanotechnology approaches, showing advantages, limits, requirements needed. Furthermore, the most recent clinical data and meta-analysis for cannabinoids used in different pain management are summarized, evaluating their real effectiveness, in order also to spare opioids and improve patients' quality of life. Promising evidence for pain treatments and for other important pathologies are also reviewed as likely future directions for cannabinoids formulations.

The Effectiveness of Cannabis and Cannabis Derivatives in Treating Lower Back Pain in the Aged Population: A Systematic Review

BACKGROUND/AIMS

Cannabis is increasingly used in the management of pain, though minimal research exists to support its use since approval. Reduction in stigma has led to a growing interest in pharmaceutical cannabinoids as a possible treatment for lower back pain (LBP). The objective of this review was to assess the role and efficacy of cannabis and its derivatives in the management of LBP and compile global data related to the role of cannabis in the management of LBP in an aging population.

METHODS

A systematic review was conducted using predetermined keywords by 3 independent researchers. Predetermined inclusion and exclusion criteria were applied, and 23 articles were selected for further analysis.

RESULTS

Studies identified both significant and insignificant impacts of cannabis on LBP. Contradicting evidence was noted on the role of cannabis in the management of anxiety and insomnia, 2 common comorbidities with LBP. The existing literature suggests that cannabis may be used in the management of LBP and comorbid symptoms.

CONCLUSIONS

Further research is needed to consider cannabis as an independent management option. There is a lack of evidence pertaining to the benefits of cannabis in an aged population, and thus, additional research is warranted to support its use in the aged population.

Delivering therapeutic cannabinoids via skin: Current state and future perspectives

Adequate evidence exists in the literature indicating a relatively positive shift with regards to the legal acceptance of cannabis and cannabis-derived products for medicinal purposes in some countries. Concomitantly, scientists are showing renewed interest in cannabis-related research work. Over the years, clinical and preclinical studies have demonstrated the therapeutic significance of cannabinoids for diverse indications. Additionally, efforts are being made to develop cannabis-related products into acceptable prescription products. FDA authorization for the commercial use of four cannabinoid-derived products, available as oral dosage forms is a significant progress already. However, there are certain drawbacks associated with the conventional delivery forms of cannabinoids. These include low oral bioavailability due to hepatic degradation, gastric instability, poor water solubility, and the side effects experienced upon the use of high doses of psychotropic cannabinoids associated with heightened plasma concentrations of the drug. These are however, limitable with the aid of transcutaneous drug delivery. Emerging topical and transdermal strategies could be exploited for the successful development of highly effective delivery systems for cannabinoids. This review discusses the feasibility of delivering therapeutic cannabinoids via skin and provides a comprehensive account of the supporting research studies that have been reported in the literature till date.

Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain

Background: Chronic non-cancer pain (CNCP) is estimated to affect 20% of the adult population. Current United States and Canadian Chronic non-cancer pain guidelines recommend careful reassessment of the risk-benefit ratio for doses greater than 90 mg morphine equivalent dose (MED), due to low evidence for improved pain efficacy at higher morphine equivalent dose and a significant increase in morbidity and mortality. There are a number of human studies demonstrating cannabis opioid synergy. This preliminary evidence suggests a potential role of cannabis as an adjunctive therapy with or without opioids to optimize pain control.

Methods: In 2017, the Canadian Opioid Guidelines Clinical Tool was created to encourage judicious opioid prescribing for CNCP patients and to reevaluate those who have been chronically using high MED. Mirroring this approach, we draw on our clinical experiences and available evidence to create a clinical tool to serve as a foundational clinical guideline for the initiation of medical cannabis in the management of CNCP patients using chronic opioid therapy.

Findings: Following principles of harm reduction and risk minimization, we suggest cannabis be introduced in appropriately selected CNCP patients, using a stepwise approach, with the intent of pain management optimization. We use a structured approach to focus on low dose cannabis (namely, THC) initiation, slow titration, dose optimization and frequent monitoring.

Conclusion: When low dose THC is introduced as an adjunctive therapy, we observe better pain control clinically with lower doses of opioids, improved pain related outcomes and reduced opioid related harm.

"Less pain with more gain"-Managing wound-related pain with cannabis-based medicines

Wound-related pain poses a serious challenge for patients and physicians. It is a complex pathophysiologic construct that may be stratified, from the patient's perspective, into baseline pain and breakthrough pain. The current paradigm for treating wound related pain involves the overuse of opioids and other co-analgesics with little regard for breakthrough pain. These standard medications have a propensity for deleterious side effects while some of them inhibit wound healing, effectively perpetuating the wound and the related pain. In particular, the overuse of opioids is a contributor to the global opioid crisis. It is evident that a new paradigm needs to be considered. Cannabis-based medicines are a prominent prospect under investigation for their potential to reduce dosages of status quo analgesics while effectively reducing pain. The authors propose a new paradigm that emphasizes the use of Cannabis-Based Medicines, delivered through multiple routes, while recommending the need for more foundational scientific investigation into mechanisms, and clinical controlled trials to determine optimal combinations, dosages, and protocols.

The therapeutic potential of cannabinoids for integumentary wound management

The increasing legalization of Cannabis for recreational and medicinal purposes in the United States has spurred renewed interest in the therapeutic potential of cannabinoids (CBs) for human disease. The skin has its own endocannabinoid system (eCS) which is a key regulator of various homeostatic processes, including those necessary for normal physiologic wound healing. Data on the use of CBs for wound healing are scarce. Compelling pre-clinical evidence supporting the therapeutic potential of CBs to improve wound healing by modulating key molecular pathways is herein reviewed. These findings merit further exploration in basic science, translational and clinical studies.

Analgesic efficacy of sufentanil in dressings after surgical treatment of burn wounds

BACKGROUND

The aim of this study was to assess the analgesic efficacy of sufentanil in dressings after surgical treatment of burn wounds.

PATIENTS AND METHODS

Twenty adult patients, who underwent surgical treatment of third-degree burn wounds under general anesthesia, were included. Two of the patients underwent surgery twice. During surgery, patients received 50-100 μg fentanyl every 20-30 min and, after surgery, patients received 100 mg ketoprofen twice daily. Additionally, ten patients (group 1) received 50 μg sufentanil added to the burn wound dressings soaked in octenidine and phenoxyethanol while 10 patients (group 2) received 25 μg sufentanil added to the same dressings. The rescue analgesic, which was administered when pain intensified, was 5 mg subcutaneous morphine. Plasma sufentanil concentrations were assayed at 1, 2, 3, and 6 h after surgery completion and when pain was reported, along with pain intensity evaluation.

RESULTS

Sufentanil was not detected in the serum of any patients. Rescue morphine was given during the postoperative period (24 h) in one patient in group 1 (who underwent surgery twice) and three patients in group 2. The mean sufentanil concentration in dressings was higher in group 1 (0.13 ± 0.03) than group 2 (0.06 ± 0.03 μg/mL; p < 0.001). The group 1 patient who received rescue morphine had a sufentanil concentration of 0.10 μg/mL, which was the lowest concentration in group 1. Group 2 patients who received rescue morphine had sufentanil concentrations of at least two-fold lower (0.03-0.05 μg/mL). No adverse effects were observed.

CONCLUSIONS

Sufentanil in dressings after burn wound surgery provides effective and safe analgesia and the sufentanil concentration in dressings should be ≥0.10 μg/mL in a solution of octenidine and phenoxyethanol.

Pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis that presents with rapidly developing, painful skin ulcers hallmarked by undermined borders and peripheral erythema. Epidemiological studies indicate that the average age of PG onset is in the mid-40s, with an incidence of a few cases per million person-years. PG is often associated with a variety of other immune-mediated diseases, most commonly inflammatory bowel disease and rheumatoid arthritis. The cause of PG is not well understood, but PG is generally considered an autoinflammatory disorder. Studies have focused on the role of T cells, especially at the wound margin; these cells may support the destructive autoinflammatory response by the innate immune system. PG is difficult to diagnose as several differential diagnoses are possible; in addition to clinical examination, laboratory tests of biopsied wound tissue are required for an accurate diagnosis, and new validated diagnostic criteria will facilitate the process. Treatment of PG typically starts with fast-acting immunosuppressive drugs (corticosteroids and/or cyclosporine) to reduce inflammation followed by the addition of more slowly acting immunosuppressive drugs with superior adverse event profiles, including biologics (in particular, anti-tumour necrosis factor (TNF) agents). Appropriate wound care is also essential. Future research should focus on PG-specific outcome measures and PG quality-of-life studies.

Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: An open label trial

Non-Uremic Calciphylaxis (NUC) is a rare condition that often manifests as intractable and painful integumentary wounds, afflicting patients with a high burden of co-morbidity. The Endocannabinoid System (ECS) is a ubiquitous signalling system that is theorised to be dysregulated within wound beds and associated peri-wound tissues. Preclinical research has shown that the dominant chemical classes derived from the cannabis plant, cannabinoids, terpenes, and flavonoids, interact with the integumentary ECS to promote wound closure and analgesia. This is a prospective open label cohort study involving two elderly Caucasian females with recalcitrant NUC leg ulcers of greater than 6 months duration. Topical Cannabis-Based Medicines (TCBM) composed of cannabinoids, terpenes, and flavonoids were applied daily to both the wound bed and peri-wound tissues until complete wound closure was achieved. Wounds were photographed regularly, and the digital images were subjected to planimetric analysis to objectively quantify the degree of granulation and epithelization. Analgesic utilisation, as a surrogate/proxy for pain scores, was also tracked. The cohort had a mean M3 multimorbidity index score of 3.31. Complete wound closure was achieved in a mean of 76.3 days. Additionally, no analgesics were required after a mean of 63 days. The treatments were well tolerated with no adverse reactions. The positive results demonstrated in very challenging wounds such as NUC, among highly complex patients, suggest that TCBM may have an even broader role within integumentary and wound management. This treatment paradigm warrants being trialled in other wound types and classes, and ultimately should be subjected to randomised controlled trials.

Mechanisms of Cannabinoids and Potential Applicability to Skin Diseases

The legalisation of cannabis in a growing number of jurisdictions has led to increasing interest in its potential therapeutic effects in a range of disorders, including cutaneous conditions. Cannabinoids have been used as natural medicines for centuries; however, their biological activity in the skin is a new area of study. Recent data suggest that cannabinoids are involved in neuro-immuno-endocrine modulation of skin functioning, yet their effect on the features of dermatologic conditions is unclear. This article sought to review the mechanisms by which cannabinoids regulate skin functioning through the lens of relevance to treatment of dermatologic diseases looking at the effects of cannabinoids on a range of cellular activities and dermatologic conditions both in vitro and in vivo. We identified studies demonstrating an inhibitory effect of cannabinoids on skin inflammation, proliferation, fibrosis, pain, and itch-biological mechanisms involved in the pathogenesis of many dermatologic conditions. Cannabinoids have the potential to expand the therapeutic repertoire of a wide spectrum of skin disorders. Given their widespread unregulated use by the general public, basic and clinical studies are required to elucidate the effectiveness and long-term effects of topical and systemic cannabinoids in cutaneous disorders.

Cannabis for the Treatment of Inflammatory Bowel Disease: A True Medicine or a False Promise?

Cannabis is the most widely used recreational drug worldwide and is used by some patients with inflammatory bowel disease (IBD) to ameliorate their disease. Whereas epidemiological studies indicate that as many as 15% of IBD patients use cannabis, studies inspecting cannabis use in IBD are few and small. We have conducted several studies looking at the use of cannabis in IBD. In Crohn's disease, we demonstrated that cannabis reduces the Crohn's disease activity index (CDAI) by >100 points (on a scale of 0-450).Two small studies in ulcerative colitis showed a marginal benefit. However, no improvement was observed in inflammatory markers or in endoscopic score in either disease. Many questions regarding cannabis use in IBD remain unanswered. For example, cannabis is a complex plant containing many ingredients, and the synergism or antagonism between them likely plays a role in the relative efficacy of various cannabis strains. The optimal doses and mode of consumption are not determined, and the most common form of consumption, i.e. smoking, is unacceptable for delivering medical treatment. Cannabis is a psychotropic drug, and the consequences of long-term use are unknown. Despite all these limitations, public opinion regards cannabis as a harmless drug with substantial medical efficacy. In Israel, the number of licenses issued for the medical use of cannabis is rising rapidly, as are the acknowledged indications for such use, but good-quality evidence for the effectiveness of cannabis is still lacking. Further studies investigating the medical use of cannabis are urgently needed.

Associations of PTSD, chronic pain, and their comorbidity on cannabis use disorder: Results from an American nationally representative study

BACKGROUND

Cannabis can be prescribed for posttraumatic stress disorder (PTSD) and chronic pain, and comorbid cannabis use disorder (CUD) can occur in both conditions. Research demonstrates that PTSD and chronic pain commonly co-occur.

METHODS

Data were acquired from the National Epidemiologic Survey on Alcohol and Related Conditions-III (N = 36,309). Past-year CUD and PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Past-year physician-confirmed chronic pain was self-reported and classified as musculoskeletal (e.g., arthritis), digestive (e.g., pancreatitis), and nerve (e.g., reflex sympathetic dystrophy) pain. Weighted cross-tabulations assessed sociodemographic, psychiatric, and chronic pain condition variables among those with PTSD versus no PTSD, among the entire sample and among those with CUD and chronic pain. Multiple logistic regressions examined the relationship between PTSD and chronic pain with CUD. CUD characteristics were also evaluated across PTSD and chronic pain groups.

RESULTS

Rates of CUD were elevated in PTSD (9.4%) compared to those without (2.2%). The odds of CUD were greater for PTSD+digestive pain, PTSD+nerve pain, and PTSD+any chronic pain compared to having neither PTSD nor chronic pain (odds ratio range: 1.88-2.32). PTSD with and without comorbid chronic pain was associated with overall elevated rates of adverse CUD characteristics, including earlier age of onset, greater usage, and greater CUD severity.

CONCLUSIONS

PTSD with and without chronic pain is associated with elevated rates and severity of CUD. These results may have implications for prescribing practices and understanding individuals at risk for developing CUD.

Cannabinoids: Potential Role in Inflammatory and Neoplastic Skin Diseases

The endocannabinoid system is a complex and nearly ubiquitous network of endogenous ligands, enzymes, and receptors that can also be stimulated by exogenous compounds such as those derived from the marijuana plant, Cannabis sativa. Recent data have shown that the endocannabinoid system is fully functional in the skin and is responsible for maintaining many aspects of skin homeostasis, such as proliferation, differentiation, and release of inflammatory mediators. Because of its role in regulating these key processes, the endocannabinoid system has been studied for its modulating effects on both inflammatory disorders of the skin and skin cancer. Although legal restrictions on marijuana as a Schedule I drug in the USA have made studying cannabinoid compounds unfavorable, an increasing number of studies and clinical trials have focused on the therapeutic uses of cannabinoids. This review seeks to summarize the current, and rapidly expanding field of research on the broad potential uses of cannabinoids in inflammatory and neoplastic diseases of the skin.

Cannabis and Its Secondary Metabolites: Their Use as Therapeutic Drugs, Toxicological Aspects, and Analytical Determination

Although the medicinal properties of Cannabis species have been known for centuries, the interest on its main active secondary metabolites as therapeutic alternatives for several pathologies has grown in recent years. This potential use has been a revolution worldwide concerning public health, production, use and sale of cannabis, and has led inclusively to legislation changes in some countries. The scientific advances and concerns of the scientific community have allowed a better understanding of cannabis derivatives as pharmacological options in several conditions, such as appetite stimulation, pain treatment, skin pathologies, anticonvulsant therapy, neurodegenerative diseases, and infectious diseases. However, there is some controversy regarding the legal and ethical implications of their use and routes of administration, also concerning the adverse health consequences and deaths attributed to marijuana consumption, and these represent some of the complexities associated with the use of these compounds as therapeutic drugs. This review comprehends the main secondary metabolites of Cannabis, approaching their therapeutic potential and applications, as well as their potential risks, in order to differentiate the consumption as recreational drugs. There will be also a focus on the analytical methodologies for their analysis, in order to aid health professionals and toxicologists in cases where these compounds are present.

Endocannabinoid System Components: Overview and Tissue Distribution

Marijuana/cannabinoid research has been transformed into mainstream science during the last half-century. Evidence based research and remarkable biotechnological advances demonstrate that phytocannabinoids and endocannabinoid (eCBs) acting on cannabinoid receptors (CBRs) regulate various aspects of human physiological, behavioral, immunological and metabolic functions. The distribution and function of the components of the endocannabinoid system (ECS) in the central nervous system (CNS) and immune processes have garnished significant research focus with major milestones. With these advances in biotechnology, rapid extension of the ECS research in the periphery has gained momentum. In this chapter, we review the components and tissue distribution of this previously unknown but ubiquitous and complex ECS that is involved in almost all aspects of mammalian physiology and pathology.

Pyoderma Gangrenosum: A Review for the Gastroenterologist

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease of unknown etiology often associated with systemic inflammatory conditions, most commonly inflammatory bowel disease (IBD). The most common presentation of PG is spontaneous rapid formation of an extremely painful ulcer on the extremities, associated with significant morbidity and mortality. Rarely, PG can also occur as a chronic peristomal complication or as an acute postoperative complication of a surgical wound. The clinical course is unpredictable; it may not correlate with IBD activity and may even precede a diagnosis of IBD. Pyoderma gangrenosum is a diagnosis of exclusion. Treatment is challenging, often involving a variety of immunosuppressive therapies. This review aims to provide an update for the gastroenterologist on the pathogenesis, presentation, diagnosis, and management of PG, a rare complication of IBD.