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Maglaviceanu A, Peer M, Rockel J, Bonin RP, Fitzcharles MA, Ladha KS, Bhatia A, Leroux T, Kotra L, Kapoor M, Clarke H. The State of Synthetic Cannabinoid Medications for the Treatment of Pain. CNS Drugs 2024:10.1007/s40263-024-01098-9. [PMID: 38951463 DOI: 10.1007/s40263-024-01098-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 07/03/2024]
Abstract
Synthetic cannabinoids are compounds made in the laboratory to structurally and functionally mimic phytocannabinoids from the Cannabis sativa L. plant, including delta-9-tetrahydrocannabinol (THC). Synthetic cannabinoids (SCs) can signal via the classical endogenous cannabinoid system (ECS) and the greater endocannabidiome network, highlighting their signalling complexity and far-reaching effects. Dronabinol and nabilone, which mimic THC signalling, have been approved by the Food and Drug Administration (FDA) for treating nausea associated with cancer chemotherapy and/or acquired immunodeficiency syndrome (AIDS). However, there is ongoing interest in these two drugs as potential analgesics for a variety of other clinical conditions, including neuropathic pain, spasticity-related pain, and nociplastic pain syndromes including fibromyalgia, osteoarthritis, and postoperative pain, among others. In this review, we highlight the signalling mechanisms of FDA-approved synthetic cannabinoids, discuss key clinical trials that investigate their analgesic potential, and illustrate challenges faced when bringing synthetic cannabinoids to the clinic.
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Affiliation(s)
- Anca Maglaviceanu
- Division of Orthopaedics, Osteoarthritis Research Program, Schroeder Arthritis Institute, University Health Network, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Miki Peer
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, and Women's College Hospital, Toronto, ON, Canada
| | - Jason Rockel
- Division of Orthopaedics, Osteoarthritis Research Program, Schroeder Arthritis Institute, University Health Network, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
| | - Robert P Bonin
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- University of Toronto Centre for the Study of Pain, University of Toronto, Toronto, ON, Canada
| | - Mary-Ann Fitzcharles
- Department of Rheumatology, McGill University, Montreal, Canada
- Alan Edwards Pain Management Unit, McGill University, Montreal, Canada
| | - Karim S Ladha
- Department of Anesthesia, St. Michael's Hospital, Toronto, Canada
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Cannabinoid Therapeutics, University Health Network, Toronto, ON, Canada
| | - Anuj Bhatia
- Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, Toronto Western Hospital-University Health Network, Toronto, ON, Canada
- Centre for Cannabinoid Therapeutics, University Health Network, Toronto, ON, Canada
| | - Timothy Leroux
- Division of Orthopaedics, Osteoarthritis Research Program, Schroeder Arthritis Institute, University Health Network, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Lakshmi Kotra
- Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Pharmaceutical Sciences, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
- Centre for Cannabinoid Therapeutics, University Health Network, Toronto, ON, Canada
| | - Mohit Kapoor
- Division of Orthopaedics, Osteoarthritis Research Program, Schroeder Arthritis Institute, University Health Network, Toronto, Canada
- Krembil Research Institute, University Health Network, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Centre for Cannabinoid Therapeutics, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Hance Clarke
- Krembil Research Institute, University Health Network, Toronto, Canada.
- Department of Anesthesia, St. Michael's Hospital, Toronto, Canada.
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Centre for Cannabinoid Therapeutics, University Health Network, Toronto, ON, Canada.
- Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada.
- Transitional Pain Service, Pain Research Unit, Department of Anaesthesia and Pain Management, Toronto General Hospital, Toronto, ON, M5G 2C4, Canada.
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Pollak U, Avniel-Aran A, Binshtok AM, Bar-Yosef O, Bronicki RA, Checchia PA, Finkelstein Y. Exploring the Possible Role of Cannabinoids in Managing Post-cardiac Surgery Complications: A Narrative Review of Preclinical Evidence and a Call for Future Research Directions. J Cardiovasc Pharmacol 2024; 83:537-546. [PMID: 38498618 DOI: 10.1097/fjc.0000000000001560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Abstract
ABSTRACT Open-heart surgery with cardiopulmonary bypass often leads to complications including pain, systemic inflammation, and organ damage. Traditionally managed with opioids, these pain relief methods bring potential long-term risks, prompting the exploration of alternative treatments. The legalization of cannabis in various regions has reignited interest in cannabinoids, such as cannabidiol, known for their anti-inflammatory, analgesic, and neuroprotective properties. Historical and ongoing research acknowledges the endocannabinoid system's crucial role in managing physiological processes, suggesting that cannabinoids could offer therapeutic benefits in postsurgical recovery. Specifically, cannabidiol has shown promise in managing pain, moderating immune responses, and mitigating ischemia/reperfusion injury, underscoring its potential in postoperative care. However, the translation of these findings into clinical practice faces challenges, highlighting the need for extensive research to establish effective, safe cannabinoid-based therapies for patients undergoing open-heart surgery. This narrative review advocates for a balanced approach, considering both the therapeutic potential of cannabinoids and the complexities of their integration into clinical settings.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Adi Avniel-Aran
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander M Binshtok
- Department of Medical Neurobiology, Institute for Medical Research Israel-Canada, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Omer Bar-Yosef
- Pediatric Neurology and Child Development, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronald A Bronicki
- Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX
- Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX
| | - Paul A Checchia
- Department of Pediatrics, Critical Care Medicine and Cardiology, Baylor College of Medicine, Houston, TX
- Pediatric Cardiovascular Intensive Care Unit, Texas Children's Hospital, Houston, TX
| | - Yaron Finkelstein
- Division of Emergency Medicine, Faculty of Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; and
- Division of Clinical Pharmacology and Toxicology, Faculty of Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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3
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Karst M. Overview: Chronic Pain and Cannabis-Based Medicines. PHARMACOPSYCHIATRY 2024; 57:152-159. [PMID: 38198809 PMCID: PMC11076105 DOI: 10.1055/a-2231-6630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/07/2023] [Indexed: 01/12/2024]
Abstract
Chronic pain is primarily conceptualized as a disease in its own right when it is associated with emotional distress and functional impairment. Pathophysiologically, dysfunction of the cortico-mesolimbic connectome is of major importance, with overlapping signals in the nociceptive and stress systems. The endocannabinoid system plays an important role in the central processing of nociceptive signals and regulates the central stress response. Clinically, there is moderate evidence that cannabis-based medicines (CBM) can contribute to a significant reduction in pain, especially the associated pain affect, and improvement in physical function and sleep quality in a proportion of patients with chronic pain. The analgesic effect appears to be largely independent of the cause of pain. In this context, CBM preferentially regulates stress-associated pain processing.
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Affiliation(s)
- Matthias Karst
- Anesthesiology, Pain Clinic, Hannover Medical School, Hannover,
Germany
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Stone AL, Pham A, Osmundson SS, Pedowitz A, Kingsley PJ, Marnett LJ, Patel S, Wickersham N, Sorabella LL, Bruehl S. Interactions Between Endocannabinoid and Endogenous Opioid Systems Prospectively Influence Postoperative Opioid Use in Pregnant Patients Undergoing Cesarean Delivery. THE JOURNAL OF PAIN 2024:104548. [PMID: 38663651 DOI: 10.1016/j.jpain.2024.104548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 03/09/2024] [Accepted: 04/16/2024] [Indexed: 05/08/2024]
Abstract
Both endocannabinoid (EC) and endogenous opioid systems are involved in nociceptive processing and may work together synergistically based on preclinical models. This study evaluated the interactive effects of preoperative beta-endorphin concentrations (a key analgesic endogenous opioid) in cerebrospinal fluid (CSF) and ECs (CSF and plasma 2-arachidonoylglycerol [2-AG] and plasma anandamide [AEA]) on postoperative opioid use and pain intensity in a prospective cohort of n = 112 pregnant patients undergoing scheduled cesarean delivery. Maternal blood and CSF samples were collected preoperatively for beta-endorphin and EC assays. Patients completed measures of outpatient opioid use (number of tablets used and days of use) and average pain intensity at 2 weeks postoperatively. Results of general linear model analyses controlling for maternal age, BMI at time of delivery, and race revealed significant multiplicative interactions between EC and beta-endorphin concentrations on number of opioid tablets used (based on pill count), days of opioid use, and total milligram morphine equivalents used in the 2 week follow-up period. Elevated preoperative plasma and CSF 2-AG predicted reduced outpatient opioid analgesic use particularly for patients low in CSF beta-endorphin. Similar analyses for pain intensity at 2-week follow-up indicated a significant interaction (p<.02) characterized by higher preoperative beta-endorphin concentrations being associated with lower subsequent pain only for individuals with low preoperative plasma AEA concentrations. Further exploration of interactions between EC and endogenous opioid inhibitory systems as they influence responses to opioid analgesics in other clinical pain populations may help guide development of precision pain management approaches. PERSPECTIVE: In the postoperative setting of patients undergoing cesarean delivery, elevated endocannabinoids were linked to reduced outpatient opioid analgesic use in individuals who had low endogenous opioid concentrations in cerebrospinal fluid. Further exploration of interactions between these two inhibitory systems as they impact on responses to pain management interventions appears warranted.
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Affiliation(s)
- Amanda L Stone
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amelie Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Sarah S Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alex Pedowitz
- University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA
| | - Philip J Kingsley
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA; A.B. Hancock Memorial Laboratory for Cancer Research, Vanderbilt University, Nashville, TN
| | - Larry J Marnett
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - Sachin Patel
- Department of Psychiatry, Northwestern University School of Medicine, Chicago, IL, USA
| | - Nancy Wickersham
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Botea MO, Andereggen L, Urman RD, Luedi MM, Romero CS. Cannabinoids for Acute Pain Management: Approaches and Rationale. Curr Pain Headache Rep 2024:10.1007/s11916-024-01252-4. [PMID: 38607548 DOI: 10.1007/s11916-024-01252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
PURPOSE OF THE REVIEW Acute pain management remains a challenge and postoperative pain is often undermanaged despite many available treatment options, also including cannabinoids. RECENT FINDINGS In the light of the opioid epidemic, there has been growing interest in alternative care bundles for pain management, including cannabinoids as potential treatment to decrease opioid prescribing. Despite the lack of solid evidence on the efficacy of cannabinoids, their use among patients with pain, including those using opioids, is currently increasing. This use is supported by data suggesting that cannabinoids could potentially contribute to a better pain management and to a reduction in opioid doses while maintaining effective analgesia with minimum side effects. The scientific basis for supporting the use of cannabis is extensive, although it does not necessarily translate into relevant clinical outcomes. The use of cannabinoids in acute pain did not always consistently show statistically significant results in improving acute pain. Large randomized, controlled trials evaluating diverse cannabis extracts are needed in different clinical pain populations to determine safety and efficacy.
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Affiliation(s)
- Mihai O Botea
- Department of Anaesthesiology and Critical Care, Medicover Pelican Clinic Hospital, Oradea, Romania
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital of Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Richard D Urman
- Department of Anaesthesiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Markus M Luedi
- Department of Anaesthesiology, Rescue- and Pain Medicine, Cantonal Hospital of St, Gallen, St. Gallen, Switzerland.
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carolina S Romero
- Department of Anaesthesiology and Critical Care, Hospital General Universitario De Valencia, Valencia, Spain
- Research Methods Department, Universidad Europea de Valencia, Valencia, Spain
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Jessen MH, Petersen M, Leutscher PDC. Cannabis medicine for chronic pain. Ugeskr Laeger 2024; 186:V08230546. [PMID: 38708699 DOI: 10.61409/v08230546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
In the last decade, patients with chronic pain have expressed increasing interest in cannabis-derived products for adjuvant therapy when treatment is deemed refractory to conventional analgesics. At present, clinical evidence to support this treatment approach appears to be sparse. Not because clinical studies as such are lacking, but rather as a result of methodological bias in relation to study design, patient populations, and treatment protocols. In this review, research in cannabis medicine for relief of chronic pain is reviewed, mainly with reference to published meta-analytic studies.
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Affiliation(s)
- Mia Hovgaard Jessen
- Center for Klinisk Forskning, Regionshospital Nordjylland, Hjørring
- Klinisk Institut, Aalborg Universitet
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Zaman T, Bravata DM, Byers A, Krebs E, Leonard S, Austin C, Sandbrink F, Hasin DS, Keyhani S. A national study of clinical discussions about cannabis use among Veteran patients prescribed opioids. J Cannabis Res 2024; 6:12. [PMID: 38493111 PMCID: PMC10943860 DOI: 10.1186/s42238-024-00221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/15/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND The Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use. OBJECTIVE To determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use. DESIGN We identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts. SUBJECTS Twelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients. MAIN MEASURES The presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use. KEY RESULTS Among the 12,070 patients, 65.8% (N = 7,948) had a cannabis term, whereas 34.1% (N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64-0.82]. CONCLUSIONS One-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon.
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Affiliation(s)
- Tauheed Zaman
- Addiction Recovery and Treatments Services, San Francisco VA Health Care System, 4150 Clement Street, #116F, San Francisco VA Medical Center, San Francisco, CA, 94121, USA.
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA.
| | - Dawn M Bravata
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
- Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
- Regenstrief Institute, Indianapolis, IN, USA
| | - Amy Byers
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, CA, USA
- Medical Service, San Francisco VA Health Care System, San Francisco, USA
| | - Erin Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samuel Leonard
- Medical Service, San Francisco VA Health Care System, San Francisco, USA
| | - Charles Austin
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Friedhelm Sandbrink
- National Pain Management, Opioid Safety and Prescription Drug Monitoring Program, Veterans Health Administration, Washington, DC, USA
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Deborah S Hasin
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Salomeh Keyhani
- Medical Service, San Francisco VA Health Care System, San Francisco, USA
- Division of General Internal Medicine, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
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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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Osaghae I, Talluri R, Chido‐Amajuoyi OG, Tanco K, Shah DP, Pande M, Shete S. Awareness and interest in cannabis use for cancer management among cancer survivors. Cancer Med 2024; 13:e6902. [PMID: 38180296 PMCID: PMC10807618 DOI: 10.1002/cam4.6902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/16/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND We examined the awareness, interest, and information sources relating to cannabis use for cancer management (including management of cancer symptoms and treatment-related side effects) and determined factors associated with cancer survivors' awareness and interest in learning about cannabis use for cancer management. METHODS This was a cross-sectional study of adult cancer survivors (N = 1886) receiving treatment at a comprehensive cancer center. Weighted prevalence and multivariable logistic regression analyses were conducted. RESULTS Among cancer survivors, 88% were aware and 60% were interested in learning about cannabis use for cancer management. Common sources of information to learn about cannabis use for cancer management were cancer doctors/nurses (82%), other patients with cancer (27%), websites/blogs (26%), marijuana stores (20%), and family/friends (18%). The odds of being aware of cannabis use for cancer management was lower among male compared to female survivors (adjusted odds ratio [AOR]: 0.61; 95% confidence interval [CI]: 0.41-0.90), non-Hispanic Blacks compared to non-Hispanic Whites (AOR: 0.36; 95% CI: 0.21-0.62), and survivors who do not support the legalization of cannabis for medical use compared to those who do (AOR: 0.10; 95% CI: 0.04-0.23). On the other hand, the odds of being interested in cannabis use for cancer management was higher among non-Hispanic Blacks compared to non-Hispanic Whites (AOR: 1.65; 95% CI: 1.04-2.62), and among cancer survivors actively undergoing cancer treatment compared to patients on non-active treatment (AOR: 2.25; 95% CI: 1.74-2.91). CONCLUSION Awareness of cannabis use for cancer management is high within the cancer survivor population. Results indicated health care providers are leading information source and should receive continued medical education on cannabis-specific guidelines. Similarly, tailored educational interventions are needed to guide survivors on the benefits and risks of cannabis use for cancer management.
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Affiliation(s)
- Ikponmwosa Osaghae
- Department of EpidemiologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Division of Cancer Prevention and Population SciencesThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Rajesh Talluri
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of Data ScienceUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | | | - Kimberson Tanco
- Department of Palliative, Rehabilitation and Integrative MedicineThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Dimpy P. Shah
- Mays Cancer Center, UT Health San Antonio MD Anderson Cancer CenterSan AntonioTexasUSA
| | - Mala Pande
- Department of Gastroenterology, Hepatology and NutritionThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Sanjay Shete
- Department of EpidemiologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
- Division of Cancer Prevention and Population SciencesThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
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10
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Wardill HR, Wooley LT, Bellas OM, Cao K, Cross CB, van Dyk M, Kichenadasse G, Bowen JM, Zannettino ACW, Shakib S, Crawford GB, Boublik J, Davis MM, Smid SD, Price TJ. Supporting gut health with medicinal cannabis in people with advanced cancer: potential benefits and challenges. Br J Cancer 2024; 130:19-30. [PMID: 37884682 PMCID: PMC10781684 DOI: 10.1038/s41416-023-02466-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 10/08/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
The side effects of cancer therapy continue to cause significant health and cost burden to the patient, their friends and family, and governments. A major barrier in the way in which these side effects are managed is the highly siloed mentality that results in a fragmented approach to symptom control. Increasingly, it is appreciated that many symptoms are manifestations of common underlying pathobiology, with changes in the gastrointestinal environment a key driver for many symptom sequelae. Breakdown of the mucosal barrier (mucositis) is a common and early side effect of many anti-cancer agents, known to contribute (in part) to a range of highly burdensome symptoms such as diarrhoea, nausea, vomiting, infection, malnutrition, fatigue, depression, and insomnia. Here, we outline a rationale for how, based on its already documented effects on the gastrointestinal microenvironment, medicinal cannabis could be used to control mucositis and prevent the constellation of symptoms with which it is associated. We will provide a brief update on the current state of evidence on medicinal cannabis in cancer care and outline the potential benefits (and challenges) of using medicinal cannabis during active cancer therapy.
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Affiliation(s)
- Hannah R Wardill
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia.
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia.
| | - Luke T Wooley
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Olivia M Bellas
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Katrina Cao
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
- School of Public Health, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Courtney B Cross
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Supportive Oncology Research Group, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Madele van Dyk
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre/Flinders University, SA Health, Adelaide, SA, Australia
| | - Ganessan Kichenadasse
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre/Flinders University, SA Health, Adelaide, SA, Australia
- Northern Adelaide Local Health Network South Australia, SA Health, Adelaide, SA, Australia
| | - Joanne M Bowen
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Andrew C W Zannettino
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Sepehr Shakib
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Gregory B Crawford
- Northern Adelaide Local Health Network South Australia, SA Health, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | | | - Mellar M Davis
- The Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Scott D Smid
- The School of Biomedicine, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Timothy J Price
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
- Queen Elizabeth Hospital, Adelaide, SA, Australia
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11
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Osaghae I, Chido-Amajuoyi OG, Khalifa BAA, Talluri R, Shete S. Cannabis Use among Cancer Survivors: Use Pattern, Product Type, and Timing of Use. Cancers (Basel) 2023; 15:5822. [PMID: 38136367 PMCID: PMC10741826 DOI: 10.3390/cancers15245822] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023] Open
Abstract
Despite growing interest in the use of cannabis for the treatment of cancer-related symptoms, there are limited studies that have assessed the use pattern, type, and mode of delivery of cannabis products used by cancer survivors. This study describes the current state of the use pattern, product type, and mode of delivery of cannabis used by cancer survivors. This was a cross-sectional study of cancer survivors from 41 U.S. states who received treatment at the largest NCI-designated comprehensive cancer center. The weighted prevalence of the use patterns, product types, and modes of delivery of cannabis used by cancer survivors was estimated. A total of 1886 cancer survivors were included in the study, with 915 (48% [95% CI: 45-51]) reporting ever using cannabis. Of survivors who had ever used cannabis, 36% (95% CI: 33-40) were current users. Among survivors who reported cannabis use after diagnosis, 40% used cannabis during and after cancer treatment, 35% used cannabis during treatment, and 25% used cannabis after completing their cancer treatment. Additionally, 48% of survivors reported an increase in cannabis use since cancer diagnosis. The commonest types of cannabis products used by cancer survivors were dry leaf cannabis (71%), cannabidiol (CBD) oil (46%), and cannabis candy (40%). Moreover, cancer survivors frequently used baked goods (32%), creams and gels (21%), and tinctures (18%). Furthermore, among ever users, the predominant mode of use was cannabis inhalation/smoking (69%) compared to eating/drinking (59%). More so, the common mode of inhalation/smoking of cannabis products were rolled cannabis cigarettes (79%), pipes (36%), water pipes (34%), vaporizers or vapes (14%), and e-cigarette devices (14%). A substantial number of cancer survivors use cannabis during cancer treatment, with increased use following cancer diagnosis. The forms and modes of delivery of cannabis varied among survivors, with most survivors inhaling or smoking cannabis. There is a need to educate healthcare providers (HCPs) and survivors on current evidence of cannabis use and strengthen cannabis regulatory frameworks to optimize benefits and minimize adverse events from cannabis use during cancer treatment.
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Affiliation(s)
- Ikponmwosa Osaghae
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | | | - Banda A. A. Khalifa
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Rajesh Talluri
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Data Science, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Sanjay Shete
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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12
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Ho TJ, Lin CF, Chen JK, Kung YL, Wu LK, Chang Chien CY, Huang CP. Electroacupuncture attenuates inflammatory pain via peripheral cannabinoid receptor type 1 signaling pathway in mice. PLoS One 2023; 18:e0295432. [PMID: 38060514 PMCID: PMC10703209 DOI: 10.1371/journal.pone.0295432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Pain is strongly associated with neuro-immune activation. Thus, the emerging role of the endocannabinoid system in neuro-inflammation is important. Acupuncture has been used for over 2500 years and is widely accepted for the management of pain. Our study aimed to investigate the effects of electroacupuncture on the regulation of cannabinoid receptor type 1 within the peripheral nervous system. Inflammatory pain was induced by injecting Complete Freund's adjuvant to induce mechanical and thermal hyperalgesia. Electroacupuncture significantly attenuated the mechanical and thermal sensitivities, and AM251, a cannabinoid receptor type 1 antagonist, eliminated these effects. Dual immunofluorescence staining demonstrated that electroacupuncture elevated expression of cannabinoid receptor type 1, co-localized with Nav 1.8. Furthermore, electroacupuncture significantly reduced levels of Nav 1.8 and COX-2 by western blot analysis, but not vice versa as AM251 treatment. Our data indicate that electroacupuncture mediates antinociceptive effects through peripheral endocannabinoid system signaling pathway and provide evidence that electroacupuncture is beneficial for pain treatment.
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Affiliation(s)
- Tsung-Jung Ho
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Post‑Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Ching-Fang Lin
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Jhong-Kuei Chen
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- School of Post‑Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yen-Lun Kung
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Li-Kung Wu
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Chen-Ying Chang Chien
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
| | - Chun-Ping Huang
- Integration Center of Traditional Chinese and Modern Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
- Department of Chinese Medicine, Hualien Tzu Chi Hospital, Hualien, Taiwan
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13
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Slivicki RA, Wang JG, Nhat VTT, Kravitz AV, Creed MC, Gereau RW. Impact of Δ 9-Tetrahydrocannabinol and oxycodone co-administration on measures of antinociception, dependence, circadian activity, and reward in mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.04.569809. [PMID: 38105953 PMCID: PMC10723318 DOI: 10.1101/2023.12.04.569809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Oxycodone is commonly prescribed for moderate to severe pain disorders. While efficacious, long-term use can result in tolerance, physical dependence, and the development of opioid use disorder. Cannabis and its derivatives such as Δ9-Tetrahydrocannabinol (Δ9-THC) have been reported to enhance oxycodone analgesia in animal models and in humans. However, it remains unclear if Δ9-THC may facilitate unwanted aspects of oxycodone intake, such as tolerance, dependence, and reward at analgesic doses. This study sought to evaluate the impact of co-administration of Δ9-THC and oxycodone across behavioral measures related to antinociception, dependence, circadian activity, and reward in both male and female mice. Oxycodone and Δ9-THC produced dose-dependent antinociceptive effects in the hotplate assay that were similar between sexes. Repeated treatment (twice daily for 5 days) resulted in antinociceptive tolerance. Combination treatment of oxycodone and Δ9-THC produced a greater antinociceptive effect than either administered alone, and delayed the development of antinociceptive tolerance. Repeated treatment with oxycodone produced physical dependence and alterations in circadian activity, neither of which were exacerbated by co-treatment with Δ9-THC. Combination treatment of oxycodone and Δ9-THC produced CPP when co-administered at doses that did not produce preference when administered alone. These data indicate that Δ9-THC may facilitate oxycodone-induced antinociception without augmenting certain unwanted features of opioid intake (e.g. dependence, circadian rhythm alterations). However, our findings also indicate that Δ9-THC may facilitate rewarding properties of oxycodone at therapeutically relevant doses which warrant consideration when evaluating this combination for its potential therapeutic utility.
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Affiliation(s)
- Richard A. Slivicki
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
| | - Justin G. Wang
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
- Neuroscience Graduate Program, Division of Biology & Biomedical Sciences, Washington University, St. Louis, MO
| | - Vy Trinh Tran Nhat
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
| | - Alexxai V. Kravitz
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
- Department of Psychiatry, Washington University, St. Louis, MO
- Department of Neuroscience, Washington University, St. Louis, MO
| | - Meaghan C. Creed
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
- Department of Neuroscience, Washington University, St. Louis, MO
| | - Robert W. Gereau
- Washington University Pain Center and Department of Anesthesiology, Washington University, St. Louis, MO
- Department of Neuroscience, Washington University, St. Louis, MO
- Department of Biomedical Engineering, Washington University, St. Louis, MO
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14
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Diep C, Ladha KS. Reply to: 'Co-use of opioids with cannabis - evaluating risks and benefits'. Reg Anesth Pain Med 2023; 48:626-627. [PMID: 37263745 DOI: 10.1136/rapm-2023-104626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Calvin Diep
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, Ontario, Canada
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15
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Canals PC, Aguilar AG, Carter GT, Shields CM, Westerkamp A, D'Elia M, Aldrich J, Moore RN, Moore AT, Piper BJ. Patient Reported Outcomes Using Medical Cannabis for Managing Pain in Charcot-Marie-Tooth Disease. Am J Hosp Palliat Care 2023; 40:1163-1167. [PMID: 36793224 DOI: 10.1177/10499091231158388] [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] [Indexed: 02/17/2023] Open
Abstract
Objective: Chronic pain is a major problem for patients with Charcot-Marie-Tooth (CMT) disease. This exploratory study examined patient reported efficacy of medical cannabis for pain management in this population. Methods: Participants (N = 56; 71.4% female; Age = 48.9, SD = 14.6; 48.5% CMT1) were recruited though the Hereditary Neuropathy Foundation. The online survey contained 52 multiple choice questions about demographics, medical cannabis use, symptomology, efficacy, and adverse effects. Results: Nearly all (90.9%) of respondents reported experiencing pain, including all (100%) females and 72.7% of males (chi-square P < .05) with 91.7% of respondents indicating cannabis provided at least 50% pain relief. The most frequent response was an 80% reduction in pain. Moreover, 80.0% of respondents reported using less opiates, 69% noted using less sleep medication, and 50.0% reported using less anxiety/antidepressant medications. Negative side effects were noted by 23.5% of respondents. However, almost all (91.7%) of that subgroup did not have plans to stop consuming cannabis. One-third (33.9%) possessed a medical cannabis certificate. Patient perceptions of their physicians' attitudes regarding patient medical cannabis use greatly impacted whether respondents informed their providers of their usage. Conclusion: The vast majority of patients with CMT reported that cannabis was effective to manage pain symptoms. These data support the need for prospective, randomized, controlled trials using standardized dosing protocols to further delineate and optimize the potential use of cannabis to treat pain related to CMT.
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Affiliation(s)
- Priscilla C Canals
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Alexia G Aguilar
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Gregory T Carter
- Providence St Luke's Rehabilitation Medical Center, Hereditary Neuropathy Foundation Center of Excellence, Spokane, WA, USA
| | | | | | | | - Joy Aldrich
- Hereditary Neuropathy Foundation, New York, NY, USA
| | | | | | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
- Center for Pharmacy Innovation and Outcomes, Precision Health Center, Forty Fort, PA, USA
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16
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Kitchen C, Kabba JA, Nelson EU, Adu-Gyamfi S, Ssekamatte T, Mametja M, Yang C, Chang J, Fang Y. Medicinal use of cannabis: A qualitative study of the perspectives of doctors and pharmacists from six African countries. J Ethn Subst Abuse 2023:1-25. [PMID: 37791493 DOI: 10.1080/15332640.2023.2259830] [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: 10/05/2023]
Abstract
We conducted a qualitative study to examine the enablers and barriers influencing the implementation of medical cannabis from the perspectives of practicing doctors and pharmacists within the African context. Interviews were conducted to investigate medical professionals' perceptions and concerns regarding medicinal cannabis. Three major themes were identified: beliefs about consequences, optimism, and environmental resources and context. Depending on the context of use, medical professionals described cannabis as potentially useful as an adjunct medicine and yet problematic owing to knowledge and social barriers, particularly religion. Implementation strategies tailored to address structural and social concerns to providing optimal care are needed to ensure that medical professionals are well versed in policy and clinical aspects.
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Affiliation(s)
- Chenai Kitchen
- Xi'an Jiaotong University, Xi'an, China
- Western Technological Innovation Harbour, Xi'an, China
| | - John Alimamy Kabba
- Xi'an Jiaotong University, Xi'an, China
- Western Technological Innovation Harbour, Xi'an, China
| | | | | | | | | | - Caijun Yang
- Xi'an Jiaotong University, Xi'an, China
- Western Technological Innovation Harbour, Xi'an, China
| | - Jie Chang
- Xi'an Jiaotong University, Xi'an, China
- Western Technological Innovation Harbour, Xi'an, China
| | - Yu Fang
- Xi'an Jiaotong University, Xi'an, China
- Western Technological Innovation Harbour, Xi'an, China
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17
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Hilker A. [Cannabis as medication]. MMW Fortschr Med 2023; 165:52-60. [PMID: 37857969 DOI: 10.1007/s15006-023-2980-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Angelika Hilker
- Privatärztliche Praxis, Kemnader Str.304, 44797, Bochum, Deutschland.
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18
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Campbell CM, Mun CJ, Hamilton KR, Bergeria CL, Huhn AS, Speed TJ, Vandrey R, Dunn KE. Within-subject, double-blind, randomized, placebo-controlled evaluation of combining the cannabinoid dronabinol and the opioid hydromorphone in adults with chronic pain. Neuropsychopharmacology 2023; 48:1630-1638. [PMID: 37202479 PMCID: PMC10516978 DOI: 10.1038/s41386-023-01597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/20/2023]
Abstract
The potential synergistic effects of combining cannabinoids and opioids for analgesia has received considerable attention. No studies to date have evaluated this combination in patients with chronic pain. The present study aimed to evaluate the combined analgesic and drug effects of oral opioid (hydromorphone) and delta-9-tetrahydrocannabinol (dronabinol), as well as their effects on physical and cognitive functioning, and human abuse potential (HAP) outcomes among individuals with knee osteoarthritis (KOA). This was a within-subject, double-blind, randomized, placebo-controlled study. Participants (N = 37; 65% women; mean age = 62) diagnosed with knee osteoarthritis of ≥3/10 average pain intensity were included. Participants received (1) placebo-placebo, (2) hydromorphone (4 mg)-placebo; (3) dronabinol (10 mg)-placebo, and (4) hydromorphone (4 mg)-dronabinol (10 mg). Clinical and experimentally-induced pain, physical and cognitive function, subjective drug effects, HAP, adverse events, and pharmacokinetics were evaluated. No significant analgesic effects were observed for clinical pain severity or physical functioning across all drug conditions. Little enhancement of hydromorphone analgesia by dronabinol was observed on evoked pain indices. While subjective drug effects and some HAP ratings were increased in the combined drug condition, these were not significantly increased over the dronabinol alone condition. No serious adverse events were reported; hydromorphone produced more mild adverse events than placebo, but hydromorphone + dronabinol produced more moderate adverse events than both placebo and hydromorphone alone. Only hydromorphone impaired cognitive performance. Consistent with laboratory studies on healthy adults, the present study shows minimal benefit of combining dronabinol (10 mg) and hydromorphone (4 mg) for analgesia and improving physical functioning in adults with KOA.
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Affiliation(s)
- Claudia M Campbell
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Chung Jung Mun
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Arizona State University, Edson College of Nursing and Health Innovation, Phoenix, AZ, USA
| | - Katrina R Hamilton
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cecilia L Bergeria
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew S Huhn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Traci J Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ryan Vandrey
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly E Dunn
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Christensen C, Rose M, Cornett C, Allesø M. Decoding the Postulated Entourage Effect of Medicinal Cannabis: What It Is and What It Isn't. Biomedicines 2023; 11:2323. [PMID: 37626819 PMCID: PMC10452568 DOI: 10.3390/biomedicines11082323] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
The 'entourage effect' term was originally coined in a pre-clinical study observing endogenous bio-inactive metabolites potentiating the activity of a bioactive endocannabinoid. As a hypothetical afterthought, this was proposed to hold general relevance to the usage of products based on Cannabis sativa L. The term was later juxtaposed to polypharmacy pertaining to full-spectrum medicinal Cannabis products exerting an overall higher effect than the single compounds. Since the emergence of the term, a discussion of its pharmacological foundation and relevance has been ongoing. Advocates suggest that the 'entourage effect' is the reason many patients experience an overall better effect from full-spectrum products. Critics state that the term is unfounded and used primarily for marketing purposes in the Cannabis industry. This scoping review aims to segregate the primary research claiming as well as disputing the existence of the 'entourage effect' from a pharmacological perspective. The literature on this topic is in its infancy. Existing pre-clinical and clinical studies are in general based on simplistic methodologies and show contradictory findings, with the clinical data mostly relying on anecdotal and real-world evidence. We propose that the 'entourage effect' is explained by traditional pharmacological terms pertaining to other plant-based medicinal products and polypharmacy in general (e.g., synergistic interactions and bioenhancement).
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Affiliation(s)
- Catalina Christensen
- Tetra Pharm Technologies ApS, Rugmarken 10, DK-3650 Ølstykke, Denmark; (M.R.); (M.A.)
| | - Martin Rose
- Tetra Pharm Technologies ApS, Rugmarken 10, DK-3650 Ølstykke, Denmark; (M.R.); (M.A.)
| | - Claus Cornett
- Department of Pharmacy, University of Copenhagen, Universitetsparken 2, DK-2100 Copenhagen, Denmark;
| | - Morten Allesø
- Tetra Pharm Technologies ApS, Rugmarken 10, DK-3650 Ølstykke, Denmark; (M.R.); (M.A.)
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20
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Farkas DJ, Cooper ZD, Heydari LN, Hughes AC, Rawls SM, Ward SJ. Kratom Alkaloids, Cannabinoids, and Chronic Pain: Basis of Potential Utility and Role in Therapy. Cannabis Cannabinoid Res 2023. [PMID: 37466474 DOI: 10.1089/can.2023.0064] [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: 07/20/2023] Open
Abstract
Introduction: Chronic neuropathic pain is as a severe detriment to overall quality of life for millions of Americans. Current pharmacological treatment options for chronic neuropathic pain are generally limited in efficacy and may pose serious adverse effects such as risk of abuse, nausea, dizziness, and cardiovascular events. Therefore, many individuals have resorted to methods of pharmacological self-treatment. This narrative review summarizes the existing literature on the utilization of two novel approaches for the treatment of chronic pain, cannabinoid constituents of Cannabis sativa and alkaloid constituents of Mitragyna speciosa (kratom), and speculates on the potential therapeutic benefits of co-administration of these two classes of compounds. Methods: We conducted a narrative review summarizing the primary motivations for use of both kratom and cannabis products based on epidemiological data and summarize the pre-clinical evidence supporting the application of both kratom alkaloids and cannabinoids for the treatment of chronic pain. Data collection was performed using the PubMed electronic database. The following word combinations were used: kratom and cannabis, kratom and pain, cannabis and pain, kratom and chronic pain, and cannabis and chronic pain. Results: Epidemiological evidence reports that the self-treatment of pain is a primary motivator for use of both kratom and cannabinoid products among adult Americans. Further evidence shows that use of cannabinoid products may precede kratom use, and that a subset of individuals concurrently uses both kratom and cannabinoid products. Despite its growing popularity as a form of self-treatment of pain, there remains an immense gap in knowledge of the therapeutic efficacy of kratom alkaloids for chronic pain in comparison to that of cannabis-based products, with only three pre-clinical studies having been conducted to date. Conclusion: There is sufficient epidemiological evidence to suggest that both kratom and cannabis products are used to self-treat pain, and that some individuals actively use both drugs, which may produce potential additive or synergistic therapeutic benefits that have not yet been characterized. Given the lack of pre-clinical investigation into the potential therapeutic benefits of kratom alkaloids against forms of chronic pain, further research is warranted to better understand its application as a treatment alternative.
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Affiliation(s)
- Daniel J Farkas
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Ziva D Cooper
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
- UCLA Center for Cannabis and Cannabinoids, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, California, USA
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, California, USA
| | - Laila N Heydari
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Amanda C Hughes
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Scott M Rawls
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Department of Neural Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Sara Jane Ward
- Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Department of Neural Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
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21
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Creanga-Murariu I, Filipiuc LE, Cuciureanu M, Tamba BI, Alexa-Stratulat T. Should oncologists trust cannabinoids? Front Pharmacol 2023; 14:1211506. [PMID: 37521486 PMCID: PMC10373070 DOI: 10.3389/fphar.2023.1211506] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/03/2023] [Indexed: 08/01/2023] Open
Abstract
Cannabis enjoyed a "golden age" as a medicinal product in the late 19th, early 20th century, but the increased risk of overdose and abuse led to its criminalization. However, the 21st century have witnessed a resurgence of interest and a large body of literature regarding the benefits of cannabinoids have emerged. As legalization and decriminalization have spread around the world, cancer patients are increasingly interested in the potential utility of cannabinoids. Although eager to discuss cannabis use with their oncologist, patients often find them to be reluctant, mainly because clinicians are still not convinced by the existing evidence-based data to guide their treatment plans. Physicians should prescribe cannabis only if a careful explanation can be provided and follow up response evaluation ensured, making it mandatory for them to be up to date with the positive and also negative aspects of the cannabis in the case of cancer patients. Consequently, this article aims to bring some clarifications to clinicians regarding the sometimes-confusing various nomenclature under which this plant is mentioned, current legislation and the existing evidence (both preclinical and clinical) for the utility of cannabinoids in cancer patients, for either palliation of the associated symptoms or even the potential antitumor effects that cannabinoids may have.
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Affiliation(s)
- Ioana Creanga-Murariu
- Advanced Research and Development Center for Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- Oncology Department, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Leontina Elena Filipiuc
- Advanced Research and Development Center for Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Magda Cuciureanu
- Pharmacology Department, Clinical Pharmacology and Algesiology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
| | - Bogdan-Ionel Tamba
- Advanced Research and Development Center for Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
- Pharmacology Department, Clinical Pharmacology and Algesiology, “Grigore T. Popa” University of Medicine and Pharmacy, Iași, Romania
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22
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Gewandter JS, Edwards RR, Hill KP, Wasan AD, Hooker JE, Lape EC, Besharat S, Cowan P, Foll BL, Ditre JW, Freeman R. Cannabinoid Therapy: Attitudes and Experiences of People With Chronic Pain. Clin J Pain 2023; 39:249-258. [PMID: 36971412 PMCID: PMC10563515 DOI: 10.1097/ajp.0000000000001109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/06/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Clinical trials of cannabinoids for chronic pain have mixed and often inconclusive results. In contrast, many prospective observational studies show the analgesic effects of cannabinoids. This survey study aimed to examine the experiences/attitudes of individuals with chronic pain who are currently taking, have previously taken, or never taken cannabinoids for chronic pain to inform future research. METHODS This study is based on a cross-sectional, web-based survey of individuals with self-reported chronic pain. Participants were invited to participate through an email that was distributed to the listservs of patient advocacy groups and foundations that engage individuals with chronic pain. RESULTS Of the 969 respondents, 444 (46%) respondents reported currently taking, 213 (22%) previously taken, and 312 (32%) never taken cannabinoids for pain. Participants reported using cannabinoids to treat a wide variety of chronic pain conditions. Those currently taking cannabinoids (vs previously) more frequently reported: (1) large improvements from cannabinoids in all pain types, including particularly difficult-to-treat chronic overlapping pain conditions (eg, pelvic pain), (2) improvements in comorbid symptoms (eg, sleep), and (3) lower interference from side effects. Those currently taking cannabinoids reported more frequent and satisfactory communication with clinicians regarding cannabinoid use. Those never taken cannabinoids reported a lack of suggestion/approval of a clinician (40%), illegality (25%), and lack of FDA regulation (19%) as reasons for never trying cannabinoids. CONCLUSION These findings underscore the importance of conducting high-quality clinical trials that include diverse pain populations and clinically relevant outcomes that if successful, could support FDA approval of cannabinoid products. Clinicians could then prescribe and monitor these treatments similarly to other chronic pain medications.
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Affiliation(s)
- Jennifer S. Gewandter
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston, Massachusetts, USA
| | - Kevin P. Hill
- Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajay D. Wasan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julia E. Hooker
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Emma C. Lape
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Soroush Besharat
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | | | - Bernard Le Foll
- Department of Family and Community Medicine, University of Toronto, CA
- Addictions Division, Centre for Addiction and Mental Health, Toronto, CA
| | - Joseph W. Ditre
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Roy Freeman
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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23
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Rivera-Garcia MT, Rose RM, Wilson-Poe AR. High-CBD Cannabis Vapor Attenuates Opioid Reward and Partially Modulates Nociception in Female Rats. ADDICTION NEUROSCIENCE 2023; 5:100050. [PMID: 36937502 PMCID: PMC10019487 DOI: 10.1016/j.addicn.2022.100050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic pain patients report analgesic effects when using cannabidiol (CBD), a phytocannabinoid found in whole-plant cannabis extract (WPE). Several studies suggest that cannabis-derived products may serve as an analgesic adjunct or alternative to opioids, and importantly, CBD may also attenuate the abuse potential of opioids. Vaping is a popular route of administration among people who use cannabis, however both the therapeutic and hazardous effects of vaping are poorly characterized. Despite the fact that chronic pain is more prevalent in women, the ability of inhaled high-CBD WPE to relieve pain and reduce opioid reward has not been studied in females. Here, we present a comprehensive analysis of high-CBD WPE vapor inhalation in female rats. We found that WPE was modestly efficacious in reversing neuropathy-induced cold allodynia in rats with spared nerve injury (SNI). Chronic exposure to WPE did not affect lung cytoarchitecture or estrous cycle, and it did not induce cognitive impairment, social withdrawal or anxiolytic effects. WPE inhalation prevented morphine-induced conditioned place preference and reinstatement. Similarly, WPE exposure reduced fentanyl self-administration in rats with and without neuropathic pain. We also found that WPE vapor lacks of reinforcing effects compared to the standard excipient used in most vapor administration research. Combined, these results suggest that although high-CBD vapor has modest analgesic effects, it has a robust safety profile, no abuse potential, and it significantly reduces opioid reward in females. Clinical studies examining high-CBD WPE as an adjunct treatment during opioid use disorder are highly warranted.
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Affiliation(s)
- Maria T Rivera-Garcia
- RS Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, United States
| | - Rizelle Mae Rose
- RS Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, United States
| | - Adrianne R Wilson-Poe
- RS Dow Neurobiology Laboratories, Legacy Research Institute, Portland, OR, United States
- Integrative Physiology and Neuroscience, Washington State University
- Corresponding author. Adrianne R Wilson-Poe, Ph.D., 1225 NE 2nd Ave, suite 249, Portland, OR 97232, USA. Tel. (503) 413-1754, (A.R. Wilson-Poe)
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24
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Bapir L, Erridge S, Nicholas M, Pillai M, Dalavaye N, Holvey C, Coomber R, Hoare J, Khan S, Weatherall MW, Rucker JJ, Platt M, Sodergren MH. Comparing the effects of medical cannabis for chronic pain patients with and without co-morbid anxiety: A cohort study. Expert Rev Neurother 2023; 23:281-295. [PMID: 36803620 DOI: 10.1080/14737175.2023.2181696] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
INTRODUCTION There is growing evidence on the efficacy of cannabis-based medicinal products (CBMPs) for chronic pain (CP). Due to the interaction between CP and anxiety, and the potential impact of CBMPs on both anxiety and CP, this article aimed to compare the outcomes of CP patients with and without co-morbid anxiety following CBMP treatment. METHODS Participants were prospectively enrolled and categorized by baseline General Anxiety Disorder-7(GAD-7) scores, into 'no anxiety'(GAD-7 < 5) and 'anxiety'(GAD-7 ≥ 5) cohorts. Primary outcomes were changes in Brief Pain Inventory Short-Form, Short-form McGill Pain Questionnaire-2, Pain Visual Analogue Scale, Sleep Quality Scale (SQS), GAD-7 and EQ-5D-5L index values at 1, 3 and 6 months. RESULTS 1254 patients (anxiety = 711; no anxiety = 543) met inclusion criteria. Significant improvements in all primary outcomes were observed at all timepoints (p < 0.050), except GAD-7 in the no anxiety group(p > 0.050). The anxiety cohort reported greater improvements in EQ-5D-5L index values, SQS and GAD-7(p < 0.050), but there were no consistent differences in pain outcomes. CONCLUSION A potential association between CBMPs and improvements in pain and health-related quality of life (HRQoL) in CP patients was identified. Those with co-morbid anxiety reported greater improvements in HRQoL.
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Affiliation(s)
- Lara Bapir
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK
| | - Simon Erridge
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Medicine, Sapphire Medical Clinics, London, UK
| | - Martha Nicholas
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK
| | - Manaswini Pillai
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK
| | - Nishaanth Dalavaye
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK
| | - Carl Holvey
- Department of Medicine, Sapphire Medical Clinics, London, UK
| | - Ross Coomber
- Department of Medicine, Sapphire Medical Clinics, London, UK.,Department of Trauma and Orthopaedics, St. George's Hospital NHS Trust, London, UK
| | - Jonathan Hoare
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Medicine, Sapphire Medical Clinics, London, UK
| | - Shaheen Khan
- Department of Medicine, Sapphire Medical Clinics, London, UK.,Department of Palliative Care, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Mark W Weatherall
- Department of Medicine, Sapphire Medical Clinics, London, UK.,Department of Palliative Medicine, Buckinghamshire Healthcare NHS Trust, Amersham, UK
| | - James J Rucker
- Department of Medicine, Sapphire Medical Clinics, London, UK.,Department of Psychological Medicine, Kings College London, London, UK.,Centre for Affective Disorders, South London & Maudsley NHS Foundation Trust, London, UK
| | - Michael Platt
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Medicine, Sapphire Medical Clinics, London, UK
| | - Mikael H Sodergren
- Imperial College Medical Cannabis Research Group Department of Surgery and Cancer, Imperial College London, London, UK.,Department of Medicine, Sapphire Medical Clinics, London, UK
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25
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Nguyen T, Li Y, Greene D, Stancliff S, Quackenbush N. Changes in Prescribed Opioid Dosages Among Patients Receiving Medical Cannabis for Chronic Pain, New York State, 2017-2019. JAMA Netw Open 2023; 6:e2254573. [PMID: 36716026 PMCID: PMC9887491 DOI: 10.1001/jamanetworkopen.2022.54573] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
IMPORTANCE Patients with chronic pain often receive long-term opioid therapy (LOT), which places them at risk of opioid use disorder and overdose. This presents the need for alternative or companion treatments; however, few studies on the association of medical cannabis (MC) with reducing opioid dosages exist. OBJECTIVE To assess changes in opioid dosages among patients receiving MC for longer duration compared with shorter duration. DESIGN, SETTING, AND PARTICIPANTS This cohort study of New York State Prescription Monitoring Program data from 2017 to 2019 included patients receiving MC for chronic pain while also receiving opioid treatment. Of these, patients receiving LOT prior to receiving MC were selected. Individuals were studied for 8 months after starting MC. Data were analyzed from November 2021 to February 2022. EXPOSURES Selected patients were divided into 2 groups based on the duration of receiving MC: the nonexposure group received MC for 30 days or fewer, and the exposure group received MC for more than 30 days. MAIN OUTCOMES AND MEASURES The main outcome was opioid dosage, measured by mean daily morphine milligram equivalent (MME). Analyses were conducted for 3 strata by opioid dosage prior to receiving MC: MME less than 50, MME of 50 to less than 90, and MME of 90 or greater. RESULTS A total of 8165 patients were included, with 4041 (median [IQR] age, 57 [47-65] years; 2376 [58.8%] female) in the exposure group and 4124 (median [IQR] age, 54 (44-62) years; 2370 [57.5%] female) in the nonexposure group. Median (IQR) baseline MMEs for the exposure vs nonexposure groups were 30.0 (20.0-40.0) vs 30.0 (20.0-40.0) in the lowest stratum, 60.0 (60.0-70.0) vs 60.0 (60.0-90.0) in the middle stratum, and 150.0 (100.0-216.2) vs 135.0 (100.0-218.0) in the highest stratum. During follow-up, significantly greater reductions in opioid dosage were observed among the exposure group. A dose-response association of patients' opioid dosage at baseline was observed with the differences in the monthly MME reductions between exposure and nonexposure groups, with a difference of -1.52 (95% CI, -1.67 to -1.37) MME for the lowest stratum, -3.24 (95% CI, -3.61 to -2.87) MME for the middle stratum, and -9.33 (95% CI, -9.89 to -8.77) MME for the highest stratum. The daily MME for the last month of the follow-up period among patients receiving longer MC was reduced by 48% in the lowest stratum, 47% in the middle stratum, and 51% in the highest stratum compared with the baseline dosages. Among individuals in the nonexposure group, daily MME was reduced by only 4% in the lowest stratum, 9% in the middle stratum, and 14% in the highest stratum. CONCLUSIONS AND RELEVANCE In this cohort study of patients receiving LOT, receiving MC for a longer duration was associated with reductions in opioid dosages, which may lower their risk of opioid-related morbidity and mortality.
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Affiliation(s)
- Trang Nguyen
- New York State Department of Health, Albany
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York
| | - Yunshu Li
- New York State Department of Health, Albany
- Department of Epidemiology and Biostatistics, University at Albany School of Public Health, Rensselaer, New York
| | - Danielle Greene
- City University of New York Graduate School of Public Health and Health Policy, New York, New York
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26
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Clinical Research Evidence Supporting Administration and Dosing Recommendations of Medicinal Cannabis as Analgesic in Cancer Patients. J Clin Med 2022; 12:jcm12010307. [PMID: 36615107 PMCID: PMC9821014 DOI: 10.3390/jcm12010307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023] Open
Abstract
The analgesic potential of Cannabis sativa L.-based medicinal cannabis products for treatment of cancer associated chronic pains has gained increased interest in recent years. To ensure a controlled distribution of these products and investigate their therapeutic potential, several countries have established so-called pilot trials. Many doctors, however, are hesitant to prescribe medicinal cannabis primarily due to lack of research evidence regarding the products' efficacy, safety and thus questionable dosing guidelines. This review aims to elucidate clinical research supporting administration of medicinal cannabis in cancer patients for analgesic purposes. The cannabinoids' effects on the endocannabinoid system (ECS) and its implication in pain regulation is included to illustrate the complexity related to this research field. Published clinical studies on medicinal cannabis primarily consist of observational studies and only one pilot randomized controlled trial (RCT), where more RCTs exist on the cannabis-based product, Sativex® (GW Pharma Ltd., Cambridge, UK). The studies indicate analgesic potential, however non-significantly, for most patients and with acceptable safety profile. Summarizing, high-quality RCTs are scarce in this research field, and the limitations of the observational studies complicates interpretation of clinical outcomes. Despite discrepancy among the studies, they do show indications for administration and dosing regimens providing analgesic effects for some cancer patients.
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27
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Eichorn NL, Shult HT, Kracht KD, Berlau DJ. Making a joint decision: Cannabis as a potential substitute for opioids in obstetrics and gynecology. Best Pract Res Clin Obstet Gynaecol 2022; 85:59-67. [PMID: 35970747 DOI: 10.1016/j.bpobgyn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
There is a growing body of evidence that cannabis may be effective as an analgesic with potential to reduce opioid usage in chronic pain. This review synthesizes the available literature to elucidate the possible role that cannabis might play in reducing opioid use in gynecological disorders that may potentially lead to a recommendation of substituting opioids with cannabis. With reports of a decrease in opioid use after cannabis initiation, an opioid-sparing effect has been seen in gynecologic malignancies such as ovarian, uterine, endometrial, and cervical cancers, in addition to chronic pelvic pain (CPP). Though many studies have found an association between cannabis and various adverse maternal and neonatal outcomes, there is a lack of randomized controlled trials making it difficult to claim a directly causal relationship between cannabis and these adverse outcomes. Additionally, with increased use of cannabis during pregnancy, the evidence of possible benefits and risks to mothers and fetuses is examined.
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Affiliation(s)
- Nicole L Eichorn
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Hannah T Shult
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Kelsie D Kracht
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA
| | - Daniel J Berlau
- Departent of Pharmaceutical Sciences, Regis University School of Pharmacy, 3333 Regis Blvd. H-28, Denver, CO, 80221, USA.
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28
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Graham M, Martin J, Lucas C, Murnion B, Schneider J. Cannabidiol drug interaction considerations for prescribers and pharmacists. Expert Rev Clin Pharmacol 2022; 15:1383-1397. [DOI: 10.1080/17512433.2022.2142114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Myfanwy Graham
- Australian Centre for Cannabinoid Clinical and Research Excellence, Newcastle, New South Wales, Australia
- Centre for Drug Repurposing & Medicines Research, School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia
| | - Jennifer Martin
- Australian Centre for Cannabinoid Clinical and Research Excellence, Newcastle, New South Wales, Australia
- Centre for Drug Repurposing & Medicines Research, School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia
| | - Catherine Lucas
- Australian Centre for Cannabinoid Clinical and Research Excellence, Newcastle, New South Wales, Australia
- Centre for Drug Repurposing & Medicines Research, School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia
| | - Bridin Murnion
- Discipline of Addiction Medicine, University of Sydney, New South Wales, Australia
| | - Jennifer Schneider
- Australian Centre for Cannabinoid Clinical and Research Excellence, Newcastle, New South Wales, Australia
- Centre for Drug Repurposing & Medicines Research, School of Medicine and Public Health, The University of Newcastle, New South Wales, Australia
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29
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Roberts CJ, Hopp FA, Hogan QH, Dean C. Anandamide in the dorsal periaqueductal gray inhibits sensory input without a correlation to sympathoexcitation. NEUROBIOLOGY OF PAIN (CAMBRIDGE, MASS.) 2022; 12:100104. [PMID: 36531614 PMCID: PMC9755024 DOI: 10.1016/j.ynpai.2022.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/09/2022] [Accepted: 09/15/2022] [Indexed: 01/11/2023]
Abstract
There is growing literature supporting cannabinoids as a potential therapeutic for pain conditions. The development of chronic pain has been associated with reduced concentrations of the endogenous cannabinoid anandamide (AEA) in the midbrain dorsal periaqueductal gray (dPAG), and microinjections of synthetic cannabinoids into the dPAG are antinociceptive. Therefore, the goal of this study was to examine the role of the dPAG in cannabinoid-mediated sensory inhibition. Given that cannabinoids in the dPAG also elicit sympathoexcitation, a secondary goal was to assess coordination between sympathetic and antinociceptive responses. AEA was microinjected into the dPAG while recording single unit activity of wide dynamic range (WDR) dorsal horn neurons (DHNs) evoked by high intensity mechanical stimulation of the hindpaw, concurrently with renal sympathetic nerve activity (RSNA), in anesthetized male rats. AEA microinjected into the dPAG decreased evoked DHN activity (n = 24 units), for half of which AEA also elicited sympathoexcitation. AEA actions were mediated by cannabinoid 1 receptors as confirmed by local pretreatment with the cannabinoid receptor antagonist AM281. dPAG microinjection of the synaptic excitant DL-homocysteic acid (DLH) also decreased evoked DHN activity (n = 27 units), but in all cases this was accompanied by sympathoexcitation. Thus, sensory inhibition elicited from the dPAG is not exclusively linked with sympathoexcitation, suggesting discrete neuronal circuits. The rostrocaudal location of sites may affect evoked responses as AEA produced sensory inhibition without sympathetic effects at 86 % of caudal compared to 25 % of rostral sites, supporting anatomically distinct neurocircuits. These data indicate that spatially selective manipulation of cannabinoid signaling could provide analgesia without potentially harmful autonomic activation.
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Key Words
- AEA, N-arachidonylethanolamine, anandamide
- Antinociception
- CB1R, cannabinoid type one receptor
- CV, cardiovascular
- Cannabinoid
- DHN, dorsal horn neuron
- DLH, DL-homocysteic acid
- Dorsal horn
- FAAH, fatty acid amide hydrolase
- GPCR, G protein-coupled receptor
- IML, intermediolateral cell column
- MAP, mean arterial pressure
- NTS, nucleus tractus solitarius
- PAG, periaqueductal gray
- PPAR, peroxisome proliferator activated receptor
- RSNA, renal sympathetic nerve activity
- RVLM, rostral ventrolateral medulla
- RVMM, rostral ventromedial medulla
- Rat
- SIA, stress-induced analgesia
- SNS, sympathetic nervous system
- Sympathetic nervous system
- TRPV1, transient receptor potential vanilloid type 1
- WDR, wide dynamic range
- dPAG, dorsal periaqueductal gray
- vPAG, ventral periaqueductal gray
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Affiliation(s)
- Christopher J. Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
| | - Francis A. Hopp
- Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
| | - Quinn H. Hogan
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA
| | - Caron Dean
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA,Department of Anesthesiology, Zablocki Veterans Affairs Medical Center, Milwaukee, WI 53295, USA,Corresponding author at: Department of Anesthesiology, Research Service 151, Zablocki VA Medical Center, Milwaukee, WI 53295, USA.
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30
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Yu Y, Tsang QK, Jaramillo-Polanco J, Lomax AE, Vanner SJ, Reed DE. Cannabinoid 1 and mu-Opioid Receptor Agonists Synergistically Inhibit Abdominal Pain and Lack Side Effects in Mice. J Neurosci 2022; 42:6313-6324. [PMID: 35790401 PMCID: PMC9398536 DOI: 10.1523/jneurosci.0641-22.2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 05/26/2022] [Accepted: 06/27/2022] [Indexed: 11/21/2022] Open
Abstract
While effective in treating abdominal pain, opioids have significant side effects. Recent legalization of cannabis will likely promote use of cannabinoids as an adjunct or alternative to opioids, despite a lack of evidence. We aimed to investigate whether cannabinoids inhibit mouse colonic nociception, alone or in combination with opioids at low doses. Experiments were performed on C57BL/6 male and female mice. Visceral nociception was evaluated by measuring visceromotor responses (VMR), afferent nerve mechanosensitivity in flat-sheet colon preparations, and excitability of isolated DRG neurons. Blood oxygen saturation, locomotion, and defecation were measured to evaluate side effects. An agonist of cannabinoid 1 receptor (CB1R), arachidonyl-2'-chloroethylamide (ACEA), dose-dependently decreased VMR. ACEA and HU-210 (another CB1R agonist) also attenuated colonic afferent nerve mechanosensitivity. Additionally, HU-210 concentration-dependently decreased DRG neuron excitability, which was reversed by the CB1R antagonist AM-251. Conversely, cannabinoid 2 receptor (CB2R) agonists did not attenuate VMR, afferent nerve mechanosensitivity, or DRG neuron excitability. Combination of subanalgesic doses of CB1R and µ-opioid receptor agonists decreased VMR; importantly, this analgesic effect was preserved after 6 d of twice daily treatment. This combination also attenuated afferent nerve mechanosensitivity and DRG neuron excitability, which was inhibited by neuronal nitric oxide synthase and guanylate cyclase inhibitors. This combination avoided side effects (decreased oxygen saturation and colonic transit) caused by analgesic dose of morphine. Activation of CB1R, but not CB2R, decreased colonic nociception both alone and in synergy with µ-opioid receptor. Thus, CB1R agonists may enable opioid dose reduction and avoid opioid-related side effects.SIGNIFICANCE STATEMENT One of the most cited needs for patients with abdominal pain are safe and effective treatment options. The effectiveness of opioids in the management of abdominal pain is undermined by severe adverse side effects. Therefore, strategies to replace opioids or reduce the doses of opioids to suppress abdominal pain is needed. This study in mice demonstrates that cannabinoid 1 receptor (CB1R) agonists inhibit visceral sensation. Furthermore, a combination of subanalgesic doses of µ-opioid receptor agonist and CB1R agonist markedly reduce abdominal pain without causing the side effects of high-dose opioids. Thus, CB1R agonists, alone or in combination with low-dose opioids, may be a novel and safe treatment strategy for abdominal pain.
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Affiliation(s)
- Yang Yu
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Quentin K Tsang
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Josue Jaramillo-Polanco
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Alan E Lomax
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - Stephen J Vanner
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
| | - David E Reed
- Gastrointestinal Diseases Research Unit, Queen's University, Kingston, Ontario K7L 2V7, Canada
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