The perceived effects of marijuana on spinal cord injured males

Approaches to neuropathic amputation-related pain: narrative review of surgical, interventional, and medical treatments

BACKGROUND/IMPORTANCE

Neuropathic amputation-related pain can consist of phantom limb pain (PLP), residual limb pain (RLP), or a combination of both pathologies. Estimated of lifetime prevalence of pain and after amputation ranges between 8% and 72%.

OBJECTIVE

This narrative review aims to summarize the surgical and non-surgical treatment options for amputation-related neuropathic pain to aid in developing optimized multidisciplinary and multimodal treatment plans that leverage multidisciplinary care.

EVIDENCE REVIEW

A search of the English literature using the following keywords was performed: PLP, amputation pain, RLP. Abstract and full-text articles were evaluated for surgical treatments, medical management, regional anesthesia, peripheral block, neuromodulation, spinal cord stimulation, dorsal root ganglia, and peripheral nerve stimulation.

FINDINGS

The evidence supporting most if not all interventions for PLP are inconclusive and lack high certainty. Targeted muscle reinnervation and regional peripheral nerve interface are the leading surgical treatment options for reducing neuroma formation and reducing PLP. Non-surgical options include pharmaceutical therapy, regional interventional techniques and behavioral therapies that can benefit certain patients. There is a growing evidence that neuromodulation at the spinal cord or the dorsal root ganglia and/or peripheral nerves can be an adjuvant therapy for PLP.

CONCLUSIONS

Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.

Analyzing the Impact of Cannabinoids on the Treatment of Spinal Disorders

PURPOSE OF REVIEW

Cannabis is among the most used illicit substances globally, with medical applications, increased legalization, and shifting social attitudes leading to increased use in recent years. Cannabinoids are a group of psychoactive substances found within the cannabis plant, with the most common being Δ9-tetrahydrocannabinol and cannabidiol. Due to the high prevalence of use, it is increasingly important to evaluate the effects of cannabis and cannabinoids on spine patients, in both operative and nonoperative settings.

RECENT FINDINGS

Cannabis and cannabinoids may be effective in treating patients with chronic conditions such as back pain and spinal cord injuries. Longitudinal effects and implications on surgical outcomes and complications are poorly understood. High-quality, outcomes-focused research can inform approaches for clinicians to approach cannabis and cannabinoid use. Studies to elucidate the standardization of cannabis regimens can help develop guidelines for potential therapeutic applications. Cannabis and cannabinoids may be useful alternatives or additions for many spine patients, but future research is needed for recommendations to be determined. Our manuscript reviews the available literature regarding cannabis use and various spinal conditions, organizing our findings into the following narrative themes: (1) the management of chronic lower back pain, (2) perioperative outcomes, (3) cannabis use in general orthopaedic procedures, and (4) spinal cord injuries.

The Therapeutic Potential and Usage Patterns of Cannabinoids in People with Spinal Cord Injuries: A Systematic Review

BACKGROUND

People with spinal cord injuries (SCI) commonly experience pain and spasticity; limitations of current treatments have generated interest in cannabis as a possible therapy.

OBJECTIVES

We conducted this systematic review to: 1) examine usage patterns and reasons for cannabinoid use, and 2) determine the treatment efficacy and safety of cannabinoid use in people with SCI.

METHODS

PubMed, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature databases were queried for keywords related to SCI and cannabinoids.

RESULTS

7,232 studies were screened, and 34 were included in this systematic review. Though 26 studies addressed cannabinoid usage, only 8 investigated its therapeutic potential on outcomes such as pain and spasticity. The most common method of use was smoking. Relief of pain, spasticity and recreation were the most common reasons for use. A statistically significant reduction of pain and spasticity was observed with cannabinoid use in 83% and 100% of experimental studies, respectively. However, on examination of randomized control trials (RCTs) alone, effect sizes ranged from - 0.82 to 0.83 for pain and -0.95 to 0.09 for spasticity. Cannabinoid use was associated with fatigue and cognitive deficits.

CONCLUSION

Current evidence suggests that cannabinoids may reduce pain and spasticity in people with SCI, but its effect magnitude and clinical significance are unclear. Existing information is lacking on optimal dosage, method of use, composition and concentration of compounds. Long-term, double-blind, RCTs, assessing a wider range of outcomes should be conducted to further understand the effects of cannabinoid use in people with SCI.

Characteristics of Individuals with Spinal Cord Injury Who Use Cannabis for Therapeutic Purposes

Background: People with spinal cord injury (SCI) are accessing cannabis for therapeutic purposes (CTP), the use of which has been legalized in more than 20 states. In the past, illicit marijuana use had positive correlations with other health risk behaviors. It is not known whether access to CTP has shifted patterns of use and altered health outcomes. Objective: To describe the self-reported patterns of CTP use among individuals with SCI and correlations with health behaviors and health indicators. Method: Secondary analysis of data from a cross-sectional study involving community-dwelling individuals with chronic SCI and neurogenic bladder and bowel, at least 5 years post injury. Data were collected via structured interviews. Results: 92.2% of the current sample (n = 244) lived in states that, at the time of the study, permitted the use of CTP. 22.5% reported using CTP at least monthly to relieve pain (70.4%) and spasticity (46.3%). Of those 54 participants, 52.7% were daily users. Whereas 23.0% of non-CTP users endorsed having prescriptions for at least one opioid-based medication, 38.1% of CTP users did so, suggesting that CTP use does not mitigate opioid use. Users were more likely to be single and live alone, report more bladder complications, and perceive their psychosocial functioning as more compromised than non-users. Conclusion: A relatively large percentage of individuals with chronic SCI appear to use CTP on a regular basis. Results suggest that they may be more vulnerable to complications and to risk factors for substance use disorders in SCI, such as social isolation. Although the generalizability of these findings is limited by the sampling strategies and the eligibility criteria of the larger study, CTP use should be assessed and considered when planning health interventions.

Treatments for chronic pain in persons with spinal cord injury: A survey study

BACKGROUND/OBJECTIVE

To determine the degree and duration of pain relief provided by specific pain treatments used by individuals with spinal cord injury (SCI) who have chronic pain.

DESIGN

Postal survey.

SETTING

Community.

PARTICIPANTS

Participants were 117 individuals who had traumatic SCI, were 18 years of age or older, and reported a chronic pain problem.

MAIN OUTCOME MEASURES

Questions assessing current or past use of 26 different pain treatments, the amount of relief each treatment provided, and the length of time that any pain relief usually lasts.

RESULTS

The medications tried most often were nonsteroidal anti-inflammatory drugs (tried by 71%) and acetaminophen (tried by 70%); these medications were still being used by more than one half of the patients who had tried them. Opioids produced the greatest degree of pain relief on average (mean, 6.27 +/- 3.05 [SD] on a 0-10 scale, with 0 = no relief and 10 = complete relief) but were unlikely to be continued by those who tried them. Although 38% of respondents with pain had tried gabapentin, only 17% were still using it, and average pain relief was only moderate (mean, 3.32 +/- 3.03 on the 0-10 relief scale). Seventy-three percent of the respondents had tried at least 1 of 7 alternative pain treatments, and the most frequently tried were massage, marijuana, and acupuncture. The most relief was provided by massage (mean, 6.05 +/- 2.47] on the 0-10 relief scale) and marijuana (mean, 6.62 +/- 2.54 on the 0-10 relief scale). The relief from the various treatments, including most medications, tended to last only minutes or hours; however, pain relief from alternative treatments such as massage, acupuncture, and hypnosis was reported to last for days in 25% to 33% of those who tried these treatments.

CONCLUSIONS

Many patients are not finding adequate pain relief from commonly prescribed medications. Alternative therapies should be considered as additional treatment options in this population.

[Therapeutic use of cannabinoids in neurology]

This review gives insight into the potential therapeutical role of cannabinoids in neurology. Preclinical data are presented which could give a rationale for the clinical use of cannabinoids in the fields of multiple sclerosis, spasticity, epilepsy, movement disorders, and neuroprotection after traumatic head injury or ischemic stroke. Besides, clinical data (case reports, open-label and randomised controlled studies) dealing with the therapeutical use of cannabinoids in these fields are reported and discussed. At present, clinical data are insufficient to recommend the use of cannabinoids in any neurological disease as standard therapy. Several questions still have to be answered (which cannabinoid? which way of administration? stimulation of endogenous cannabinoids? separation between desired and undesired effects?), and controlled studies are still needed to clarify the potential therapeutical role of cannabinoids in neurology.

A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms

OBJECTIVES

To determine whether plant-derived cannabis medicinal extracts (CME) can alleviate neurogenic symptoms unresponsive to standard treatment, and to quantify adverse effects.

DESIGN

A consecutive series of double-blind, randomized, placebo-controlled single-patient cross-over trials with two-week treatment periods.

SETTING

Patients attended as outpatients, but took the CME at home.

SUBJECTS

Twenty-four patients with multiple sclerosis (18), spinal cord injury (4), brachial plexus damage (1), and limb amputation due to neurofibromatosis (1).

INTERVENTION

Whole-plant extracts of delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), 1:1 CBD:THC, or matched placebo were self-administered by sublingual spray at doses determined by titration against symptom relief or unwanted effects within the range of 2.5-120 mg/24 hours. Measures used: Patients recorded symptom, well-being and intoxication scores on a daily basis using visual analogue scales. At the end of each two-week period an observer rated severity and frequency of symptoms on numerical rating scales, administered standard measures of disability (Barthel Index), mood and cognition, and recorded adverse events.

RESULTS

Pain relief associated with both THC and CBD was significantly superior to placebo. Impaired bladder control, muscle spasms and spasticity were improved by CME in some patients with these symptoms. Three patients had transient hypotension and intoxication with rapid initial dosing of THC-containing CME.

CONCLUSIONS

Cannabis medicinal extracts can improve neurogenic symptoms unresponsive to standard treatments. Unwanted effects are predictable and generally well tolerated. Larger scale studies are warranted to confirm these findings.

Cannabinoids and multiple sclerosis

There is a growing amount of evidence to suggest that cannabis and individual cannabinoids may be effective in suppressing certain symptoms of multiple sclerosis and spinal cord injury, including spasticity and pain. Anecdotal evidence is to be found in newspaper reports and also in responses to questionnaires. Clinical evidence comes from trials, albeit with rather small numbers of patients. These trials have shown that cannabis, Delta(9)-tetrahydrocannabinol, and nabilone can produce objective and/or subjective relief from spasticity, pain, tremor, and nocturia in patients with multiple sclerosis (8 trials) or spinal cord injury (1 trial). The clinical evidence is supported by results from experiments with animal models of multiple sclerosis. Some of these experiments, performed with mice with chronic relapsing experimental allergic encephalomyelitis (CREAE), have provided strong evidence that cannabinoid-induced reductions in tremor and spasticity are mediated by cannabinoid receptors, both CB(1) and CB(2). Endocannabinoid concentrations are elevated in the brains and spinal cords of CREAE mice with spasticity, and in line with this observation, spasticity exhibited by CREAE mice can be ameliorated by inhibitors of endocannabinoid membrane transport or enzymic hydrolysis. Research is now needed to establish whether increased endocannabinoid production occurs in multiple sclerosis. Future research should also be directed at obtaining more conclusive evidence about the efficacy of cannabis or individual cannabinoids against the signs and symptoms of these disorders, at devising better modes of administration for cannabinoids and at exploring strategies that maximize separation between the sought-after therapeutic effects and the unwanted effects of these drugs.

[The pharmacology of cannabinoid derivatives: are there applications to treatment of pain?]

OBJECTIVE

To present the cannabinoid system together with recent findings on the pharmacology of these compounds in the treatment of pain.

DATA SOURCES

Search through Medline database of articles published in French and English since 1966. Also use of other publications such as books on cannabis.

STUDY SELECTION

All the relevant documents within the theme of this review were used.

DATA EXTRACTION

All the data linked to the present topic were searched.

DATA SYNTHESIS

Recent advances have dramatically increased our understanding of cannabinoid pharmacology. The psychoactive constituents of Cannabis sativa have been isolated, synthetic cannabinoids described and an endocannabinoid system identified, together with its component receptors and ligands. Strong laboratory evidence now underwrites anecdotal claims of cannabinoid analgesia in inflammatory and neuropathic pain. Sites of analgesic action have been identified in brain, spinal cord and the periphery, with the latter two presenting attractive targets for divorcing the analgesic and psychotrophic effects of cannabinoids. Clinical trials are now required, but are hindered by a paucity of cannabinoids of suitable bioavailability and therapeutic ratio.

CONCLUSION

The cannabinoid system is a major target in the treatment of pain and its therapeutic potential should be assessed in the near future by the performance of new clinical trials.

Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful

OBJECTIVE

The objective was to investigate, in two community samples of people with spinal cord injuries, the frequency of use of different pain treatments and the perceived helpfulness of these treatments.

DESIGN AND SETTING

A postal survey was conducted in the community.

PARTICIPANTS

The participants were 471 persons aged 18 years or older who had spinal cord injuries and pain. There were 2 separate samples (n = 308 and n = 163).

OUTCOME MEASURES

The pain treatments used, the helpfulness of these treatments, and the Chronic Pain Grade questionnaire answers were assessed.

RESULTS

Respondents reported multiple pain treatments (range of 0-14 and median of 4 in sample 1; range of 0-16 and median of 4 in sample 2). The most commonly reported treatments were oral medications and physical therapy. Medication types most commonly reported were nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids. The treatments rated as most helpful were opioid medications, physical therapy, and diazepam therapy, and those rated as least helpful were spinal cord stimulation, counseling or psychotherapy, administration of acetaminophen, and administration of amitriptyline. Alternative treatments reported as most helpful were massage therapy and use of marijuana. Acupuncture was tried by many but was rated as only moderately helpful.

CONCLUSIONS

This survey of two large samples of community-dwelling individuals with spinal cord injury-related chronic pain indicates that multiple pain treatments are tried but only a few are rated as more than somewhat helpful. Furthermore, the treatments that are most commonly reported are not always those that are rated as most helpful. The findings point to a number of potentially fruitful directions for future research.

Pharmacological actions and therapeutic uses of cannabis and cannabinoids

This review highlights the pharmacology, pharmacokinetics, pharmacological actions, therapeutic uses and adverse effects of cannabinoids. The effect of cannabinoids on anaesthesia is mentioned briefly. Important advances have taken place in cannabinoid research over the last few years and have led to the discovery of novel ligands. The possible clinical applications of these ligands and the direction of future research are discussed.

The role of cannabinoids in neurodegenerative diseases

An understanding of the actions of Cannabis (Marijuana) has evolved from folklore to science over the previous hundred years. This progression was spurred by the discovery of an endogenous cannabinoid system consisting of two receptors and two endogenous ligands. This system appears to be intricately involved in normal physiology, specifically in the control of movement, formation of memories and appetite control. As we are developing an increased understanding of the physiological role of endocannabinoids it is becoming clear that they may be involved in the pathology of several neurological diseases. Furthermore an array of potential therapeutic targets is being determined--including specific cannabinoid agonists and antagonists as well as compounds that interrupt the synthesis, uptake or metabolism of the endocannabinoids. This article reviews the recent progress in understanding the contribution of endocannabinoids to the pathology and therapy of Huntington's disease. Parkinson's disease, schizophrenia and tremor.

Brain cannabinoid systems as targets for the therapy of neurological disorders

Unprecedented developments in cannabinoid research within the past decade include discovery of a brain (CB1) and peripheral (CB2) receptor; endogenous ligands, anandamide, and 2-arachidonylglycerol; cannabinoid drug-induced partial and inverse agonism at CB1 receptors, antagonism of NMDA receptors and glutamate, and antioxidant activity; and preferential CB1 receptor localization in areas subserving spasticity, pain, abnormal involuntary movements, seizures, and amnesia. These endogenous structures and chemicals and mechanisms are potentially new pathophysiologic substrates, and targets for novel cannabinoid treatments, of several neurological disorders.

Medicinal marijuana: a comprehensive review

Considerable controversy exists regarding the role of marijuana as a therapeutic agent; however, many practitioners are taught very little about existing marijuana data. The authors therefore undertook a comprehensive literature review of the topic. References were identified using textbooks, review and opinion articles, and a primary literature review in MEDLINE. Sources were included in this review based primarily on the quality of the data. Some data exists that lends credence to many of the claims about marijuana's properties. In general, however, the body of literature about marijuana is extremely poor in quality. Marijuana and/or its components may help alleviate suffering in patients with a variety of serious illnesses. Health care providers can best minimize short term adverse consequences and drug interactions for terminally ill patients by having a thorough understanding of the pharmacology of marijuana, potential adverse reactions, infection risks, and drug interactions (along with on-going monitoring of the patient). For chronic conditions, the significance and risk of short and long term adverse effects must be weighed against the desired benefit. Patients who are best suited to medicinal marijuana will be those who will gain substantial benefit to offset these risks, and who have failed a well-documented, compliant and comprehensive approach to standard therapies.

Delta-9-tetrahydrocannabinol shows antispastic and analgesic effects in a single case double-blind trial

A double-blind study was performed comparing 5 mg delta-9-tetrahydrocannabinol (THC) p.o., 50 mg codeine p.o., and placebo in a patient with spasticity and pain due to spinal cord injury. The three conditions were applied 18 times each in a randomized and balanced order. Delta-9-THC and codeine both had an analgesic effect in comparison with placebo. Only delta-9-THC showed a significant beneficial effect on spasticity. In the dosage of THC used no altered consciousness occurred.

Therapeutic issues of marijuana and THC (tetrahydrocannabinol)

This article summarizes current knowledge about the medicinal value of cannabis and its principal psychoactive ingredient, delta 9-tetrahydrocannabinol (THC), particularly in the control of nausea and vomiting, in glaucoma, and in reduction of spasticity in multiple sclerosis. The major issues in the controversy about marijuana and medicine, primarily moral and ethical, are discussed.