Use of Cannabis to Relieve Pain and Promote Sleep by Customers at an Adult Use Dispensary

The Effects of Stigma: Older Persons and Medicinal Cannabis

Cannabis has long been stigmatized as an illicit drug. Since legalization in Canada for both medical and recreational purposes, older adults' cannabis consumption has increased more than any other age group. Yet, it is unclear how the normalization of cannabis has impacted perceptions of stigma for older adults consuming cannabis medicinally. Qualitative description was used to elucidate the experiences of older Canadians aged 60+ related to stigma and their consumption of cannabis for medicinal purposes. Data collection involved semi-structured interviews. Data analysis examined how participants managed stigma related to cannabis use. Perceived stigma was evident in many participants' descriptions of their perceptions of cannabis in the past and present, and influenced how they accessed and consumed cannabis and their comfort in discussing its use with their healthcare providers. Participants employed several distinct strategies for managing stigma-concealing, re-framing, re-focusing, and proselytizing. Findings suggest that while medical cannabis consumption is becoming increasingly normalized among older adults, stigma related to cannabis persists and continues to shape older adults' experiences. A culture shift needs to occur among healthcare providers so that they are educated about cannabis and willing to discuss the possibilities of medicinal cannabis consumption with older adults. Otherwise, older adults may seek advice from recreational or other non-medical sources. Healthcare providers require education about the use of medical cannabis, so they can better advise older adults regarding its consumption for medicinal purposes.

Comparative feasibility and preliminary efficacy of CBT for insomnia among adults seeking and not seeking addiction treatment

Two out of three adults seeking treatment for alcohol or other substance use disorders report co-occurring symptoms of insomnia. This study compared the feasibility, acceptability, and preliminary efficacy of cognitive behavioural therapy for insomnia (CBT-I) among adults seeking and not seeking treatment for substance use. Adults with alcohol or other substance use disorders (n = 22, 32% female, 82% White; Mage  = 39.5) completed assessments at baseline, post-treatment, and at 6 week follow-up. Of those, 11 were and 11 were not enrolled in substance use treatment. All received CBT-I. Multiple imputation was used for missing data. Data were analysed using repeated measures analyses of variance. In the substance use treatment group, 6/11 completed post and 5/11 completed follow-up. In the non-treatment group, 9/11 completed post and 7/11 completed follow-up. Participants in both groups reported improvements in insomnia severity, sleep onset latency, and dysfunctional beliefs about sleep, with most effects evident at post and follow-up. There was a marginal group-by-time interaction in the change in frequency of substance use, with only participants not in substance use treatment reporting decreases at follow-up. Participants in substance use treatment reported significant reductions in substance-related problems and symptoms of post-traumatic stress disorder over time; however, they also reported more symptoms at baseline. CBT-I produces similar reductions in insomnia but is relatively less feasible among individuals in (versus not in) treatment for substance use disorder. This may be due to the more complex logistics of accessing CBT-I among those in treatment. We speculate that integrating CBT-I into treatment for addictions may improve feasibility in this population. clinicaltrials.gov NCT04198311.

Trends in U.S. Medical Cannabis Registrations, Authorizing Clinicians, and Reasons for Use From 2020 to 2022

BACKGROUND

As medical cannabis availability increases, up-to-date trends in medical cannabis licensure can inform clinical policy and care.

OBJECTIVE

To describe current trends in medical cannabis licensure in the United States.

DESIGN

Ecological study with repeated measures.

SETTING

Publicly available state registry data from 2020 to 2022.

PARTICIPANTS

People with medical cannabis licenses and clinicians authorizing cannabis licenses in the United States.

MEASUREMENTS

Total patient volume and prevalence per 10 000 persons in the total population, symptoms or conditions qualifying patients for licensure (that is, patient-reported qualifying conditions), and number of authorizing clinicians.

RESULTS

In 2022, of 39 jurisdictions allowing medical cannabis use, 34 reported patient numbers, 19 reported patient-reported qualifying conditions, and 29 reported authorizing clinician numbers. Enrolled patients increased 33.3% from 2020 (3 099 096) to 2022 (4 132 098), with a corresponding 23.0% increase in the population prevalence of patients (175.0 per 10 000 in 2020 to 215.2 per 10 000 in 2022). However, 13 of 15 jurisdictions with nonmedical adult-use laws had decreased enrollment from 2020 to 2022. The proportion of patient-reported qualifying conditions with substantial or conclusive evidence of therapeutic value decreased from 70.4% (2020) to 53.8% (2022). Chronic pain was the most common patient-reported qualifying condition in 2022 (48.4%), followed by anxiety (14.2%) and posttraumatic stress disorder (13.0%). In 2022, the United States had 29 500 authorizing clinicians (7.7 per 1000 patients), 53.5% of whom were physicians. The most common specialties reported were internal or family medicine (63.4%), physical medicine and rehabilitation (9.1%), and anesthesia or pain (7.9%).

LIMITATION

Missing data (for example, from California), descriptive analysis, lack of information on individual use patterns, and changing evidence base.

CONCLUSION

Enrollment in medical cannabis programs increased overall but generally decreased in jurisdictions with nonmedical adult-use laws. Use for conditions or symptoms without a strong evidence basis continues to increase. Given these trends, more research is needed to better understand the risks and benefits of medical cannabis.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse of the National Institutes of Health.

Use and co-use of alcohol and cannabis following physical pain in the daily life of community adults engaged in regular substance use

OBJECTIVE

Alcohol and cannabis are often perceived as pain-relieving. However, minimal work has examined whether people use and co-use these substances following pain in daily life.

METHOD

Forty-six adults reporting weekly use of alcohol and/or cannabis completed a 60-day ecological momentary assessment protocol, answering at least four daily reports on their alcohol and cannabis use and pain (nassessments = 10,769 over 2,656 days). We examined whether self-reported pain so far that day (cumulative-average pain) was associated with subsequent alcohol and cannabis use and same-occasion co-use. Models also addressed whether associations differed for initiating versus continuing a use episode. Hypotheses were preregistered.

RESULTS

A multinomial multilevel model found that cumulative-average pain was associated with a greater likelihood of same-occasion co-use in the continuation phase but not the initiation phase, compared to no use (OR = 1.48,95% CI [1.06, 2.06], p = .023) and alcohol use (OR = 1.52, CI [1.03, 2.26], p = .037). Cumulative-average pain was largely not associated with alcohol-only and cannabis-only use. After alcohol use, greater pain was associated with cannabis use (OR = 1.37, CI [1.11, 1.70], p = .004), but not the reverse. Secondary analyses found greater previous-occasion (not cumulative) pain was associated with initiation of alcohol use and number of drinks, and initiation and continuation of cannabis use, but not number of cannabis hits.

CONCLUSIONS

Although not all hypotheses were supported, pain was associated with subsequent substance use in this sample engaged in regular substance use and not recruited for chronic pain. Cumulative pain may be particularly related to alcohol-cannabis same-occasion co-use, which may increase the risk of substance use-related problems over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Thoughtfully Integrating Cannabis Products Into Chronic Pain Treatment

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

Cannabis use and sleep disturbances among White, Black, and Latino adults in the United States: A cross-sectional study of National Comorbidity Survey-Replication (2001-2003) data

OBJECTIVE

Research investigating cannabis use and sleep health is limited, and results are mixed. Few studies were nationally representative with racially-ethnically diverse samples or assessed potential modifiers. Our objective was to investigate cross-sectional associations between reported cannabis use and sleep disturbances by potential modifiers among non-Hispanic White, non-Hispanic Black, and Hispanic/Latino men and women in the United States.

METHODS

We used nationally representative National Comorbidity Survey-Replication data collected from 2001 to 2003 among 3929 adults. Poisson regression with robust variance estimated prevalence ratios (PR) and 95% confidence intervals of patterns of sleep disturbances identified through latent class analysis. Models adjusted for sociodemographic, health behavior, and clinical characteristics were stratified by race-ethnicity and by race-ethnicity along with sex/gender, and age, separately.

RESULTS

Over half of adults reported cannabis use (52%-ever/lifetime vs 48%-never). We identified two latent classes: multiple sleep disturbances with daytime sleepiness and no sleep disturbances with some daytime sleepiness. Prevalence of multiple sleep disturbances with daytime sleepiness was higher among participants reporting lifetime cannabis use (23% vs 20%). Associations did not vary by race-ethnicity or sex/gender. Lifetime vs never cannabis use was marginally associated with a higher prevalence of multiple sleep disturbances with daytime sleepiness only among adults aged 25-29years (PR=1.09 [95% confidence interval: 1.00-1.18]; eg, PRage 40+ years=1.00 [0.97-1.03], pinteraction=0.03).

CONCLUSIONS

Associations between cannabis use and sleep may vary by age. Replication with more recent data and prospective studies that investigate intersectional identities among diverse populations with objective assessments are warranted.

Cannabis dispensary staff approaches to counseling on potential contraindications to cannabis use: insights from a national self-report survey

BACKGROUND

Legal cannabis is available in more than half of the United States. Health care professionals (HCPs) rarely give recommendations on dosing or safety of cannabis due to limits imposed by policy and lack of knowledge. Customer-facing cannabis dispensary staff, including clinicians (pharmacists, nurses, physician's assistants), communicate these recommendations in the absence of HCP recommendations. Little is known about how dispensary staff approach individuals with complex medical and psychiatric comorbidities. Using responses from a national survey, we describe how cannabis dispensary staff counsel customers with medical and psychiatric comorbidities on cannabis use and examine whether state-specific cannabis policy is associated with advice given to customers.

METHODS

National, cross-sectional online survey study from February 13, 2020 to October 2, 2020 of dispensary staff at dispensaries that sell delta-9-tetrahydrocannabinol containing products. Measures include responses to survey questions about how they approach customers with medical and psychiatric comorbidities; state medicalization score (scale 0-100; higher score indicates more similarity to regulation of traditional pharmacies); legalized adult-use cannabis (yes/no). We conducted multiple mixed effects multivariable logistic regression analyses to understand relationships between state medicalization and dispensary employees' perspectives.

RESULTS

Of 434 eligible respondents, most were budtenders (40%) or managers (32%), and a minority were clinicians (18%). State medicalization score was not associated with responses to most survey questions. It was associated with increased odds of encouraging customers with medical comorbidities to inform their traditional HCP of cannabis use (Odds ratio [OR]=1.2, 95% confidence interval [CI] 1.0-1.4, p=0.03) and reduced odds of recommending cannabis for individuals with cannabis use disorder (CUD) (OR=0.8, 95% CI 0.7-1.0, p=0.04). Working in a state with legalized adult-use cannabis was associated with recommending traditional health care instead of cannabis in those with serious mental illness (OR 2.2, 95% CI 1.1-4.7, p=0.04). Less than half of respondents believed they had encountered CUD (49%), and over a quarter did not believe cannabis is addictive (26%).

CONCLUSIONS

When managing cannabis dosing and safety in customers with medical and psychiatric comorbidity, dispensary staff preferred involving individuals' traditional HCPs. Dispensary staff were skeptical of cannabis being addictive. While state regulations of dispensaries may impact the products individuals have access to, they were not associated with recommendations that dispensary staff gave to customers. Alternative explanations for dispensary recommendations may include regional or store-level variation not captured in this analysis.

Cannabis use for Sleep Disturbance Among Older Patients in a Geriatrics Clinic

Cannabis use is growing among older adults to manage medical concerns including poor sleep. In this study, we characterized how patients seen at a geriatrics clinic use cannabis to address sleep disturbance. Specifically, we conducted an anonymous survey of 568 adults, including 83 who reported cannabis use within the past 3 years, to inquire about such use. We compared cannabis use characteristics between those using it for sleep disturbance versus all other conditions. We considered a p-value <.10 to be statistically significant. Among the cannabis users in our sample, 29% reported using cannabis for sleep disturbance (N = 24). They were more likely than other users to be female (p = .07), consume cannabis more frequently (p = .01), use products containing tetrahydrocannabinol (THC) (vs. cannabidiol [CBD]-only; p < .01), and use cannabis to target more symptoms (p < .01). As cannabis use continues to grow in older populations, it is essential to delineate better how cannabis may be used safely and effectively to improve older adults' sleep health.

The Information-Seeking Behavior and Unmet Knowledge Needs of Older Medicinal Cannabis Consumers in Canada: A Qualitative Descriptive Study

INTRODUCTION

Older Canadians (age 60+) are increasingly using cannabis to treat their health problems, but little is known regarding how they learn about medicinal cannabis. This study explored the perspectives of older cannabis consumers, prospective consumers, healthcare professionals, and cannabis retailers on older adults' information-seeking behavior and unmet knowledge needs.

METHODS

A qualitative descriptive design was used. Semi-structured telephone interviews were conducted with a purposeful sample of 36 older cannabis consumers and prospective consumers, as well as 4 healthcare professionals and 5 cannabis retailers from across Canada, for a total sample of 45 participants. Data were thematically analyzed.

RESULTS

Three main themes characterizing older cannabis consumers' information-seeking were identified: (1) knowledge sources, (2) types of information sought, and (3) unmet knowledge needs. Participants accessed a variety of knowledge sources to inform themselves about medicinal cannabis. Cannabis retailers were identified as providing medical information to many older adults, despite regulations to the contrary. Cannabis-specialized healthcare professionals were also viewed as key knowledge sources, while primary care providers were perceived as both knowledge sources and gatekeepers limiting access to information. The types of information participants sought included the effects and potential benefits of medicinal cannabis, the side effects and risks involved, and guidance regarding suitable cannabis products. Participants' most salient unmet knowledge needs focused on dosing and use of cannabis to treat specific health conditions.

DISCUSSION

Findings suggest that barriers to learning about medical cannabis among older consumers identified in prior research remain pervasive and cut across jurisdictions. To address these barriers, there is a need for better knowledge products tailored to older cannabis consumers and their information needs, and further education for primary healthcare providers on medicinal cannabis and its therapeutic applications with older patients.

Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review

STUDY OBJECTIVES

To perform a qualitative scoping literature review for studies involving the effects of cannabis on sleep and sleep disorders.

METHODS

Two electronic databases, MEDLINE and EMBASE, searched for comprehensive published abstracted studies that involved human participants. Inclusion criteria were article of any type, published in English, a target population of cannabis users, and reported data on cannabis effect on sleep and sleep disorders. The Joanna Briggs Institute's (JBI) approach was elected as the methodology framework guidance in the scoping review process.

RESULTS

A total of 40 unique publications were found. The majority (82.5%) were from the Americas with 60% published in the last decade. Of the 40 studies, only 25% were randomized control trials, and the sleep outcome measurements were similar and comparable in only 20%. Cannabis users studied were reported either 73% frequent users or 27% sporadic users. The utilization of cannabis showed improved sleep (21%), worse sleep (48%), mixed results (14%), or no impact at all (17%) in the studies published in the last 5 decades.

CONCLUSIONS

Our findings summarize the lack of robust evidence to support the use of cannabis for sleep disorders. The varied cannabis user-related characteristics may account for the inconsistent results identified. Further studies assessing cannabis and sleep are needed to discern what works in what context, how it works, and for whom.

CITATION

Amaral C, Carvalho C, Scaranelo A, Chapman K, Chatkin J, Ferreira I. Cannabis and sleep disorders: not ready for prime time? A qualitative scoping review. J Clin Sleep Med. 2023;19(5):975-990.

Prenatal marijuana exposure and visual perception in toddlers: Evidence of a sensory processing deficit

Background

Research has identified a link between prenatal marijuana exposure and multiple outcomes in children, including cognitive development. Several studies have found specific differences in sensory processing and attention, with visual perception especially impacted in school age children. The current study explored whether this effect is evident at an earlier age, and thus our goal was to investigate the relationship between in-utero marijuana exposure and sensory processing capabilities in toddlers. We hypothesized that in-utero marijuana exposure throughout pregnancy would specifically predict visual sensory hyperactivity in children as young as 15 months of age.

Methods

Participants were 225 15-month-old children whose mothers were recruited during pregnancy. Substance exposure was prospectively collected and biochemically verified, with marijuana coded as no exposure, 1st trimester exposure only, or exposure throughout pregnancy. The Infant Toddler Sensory Profile evaluated 5 domains of sensory processing (visual, auditory, tactile, vestibular, oral).

Results

Prenatal marijuana exposure throughout pregnancy, but not when limited to the first trimester, predicted a two-fold increased likelihood of scoring in a range indicating high levels of seeking out and potentially over-attending to visual stimulation after controlling for potentially confounding factors including other prenatal exposures. Marijuana exposure was not significantly related to other processing domains.

Conclusion

Results indicate that links previously identified between prenatal marijuana exposure and visual function and attention may already be evident at 15 months of age, and also suggest an impact related to continuous/later pregnancy exposure. Our findings, as well as those from previous studies, all suggest visual processing differences for exposed children, differences that may predict emerging issues with visual attention and habituation. As legalization of marijuana continues to increase, further research is clearly needed to examine specific teratologic effects associated with use during pregnancy.

Medical Cannabis Use Patterns for Sleep Disorders in Australia: Results of the Cross-Sectional CAMS-20 Survey

Introduction

Sleep disorders are the third most common indication for the prescription of medical cannabis products in Australia, after pain and anxiety. While the use of cannabis for medical purposes is growing in Australia, underlying consumer behaviours and patterns of use, particularly around sleep disorders, are poorly understood.

Methods

We conducted a subanalysis of the cross-sectional "Cannabis as Medicine Survey" 2020-2021 (CAMS-20) (N = 1600), to explore the characteristics of a sample of Australians who were using prescribed and/or illicit medical cannabis to treat a self-reported sleep disorder.

Results

When asked to specify up to seven different conditions they were treating with medical cannabis, a total of 1030 (64%) respondents [mean (SD) 44.9 (13.6) years] selected a sleep disorder, with "insomnia disorder" (85.5%), 'sleep-related movement disorders' (26%) and 'sleep-related breathing disorders' (11.1%) the most common subtypes. Only 165 (16.8%) respondents selected a self-reported sleep disorder as the main health condition being treated. Relative to other health conditions, use of medical cannabis for a self-reported sleep disorder was associated with younger age, increased likelihood of using both prescribed and illicit forms of medical cannabis, inhaled routes of administration, and THC-dominant products. Most respondents reported a reduction in the use of benzodiazepines and alcohol since starting medical cannabis. Binary logistic regression showed that respondents who predominantly used inhaled routes of administration, and concomitant use of medical cannabis for pain, mental health and/or substance use disorder, or a gastrointestinal disorder, were significantly more likely to also use medical cannabis to treat a self-reported sleep disorder.

Conclusion

Overall, these results suggest that self-reported sleep disorders are often being treated with medical cannabis alongside other health conditions (often pain or a mental health disorder) and that use of inhaled methods, THC-dominant products, and illicit sources of medical cannabis are common among people with self-reported sleep disorders in Australia.

Cannabinoids in Late Life Parkinson's Disease and Dementia: Biological Pathways and Clinical Challenges

The use of cannabinoids as therapeutic drugs has increased among aging populations recently. Age-related changes in the endogenous cannabinoid system could influence the effects of therapies that target the cannabinoid system. At the preclinical level, cannabidiol (CBD) induces anti-amyloidogenic, antioxidative, anti-apoptotic, anti-inflammatory, and neuroprotective effects. These findings suggest a potential therapeutic role of cannabinoids to neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer. Emerging evidence suggests that CBD and tetrahydrocannabinol have neuroprotective therapeutic-like effects on dementias. In clinical practice, cannabinoids are being used off-label to relieve symptoms of PD and AD. In fact, patients are using cannabis compounds for the treatment of tremor, non-motor symptoms, anxiety, and sleep assistance in PD, and managing responsive behaviors of dementia such as agitation. However, strong evidence from clinical trials is scarce for most indications. Some clinicians consider cannabinoids an alternative for older adults bearing Parkinson's disease and Alzheimer's dementia with a poor response to first-line treatments. In our concept and experience, cannabinoids should never be considered a first-line treatment but could be regarded as an adjuvant therapy in specific situations commonly seen in clinical practice. To mitigate the risk of adverse events, the traditional dogma of geriatric medicine, starting with a low dose and proceeding with a slow titration regime, should also be employed with cannabinoids. In this review, we aimed to address preclinical evidence of cannabinoids in neurodegenerative disorders such as PD and AD and discuss potential off-label use of cannabinoids in clinical practice of these disorders.

Healthcare professionals' perspectives on the use of medicinal cannabis to manage chronic pain: A systematic search and narrative review

RATIONALE, AIMS, AND OBJECTIVES

Chronic pain is a global public health problem that negatively impacts individuals' quality of life and imposes a substantial economic burden on societies. The use of medicinal cannabis (MC) is often considered by patients to help manage chronic pain as an alternative or supplement to more conventional treatments, given enabling legalization in a number of countries. However, healthcare professionals involved in providing guidance for patients related to MC are often doing so in the absence of strong evidence and clinical guidelines. Therefore, it is crucial to understand their perspectives regarding the clinical use and relevance of MC for chronic pain. As little is known about attitudes of HCPs with regard to MC use for chronic pain specifically, the aim of this review was to identify and synthesize the published evidence on this topic.

METHODS

A systematic search was conducted across six databases: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, and PubMed from 2001 to March 26, 2021. Three authors independently performed the study selection and data extraction. Thematic analysis was undertaken to identify key themes.

RESULTS

A total of 26 studies were included, involving the United States, Israel, Canada, Australia, Ireland, and Norway, and the perspectives of physicians, nurses, and pharmacists. Seven key themes were identified: MC as a treatment option for chronic pain, and perceived indicated uses; willingness to prescribe MC; legal issues; low perceived knowledge and the need for education; comparative safety of MC versus opioids; addiction and abuse; and perceived adverse effects; CONCLUSION: To support best practice in the use of MC for chronic pain, healthcare professionals require education and training, as well as clinical guidelines that provide evidence-based information about efficacy, safety, and appropriate dosage of products for this indication. Until these gaps are addressed, healthcare professionals will be limited in their capacity to make treatment recommendations about MC for people/patients with chronic pain.

Prospective associations between sleep disturbances and cannabis use among Veterans: A behavioral economic approach

BACKGROUND

Veterans often use cannabis for sleep despite limited evidence of its efficacy. Moreover, how sleep disturbances impact cannabis use longitudinally is unclear. We applied a behavioral economic framework to examine whether sleep disturbances and cannabis demand (i.e., relative value) were related risk-factors for future cannabis use and problems.

METHODS

Veterans deployed post-9/11/2001 who reported past 6-month cannabis use at baseline (n = 126) completed surveys on their sleep disturbances, demand via the Marijuana Purchase Task (MPT), and cannabis use. Mediation analyses using Hayes' PROCESS Macro and zero-inflated negative binomial models tested indirect effects of baseline sleep disturbances on 12-month cannabis use frequency, quantity, and problems via 6-month cannabis demand (i.e., intensity, Omax, Pmax, and breakpoint).

RESULTS

Only Omax (i.e., maximum expenditure for cannabis) was a significant mediator for 12-month cannabis use quantity and problems when examined concurrently with other demand indices after controlling for covariates. Intensity (i.e., purchase at zero cost) was a significant mediator for 12-month cannabis use frequency when examined concurrently with other demand indices in models controlling for lifetime cannabis use, but not past 30-day use at baseline.

CONCLUSION

Cannabis demand, specifically intensity and Omax, may help to identify Veterans with sleep disturbances who are at increased risk for escalating their cannabis use. Subsequent research should assess the extent that sleep disturbances impact cannabis demand in the context of withdrawal, which will inform novel prevention and intervention strategies geared toward reducing negative cannabis-related outcomes among Veterans.

Online survey of medicinal cannabis users: Qualitative analysis of patient-level data

Aim: To characterize perceived benefits and challenges experienced by medicinal cannabis users.

Methods: An anonymous online survey collected demographics, health information, and open-ended responses from medicinal cannabis users regarding perceptions, motivations, and experience of treatment. Qualitative open-ended responses were thematically analyzed.

Results: Respondents (N = 808) were predominantly White (79%), female (63%), with a mean (SD) age of 38 (20). Two hundred eighty-four (35%) respondents provided data on a dependent family member (e.g., child; 22% of total sample). Most used cannabidiol (CBD)-dominant products (58%), primarily for neurological disorders (38%) or pain (25%). Primary motivations for medicinal cannabis use were based on beliefs that traditional treatments were ineffective and/or had intolerable side effects (51%), positive scientific or media portrayals of the safety/efficacy of cannabis as a therapeutic (29%), or preference for “natural” treatments over pharmaceuticals (21%). A majority of respondents (77%) attributed positive effects to the medicinal use of cannabis/cannabinoids. These included physical symptom improvements such as reduced pain (28%), improved sleep (18%), and seizure reduction (18%), and mental health improvements including reduced anxiety (22%) and improved mood (11%). Additionally, respondents reported reduced use of other medications (e.g., opioids) (12%), and improved quality of life (14%). Problems associated with use were cited by 41% of respondents, and included unwanted side effects (16%), lack of information or medical support (16%), prohibitive costs (12%), and legal concerns (10%).

Conclusion: Most participants reported benefits from cannabis use for a variety of conditions where traditional treatments were ineffective or unacceptable. Concerns regarding cannabis side effects, legality, lack of information, and cost were raised. Data indicate greater research and education on the safety and efficacy of medicinal cannabis/cannabinoid use is warranted.

Older adults experiences of using recreational cannabis for medicinal purposes following legalization

BACKGROUND AND OBJECTIVES

Legalization of recreational, or non-medical, cannabis in Canada in 2018 was followed by significant increase in use among older adults. Non-medical cannabis is often used medicinally in this population for issues such as pain, insomnia, and appetite stimulation. The purpose of this study was to explore new cannabis use among older adults within an evolving socio-legal context.

RESEARCH DESIGN AND METHODS

Normalization theory provided the theoretical foundation and qualitative description was the guiding methodology. A convenience sample of twelve participants (ten women, two men) aged 71 to 85 years old was recruited. Data were collected using semi-structured interviews and analyzed thematically.

RESULTS

Findings illustrate factors that influenced participants' beliefs and contributed to their decisions to begin using cannabis in later life. The most important factor was legalization, which sparked a shift in beliefs around using cannabis and shaped the beginning of de-stigmatization around using this substance. Increasing acceptance in their social networks and visibility of cannabis in the media also informed decision-making. However, using cannabis for non-medicinal or social reasons remained stigmatized.

DISCUSSION AND IMPLICATIONS

This research indicates that older adults' beliefs about cannabis use are shifting and this is likely related to legalization and broader social acceptance of cannabis. As a consequence, increased public health education is needed to improve health literacy about cannabis use during this stage of the life-course.

U.S. Trends in Registration for Medical Cannabis and Reasons for Use From 2016 to 2020 : An Observational Study

BACKGROUND

Cannabis policy liberalization has increased cannabis availability for medical or recreational purposes. Up-to-date trends in medical cannabis licensure can inform clinical policy and care.

OBJECTIVE

To describe recent trends in medical cannabis licensure in the United States.

DESIGN

Ecological study with repeated measures.

SETTING

State registry data via state reports and data requests on medical cannabis licensure from 2016 to 2020.

PARTICIPANTS

Medical cannabis patients (persons with medical cannabis licenses) in the United States.

MEASUREMENTS

Total patient volume, patients per 10 000 of total population, and patient-reported qualifying conditions (that is, symptoms or conditions qualifying patients for licensure)-including whether these symptoms align with current therapeutic evidence of cannabis-cannabinoid efficacy.

RESULTS

In 2020, 26 states and Washington, DC reported patient numbers, and 19 states reported patient-reported qualifying conditions. Total enrolled patients increased approximately 4.5-fold from 678 408 in 2016 to 2 974 433 in 2020. Patients per 10 000 total population generally increased from 2016 to 2020, most dramatically in Oklahoma (927.1 patients per 10 000 population). However, enrollment increased in states without recreational legalization (that is, medical-only states), whereas enrollment decreased in 5 of 7 with recreational legalization (that is, recreational states). In 2020, 68.2% of patient-reported qualifying conditions had substantial or conclusive evidence of therapeutic value versus 84.6% in 2016. Chronic pain was the most common patient-reported qualifying condition in 2020 (60.6%), followed by posttraumatic stress disorder (10.6%).

LIMITATION

Missing state data; lack of rationale for discontinuing medical cannabis licensure.

CONCLUSION

Enrollment in medical cannabis programs approximately increased 4.5-fold from 2016 to 2020, although enrollment decreased in recreational states. Use for conditions or symptoms without a strong evidence basis increased from 15.4% (2016) to 31.8% (2020). Thoughtful regulatory and clinical strategies are needed to effectively manage this rapidly changing landscape.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse of the National Institutes of Health.

Characteristics of adults with a medical cannabis license, reasons for use, and perceptions of benefit following medical cannabis legalization in Oklahoma

Little is known about the risks and benefits associated with medical cannabis legalization. The current study was an online panel survey of adult Oklahomans recruited between September and October 2020 (N = 1898). Respondents with and without a medical cannabis license were compared on sociodemographic, substance use and health characteristics, and sub-analyses focused on the characteristics of licensed and unlicensed past 30-day cannabis users. Among all participants, 19.34% (n = 367) reported that they had a medical cannabis license, and 35.73% (n = 676) reported past 30-day cannabis use. Licensees were more likely to be younger (i.e., 18-35 years of age; p = 0.001), identify as a sexual minority (p < 0.001), and report past 30-day cannabis, cigarette, alcohol, and prescription opiate use (all p's ≤ 0.003). Licensed participants most commonly reported medically-recommended cannabis use for anxiety (42.51%), depression (33.24%), sleep problems (26.98%), chronic pain (24.25%), and arthritis (12.81%). The likelihood of medically-recommended cannabis use for anxiety, depression, and chronic pain differed by age group (all p's ≤ 0.028). Licensees were most likely to perceive that cannabis delivered "very much/extreme" relief from anxiety (78.57%), sleep problems (76.30%), nausea/vomiting (70.00%), and depression (67.05%). Compared to licensed past 30-day cannabis users (n = 308), unlicensed users (n = 368) were more likely to be non-White, to have ≤ high school education, to report an annual household income <$30,000, and to report current smoking (all p's ≤ 0.027). Findings provide initial information about the personal characteristics associated with having a medical cannabis license in Oklahoma, the reasons for medical cannabis use, and the perceived medical benefits.

Medical Cannabis Use Among Older Adults in Canada: Self-Reported Data on Types and Amount Used, and Perceived Effects

Background

Medical cannabis use is growing among older adults. In this retrospective study, we aimed to assess the characteristics of older medical cannabis users including the indications, type and amount of cannabis used, perceived changes in symptoms after cannabis use, change in dose of concurrent medications, and adverse effects.

Methods

Data were collected between October 2014 and October 2020 from patients who were consulting the Canada-wide network of clinics of a medical cannabis provider and who were willing to answer questionnaires based on their medical status. The current study included older adults (≥ 65 years) who completed questionnaires at intake and first follow-up visits. Data were summarized with descriptive statistics, which were compared between men and women with t tests or chi-squared tests. Tests of proportions assessed categorical responses for perceived effects after cannabis use. Logistic regression was used to assess trends in cannabis usage.

Results

Data included that from 9766 older adult users at intake (mean ± SD age = 73.2 ± 6.8 years, females = 60.0%), among whom 4673 (females = 61.4%) returned for follow-up after 90.6 ± 58 days. The most common primary indication for which medical cannabis was sought was pain (67.7%), which was more common in women, whereas oncological and neurological conditions were more common in men. At follow-up, cannabis oil was used by 81.0% of older adults, among whom compositions containing only or mostly cannabidiol (CBD) had been used by 83.6%. Adverse effects reported by older adults at the follow-up visit included dry mouth (12.8%), drowsiness (8.6%), and dizziness (4.0%). The majority of older adults reported improvements in pain (72.7%, z = 1482.6, p < 0.0001, compared to worsening or no change), sleep (64.5%, z = 549.4, p < 0.0001), and mood (52.8%, z = 16.4, p < 0.0001), with 35.6% reporting use of a reduced dose of opioids and 19.9% a reduced dose of benzodiazepines.

Interpretation

Among older adults, medical cannabis is used more often by women, with CBD-containing cannabis oils being the most commonly used. Users reported improved pain, sleep, and mood symptoms at follow-up after cannabis use. This study describes the patterns of use of medical cannabis by older adults and highlights the need for research to determine appropriate indications, precise doses of active ingredients, and short- and long-term outcomes among older adults.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00913-y.

Cannabis use as a moderator of cognitive behavioral therapy for insomnia

STUDY OBJECTIVES

Cannabis use is common among young adults and has been proposed as a potential treatment for insomnia. However, controlled studies examining the impact of cannabis use on insomnia symptoms are rare. This secondary analysis of published trial data tested cannabis use during cognitive behavioral treatment for insomnia (CBT-I) as a moderator of treatment efficacy.

METHODS

Young adults (ages 18-30 years) who reported past-month binge drinking (4/5+ drinks for women/men) and met DSM-5 and research diagnostic criteria for Insomnia Disorder were randomized to CBT-I (n=28) or sleep hygiene (SH; n=28). Interaction effects were tested using multilevel models. Outcomes included insomnia severity, actigraphy-assessed sleep efficiency, diary-assessed sleep quality, drinking quantity, and alcohol-related consequences.

RESULTS

Twenty-six participants (46%; 12 SH and 14 CBT-I) reported using cannabis during the treatment phase of the study, on an average of 23% of treatment days (range=3-100%). Relative to those who did not use cannabis, participants who used cannabis during treatment reported heavier drinking and more frequent cigarette use. Approximately 1 in 4 cannabis users (27%) reported using cannabis to help with sleep; however, cannabis and non-cannabis users did not differ in use of alcohol as a sleep aid. Controlling for sex, race, drinking quantity, cigarette use, symptoms of depression, and symptoms of anxiety, use of cannabis during treatment did not moderate CBT-I effects on insomnia severity (b= -.002, p=.99) or other outcomes (all p >.20).

CONCLUSIONS

CBT-I is effective in reducing insomnia symptoms among young adult drinkers with insomnia, regardless of cannabis use.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT03627832.

Description of collaborative, fee-for-service, office-based, pharmacist-directed medical cannabis therapy management service for patients with chronic pain

BACKGROUND

Treatment with medical cannabis (MC) in the United States tends to be patient-driven in nature despite evidence that suggests that patients have remarkably poor knowledge on the medical use of this treatment modality.

OBJECTIVE

To develop and pilot a collaborative, fee-for-service (FFS), office-based, pharmacist-directed MC therapy management (MCTM) service for patients suffering chronic pain.

PRACTICE DESCRIPTION

A collaborative, FFS, office-based, pharmacist-directed MCTM service where patients are seen after a physician deems them suitable for treatment with MC. The pharmacist designs the initial treatment regimen by selecting a formulation, dose, route, and frequency of administration and then manages ongoing therapy by making regimen changes based on the patient's response, adverse effects, and financial concerns.

PRACTICE INNOVATION

The creation of a specialized service where a registered MC pharmacist is positioned in a collaborating provider's office and sees patients face-to-face for the provision of MCTM services.

EVALUATION METHODS

Patient retention, revenue generated, and ability to replicate the service were evaluated. Patient satisfaction was assessed by collecting subjective feedback on the service.

RESULTS

The pilot site that developed the service has seen 133 patients from 2016 to 2021 and has retained 89% of patients after 5 years of quarterly appointments. Patients appear willing to pay out of pocket for the service, and the revenue generated covers the pharmacist's and collaborating physician's time as well as additional overhead. The service has been replicated at 2 additional sites, and patient feedback has been positive.

CONCLUSIONS

MCTM is another useful pharmacist service that patients are willing to pay for. MCTM services decrease the collaborating provider's workload while still allowing them to offer their patients personalized treatment with MC. In our experience, the service retains patients, generates enough revenue to cover costs, can be replicated, and is well received by patients.

Medical Cannabis and Cannabinoids for Impaired Sleep: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

STUDY OBJECTIVES

We conducted a systematic review to explore the effectiveness of medical cannabis for impaired sleep.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and PsychINFO to January 2021 for randomized trials of medical cannabis or cannabinoids for impaired sleep vs. any non-cannabis control. When possible, we pooled effect estimates for all patient-important sleep-related outcomes and used the GRADE approach to appraise the certainty of evidence.

RESULTS

Thirty-nine trials (5,100 patients) were eligible for review, of which 38 evaluated oral cannabinoids and 1 administered inhaled cannabis. The median follow-up was 35 days, and most trials (33 of 39) enrolled patients living with chronic cancer or noncancer chronic pain. Among patients with chronic pain, moderate certainty evidence found that medical cannabis probably results in a small improvement in sleep quality versus placebo (modeled risk difference [RD] for achieving the minimally important difference [MID], 8% [95% CI, 3 to 12]). Moderate to high certainty evidence shows that medical cannabis vs. placebo results in a small improvement in sleep disturbance for chronic non-cancer pain (modeled RD for achieving the MID, 19% [95% CI, 11 to 28]) and a very small improvement in sleep disturbance for chronic cancer pain (WMD of -0.19cm [95%CI, -0.36 to -0.03cm]; interaction p=0.03). Moderate to high certainty evidence shows medical cannabis, versus placebo, results in a substantial increase in the risk of dizziness (RD 29% [95%CI, 16 to 50], for trials with ≥3 months follow-up), and a small increase in the risk of somnolence, dry mouth, fatigue, and nausea (RDs ranged from 6% to 10%).

CONCLUSION

Medical cannabis and cannabinoids may improve impaired sleep among people living with chronic pain, but the magnitude of benefit is likely small.

Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process

BACKGROUND

Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed.

METHODS

Using a multistage modified Delphi process, twenty global experts across nine countries developed consensus-based recommendations on how to dose and administer medical cannabis in patients with chronic pain.

RESULTS

There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed. A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC. A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every 7 days until a maximum daily dose of 40 mg/day of THC. A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day.

CONCLUSIONS

In summary, using a modified Delphi process, expert consensus-based recommendations were developed on how to dose and administer medical cannabis for the treatment of patients with chronic pain.

Cannabinoids and sleep-wake cycle: The potential role of serotonin

Cannabis sativa (Marijuana) has a long history as a medicinal plant and Δ9-tetrahydrocannabinol (Δ9-THC) is the most active component in this plant. Cannabinoids are interesting compounds with various modulatory effects on physiological processes and cognitive functions. The use of cannabinoids is a double-edged sword, because they induce both adverse and therapeutic properties. One of the most important roles of cannabinoids is modulating sleep-wake cycle. Sleep, its cycle, and its mechanism are highly unknown. Also, the effects of cannabinoids on sleep-wake cycle are so inconsistent. Thus, understanding the role of cannabinoids in modulating sleep-wake cycle is a critical scientific goal. Cannabinoids interact with many neurotransmitter systems. In this review article, we chose serotonin due to its important role in regulating sleep-wake cycle. We found that the interaction between cannabinoids and serotonergic signaling especially in the dorsal raphe is extensive, unknown, and controversial.

Are Sweet Dreams Made of These? Understanding the Relationship Between Sleep and Cannabis Use

Introduction: There is widespread literature on the interaction between cannabis use and sleep, yet the mechanisms that underlie this relationship are not well understood. Several factors lead to inconsistencies in this relationship suggesting a nuanced interaction between cannabis and sleep. An important question that remains to be addressed is the temporal relationship between disrupted sleep and cannabis use. This literature review summarizes the existing literature on the association between disrupted sleep and cannabis toward the goal of addressing the question of the chronology of these reported effects. Materials and Methods: We conducted a review of the literature using PubMed to summarize current knowledge on the association between cannabis use and sleep in humans. Results: We identified 31 studies on the association of cannabis use and sleep. The findings from these studies were mixed. Cannabis was associated with a variety of impacts on sleep ranging from beneficial effects, such as reduced sleep-onset latency, to negative outcomes, such as reduced sleep duration and suppressed rapid eye movement oscillations. The chronology of the interaction of cannabis and sleep was unclear, although much of the current literature focus on factors that modulate how cannabis impairs sleep after initial use. Conclusion: There was sufficient evidence to suggest that cannabis use alters circadian rhythms, and hence, negatively impacts sleep. The current literature is largely from studies utilizing self-report measures of sleep; thus, objective measures of sleep are needed. In addition, although there were no empirical studies on the temporal relationship between cannabis use and sleep, the majority of the literature focused on characterizing sleep impairment after cannabis use.

A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

Evaluation of Patient Reported Safety and Efficacy of Cannabis From a Survey of Medical Cannabis Patients in Canada

With the medical use of cannabis permitted in Canada since 2001, patients seek to use this botanical drug to treat a range of medical conditions. However, many healthcare practitioners express the need for further scientific evidence around the use of medical cannabis. This real-world evidence study aimed to address the paucity of scientific data by surveying newly registered medical cannabis patients, before beginning medical cannabis treatment, and at one follow up 6 weeks after beginning medical cannabis treatment. The goal was to collect data on efficacy, safety and cannabis product type information to capture the potential impact medical cannabis had on patient-reported quality of life (QOL) and several medical conditions over a 6-week period using validated questionnaires. The 214 participants were mainly male (58%) and 57% of the population was older than 50. The most frequently reported medical conditions were recurrent pain, post-traumatic stress disorder (PTSD), anxiety, sleep disorders [including restless leg syndrome (RLS)], and arthritis and other rheumatic disorders. Here we report that over 60% of our medical cannabis cohort self-reported improvements in their medical conditions. With the use of validated surveys, we found significant improvements in recurrent pain, PTSD, and sleep disorders after 6 weeks of medical cannabis treatment. Our findings from patients who reported arthritis and other rheumatic disorders are complex, showing improvements in pain and global activity sub-scores, but not overall changes in validated survey scores. We also report that patients who stated anxiety as their main medical condition did not experience significant changes in their anxiety after 6 weeks of cannabis treatment, though there were QOL improvements. While these results show that patients find cannabis treatment effective for a broad range of medical conditions, cannabis was not a remedy for all the conditions investigated. Thus, there is a need for future clinical research to support the findings we have reported. Additionally, while real-world evidence has not historically been utilized by regulatory bodies, we suggest changes in public policy surrounding cannabis should occur to reflect patient reported efficacy of cannabis from real-world studies due to the uniqueness of medical cannabis's path to legalization.

Daily associations between sleep and opioid use among adults with comorbid symptoms of insomnia and fibromyalgia

STUDY OBJECTIVES

Disturbed sleep and use of opioid pain medication are common among individuals with chronic pain. Anecdotally, opioids are thought to promote sleep by relieving pain. This study aimed to determine whether opioid use is associated with daily sleep parameters (and vice versa) in adults with comorbid symptoms of insomnia and fibromyalgia.

METHODS

Individuals reporting symptoms of insomnia and opioid use for fibromyalgia (n = 65, 93% women, 79% White) wore wrist actigraphy and completed daily diaries for 14 days (910 observations). Analyses examined daily associations between opioid dose (measured in lowest recommended dosage units) and three sleep parameters (actigraphy/self-reported total wake time and self-reported sleep quality). Multilevel models were used to account for the clustering of daily sleep and opioid assessments (level 1) within individuals (level 2).

RESULTS

Opioid use did not have a significant daily effect on total wake time or sleep quality, and sleep parameters did not significantly impact opioid use the next day; however, participants reported worse sleep quality and greater doses of opioids on evenings that they experienced greater pain.

CONCLUSIONS

Among adults reporting symptoms of insomnia and opioid use for fibromyalgia pain, opioid use is not reliably associated with wake time or sleep quality that night, and these sleep parameters are not significantly associated with opioid use the next day; however, evening pain has an adverse daily impact on both sleep quality and opioid use. Studies identifying strategies to prevent and manage fibromyalgia pain are needed, especially for individuals reporting comorbid insomnia and opioid use.

Sleep deficits and cannabis use behaviors: an analysis of shared genetics using linkage disequilibrium score regression and polygenic risk prediction

STUDY OBJECTIVES

Estimate the genetic relationship of cannabis use with sleep deficits and an eveningness chronotype.

METHODS

We used linkage disequilibrium score regression (LDSC) to analyze genetic correlations between sleep deficits and cannabis use behaviors. Secondly, we generated sleep deficit polygenic risk score (PRS) and estimated their ability to predict cannabis use behaviors using linear and logistic regression. Summary statistics came from existing genome-wide association studies of European ancestry that were focused on sleep duration, insomnia, chronotype, lifetime cannabis use, and cannabis use disorder (CUD). A target sample for PRS prediction consisted of high-risk participants and participants from twin/family community-based studies (European ancestry; n = 760, male = 64%; mean age = 26.78 years). Target data consisted of self-reported sleep (sleep duration, feeling tired, and taking naps) and cannabis use behaviors (lifetime ever use, number of lifetime uses, past 180-day use, age of first use, and lifetime CUD symptoms).

RESULTS

Significant genetic correlation between lifetime cannabis use and an eveningness chronotype (rG = 0.24, p < 0.001), as well as between CUD and both short sleep duration (<7 h; rG = 0.23, p = 0.017) and insomnia (rG = 0.20, p = 0.020). Insomnia PRS predicted earlier age of first cannabis use (OR = 0.92, p = 0.036) and increased lifetime CUD symptom count (OR = 1.09, p = 0.012).

CONCLUSION

Cannabis use is genetically associated with both sleep deficits and an eveningness chronotype, suggesting that there are genes that predispose individuals to both cannabis use and sleep deficits.

Multitargeting the sleep-pain interaction with pharmacological approaches: A narrative review with suggestions on new avenues of investigation

The multimorbidity formed by sleep disturbances and pain conditions is highly prevalent and has a significant impact in global health and in the socioeconomic system. Although different approaches have been directed toward its management, evidence regarding an optimal treatment is lacking, and pharmacological options are often preferred. Health professionals (e.g., pain and sleep clinicians) tend to focus on their respective expertise, targeting a single symptom with a single drug. This may increase polypharmacy and the risk of drug interactions, adverse events, and mortality. Hence, the use of medications that can directly or indirectly improve sleep, pain, and other possible accompanying conditions without exacerbating them becomes especially relevant. The objectives of this comprehensive review are to: a) describe the beneficial or deleterious effects that some commonly used medications to manage pain have on sleep and sleep disorders; and b) describe the beneficial or deleterious effects that frequently prescribed medications for sleep may have on pain. Moreover, medications targeting some specific sleep-pain interactions will be suggested and future directions for improving sleep and alleviating pain of these patients will be provided with clinical and research perspectives.

Cannabis for Chronic Pain: A Rapid Systematic Review of Randomized Control Trials

BACKGROUND

The high prevalence of inadequately managed chronic pain indicates the need for alternative and multimodal treatment options. Use of cannabinoids in medicine is becoming a growing area of interest, specifically in the context of chronic pain. The efficacy of cannabinoids for the treatment of chronic pain is not well established.

AIMS

The objectives of this rapid systematic literature review are to summarize the efficacy and secondary effects of cannabinoids for chronic pain management.

DESIGN

Rapid systematic review of randomized control trials.

PARTICIPANTS

Individuals with chronic pain (n = 1352).

METHODS

Embase, Cochrane, PubMed, and CINAHL databases were searched. Inclusion criteria included cannabis of any formulation used to treat chronic pain of any origin.

RESULTS

Thirteen randomized controlled trials met the inclusion criteria. Five demonstrated moderate analgesic effects of cannabis for chronic pain, and eight concluded there were no significant impacts on pain in the cannabis-treated group versus the control group.

CONCLUSIONS

Evidence on the efficacy of cannabinoids for chronic pain shows patient-perceived benefit but inconsistent other treatment effects. These findings indicate cannabinoids may have a modest analgesic effect for chronic neuropathic pain conditions, and that the use of cannabinoids is relatively safe, with few severe adverse events. This review concludes that cannabinoids may have a potential role in chronic pain management. Inconsistent evidence on the efficacy of cannabis to treat chronic pain indicates the need for more studies on a larger scale. Clinicians should draw on available evidence and consider cannabinoids as a potential approach to chronic pain management.

Age-Related Differences in Cannabis Product Use

Cannabis use varies with age and gender, but less is known regarding specific product choices. Previous work suggests that older adults are inclined to stick to the more "classic" and familiar, while "novel" products are more likely to appeal to younger populations. We examined cross-sectional, retrospective data to determine whether the type of cannabis products used varied according to participant age (N = 1406, 71.3% female). The extensive list of products included: loose flower, pre-rolled joints, edibles, concentrates, oil vaporizers (vape pens), dry vaporizers, tinctures, topicals, and ingestible oils. Overall, rates of use for cannabis-infused ingestible oils, topicals, and tinctures are the lowest and show no age or gender-related differences. In contrast, the use of pre-rolled joints, vape pens, and edibles tends to decrease with age. Loose flower and dry vaporizer use also decrease with age, although less consistently. These age-related differences in product choices can facilitate prevention and treatment efforts toward specific populations. While harm-reduction efforts targeting loose flower and edible products would benefit all age groups, those targeting concentrates might focus only on younger users. On the other hand, learning about concentrates might be beneficial for older medical users due to their larger THC doses and rapid onset.

Requirements for Cannabis Product Labeling by U.S. State

Introduction: As more states allow for medical and nonregistered adult cannabis (i.e., marijuana) use, ensuring proper utilization should be a priority. Standardized labeling for foods and pharmaceutical drugs promotes consumer safety. This study investigated cannabis product labeling requirements in the United States. Materials and Methods: Researchers compiled the requirements for cannabis product labeling across 31 U.S. states with medical cannabis programs from state regulatory publications. Results: Information requirements ranged considerably by U.S. state. All states required delta-9-tetrahydrocannabinol content and manufacturer contact information, >80% of states required the batch number, health risks, production tracking, a cannabis symbol, cannabidiol content, children disclaimer, and an impairment disclaimer. There appeared to be a random pattern in requirements for other specific items. The relationships between the extent of cannabis product labeling requirements and the number of years that a state had a medical cannabis program or whether states allowed nonregistered adult use cannabis were not significant, although there was a trend for nonregistered adult use states to require more recommended label attributes. Conclusion: A comprehensive framework for cannabis use is needed to protect the public, maximize benefits, and minimize harms and risks. Standardization of cannabis product labeling requirements would benefit consumers and promote safer and more effective usage of cannabis products.

Exploring New Use of Cannabis among Older Adults

Objectives: In Canada, cannabis prohibition ended in October 2018. Older adults are the fastest growing group of cannabis users and are out-pacing other groups as new users. Clinical evidence indicates that cannabis may be helpful for select medicinal purposes in this population. Yet there is limited research about older adults experiences of starting to use cannabis in later life. The purpose of this study was to begin to address this gap. Methods: This study employed qualitative description. A convenience sample of Canadian community-dwelling older adults who were new users of cannabis were recruited. Data were collected using semi-structured interviews. Data analysis was inductive and thematic. Results: Twelve older adults between the ages of 71 and 85 participated. All of the participants used cannabis for medicinal reasons, however, only one had a prescription. The main reasons for using were: pain management, alternative to prescription or over-the-counter medication, and sleep aide. Most participants obtained cannabis from non-licensed stores. Eleven discussed cannabis use with their family physicians, however, none received prescriptions from them. The main sources of information were friends, cannabis store staff, and the media. Conclusions: Older adults who begin using cannabis are likely using for what they perceive to be medicinal purposes for a range of issues. However, they receive minimal guidance from their family physicians and instead obtain information from non-clinician sources. Clinical implications: Cannabis screening should be included in geriatric assessments and medicine reconciliation. Continuing education for clinicians needs to address knowledge gaps about cannabis use among older adults.

Cannabis use and sleep: Expectations, outcomes, and the role of age

STUDY OBJECTIVES

Determine relationship between cannabis use with 1) expectations of cannabis being a sleep aid, 2) subjective sleep outcomes, and 3) the influence of age on these relationships.

METHODS

In 152 moderate cannabis users with a wide age range (67% female, mean age = 31.45, SD = 12.96, age range = 21-70; mean days of cannabis use in prior two weeks = 5.54, SD = 5.25) we examined the influence of cannabis use history and behaviors on expectations of cannabis being a sleep aid and sleep outcomes via the Pittsburgh Sleep Quality Index (PSQI). Moderation analysis examined the role of age in the relationship between cannabis use and sleep outcomes.

RESULTS

Endorsing current cannabis use and more days of cannabis use were associated with increased expectations that cannabis use improves sleep (all β > 0.03, p < 0.04). Frequency of recent use and reported average THC or CBD concentration were largely not associated with sleep outcomes. However, endorsing current cannabis use was associated with worse subjective sleep quality (β = 1.34, p = 0.02) and increased frequency of consuming edibles was associated with worse subjective sleep efficiency (β = 0.03, p = 0.04), lower sleep duration (β = 0.03, p = 0.01), and higher global PSQI scores (worse overall sleep) (β = 0.10, p = 0.01). Additionally, age had a moderating influence on the relationship between increased self-reported concentration of CBD and both better sleep duration and sleep quality (both p < 0.03). While the main effects of cannabis use on sleep outcomes did not survive multiple comparisons correction test (all p adj > 0.34), the adjusted p values for the main effects of cannabis behaviors/history on expectations of cannabis as a sleep aid (p adj = 0.07-0.09) and the main effects of CBD concentration on sleep duration (p adj = 0.08), as well as the interaction terms of CBD and age for that model (p adj = 0.07), were trending.

CONCLUSION

Cannabis users have increased expectations of cannabis being a sleep aid, but few associations existed between cannabis use and sleep outcomes. The two exceptions were endorsing any cannabis use and frequency of edible use. Additionally, age may be an important moderator of the potential positive influence CBD concentration can have on sleep.

Motivations and expectations for using cannabis products to treat pain in humans and dogs: a mixed methods study

BACKGROUND

Social media and academic literature suggest that more people are using cannabis to treat their own or their dog's chronic pain. This study identifies the reasons people use cannabis products to treat their own pain or their dog's pain and explores whether these products have fulfilled their expectations.

METHODS

An anonymous, online survey was used to collect quantitative and qualitative self-report data on respondents' perceptions, motivations and expectations about their or their dog's chronic pain and cannabis use. The analyses are based on U.S. adults who reported using cannabis products to treat their own (N = 313) or their dog's (N = 204) chronic pain. Quantitative responses from the two groups were compared using Chi-Square tests and qualitative data were analyzed using a thematic analysis.

RESULTS

Human patients and dog owners reported similar motivations for using cannabis products to treat chronic pain, with the more popular reasons being that cannabis products are natural, are preferred over conventional medication, are believed to be the best treatment or good treatment option for pain. Similar proportions of human patients and dog owners reported that the use of cannabis products fulfilled their expectations (86% vs. 82% respectively, χ2 (1, 200) = .59, p = .32). The qualitative data revealed that their expectations were met by reducing pain, increasing relaxation, and improving sleep, coping, functionality and overall well being. Additionally, the qualitative data suggests that cannabis products offer a return to normalcy and a restored sense of self to human and dog patients.

CONCLUSIONS

The results suggest that people choose cannabis products because they are natural and a possible solution to managing chronic pain when conventional medicines have not been effective. Most people report that their expectations regarding pain management are fulfilled by these products. More accurate assessments are vital, however, for understanding both the objective biomedical and subjective socioemotional benefits of cannabis products for effective pain management for human and dog patients. In addition, objective factual information regarding cannabis products for effective pain management in humans and dogs is needed. It is recommended that both physicians and veterinarians work towards feeling more comfortable proactively broaching the subject of cannabis use with additional training and education.

Attitudes about cannabis mediate the relationship between cannabis knowledge and use in active adult athletes

BACKGROUND

Little is known about how cannabis knowledge and attitudes impact cannabis use behavior.

OBJECTIVE

To test the knowledge-attitudes-behavior paradigm in active adult athletes.

DESIGN

The Athlete Pain, Exercise, and Cannabis Experience (PEACE) Survey, a cross-sectional survey study, used social media and email blasts to recruit participants and SurveyGizmo to collect data.

PARTICIPANTS

Self-defined active adult athletes (n = 1161).

MAIN MEASURES

Knowledge about cannabis was evaluated with four questions. Attitudes toward cannabis was evaluated with 11 questions. The attitudes questions were used in a TwoStep Cluster analysis in SPSS to assign group membership by attitudes. Chi-square was used to determine if there were differences in cluster membership by demographic factors and if knowledge about cannabis differed by cluster membership. Regression analysis was performed to determine if cannabis attitudes mediated the relationship between cannabis knowledge and cannabis use.

KEY RESULTS

A three-cluster solution was the best fit to the data. The clusters were named Conservative (n = 374, 32.2%), Unsure (n = 533, 45.9%), and Liberal (n = 254, 21.9). There was a significant difference among the clusters for all 11 attitudes items (all p < 0.001). Attitude cluster membership was significantly different by age (p < 0.001), primary sport (p < 0.05), and knowledge about cannabis (p < 0.001). Athletes in the liberal cluster answered the knowledge questions correctly most often. Attitudes mediated the relationship between cannabis knowledge and cannabis use [Never (32.4%), Past (41.6%), Current (26.0%)] with athletes in the liberal cluster showing more knowledge and greater likelihood to be a current cannabis user (p < 0.001). Among current cannabis users there were differential patterns of cannabis use depending on their attitudes and knowledge; liberal athletes tended to co-use THC and CBD and used cannabis longer. (p < 0.001).

CONCLUSIONS

Cannabis education needs to consider attitudes about cannabis, especially among those who might benefit from medical cannabis.

Cannabidiol (CBD) and Δ9-tetrahydrocannabinol (THC) for chronic insomnia disorder ('CANSLEEP' trial): protocol for a randomised, placebo-controlled, double-blinded, proof-of-concept trial

INTRODUCTION

Insomnia is a highly prevalent and costly condition that is associated with increased health risks and healthcare utilisation. Anecdotally, cannabis use is frequently reported by consumers to promote sleep. However, there is limited research on the effects of cannabis on sleep and daytime function in people with insomnia disorder using objective measures. This proof-of-concept study will evaluate the effects of a single dose of an oral cannabis-based medicine on sleep and daytime function in participants with chronic insomnia disorder.

METHODS AND ANALYSIS

A randomised, crossover, placebo-controlled, single-dose study design will be used to test the safety and efficacy of an oral oil solution ('ETC120') containing 10 mg Δ9-tetrahydrocannabinol (THC) and 200 mg cannabidiol (CBD) in 20 participants diagnosed with chronic insomnia disorder. Participants aged 35-60 years will be recruited over an 18-month period commencing August 2019. Each participant will receive both the active drug and matched placebo, in a counterbalanced order, during two overnight study assessment visits, with at least a 1-week washout period between each visit. The primary outcomes are total sleep time and wake after sleep onset assessed via polysomnography. In addition, 256-channel high-density electroencephalography and source modelling using structural brain MRI will be used to comprehensively examine brain activation during sleep and wake periods on ETC120 versus placebo. Next-day cognitive function, alertness and simulated driving performance will also be investigated.

ETHICS AND DISSEMINATION

Ethics approval was received from Bellberry Human Research Ethics Committee (2018-04-284). The findings will be disseminated in a peer-reviewed open-access journal and at academic conferences.

TRIAL REGISTRATION NUMBER

ANZCTRN12619000714189.

Medical Cannabis for the Primary Care Physician

Medical cannabis use is common in the United States and increasingly more socially acceptable. As more patients seek out and acquire medical cannabis, primary care physicians will be faced with a growing number of patients seeking information on the indications, efficacy, and safety of medical cannabis. We present a case of a patient with several chronic health conditions who asks her primary care provider whether she should try medical cannabis. We provide a review of the pharmacology of medical cannabis, the state of evidence regarding the efficacy of medical cannabis, variations in the types of medical cannabis, and safety monitoring considerations for the primary care physician.