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Lewis M, Baroutian S, Hanning SM. Phytocannabinoids for the Treatment of Neuropathic Pain: A Scoping Review of Randomised Controlled Trials Published Between 2012 and 2023. Curr Pain Headache Rep 2024; 28:109-118. [PMID: 38095748 DOI: 10.1007/s11916-023-01196-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 03/10/2024]
Abstract
PURPOSE OF REVIEW Neuropathic pain (NP) remains a challenge to treat, with 50% of patients experiencing limited efficacy from current treatments. Medicinal cannabis, which contains tetrahydrocannabinol (THC), cannabidiol (CBD) and other minor cannabinoids, is garnering attention as an alternative treatment for NP. This paper reviews the clinical evidence for phytocannabinoid treatment of NP. RECENT FINDINGS Seventeen randomised controlled trials (RCT) were identified for inclusion in this review. Of these, ten studies using phytocannabinoid preparations containing THC alone had the most evidence for pain relief. Four studies investigating THC/CBD combinations showed some reductions in pain scores, although not all findings were statistically significant, whereas studies investigating CBD (two studies) or cannabidivarin (one study) showed no analgesic effect over placebo. However, CBD studies were of small sample size when compared to other studies in the review and short duration. Results for treatment of diabetic peripheral neuropathy patients with THC showed better improvements over those for NP induced by chemotherapy and multiple sclerosis, with these trials using vaporised whole plant cannabis. This formulation may have trace amounts of other minor cannabinoids, compared with synthetic cannabinoids such as dronabinol or nabilone that were investigated in other studies. This review provides an overview of RCTs that have investigated phytocannabinoid use for the treatment of NP. There appears to be evidence to necessitate further high quality RCTs into novel formulations of phytocannabinoids for the treatment of NP.
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Affiliation(s)
- Marc Lewis
- Department of Chemical and Materials Engineering, The University of Auckland, Auckland, 1010, New Zealand
| | - Saeid Baroutian
- Department of Chemical and Materials Engineering, The University of Auckland, Auckland, 1010, New Zealand
- Circular Innovations (CIRCUIT) Research Centre, The University of Auckland, Auckland, 1010, New Zealand
- Ngā Ara Whetū Centre for Climate, Biodiversity and Society, The University of Auckland, Auckland, 1010, New Zealand
| | - Sara M Hanning
- School of Pharmacy, The University of Auckland, Auckland, 1010, New Zealand.
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Sokolaj E, Assareh N, Anderson K, Aubrey KR, Vaughan CW. Cannabis constituents for chronic neuropathic pain; reconciling the clinical and animal evidence. J Neurochem 2023. [PMID: 37747128 DOI: 10.1111/jnc.15964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Chronic neuropathic pain is a debilitating pain syndrome caused by damage to the nervous system that is poorly served by current medications. Given these problems, clinical studies have pursued extracts of the plant Cannabis sativa as alternative treatments for this condition. The vast majority of these studies have examined cannabinoids which contain the psychoactive constituent delta-9-tetrahydrocannabinol (THC). While there have been some positive findings, meta-analyses of this clinical work indicates that this effectiveness is limited and hampered by side-effects. This review focuses on how recent preclinical studies have predicted the clinical limitations of THC-containing cannabis extracts, and importantly, point to how they might be improved. This work highlights the importance of targeting channels and receptors other than cannabinoid CB1 receptors which mediate many of the side-effects of cannabis.
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Affiliation(s)
- Eddy Sokolaj
- Pain Management Research Institute, Kolling Institute of Medical Research, Northern Clinical School, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Neda Assareh
- Pain Management Research Institute, Kolling Institute of Medical Research, Northern Clinical School, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Kristen Anderson
- Pain Management Research Institute, Kolling Institute of Medical Research, Northern Clinical School, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Karin R Aubrey
- Pain Management Research Institute, Kolling Institute of Medical Research, Northern Clinical School, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Christopher W Vaughan
- Pain Management Research Institute, Kolling Institute of Medical Research, Northern Clinical School, Royal North Shore Hospital, University of Sydney, Sydney, New South Wales, Australia
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Erku D, Shrestha S, Scuffham P. Cost-Effectiveness of Medicinal Cannabis for Management of Refractory Symptoms Associated With Chronic Conditions: A Systematic Review of Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1520-1530. [PMID: 34593176 DOI: 10.1016/j.jval.2021.04.1276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 04/02/2021] [Accepted: 04/10/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Although there is a growing body of evidence suggesting that cannabinoids may relieve symptoms of some illnesses, they are relatively high-cost therapies compared with illicit growth and supply. This article aimed to comprehensively review economic evaluations of medicinal cannabis for alleviating refractory symptoms associated with chronic conditions. METHODS Seven electronic databases were searched for articles published up to September 6, 2020. The quality of reporting of economic evaluations was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. The extracted data were grouped into subcategories according to types of medical conditions, organized into tables, and reported narratively. RESULTS This review identified 12 cost-utility analyses conducted across a variety of diseases including multiple sclerosis (MS) (N = 8), pediatric drug-resistant epilepsies (N = 2), and chronic pain (N = 2). The incremental cost-effectiveness ratio varied widely from cost saving to more than US$451 800 per quality-adjusted life-year depending on the setting, perspectives, types of medicinal cannabis, and indications. Nabiximols is a cost-effective intervention for MS spasticity in multiple European settings. Cannabidiol was found to be a cost-effective for Dravet syndrome in a Canadian setting whereas a cost-utility analysis conducted in a US setting deemed cannabidiol to be not cost-effective for Lennox-Gastaut syndrome. Overall study quality was good, with publications meeting 70% to 100% (median 83%) of the Consolidated Health Economic Evaluation Reporting Standards checklist criteria. CONCLUSIONS Medicinal cannabis-based products may be cost-effective treatment options for MS spasticity, Dravet syndrome, and neuropathic pain, although the literature is nascent. Well-designed clinical trials and health economic evaluations are needed to generate adequate clinical and cost-effectiveness evidence to assist in resource allocation.
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Affiliation(s)
- Daniel Erku
- Centre for Applied Health Economics, Griffith University, Nathan, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia.
| | - Shakti Shrestha
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Paul Scuffham
- Centre for Applied Health Economics, Griffith University, Nathan, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
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The Effect of Medical Cannabis on Pain Level and Quality of Sleep among Rheumatology Clinic Outpatients. Pain Res Manag 2021; 2021:1756588. [PMID: 34531934 PMCID: PMC8440085 DOI: 10.1155/2021/1756588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 08/14/2021] [Accepted: 08/18/2021] [Indexed: 01/20/2023]
Abstract
Introduction Medical cannabis (MC) is becoming increasingly popular for the treatment of chronic pain conditions. In this study, we evaluated the effect of MC treatment on pain level and quality of sleep of patients with different medical conditions at the rheumatology clinic. Methods Patients licensed for the use of MC at the rheumatology clinics at different settings were located and contacted. Their demographic and clinical parameters were documented, including type of medical cannabis consumed, way of consumption, and current monthly consumed amount. These patients were contacted by phone and asked about the effect on pain level and quality of sleep. Results A total of 351 patients were located, and 319 completed the questionnaire. Mean age was 46 ± 12 years, 76% were female, 82% had fibromyalgia, ∼9% had mechanical problems, ∼4% had inflammatory problems, ∼4% had neurological problems, and ∼1% had other problems. The average monthly consumed dose of MC was 31, 35, 36, and 32 g, with mean pain level reduction of 77%, 82%, 83%, and 57%, and mean sleep quality improvement of 78%, 71%, 87%, and 76% among patients with fibromyalgia, mechanical, neuropathic, and inflammatory problems, respectively. Mean THC and CBD contents were 18.38% ± 4.96 and 2.62% ± 4.87, respectively. The THC concentration, duration of MC consumption, and MC consumption dose had independent significant correlations with pain reduction while only the duration of MC consumption had an independent significant correlation with sleep quality improvement. Conclusions MC had a favorable effect on pain level and quality of sleep among all spectrums of problems at the rheumatology clinic.
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Vannabouathong C, Zhu M, Chang Y, Bhandari M. Can Medical Cannabis Therapies be Cost-Effective in the Non-Surgical Management of Chronic Knee Pain? CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2021; 14:11795441211002492. [PMID: 33795939 PMCID: PMC7970188 DOI: 10.1177/11795441211002492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/18/2021] [Indexed: 11/15/2022]
Abstract
Introduction: Chronic knee pain is a common musculoskeletal condition, which usually leads
to decreased quality of life and a substantial financial burden. Various
non-surgical treatments have been developed to relieve pain, restore
function and delay surgical intervention. Research on the benefits of
medical cannabis (MC) is emerging supporting its use for chronic pain
conditions. The purpose of this study was to evaluate the cost-effectiveness
of MC compared to current non-surgical therapies for chronic knee pain
conditions. Methods: We conducted a cost-utility analysis from a Canadian, single payer
perspective and compared various MC therapies (oils, soft gels and dried
flowers at different daily doses) to bracing, glucosamine,
pharmaceutical-grade chondroitin oral non-steroidal anti-inflammatory drugs
(NSAIDs), and opioids. We estimated the quality-adjusted life years (QALYs)
gained with each treatment over 1 year and calculated incremental
cost-utility ratios (ICURs) using both the mean and median estimates for
costs and utilities gained across the range of reported values. The final
ICURs were compared to willingness-to-pay (WTP) thresholds of $66 714,
$133 428 and $200 141 Canadian dollars (CAD) per QALY gained. Results: Regardless of the estimates used (mean or median), both MC oils and soft gels
at both the minimal and maximal recommended daily doses were cost-effective
compared to all current knee pain therapies at the lowest WTP threshold.
Dried flowers were only cost-effective up to a certain dosage (0.75 and
1 g/day based on mean and median estimates, respectively), but all dosages
were cost-effective when the WTP was increased to $133 428/QALY gained. Conclusion: Our study showed that MC may be a cost-effective strategy in the management
of chronic knee pain; however, the evidence on the medical use of cannabis
is limited and predominantly low-quality. Additional trials on MC are
definitely needed, specifically in patients with chronic knee pain.
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Affiliation(s)
| | - Meng Zhu
- OrthoEvidence, Burlington, ON, Canada
| | | | - Mohit Bhandari
- OrthoEvidence, Burlington, ON, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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Habib G, Steinberg D, Jabbour A. The impact of medical cannabis consumption on the oral flora and saliva. PLoS One 2021; 16:e0247044. [PMID: 33577600 PMCID: PMC7880425 DOI: 10.1371/journal.pone.0247044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the effect of medical cannabis consumption on oral flora and saliva. DESIGN A clinical prospective study, at the rheumatology clinic of the Nazareth Hospital in Nazareth, recruiting consecutively patients approved for medical cannabis, evaluating their saliva flow, pH and microbial load of Streptococcus mutans and Lactobacillus, prior to and under medical cannabis treatment. METHODS Patients recently licensed for medical cannabis treatment, were recruited just prior to starting medical cannabis consumption (week 0), 1 and 4 weeks later, patients provided 5-minute time saliva samples, which were measured for their volume and pH, and cultured on a special microbial kit, evaluating the growth of Streptococcus mutans and Lactobacillus. RESULTS Out of 16 patients enrolled, 14 were female and had fibromyalgia. The mean age of the patients was 52.8±12.9 years. The mean saliva flow at week 0, week 1 and week 4 were 5.38±3.36 ml/5-minutes, 6 (p = 0.769) and 5.45 (p = 0.391), respectively, and for saliva pH were 6.28, 5.94 (p = 0.51) and 5.5 (p = 0.07) respectively also. The mean Streptococcus mutans growth score at weeks 0, 1 and 4 was1.8±0.75, 1.6±0.83 (p = 0.234), and 2.4±0.84 (p = 0.058), respectively. The mean Lactobacilli growth score at weeks 0, 1 and 4 was 2.59±0.88, 3.1±0.69 (p = 0.033) and 3.3±0.67 (p = 0.025), respectively. CONCLUSIONS The results of this study show that medical cannabis consumption has no significant effect on saliva volume or pH, but it may be associated with changes in salivary levels of oral microbes such as Streptococcus mutans and Lactobacilli.
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Affiliation(s)
- George Habib
- Nazareth, Azrieli Faculty of Medicine, Department of Medicine C and Rheumatology Unit, Laniado Hospital, Netanya, and Rheumatology Clinic Nazareth Hospital, Bar-Ilan University, Safed, Israel
- * E-mail:
| | - Doron Steinberg
- Faculty of Dental Medicine, Biofilm Research Laboratory, Hebrew University-Hadassah, Jerusalem, Israel
| | - Adel Jabbour
- Nazareth, Azrieli Faculty of Medicine, Medical Laboratory, Nazareth Hospital E.M.M.S, Bar-Ilan University, Safed, Israel
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Hariri N, Zare S, Murphy J, Fadare O. Cost-effectiveness of a Dual (Immunohistochemistry and Fluorescence In Situ Hybridization) HER2/neu Testing Strategy on Invasive Breast Cancers. Appl Immunohistochem Mol Morphol 2021; 29:42-48. [PMID: 32205742 DOI: 10.1097/pai.0000000000000849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The American Society of Clinical Oncology and the College of American Pathologists recommend that human epidermal growth factor receptor 2 (HER2)/neu status be determined for all invasive breast cancers. Although the most commonly used modalities to determine HER2/neu status, immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH), generally give concordant results, a small but consistent discordance rate between them has been demonstrated in prior studies. Most institutions in the United States use a "reflex testing strategy" for determining HER2/neu status. In a reflex testing strategy, cancers are screened with IHC, and FISH is reflexively performed only if the IHC results are classified as equivocal. Other institutions perform both tests on all cancers to maximize diagnostic accuracy (dual testing strategy). The cost-effectiveness of dual testing and reflex testing strategies are comparatively assessed herein. A decision analysis model was established comparing these 2 testing strategies. Model probabilities were obtained from an institutional invasive breast cancer cohort. Quality-adjusted life-years (QALYs) and cost estimates were extracted from published literature. All costs were converted to 2018 US$ values using the consumer price index. One-way sensitivity analysis was performed, as well as probabilistic sensitivity analyses with acceptability curves. A total of 1247 consecutive invasive breast cancer specimens were tested with a dual strategy. By IHC, 65%, 28%, and 10% were negative, equivocal, and positive, respectively. By FISH, 87% and 13% were HER2/neu-negative and HER2/neu-positive, respectively. Six patients whose cancers were IHC-positive (3+) were found to be FISH-negative. These 6 represented 5% of the 119 cases with HER2/neu 3+ scores and 0.55% of the 1082 cases with HER2/neu-negative results by FISH. Sixteen (2%) of 809 cases with a negative IHC result were ultimately classified as HER2/neu-amplified by FISH. These 16 cases constituted 10% of all cases that were ultimately classified as HER2/neu-amplified by FISH. Overall, a reflex testing strategy was found to be less costly than a dual testing strategy ($44,470.99 vs. $45,908.86, respectively), but was also less effective (10.28 vs. 10.30 QALYs). The incremental cost-effectiveness ratio was $70,051.55/QALY. In conclusion, in this single institutional cohort of breast cancers, a dual testing strategy to determine HER2/neu status was found to be more cost-effective than a reflex testing strategy.
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Affiliation(s)
- Nosaibah Hariri
- Department of Pathology, Anatomic Pathology Division, University of California San Diego Health
- Department of Pathology, University of Tabuk School of Medicine, Tabuk, Saudi Arabia
| | - Somaye Zare
- Department of Pathology, Anatomic Pathology Division, University of California San Diego Health
| | - James Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Oluwole Fadare
- Department of Pathology, Anatomic Pathology Division, University of California San Diego Health
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Abstract
OBJECTIVES Understanding trends of marijuana use in the USA throughout a period of particularly high adoption of marijuana-legalisation, and understanding demographics most at risk of use, is important in evolving healthcare policy and intervention. This study analyses the demographic-specific changes in the prevalence of marijuana use in the USA between 2005 and 2018. DESIGN, SETTING AND PARTICIPANTS A 14-year retrospective cross-sectional analysis of the National Health and Nutrition Examination Survey database, a publicly available biennially collected national survey, weighted to represent the entire US population. A total of 35 212 adults between 18 and 69 years old participated in the seven-cycles of surveys analysed (2005-2018). PRIMARY OUTCOME MEASURED Lifetime use, first use before 18 years old, and past-year use of marijuana. RESULTS The majority of adults reported ever using marijuana. While the overall prevalence of lifetime marijuana use remained stable (p=0.53), past-year use increased significantly between 2005 and 2018 (p<0.001) with highest rate of past-year use among younger age groups (p<0.001), males (p<0.001) and those with income below poverty level (p<0.001). Past-year use was the most common among non-Hispanic blacks, and less common among Hispanic/Mexican populations (p<0.002). Trends in past-year use increased among all age categories, males/females, all ethnicities, those with high school education/above, and those at all income levels (p<0.01 for all). CONCLUSIONS While lifetime marijuana use remained stable, past-year use significantly increased between 2005 and 2018. While past-year use remained the most common in younger age groups, males, non-Hispanic blacks and those with lower income; increasing trends in past-year use were significant for all age, sex, race and income categories, and for those with high school education/above. With high adoption of marijuana-legalisation laws during this period, our results suggest an associated increase in past-year marijuana use.An accurate understanding of those most at risk can help to inform decisions of healthcare policy-makers and professionals, and facilitate a safe transition of changing marijuana legalisation and use in the USA.
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Affiliation(s)
- William Mitchell
- Harvard School of Public Health, Harvard University, Cambridge, Massachusetts, USA
| | - Roma Bhatia
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nazlee Zebardast
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Wolf J, Urits I, Orhurhu V, Peck J, Orhurhu MS, Giacomazzi S, Smoots D, Piermarini C, Manchikanti L, Kaye AD, Kaye RJ, Viswanath O. The Role of the Cannabinoid System in Pain Control: Basic and Clinical Implications. Curr Pain Headache Rep 2020; 24:35. [PMID: 32506272 DOI: 10.1007/s11916-020-00873-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a comprehensive update of the different known components of the endogenous cannabinoid system and the mechanisms of action, as it applies to analgesia. RECENT FINDINGS Following the discovery of the endogenous cannabinoid system in the early 1990s and the subsequent characterization of the cannabinoid receptor, there has been a renewed interest in cannabinoid research. Recent work has demonstrated its efficacy as a pharmacologic agent. There is limited evidence in the literature about the understanding of the endocannabinoid system and its role in the treatment and management of acute and chronic pain. Further work may elucidate additional roles for the endocannabinoid system within our nervous system and, moreover, additional subtypes of cannabinoid receptors have yet to be discovered. Cannabinoid compounds mediate their biological effects via binding and subsequent activation of cannabinoid receptors. These receptors are located throughout the body and make up the endocannabinoid system. These receptors are best understood and have been cloned, type 1 (CB1) and type 2 (CB2) [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)] [ (1, 2)]. The CB2 receptor is located primarily in the immune system. CB1 receptors are primarily located in the nervous system with the highest concentrations in the brain and lower concentrations in the spine and peripheral nervous tissues. Cannabinoids may be promising treatments for neuropathic pain with limited evidence, whereas, the evidence for other uses is insufficient.
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Affiliation(s)
- John Wolf
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Vwaire Orhurhu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jacquelin Peck
- Department of Anesthesiology, Mount Sinai Medical Center of Florida, Miami Beach, FL, USA
| | - Mariam Salisu Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Stephen Giacomazzi
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Daniel Smoots
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | | | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA.,Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA.,Department of Anesthesiology, University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA.,Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
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