1
|
de Barros GAM, Pos AM, Sousa ÂM, Pereira CL, Nobre CDDA, Palmeira CCDA, Caruy CAA, Munhoz DC, Kraychete DC, Avelar ECQ, Fukushima FB, Garcia JBS, Torres JNL, Rodrigues KDA, Palladini M, Neto ODHC, Carmona MJC. Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2024; 74:844513. [PMID: 38740135 PMCID: PMC11167254 DOI: 10.1016/j.bjane.2024.844513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 03/12/2024] [Accepted: 04/24/2024] [Indexed: 05/16/2024]
Abstract
There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.
Collapse
Affiliation(s)
| | | | - Ângela Maria Sousa
- Universidade de São Paulo (USP), Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
| | | | - Cecília Daniele de Azevedo Nobre
- Casa de Saúde São José (Rede Santa Catarina), Rio de Janeiro, RJ, Brazil; Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | | | | | - Derli Conceição Munhoz
- Faculdade de Medicina da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil
| | | | | | - Fernanda Bono Fukushima
- Universidade Estadual Paulista (Unesp), Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil
| | | | | | | | | | | | | |
Collapse
|
2
|
Stasiłowicz-Krzemień A, Nogalska W, Maszewska Z, Maleszka M, Dobroń M, Szary A, Kępa A, Żarowski M, Hojan K, Lukowicz M, Cielecka-Piontek J. The Use of Compounds Derived from Cannabis sativa in the Treatment of Epilepsy, Painful Conditions, and Neuropsychiatric and Neurodegenerative Disorders. Int J Mol Sci 2024; 25:5749. [PMID: 38891938 PMCID: PMC11171823 DOI: 10.3390/ijms25115749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Neurological disorders present a wide range of symptoms and challenges in diagnosis and treatment. Cannabis sativa, with its diverse chemical composition, offers potential therapeutic benefits due to its anticonvulsive, analgesic, anti-inflammatory, and neuroprotective properties. Beyond cannabinoids, cannabis contains terpenes and polyphenols, which synergistically enhance its pharmacological effects. Various administration routes, including vaporization, oral ingestion, sublingual, and rectal, provide flexibility in treatment delivery. This review shows the therapeutic efficacy of cannabis in managing neurological disorders such as epilepsy, neurodegenerative diseases, neurodevelopmental disorders, psychiatric disorders, and painful pathologies. Drawing from surveys, patient studies, and clinical trials, it highlights the potential of cannabis in alleviating symptoms, slowing disease progression, and improving overall quality of life for patients. Understanding the diverse therapeutic mechanisms of cannabis can open up possibilities for using this plant for individual patient needs.
Collapse
Affiliation(s)
- Anna Stasiłowicz-Krzemień
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Wiktoria Nogalska
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Zofia Maszewska
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Mateusz Maleszka
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Maria Dobroń
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Agnieszka Szary
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Aleksandra Kępa
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
| | - Marcin Żarowski
- Department of Developmental Neurology, Poznan University of Medical Sciences, Przybyszewski 49, 60-355 Poznan, Poland;
| | - Katarzyna Hojan
- Department of Occupational Therapy, Poznan University of Medical Sciences, Swięcickiego 6, 61-847 Poznan, Poland;
- Department of Rehabilitation, Greater Poland Cancer Centre, Garbary 15, 61-866 Poznan, Poland
| | - Malgorzata Lukowicz
- Department of Rehabilitation, Centre of Postgraduate Medical Education, Konarskiego 13, 05-400 Otwock, Poland;
| | - Judyta Cielecka-Piontek
- Department of Pharmacognosy and Biomaterials, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3, 60-806 Poznan, Poland; (A.S.-K.)
- Department of Pharmacology and Phytochemistry, Institute of Natural Fibres and Medicinal Plants, Wojska Polskiego 71b, 60-630 Poznan, Poland
| |
Collapse
|
3
|
Vitetta L, Henson JD. Comment on "Hall et al., Topical cannabidiol is well tolerated in individuals with a history of elite physical performance and chronic lower extremity pain". J Cannabis Res 2024; 6:13. [PMID: 38494522 PMCID: PMC10946142 DOI: 10.1186/s42238-023-00206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/23/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
- Luis Vitetta
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia.
| | - Jeremy D Henson
- Prince of Wales Clinical School, University of NSW, Sydney, NSW, 2052, Australia
| |
Collapse
|
4
|
Safi K, Sobieraj J, Błaszkiewicz M, Żyła J, Salata B, Dzierżanowski T. Tetrahydrocannabinol and Cannabidiol for Pain Treatment-An Update on the Evidence. Biomedicines 2024; 12:307. [PMID: 38397910 PMCID: PMC10886939 DOI: 10.3390/biomedicines12020307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024] Open
Abstract
In light of the current International Association for the Study of Pain (IASP) clinical practice guidelines (CPGs) and the European Society for Medical Oncology (ESMO) guidelines, the topic of cannabinoids in relation to pain remains controversial, with insufficient research presently available. Cannabinoids are an attractive pain management option due to their synergistic effects when administered with opioids, thereby also limiting the extent of respiratory depression. On their own, however, cannabinoids have been shown to have the potential to relieve specific subtypes of chronic pain in adults, although controversies remain. Among these subtypes are neuropathic, musculoskeletal, cancer, and geriatric pain. Another interesting feature is their effectiveness in chemotherapy-induced peripheral neuropathy (CIPN). Analgesic benefits are hypothesized to extend to HIV-associated neuropathic pain, as well as to lower back pain in the elderly. The aim of this article is to provide an up-to-date review of the existing preclinical as well as clinical studies, along with relevant systematic reviews addressing the roles of various types of cannabinoids in neuropathic pain settings. The impact of cannabinoids in chronic cancer pain and in non-cancer conditions, such as multiple sclerosis and headaches, are all discussed, as well as novel techniques of administration and relevant mechanisms of action.
Collapse
Affiliation(s)
| | | | | | | | | | - Tomasz Dzierżanowski
- Palliative Medicine Clinic, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warsaw, Poland
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Leinen ZJ, Mohan R, Premadasa LS, Acharya A, Mohan M, Byrareddy SN. Therapeutic Potential of Cannabis: A Comprehensive Review of Current and Future Applications. Biomedicines 2023; 11:2630. [PMID: 37893004 PMCID: PMC10604755 DOI: 10.3390/biomedicines11102630] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
Historically, cannabis has been valued for its pain-relieving, anti-inflammatory, and calming properties. Ancient civilizations like the Egyptians, Greeks, and Chinese medicines recognized their therapeutic potential. The discovery of the endocannabinoid system, which interacts with cannabis phytoconstituents, has scientifically explained how cannabis affects the human immune system, including the central nervous system (CNS). This review explores the evolving world of cannabis-based treatments, spotlighting its diverse applications. By researching current research and clinical studies, we probe into how cannabinoids like Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) help to manage conditions ranging from chronic pain, persistent inflammation, cancer, inflammatory bowel disease, and neurological disorders to even viral diseases such as Human Immunodeficiency virus (HIV), SARS-CoV-2. and the emerging monkeypox. The long-term recreational use of cannabis can develop into cannabis use disorder (CUD), and therefore, understanding the factors contributing to the development and maintenance of cannabis addiction, including genetic predisposition, neurobiological mechanisms, and environmental influences, will be timely. Shedding light on the adverse impacts of CUD underscores the importance of early intervention, effective treatment approaches, and public health initiatives to address this complex issue in an evolving landscape of cannabis policies and perceptions.
Collapse
Affiliation(s)
- Zach J. Leinen
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68182, USA; (Z.J.L.); (R.M.); (A.A.)
| | - Rahul Mohan
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68182, USA; (Z.J.L.); (R.M.); (A.A.)
| | - Lakmini S. Premadasa
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA; (L.S.P.); (M.M.)
| | - Arpan Acharya
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68182, USA; (Z.J.L.); (R.M.); (A.A.)
| | - Mahesh Mohan
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX 78227, USA; (L.S.P.); (M.M.)
| | - Siddappa N. Byrareddy
- Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE 68182, USA; (Z.J.L.); (R.M.); (A.A.)
| |
Collapse
|
7
|
Ferraro MC, Cashin AG, Wand BM, Smart KM, Berryman C, Marston L, Moseley GL, McAuley JH, O'Connell NE. Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews. Cochrane Database Syst Rev 2023; 6:CD009416. [PMID: 37306570 PMCID: PMC10259367 DOI: 10.1002/14651858.cd009416.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. OBJECTIVES To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. METHODS We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria. Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment. MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison. There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181). There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. AUTHORS' CONCLUSIONS Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.
Collapse
Affiliation(s)
- Michael C Ferraro
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Aidan G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Benedict M Wand
- The School of Health Sciences and Physiotherapy, The University of Notre Dame Australia, Fremantle, Australia
| | - Keith M Smart
- UCD School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
- Physiotherapy Department, St Vincent's University Hospital, Dublin, Ireland
| | - Carolyn Berryman
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
- School of Biomedicine, The University of Adelaide, Kaurna Country, Adelaide, Australia
| | - Louise Marston
- Department of Primary Care and Population Health, University College London, London, UK
| | - G Lorimer Moseley
- IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, South Australia, Australia
| | - James H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Neil E O'Connell
- Department of Health Sciences, Centre for Health and Wellbeing Across the Lifecourse, Brunel University London, Uxbridge, UK
| |
Collapse
|
8
|
Hübner J, Keinki C, Büntzel J. [Complementary and alternative medicine-An option for chronic pain patients?]. Schmerz 2023; 37:215-227. [PMID: 37154977 DOI: 10.1007/s00482-023-00719-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/04/2023] [Accepted: 04/05/2023] [Indexed: 05/10/2023]
Abstract
The interest of patients with chronic pain in complementary and alternative medicine (CAM) is high. The aim of an accompanying complementary therapy is to strengthen the patient's self-efficacy, the ability to make decisions and the autonomy. The best evidence exists for physical activity and a balanced diet. Exercise combinations of strength and endurance as well as targeted strengthening of the muscles in the area of the pain are particularly suitable. When choosing the form of exercise, low-threshold training options are recommended. There is no reliable evidence for kinesio taping, homeopathy, neural therapy and draining procedures. The extensive data on acupuncture must be interpreted taking methodological limitations into account. Heat applications can support multimodal pain therapy. In the case of anti-inflammatory phytotherapeutic agents, there are good rationales from basic research and reliable empirical knowledge regarding the dosage. The evidence on cannabis is low.
Collapse
Affiliation(s)
- Jutta Hübner
- Klinik für Innere Medizin II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - Christian Keinki
- Klinik für Innere Medizin II, Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Jens Büntzel
- Klinik für Hals-Nasen-Ohren-Krankheiten, Abteilung für Palliativmedizin, Südharzklinikum Nordhausen, Nordhausen, Deutschland
| |
Collapse
|
9
|
McParland AL, Bhatia A, Matelski J, Tian C, Diep C, Clarke H, Kapustin D, Triveda A, Brull R, Singh M. Evaluating the impact of cannabinoids on sleep health and pain in patients with chronic neuropathic pain: a systematic review and meta-analysis of randomized controlled trials. Reg Anesth Pain Med 2023; 48:180-190. [PMID: 36598058 DOI: 10.1136/rapm-2021-103431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 10/25/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Chronic neuropathic pain is often debilitating and can have a significant impact on sleep health and quality of life. There is limited information on the impact of cannabinoids on sleep health when treating neuropathic pain. OBJECTIVE The objectives of this systematic review and meta-analysis were to determine the effect of cannabinoids on sleep quality, pain intensity, and patient impression of treatment efficacy in patients with neuropathic pain. EVIDENCE REVIEW Nine available medical literature databases were searched for randomized controlled trials comparing synthetic and natural cannabinoids to placebo in patients with neuropathic pain syndromes. Data on validated tools for sleep quality, pain intensity, patients' global impression of change (PGIC), and incidence of adverse effects of cannabinoids were extracted and synthesized. FINDINGS Of the 3491 studies screened, eight randomized controlled trials satisfied the inclusion criteria for this review. Analyses were performed using R -4.1.2. using the metafor package and are interpreted using alpha=0.05 as the threshold for statistical significance. Validated measures for sleep health were not used in most studies. Meta-analysis of data from six studies showed that cannabinoids were associated with a significant improvement in sleep quality (standardized mean difference (SMD): 0.40; 95% CI: 0.19 to -0.61, 95% prediction interval (PI): -0.12 to 0.88, p-value=0.002, I2=55.26, τ2=0.05, Q-statistic=16.72, GRADE: moderate certainty). Meta-analysis of data from eight studies showed a significant reduction in daily pain scores in the cannabinoid (CB) group (SMD: -0.55, 95% CI:-0.69 to -0.19, 95% PI: -1.51 to 0.39, p=0.003, I2=82.49, τ2=0.20, Q-statistic=47.69, GRADE: moderate certainty). However, sleep health and analgesic benefits were associated with a higher likelihood of experiencing daytime somnolence, nausea, and dizziness. CONCLUSIONS Cannabinoids have a role in treating chronic neuropathic pain as evidenced by significant improvements in sleep quality, pain intensity, and PGIC. More research is needed to comprehensively evaluate the impact of cannabinoids on sleep health and analgesic efficacy. PROSPERO REGISTRATION NUMBER CRD42017074255.
Collapse
Affiliation(s)
- Aidan Leonard McParland
- Department of Emergency Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anuj Bhatia
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Chenchen Tian
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Calvin Diep
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Hance Clarke
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kapustin
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Aditya Triveda
- School of Graduate Studies, McMaster University, Hamilton, Ontario, Canada
| | - Richard Brull
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Müller-Vahl KR, Pisarenko A, Szejko N, Haas M, Fremer C, Jakubovski E, Musil R, Münchau A, Neuner I, Huys D, van Elst LT, Schröder C, Ringlstetter R, Koch A, Jenz EB, Großhennig A. CANNA-TICS: Efficacy and safety of oral treatment with nabiximols in adults with chronic tic disorders - Results of a prospective, multicenter, randomized, double-blind, placebo controlled, phase IIIb superiority study. Psychiatry Res 2023; 323:115135. [PMID: 36878177 DOI: 10.1016/j.psychres.2023.115135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/08/2023]
Abstract
Preliminary data suggest that cannabis-based medicines might be a promising new treatment for patients with Tourette syndrome (TS)/chronic tic disorders (CTD) resulting in an improvement of tics, comorbidities, and quality of life. This randomized, multicenter, placebo-controlled, phase IIIb study aimed to examine efficacy and safety of the cannabis extract nabiximols in adults with TS/CTD (n = 97, randomized 2:1 to nabiximols:placebo). The primary efficacy endpoint was defined as a tic reduction of ≥ 25% according to the Total Tic Score of the Yale Global Tic Severity Scale after 13 weeks of treatment. Although a much larger number of patients in the nabiximols compared to the placebo group (14/64 (21·9%) vs. 3/33 (9·1%)) met the responder criterion, superiority of nabiximols could formally not be demonstrated. In secondary analyses, substantial trends for improvements of tics, depression, and quality of life were observed. Additionally exploratory subgroup analyses revealed an improvement of tics in particular in males, patients with more severe tics, and patients with comorbid attention deficit/hyperactivity disorder suggesting that these subgroups may benefit better from treatment with cannabis-based medication. There were no relevant safety issues. Our data further support the role of cannabinoids in the treatment of patients with chronic tic disorders.
Collapse
Affiliation(s)
- Kirsten R Müller-Vahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Anna Pisarenko
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Natalia Szejko
- Department of Neurology, Medical University of Warsaw, Poland; Department of Bioethics, Medical University of Warsaw, Poland
| | - Martina Haas
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Carolin Fremer
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Ewgeni Jakubovski
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Richard Musil
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Alexander Münchau
- Institute of Systems Motor Science, University of Lübeck, Lübeck, Germany
| | - Irene Neuner
- Departments of Psychiatry, Psychotherapy, and Psychosomatics, School of Medicine, RWTH Aachen University, Aachen, Germany; Institute of Neuroscience and Medicine (INM-4), Forschungszentrum Jülich, Jülich, Germany; JARA-BRAIN - Translational Medicine, Aachen, Germany
| | - Daniel Huys
- Department of Psychiatry and Psychotherapy, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany; Department of Psychiatry and Psychotherapy III, LVR Hospital Bonn, Bonn, Germany
| | - Ludger Tebartz van Elst
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Schröder
- Institute of Clinical Pharmacology, Hannover Medical School, Hannover, Germany
| | - Rieke Ringlstetter
- Institute of Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Armin Koch
- Institute of Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Eva Beate Jenz
- Institute of Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany
| | - Anika Großhennig
- Institute of Biostatistics, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover 30625, Germany.
| |
Collapse
|
11
|
A large Australian longitudinal cohort registry demonstrates sustained safety and efficacy of oral medicinal cannabis for at least two years. PLoS One 2022; 17:e0272241. [PMCID: PMC9674134 DOI: 10.1371/journal.pone.0272241] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction
Oral medicinal cannabis (MC) has been increasingly prescribed for a wide range of clinical conditions since 2016. Despite an exponential rise in prescriptions and publications, high quality clinical efficacy and safety studies are lacking. The outcomes of a large Australian clinical electronic registry cohort are presented.
Methods
A prospective cannabis-naïve patient cohort prescribed oral MC participated in an ongoing longitudinal registry at a network of specialised clinics. Patient MC dose, safety and validated outcome data were collected regularly over two years and analysed.
Results
3,961 patients (mean age 56.07 years [SD 19.08], 51.0% female) with multimorbidity (mean diagnoses 5.14 [SD 4.08]) and polypharmacy (mean 6.26 medications [SD 4.61]) were included in this analysis. Clinical indications were for: chronic pain (71.9%), psychiatric (15.4%), neurological (2.1%), and other diagnoses (10.7%). Median total oral daily dose was 10mg for Δ9-tetrahydrocannabinol (THC) and 22.5mg for cannabidiol (CBD). A stable dose was observed for over two years. 37.3% experienced treatment related adverse events. These were graded mild (67%), moderate (31%), severe (<2%, n = 23) and two (0.1%) serious adverse events. Statistically significant improvements at a p value of <0.001 across all outcomes were sustained for over two years, including: clinical global impression (CGI-E, +39%: CGI-I, +52%; p<0.001), pain interference and severity (BPI, 26.1% and 22.2%; p<0.001), mental health (DASS-21, depression 24.5%, anxiety 25.5%, stress 27.7%; p<0.001), insomnia (ISI, 35.0%; p<0.001), and health status (RAND SF36: physical function, 34.4%: emotional well-being, 37.3%; p<0.001). Mean number of concomitant medications did not significantly change over 2 years (p = 0.481).
Conclusions
Oral MC was demonstrated to be safe and well-tolerated for a sustained period in a large complex cohort of cannabis-naïve, multimorbid patients with polypharmacy. There was significant improvement (p<0.001) across all measured clinical outcomes over two years. Results are subject to limitations of Real World Data (RWD) for causation and generalisability. Future high quality randomised controlled trials are awaited.
Collapse
|
12
|
Sepulveda DE, Vrana KE, Graziane NM, Raup-Konsavage WM. Combinations of Cannabidiol and Δ 9-Tetrahydrocannabinol in Reducing Chemotherapeutic Induced Neuropathic Pain. Biomedicines 2022; 10:biomedicines10102548. [PMID: 36289810 PMCID: PMC9599350 DOI: 10.3390/biomedicines10102548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Neuropathic pain is a condition that impacts a substantial portion of the population and is expected to affect a larger percentage in the future. This type of pain is poorly managed by current therapies, including opioids and NSAIDS, and novel approaches are needed. We used a cisplatin-induced model of neuropathic pain in mice to assess the effects of the cannabinoids THC and CBD alone or in varying ratios as anti-nociceptive agents. In addition to testing pure compounds, we also tested extracts containing high THC or CBD at the same ratios. We found that pure CBD had little impact on mechanical hypersensitivity, whereas THC reduced mechanical hypersensitivity in both male and female mice (as has been reported in the literature). Interestingly, we found that high CBD cannabis extract, at the same CBD dose as pure CBD, was able to reduce mechanical hypersensitivity, although not to the same level as high THC extract. These data suggest that, at least for CBD-dominant cannabis extracts, there is an increase in the anti-nociceptive activity that may be attributed to other constitutes of the plant. We also found that high THC extract or pure THC is the most efficacious treatment for reducing neuropathic pain in this model.
Collapse
Affiliation(s)
- Diana E. Sepulveda
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA 17033, USA
- Department of Anesthesiology & Perioperative Medicine, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Kent E. Vrana
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA 17033, USA
| | - Nicholas M. Graziane
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA 17033, USA
- Department of Anesthesiology & Perioperative Medicine, Penn State College of Medicine, Hershey, PA 17033, USA
- Correspondence: (N.M.G.); (W.M.R.-K.); Tel.: +717-531-8433 (N.M.G.); +717-531-4172 (W.M.R.-K.)
| | - Wesley M. Raup-Konsavage
- Department of Pharmacology, Penn State College of Medicine, Hershey, PA 17033, USA
- Correspondence: (N.M.G.); (W.M.R.-K.); Tel.: +717-531-8433 (N.M.G.); +717-531-4172 (W.M.R.-K.)
| |
Collapse
|
13
|
Giossi R, Carrara F, Padroni M, Bilancio MC, Mazzari M, Enisci S, Romio MS, Boni G, Corrù F, Fittipaldo VA, Tramacere I, Pani A, Scaglione F, Fornasari D. Systematic Review and Meta-analysis Seem to Indicate that Cannabinoids for Chronic Primary Pain Treatment Have Limited Benefit. Pain Ther 2022; 11:1341-1358. [PMID: 36129666 PMCID: PMC9633894 DOI: 10.1007/s40122-022-00434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The IASP ICD-11 chronic primary pain (CPP) definition includes 19 different painful conditions. In recent years, interest in the potential role of cannabinoids in the management of CPP has increased, since they demonstrated a possible efficacy in treating pain, especially in secondary pain conditions. However, limited evidence is available for patients with CPP. The aim of this systematic review and meta-analysis is to evaluate the efficacy and safety of cannabinoid administration in CPP. METHODS PubMed, EMBASE, and Cochrane Library were searched form the beginning up to 31 October 2021 to retrieve published articles of randomized controlled trials (RCTs) or observational, retrospective or prospective, studies, investigating cannabinoids in CPP. The study screening process was completed during November 2021. The primary outcome was pain reduction by means of the visual analogue scale (VAS). Secondary outcomes were quality of life by means of the fibromyalgia impact questionnaire (FIQ) or other available scales, appetite, anxiety, depression, and sleep by means of any available scales. Safety was assessed with the reporting of serious adverse events (SAE) and discontinuation due to adverse events. Risk of bias was assessed. The weighted generic inverse variance method and Mantel-Haenszel method were used to estimate the mean difference (MD) and odds ratios (OR) with 95% confidence intervals (CI) for continuous and dichotomous outcomes, respectively. For outcome measures reported with different scales (pain, anxiety, depression), we used the standardized MD (SMD) as the effect measure and then converted it into units of the VAS scale for pain, the Beck Anxiety Inventory (BAI) for anxiety, and the Beck Depression Inventory (BDI) for depression. Summary of findings was produced using GRADEproGDT. RESULTS From 3007 identified records, we included eight articles reporting the results of eight different RCTs (four parallel and four crossover studies; seven compared to placebo and one to amitriptyline), with a total population of 240 patients. VAS pain reduction was non-significant for cannabinoids against placebo (MD = - 0.64; 95% CI - 1.30 to 0.02) or amitriptyline (MD = - 0.19; 95% CI - 0.58 to 0.19). More than 4 weeks cannabinoid treatment significantly reduced pain compared to placebo in parallel studies with more than 4 weeks of treatment duration (MD = - 1.28; 95% CI - 2.33 to - 0.22). Differences for the FIQ (MD = - 21.69; 95% CI - 46.20 to 2.82), BAI (MD = - 2.32; 95% CI - 7.99 to 3.08), and BDI (MD = 2.32; 95% CI - 1.71 to 6.35) were non-significant, likewise for discontinuation due to adverse events (OR = 2.15; 95% CI 0.44-10.65), when comparing cannabinoids to placebo. The quality of the evidence was generally low mainly as a result of imprecision and risk of bias. CONCLUSION Cannabinoid treatment in patients with CPP had limited benefit on pain relief; however, it might improve pain with long-term administration.
Collapse
Affiliation(s)
- Riccardo Giossi
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy. .,Department of Research and Clinical Development, Scientific Directorate, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy. .,Neuroimmunology and Neuromuscular Diseases Unit, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy.
| | - Federica Carrara
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Matteo Padroni
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Maria Concetta Bilancio
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Martina Mazzari
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Silvia Enisci
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Maria Silvia Romio
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Gloria Boni
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Federica Corrù
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | | | - Irene Tramacere
- Department of Research and Clinical Development, Scientific Directorate, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Via Celoria 11, 20133, Milan, Italy
| | - Arianna Pani
- Department of Oncology and Hemato-Oncology, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Hemato-Oncology, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| | - Diego Fornasari
- Department of Medical Biotechnology and Translational Medicine, Postgraduate School of Clinical Pharmacology and Toxicology, Università degli Studi di Milano, Milan, Italy
| |
Collapse
|
14
|
Vila Silván C, Vaney C, Dykukha I. Systematic reviews of randomized controlled trials of cannabinoid products in chronic pain conditions and for symptoms associated with multiple sclerosis: what do they tell us? Expert Rev Clin Pharmacol 2022; 15:415-431. [PMID: 35679523 DOI: 10.1080/17512433.2022.2088501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION : To investigate whether published systematic reviews of randomized controlled trials provide sufficient clarity to inform prescribing of cannabinoid products aimed for medicinal use, we examined their features and findings in two well-researched areas: chronic cancer/noncancer pain and multiple sclerosis (MS)-related symptoms. AREAS COVERED : Structured searches from January 2011 to 2 February 2021 identified 31 systematic reviews (with/without meta-analyses) that met the inclusion criteria. Support for the efficacy of cannabinoids was minimal in cancer pain, and somewhat stronger in noncancer (especially neuropathic) pain and MS spasticity. All systematic reviews and most meta-analyses grouped cannabinoid products together without appropriate consideration of their differential attributes (active constituent(s), concentration/strength, dosage forms, administration route), dosing regimens or treatment durations. Patient populations and efficacy outcome measures were inhomogeneous, particularly for studies in noncancer pain and MS. Separate results for specific cannabinoid formulations were rarely provided. EXPERT OPINION : The therapeutic effect of cannabinoids, as already demonstrated for some products, is not reflected clearly in the current range of systematic reviews and meta-analyses in chronic pain and MS. To truly inform evidence-based practice, future publications should aim to present results by individual product from well-conducted clinical trials using appropriate and homogeneous outcome measures in well-defined patient populations.
Collapse
Affiliation(s)
| | - Claude Vaney
- Médecin-Adjoint, Clinique de Réhabilitation, HFR Meyriez-Murten, Meyriez, Switzerland
| | - Igor Dykukha
- Medical Affairs, Almirall Hermal GmbH, Scholtzstrasse 3, Reinbek, Germany
| |
Collapse
|
15
|
Quintero JM, Pulido G, Giraldo LF, Leon MX, Diaz LE, Bustos RH. A Systematic Review on Cannabinoids for Neuropathic Pain Administered by Routes Other than Oral or Inhalation. PLANTS 2022; 11:plants11101357. [PMID: 35631782 PMCID: PMC9145866 DOI: 10.3390/plants11101357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/16/2022]
Abstract
The use of cannabis and cannabinoid products for the treatment of neuropathic pain is a growing area of research. This type of pain has a high prevalence, limited response to available therapies and high social and economic costs. Systemic cannabinoid-based therapies have shown some unwanted side effects. Alternative routes of administration in the treatment of neuropathic pain may provide better acceptance for the treatment of multiple pathologies associated with neuropathic pain. To examine the efficacy, tolerability, and safety of cannabinoids (individualized formulations, phytocannabinoids, and synthetics) administered by routes other than oral or inhalation compared to placebo and/or conventional medications in the management of neuropathic pain. This systematic review of the literature reveals a lack of clinical research investigating cannabis by routes other than oral and inhalation as a potential treatment for neuropathic pain and highlights the need for further investigation with well-designed clinical trials. There is a significant lack of evidence indicating that cannabinoids administered by routes other than oral or inhaled may be an effective alternative, with better tolerance and safety in the treatment of neuropathic pain. Higher quality, long-term, randomized controlled trials are needed to examine whether cannabinoids administered by routes other than inhalation and oral routes may have a role in the treatment of neuropathic pain.
Collapse
Affiliation(s)
- Jose-Manuel Quintero
- Department of Clinical Pharmacology, Evidence-Based Therapeutics Group, Faculty of Medicine, Clínica Universidad de La Sabana, Universidad de La Sabana, Campus del Puente del Común, Km. 7, Autopista Norte de Bogotá, Chía 140013, Colombia; (J.-M.Q.); (G.P.)
- Doctoral Programme of Biosciences, Universidad de La Sabana, Chía 140013, Colombia
| | - German Pulido
- Department of Clinical Pharmacology, Evidence-Based Therapeutics Group, Faculty of Medicine, Clínica Universidad de La Sabana, Universidad de La Sabana, Campus del Puente del Común, Km. 7, Autopista Norte de Bogotá, Chía 140013, Colombia; (J.-M.Q.); (G.P.)
| | - Luis-Fernando Giraldo
- Epidemiology and Biostatistics Department, School of Medicine, Universidad de La Sabana, Chía 140013, Colombia;
- Internal Medicine, Universidad de La Sabana, Chía 140013, Colombia
- Interventional Pulmonology and Research Department, Fundación Neumológica Colombiana, Bogotá D.C. 110131, Colombia
| | - Marta-Ximena Leon
- Grupo Dolor y Cuidados Paliativos, Universidad de La Sabana, Chía 140013, Colombia;
| | - Luis-Eduardo Diaz
- Facultad de Ingeniería, Universidad de La Sabana, Campus del Puente del Común, Km. 7, Autopista Norte, Chía 140013, Colombia;
| | - Rosa-Helena Bustos
- Department of Clinical Pharmacology, Evidence-Based Therapeutics Group, Faculty of Medicine, Clínica Universidad de La Sabana, Universidad de La Sabana, Campus del Puente del Común, Km. 7, Autopista Norte de Bogotá, Chía 140013, Colombia; (J.-M.Q.); (G.P.)
- Correspondence: ; Tel.: +57-1608615555
| |
Collapse
|
16
|
Badiola I, Doshi A, Narouze S. Cannabis, cannabinoids, and cannabis-based medicines: future research directions for analgesia. Reg Anesth Pain Med 2022; 47:rapm-2021-103109. [PMID: 35534020 DOI: 10.1136/rapm-2021-103109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
Abstract
The use of cannabis spans thousands of years and encompasses almost all dimensions of the human experience, including consumption for recreational, religious, social, and medicinal purposes. Its use in the management of pain has been anecdotally described for millennia. However, an evidence base has only developed over the last 100 years, with an explosion in research occurring in the last 20-30 years, as more states in the USA as well as countries worldwide have legalized and encouraged its use in pain management. Pain remains one of the most common reasons for individuals deciding to use cannabis medicinally. However, cannabis remains illegal at the federal level in the USA and in most countries of the world, making it difficult to advance quality research on its efficacy for pain treatment. Nonetheless, new products derived both from the cannabis plant and the chemistry laboratory are being developed for use as analgesics. This review examines the current landscape of cannabinoids research and future research directions in the management of pain.
Collapse
Affiliation(s)
- Ignacio Badiola
- Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Doshi
- Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| |
Collapse
|
17
|
The Efficacy of Cannabis on Multiple Sclerosis-Related Symptoms. Life (Basel) 2022; 12:life12050682. [PMID: 35629350 PMCID: PMC9148011 DOI: 10.3390/life12050682] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/21/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Multiple sclerosis (MS) is known as an autoimmune disease that damages the neurons in the central nervous system. MS is characterized by its most common symptoms of spasticity, muscle spasms, neuropathic pain, tremors, bladder dysfunction, dysarthria, and some intellectual problems, including memory disturbances. Several clinical studies have been conducted to investigate the effects of cannabis on the relief of these symptoms in MS patients. The efficacy of Cannabis sativa (C. Sativa) in the management of MS outcomes such as spasticity, pain, tremors, ataxia, bladder functions, sleep, quality of life, and adverse effects were assessed in this review. Most clinical studies showed the positive effects of cannabinoids with their different routes of administration, such as oromucosal spray and oral form, in reducing most MS symptoms. The oromucosal spray Nabiximols demonstrated an improvement in reducing MS spasticity, pain, and quality of life with a tolerated adverse effect. Oral cannabinoids are significantly effective for treating MS pain and spasticity, while the other symptoms indicate slight improvement and the evidence is quite inconsistent. Oromucosal spray and oral cannabis are mainly used for treating patients with MS and have positive effects on treating the most common symptoms of MS, such as pain and spasticity, whereas the other MS symptoms indicated slight improvement, for which further studies are needed.
Collapse
|
18
|
Cannabis for Rheumatic Disease Pain: a Review of Current Literature. Curr Rheumatol Rep 2022; 24:119-131. [PMID: 35486218 DOI: 10.1007/s11926-022-01065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Changing attitudes about marijuana have led to an increase in use of medicinal marijuana, especially for painful chronic conditions. Patients ask rheumatologists for guidance on this topic. This review provides up-to-date information on the safety and efficacy of medicinal cannabis for rheumatic disease pain. RECENT FINDINGS The number of publications related to rheumatic disease and cannabis has increased, but recent literature skews heavily toward reviews vs primary research. Data supporting a role for cannabinoids in rheumatic disease continue to grow. Observational and survey studies show increased use of medicinal cannabis, both by people with rheumatic disease and the general population, and suggest that patients find these treatments beneficial. Prospective studies, however, including randomized controlled clinical trials, are rare and sorely needed. As medicinal cannabis use for rheumatic diseases rises, despite lack of evidence, we review the sparse data available and provide tips for conversations about medicinal cannabis for rheumatologists.
Collapse
|
19
|
Karst M. [Cannabinoids for the treatment of chronic neuropathic pain and spasticity]. MMW Fortschr Med 2022; 164:51-60. [PMID: 35359293 DOI: 10.1007/s15006-022-0828-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Matthias Karst
- Medizinische Hochschule Hannover, Klinik f. Anästhesiologie u. Intensivmedizin, Carl-Neuberger Str. 1, 30625, Hannover, Germany.
| |
Collapse
|
20
|
Ueberall MA, Essner U, Vila Silván C, Mueller-Schwefe GHH. Comparison of the Effectiveness and Tolerability of Nabiximols (THC:CBD) Oromucosal Spray versus Oral Dronabinol (THC) as Add-on Treatment for Severe Neuropathic Pain in Real-World Clinical Practice: Retrospective Analysis of the German Pain e-Registry. J Pain Res 2022; 15:267-286. [PMID: 35140513 PMCID: PMC8819705 DOI: 10.2147/jpr.s340968] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the effectiveness and tolerability of add-on treatment with nabiximols (NBX: delta-9-tetrahydrocannabinol: cannabidiol) oromucosal spray or oral dronabinol (DRO: synthetic tetrahydrocannabinol) in patients with severe neuropathic pain poorly responsive to established treatments. Methods An analysis was conducted of anonymized, propensity score-matched real-world data from the German Pain e-Registry, using a sequential non-inferiority superiority approach, for adult outpatients with neuropathic pain who had initiated treatment with NBX or DRO between 10 March 2017 and 31 December 2019. The primary effectiveness variable was percent change from baseline in a 9-factor aggregated symptom relief (ASR-9) score, a composite index of nine distinct pain- and health-related parameters assessed using validated patient-reported instruments. Safety was assessed by the incidence of physician-confirmed treatment-related adverse events (TRAEs), and TRAEs leading to discontinuation. Results Propensity score-matched data were analyzed for 337 patients treated with NBX and 337 patients treated with DRO. Mean (standard deviation) THC dose over the 24-week evaluation period was 16.6 (6.5) mg for NBX and 17.2 (7.6) mg for DRO (p<0.001). Median (standard error) improvement relative to baseline in the ASR-9 composite score was 55.4% (0.5) for NBX and 40.5% (0.5) for DRO (least squares mean difference, 14.0 (0.7), 95% confidence interval 12.6–15.4; p<0.001), and incidences of TRAEs (21.1 vs 35%) and TRAE-related discontinuations (5.9 vs 14.8%) were significantly lower with NBX than DRO (p<0.001 for both), collectively indicating pre-specified non-inferiority and superiority of NBX. More NBX- than DRO-treated patients discontinued non-cannabinoid background pain medications and rescue analgesics, especially opioid analgesics (p<0.001 for both). Conclusion Add-on treatment with cannabinoids is effective for treatment of severe neuropathic pain with inadequate response to established treatments. In daily practice, NBX had superior effectiveness and tolerability compared to DRO. The results emphasize the importance of combining CBD with THC in this patient population.
Collapse
Affiliation(s)
- Michael A Ueberall
- Center of Excellence in Health Care Research of the German Pain Association, Institute of Neurological Sciences, Nuernberg, Germany
- Correspondence: Michael A Ueberall Center of Excellence in Health Care Research of the German Pain Association, Institute of Neurological Sciences, Nordostpark 51, Nuernberg, 90411, GermanyTel +49 911 21773760Fax +49 911 21773761 Email
| | - Ute Essner
- Medical Department, O. Meany Consultancy GmbH, Hamburg, Germany
| | | | | |
Collapse
|
21
|
Petzke F, Tölle T, Fitzcharles MA, Häuser W. Cannabis-Based Medicines and Medical Cannabis for Chronic Neuropathic Pain. CNS Drugs 2022; 36:31-44. [PMID: 34802112 PMCID: PMC8732831 DOI: 10.1007/s40263-021-00879-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2021] [Indexed: 12/25/2022]
Abstract
Neuropathic pain represents a broad category of pain syndromes that include a wide variety of peripheral and central disorders. The overall prevalence of neuropathic pain in the general population is reported to be between 7 and 10%. Management of neuropathic pain presents an unmet clinical need, with less than 50% of patients achieving substantial pain relief with medications currently recommended such as pregabalin, gabapentin, duloxetine and various tricyclic antidepressants. It has been suggested that cannabis-based medicines (CbMs) and medical cannabis (MC) may be a treatment option for those with chronic neuropathic pain. CbMs/MC are available in different forms: licensed medications or medical products (plant-derived and/or synthetic products such as tetrahydrocannabinol or cannabidiol); magistral preparations of cannabis plant derivatives with defined molecular content such as dronabinol (tetrahydrocannabinol); and herbal cannabis with a defined content of tetrahydrocannabinol and/or cannabidiol, together with other active ingredients (phytocannabinoids other than cannabidiol/tetrahydrocannabinol, terpenes and flavonoids). The availability of different types of CbMs/MC varies between countries worldwide. Systematic reviews of available randomised controlled trials have stated low-quality evidence for CbMs and MC for chronic neuropathic pain. Depending on the studies included in the various quantitative syntheses, authors have reached divergent conclusions on the efficacy of CbMs/MC for chronic neuropathic pain (from not effective to a clinically meaningful benefit). Clinically relevant side effects of CbMs/MC, especially for central nervous system and psychiatric disorders, have been reported by some systematic reviews. Recommendations for the use of CbMs/MC for chronic neuropathic pain by various medical associations also differ, from negative recommendations, no recommendation possible, recommended as third-line therapy, or recommended as an alternative in selected cases failing standard therapies within a multimodal concept. After reading this paper, readers are invited to formulate their own conclusions regarding the potential benefits and harms of CbMs/MC for the treatment of chronic neuropathic pain.
Collapse
Affiliation(s)
- Frank Petzke
- Universitätsmedizin Göttingen, Göttingen, Germany
| | - Thomas Tölle
- Department of Neurology, Technische Universität München, Munich, Germany
| | - Mary-Ann Fitzcharles
- Alan Edwards Pain Management Unit, McGill University Health Center, Montreal, QC Canada ,Division of Rheumatology, McGill University Health Centre, Quebec, QC Canada
| | - Winfried Häuser
- Internal Medicine 1, Klinikum Saarbrücken gGmbH, Winterberg 1, 66119, Saarbrücken, Germany. .,Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, Munich, Germany.
| |
Collapse
|
22
|
Ward SJ, Lichtman AH, Piomelli D, Parker LA. Cannabinoids and Cancer Chemotherapy-Associated Adverse Effects. J Natl Cancer Inst Monogr 2021; 2021:78-85. [PMID: 34850893 DOI: 10.1093/jncimonographs/lgab007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022] Open
Abstract
The use of cannabis is not unfamiliar to many cancer patients, as there is a long history of its use for cancer pain and/or pain, nausea, and cachexia induced by cancer treatment. To date, the US Food and Drug Administration has approved 2 cannabis-based pharmacotherapies for the treatment of cancer chemotherapy-associated adverse effects: dronabinol and nabilone. Over the proceeding decades, both research investigating and societal attitudes toward the potential utility of cannabinoids for a range of indications have progressed dramatically. The following monograph highlights recent preclinical research focusing on promising cannabinoid-based approaches for the treatment of the 2 most common adverse effects of cancer chemotherapy: chemotherapy-induced peripheral neuropathy and chemotherapy-induced nausea and vomiting. Both plant-derived and synthetic approaches are discussed, as is the potential relative safety and effectiveness of these approaches in relation to current treatment options, including opioid analgesics.
Collapse
Affiliation(s)
- Sara Jane Ward
- Department of Neural Sciences, Center for Substance Abuse Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Aron H Lichtman
- Department of Pharmacology and Toxicology, Department of Medicinal Chemistry, Virginia Commonwealth University, Richmond, VA, USA
| | - Daniele Piomelli
- Department of Anatomy and Neurobiology, Center for the Study of Cannabis, University of California, Irvine, CA, USA
| | - Linda A Parker
- Department of Psychology and Neuroscience, University of Guelph, Guelph, Ontario, Canada
| |
Collapse
|
23
|
Ueberall MA, Vila Silván C, Essner U, Mueller-Schwefe GHH. Effectiveness, safety and tolerability of nabiximols oromucosal spray versus typical oral long-acting opioid analgesics in patients with severe neuropathic back pain: analysis of 6-month real-world data from the German Pain e-Registry. PAIN MEDICINE 2021; 23:745-760. [PMID: 34480564 PMCID: PMC8992580 DOI: 10.1093/pm/pnab263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/20/2021] [Accepted: 08/24/2021] [Indexed: 12/22/2022]
Abstract
Objective To compare the effectiveness, safety, and tolerability of add-on nabiximols (NBX) oromucosal spray vs typical oral long-acting opioid (LAO) analgesics in patients with severe (± chronic) peripheral neuropathic back pain poorly responsive to other treatments. Methods Retrospective analysis of anonymized, propensity score–matched data from the German Pain e-Registry of adult outpatients who initiated NBX or LAO between March 2017 and March 2020. Results Data were analyzed from propensity score–matched patients treated with NBX (n = 655) or LAO (n = 655): mean age ≈51 years; 57% female; mean pain duration ≈2.6 years; chronic pain 61%; severe dysfunctional pain 93%. At 6 months, NBX was noninferior to LAO for overall symptom relief, based on the least-squares mean difference between cohorts in change from baseline in patient-reported, pain-related aggregated nine-item scale scores (−27.84%; 95% confidence interval [CI] −29.71 to −25.96; P < 0.001) and individual pain-related scale scores. Subsequent prespecified superiority analysis of the primary endpoint showed that NBX was superior to LAO: all secondary endpoints measuring symptoms of pain and physical function improved significantly with NBX and LAO, with between-group differences favoring NBX (all P < 0.001). Fewer patients treated with NBX than LAO experienced treatment-related adverse events (25.5% vs 76.0%; P < 0.001) or discontinued treatment because of treatment-related adverse events (7.9% vs 29.3%; P < 0.001). Conclusion Within study limitations (e.g., observational design, all potential biases), add-on NBX was superior to and better tolerated than add-on treatment with typical oral LAO analgesics in patients with neuropathic back pain inadequately controlled by recommended/established systemic therapies.
Collapse
Affiliation(s)
| | | | - Ute Essner
- O. Meany Consultancy GmbH, Hamburg, Germany
| | | |
Collapse
|
24
|
Serrano Afonso A, Carnaval T, Videla Cés S. Combination Therapy for Neuropathic Pain: A Review of Recent Evidence. J Clin Med 2021; 10:jcm10163533. [PMID: 34441829 PMCID: PMC8396869 DOI: 10.3390/jcm10163533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022] Open
Abstract
Pharmacological treatment is not very effective for neuropathic pain (NP). A progressive decrease in the estimated effect of NP drugs has been reported, giving rise to an increase in the use of the multimodal analgesic approach. We performed a new independent review to assess whether more and better-quality evidence has become available since the last systematic review. We evaluated the efficacy, tolerability, and safety of double-blinded randomized controlled trials involving only adult participants and comparing combination therapy (CT: ≥2 drugs) with a placebo and/or at least one other comparator with an NP indication. The primary outcome assessed was the proportion of participants reporting ≥50% pain reductions from baseline. The secondary outcome assessed was the proportion of drop-outs due to treatment-emergent adverse events. After removing duplicates, 2323 citations were screened, with 164 articles assessed for eligibility, from which 16 were included for qualitative analysis. From the latter, only five lasted for at least 12 weeks and only six complied with the required data for complete analysis. CT has been adopted for years without robust evidence. Efforts have been made to achieve better-quality evidence, but the quality has not improved over the years. In this regard, guidelines for NP should attempt to make recommendations about CT research, prioritizing which combinations to analyze.
Collapse
Affiliation(s)
- Ancor Serrano Afonso
- Department of Anesthesiology, Resuscitation and Pain Management, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain
- Correspondence:
| | - Thiago Carnaval
- Department of Clinical Pharmacology, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain;
| | - Sebastià Videla Cés
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, 08907 L’Hospitalet de Llobregat, Spain;
| |
Collapse
|