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Boehnke KF, Scott JR, Martel MO, Smith T, Bergmans RS, Kruger DJ, Williams DA, Fitzcharles MA. Substituting Medical Cannabis for Medications Among Patients with Rheumatic Conditions in the United States and Canada. ACR Open Rheumatol 2024. [PMID: 39236308 DOI: 10.1002/acr2.11717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/04/2024] [Accepted: 06/10/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVE There are numerous reports of people substituting medical cannabis (MC) for medications. Our obejctive was to investigate the degree to which this substitution occurs among people with rheumatic conditions. METHODS In a secondary analysis from a cross-sectional survey conducted with patient advocacy groups in the US and Canada, we investigated MC use and medication substitution among people with rheumatic conditions. We subgrouped by whether participants substituted MC for medications and investigated differences in perceived symptom changes and use patterns, including methods of ingestion, cannabinoid content (cannabidiol vs delta-9-tetrahydrocannabinol [THC]), and use frequency. RESULTS Among 763 participants, 62.5% reported substituting MC products for medications, including nonsteroidal anti-inflammatory drugs (54.7%), opioids (48.6%), sleep aids (29.6%), and muscle relaxants (25.2%). Following substitution, most participants reported decreases or cessation in medication use. The primary reasons for substitution were fewer adverse effects, better symptom management, and concerns about withdrawal symptoms. Substitution was associated with THC use and significantly higher symptom improvements (including pain, sleep, anxiety, and joint stiffness) than nonsubstitution, and a higher proportion of substitutors used inhalation routes than those who did not. CONCLUSION Although the determination of causality is limited by our cross-sectional design, these findings suggest that an appreciable number of people with rheumatic diseases substitute medications with MC for symptom management. Inhalation of MC products containing some THC was most commonly identified among those substituting, and disease characteristics did not differ by substitution status. Further study is needed to better understand the role of MC for symptom management in rheumatic conditions.
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Affiliation(s)
| | - J Ryan Scott
- University of Michigan Medical School, Ann Arbor
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2
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Anis S, Zalomek C, Korczyn AD, Lassman S, Rosenberg A, Gurevich T. Licensed Medical Cannabis Use in Gilles de la Tourette Syndrome: A Retrospective Long-term Follow-Up. Cannabis Cannabinoid Res 2024; 9:e878-e885. [PMID: 37172308 DOI: 10.1089/can.2022.0281] [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] [Indexed: 05/14/2023] Open
Abstract
Background: Medical cannabis (MC) is widely used in clinical practice to treat Gilles de la Tourette syndrome (GTS). However, legislation, multiple modes of administration, and inconsistent plant preparations have limited trials to assess its benefits and long-term safety. For the past decade, licensed MC has been authorized in Israel for use in resistant GTS. We aimed to describe subjects' satisfaction, consumption habits, and THC dose increment during long-term usage. Materials and Methods: A retrospective longitudinal data collection (up to 9 years) on cannabis use habits and structured questionnaires evaluating disease characteristics and MC influence from GTS subjects being treated in the Movement Disorders Unit of the Tel-Aviv Medical Center, Israel. Results: Twenty-five patients (84% male) participated in the study. The mean duration of MC use was 4.0±2.3 years (range 0.5-10). The majority of patients (96%) consumed MC primarily, but not exclusively, through inhalation methods such as smoking or vaporizing dried inflorescence. A linear increase was observed in mean monthly THC dose (p<0.0001) with an average increase of 0.6-0.7 g/year. MC led to a subjectively reported reduction in tics (75% average reduction) and symptoms associated with common comorbidities of GTS. MC was generally well tolerated, although most participants (88%) reported experiencing side effects. Conclusions: A subset of GTS subjects who use MC long term under clinical observation may subjectively improve control of symptoms. Subject-led dose increase can indicate emerging tolerance. Large randomized controlled and observational long-term trials are required to confirm these observations.
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Affiliation(s)
- Saar Anis
- Movement Disorder Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Departments of Neurology, Physiology and Pharmacology, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Corinne Zalomek
- Departments of Neurology, Physiology and Pharmacology, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amos D Korczyn
- Departments of Neurology, Physiology and Pharmacology, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Simon Lassman
- St George's Hospital, University of London, London, United Kingdom
- Arrow Project for Medical Research, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Alina Rosenberg
- School of Public Health, Epidemiology, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tanya Gurevich
- Movement Disorder Unit, Department of Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Departments of Neurology, Physiology and Pharmacology, Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
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3
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Kelly LE, Rieder MJ, Finkelstein Y. Medical cannabis for children: Evidence and recommendations. Paediatr Child Health 2024; 29:104-121. [PMID: 38586483 PMCID: PMC10996577 DOI: 10.1093/pch/pxad078] [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: 03/30/2022] [Accepted: 04/20/2023] [Indexed: 04/09/2024] Open
Abstract
Interest in using cannabis products for a medical purpose in children under the age of 18 years is increasing. There are many medical cannabis products available that can include cannabidiol (CBD) or delta-9-tetrahydrocannabinol (THC), or both. Despite many therapeutic claims, there are few rigorous studies to inform the dosing, safety, and efficacy of medical cannabis in paediatric clinical practice. This statement reviews the current evidence and provides recommendations for using medical cannabis in children. Longer-term (2-year) reports support the sustained tolerability and efficacy of cannabidiol therapy for patients with Lennox-Gastaut and Dravet syndromes. CBD-enriched cannabis extracts containing small amounts of THC have been evaluated in a small number of paediatric patients, and further research is needed to inform clinical practice guidelines. Given the widespread use of medical cannabis in Canada, paediatricians should be prepared to engage in open, ongoing discussions with families about its potential benefits and risks, and develop individualized plans that monitor efficacy, reduce harms, and mitigate drug-drug interactions.
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Affiliation(s)
- Lauren E Kelly
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
| | - Michael J Rieder
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
| | - Yaron Finkelstein
- Canadian Paediatric Society, Drug Therapy Committee, Ottawa, Ontario, Canada
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4
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Kelly LE, Rieder MJ, Finkelstein Y. Les données probantes et les recommandations sur le cannabis à des fins médicales chez les enfants. Paediatr Child Health 2024; 29:104-121. [PMID: 38586491 PMCID: PMC10996578 DOI: 10.1093/pch/pxad077] [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: 03/30/2022] [Accepted: 04/20/2023] [Indexed: 04/09/2024] Open
Abstract
L'intérêt envers l'utilisation des produits du cannabis à des fins médicales chez les enfants de moins de 18 ans augmente. De nombreux produits du cannabis à des fins médicales contiennent du cannabidiol, du delta-9-tétrahydrocannabinol ou ces deux produits. Malgré les nombreuses prétentions thérapeutiques, peu d'études rigoureuses guident la posologie, l'innocuité et l'efficacité du cannabis à des fins médicales en pédiatrie clinique. Le présent document de principes passe en revue les données probantes à jour et expose les recommandations sur l'utilisation du cannabis à des fins médicales chez les enfants. Les rapports à plus long terme (deux ans) souscrivent à la tolérabilité et à l'efficacité soutenues d'un traitement au cannabidiol chez les patients ayant le syndrome de Lennox-Gastaut ou le syndrome de Dravet. Les extraits de cannabis enrichis de cannabidiol qui renferment de petites quantités de delta-9-tétrahydrocannabinol ont été évalués auprès d'un petit nombre de patients d'âge pédiatrique, et d'autres recherches devront être réalisées pour éclairer les guides de pratique clinique. Étant donné l'utilisation répandue du cannabis à des fins médicales au Canada, les pédiatres devraient être prêts à participer à des échanges ouverts et continus avec les familles au sujet de ses avantages potentiels et de ses risques, ainsi qu'à préparer des plans individuels en vue d'en surveiller l'efficacité, de réduire les méfaits et de limiter les interactions médicamenteuses.
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Affiliation(s)
- Lauren E Kelly
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
| | - Michael J Rieder
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
| | - Yaron Finkelstein
- Société canadienne de pédiatrie, comité de la pharmacologie, Ottawa (Ontario)Canada
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5
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Bell AD, MacCallum C, Margolese S, Walsh Z, Wright P, Daeninck PJ, Mandarino E, Lacasse G, Kaur Deol J, de Freitas L, St. Pierre M, Belle-Isle L, Gagnon M, Bevan S, Sanchez T, Arlt S, Monahan-Ellison M, O'Hara J, Boivin M, Costiniuk C. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis Cannabinoid Res 2024; 9:669-687. [PMID: 36971587 PMCID: PMC10998028 DOI: 10.1089/can.2021.0156] [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] [Indexed: 03/29/2023] Open
Abstract
Background: One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual. Systematic Review Registration: PROSPERO no. 135886.
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Affiliation(s)
- Alan D. Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Caroline MacCallum
- Faculty of Medicine, Department of Internal Medicine, University of British Columbia, Vancouver, Canada
| | - Shari Margolese
- Canadian HIV Trials Network, University of British Columbia, Vancouver, Canada
| | - Zach Walsh
- Department of Psychology, University of British Columbia, Kelowna, Canada
| | | | - Paul J. Daeninck
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- CancerCare Manitoba, Winnipeg, Canada
| | - Enrico Mandarino
- Canadian HIV Trials Network, University of British Columbia, Vancouver, Canada
- MJardin Group Canada, Toronto, Canada
| | | | - Jagpaul Kaur Deol
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Lauren de Freitas
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, Canada
| | | | | | - Marilou Gagnon
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | | | - Tatiana Sanchez
- Department of Psychology, University of British Columbia, Kelowna, Canada
| | - Stephanie Arlt
- Centre for Addiction and Mental Health, Institute for Mental Health Policy Research, Toronto, Canada
| | | | | | | | - Cecilia Costiniuk
- Chronic Viral Illness Service/Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montreal, Canada
- McGill Cannabis Research Centre, McGill University, Montreal, Canada
- Research Institute of the McGill University Health Centre, Montreal, Canada
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6
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Boehnke KF, Wu CL, Clauw DJ. Thoughtfully Integrating Cannabis Products Into Chronic Pain Treatment. Anesth Analg 2024; 138:5-15. [PMID: 38100797 PMCID: PMC10730114 DOI: 10.1213/ane.0000000000005904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Cannabis products (CPs) and cannabis-based medicines (CBMs) are becoming increasingly available and are commonly used for pain management. The growing societal acceptance of cannabis and liberalization of cannabis laws allows patients to access CPs with minimal clinical oversight. While there is mechanistic plausibility that CPs and CBMs may be useful for pain management, the clinical trial literature is limited and does not refute or support the use of CBMs for pain management. Complicating matters, a large and growing body of observational literature shows that many people use CPs for pain management and in place of other medications. However, products and dosing regimens in existing trials are not generalizable to the current cannabis market, making it difficult to compare and reconcile these 2 bodies of literature. Given this complexity, clinicians need clear, pragmatic guidance on how to appropriately educate and work with patients who are using CBMs for pain management. In this review, we narratively synthesize the evidence to enable a clear view of current landscape and provide pragmatic advice for clinicians to use when working with patients. This advice revolves around 3 principles: (1) maintaining the therapeutic alliance; (2) harm reduction and benefit maximization; and (3) pragmatism, principles of patient-centered care, and use of best clinical judgment in the face of uncertainty. Despite the lack of certainty CPs and chronic pain management use, we believe that following these principles can make most of the clinical opportunity presented by discussions around CPs and also enhance the likelihood of clinical benefit from CPs.
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Affiliation(s)
- Kevin F. Boehnke
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Christopher L. Wu
- Department of Anesthesiology, Pain Medicine and Critical Care; Hospital for Special Surgery; New York, NY, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel J. Clauw
- Anesthesiology Department, Chronic Pain and Fatigue Research Center, University of Michigan Medical School, Ann Arbor, MI, USA
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7
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Abstract
The cannabis plant has been used for centuries to manage the symptoms of various ailments including pain. Hundreds of chemical compounds have been identified and isolated from the plant and elicit a variety of physiological responses by binding to specific receptors and interacting with numerous other proteins. In addition, the body makes its own cannabinoid-like compounds that are integrally involved in modulating normal and pathophysiological processes. As the legal cannabis landscape continues to evolve within the United States and throughout the world, it is important to understand the rich science behind the effects of the plant and the implications for providers and patients. This narrative review aims to provide an overview of the basic science of the cannabinoids by describing the discovery and function of the endocannabinoid system, pharmacology of cannabinoids, and areas for future research and therapeutic development as they relate to perioperative and chronic pain medicine.
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Affiliation(s)
- Alexandra Sideris
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
- HSS Research Institute, New York, New York
| | | | - Martin Kaczocha
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
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8
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Bon M, Dardis A, Scarpa M, Sechi A. Relief of nocturnal neuropathic pain with the use of cannabis in a patient with Fabry disease. Mol Genet Metab Rep 2023; 37:101010. [PMID: 38053923 PMCID: PMC10694749 DOI: 10.1016/j.ymgmr.2023.101010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 12/07/2023] Open
Abstract
Neuropathic pain is one of the most invalidating symptoms in patients with Fabry disease (FD), affecting their quality of life, it is linked to small fiber neuropathy and it may not respond to available disease specific treatments. We report the case of a 32 years old man with classic FD and severe neuropathic pain who, after the failure of several standard pharmaceutical approaches, was treated with medical cannabis with relief of nocturnal pain and sleep improvement.
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Affiliation(s)
- Martina Bon
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Andrea Dardis
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Maurizio Scarpa
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Annalisa Sechi
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
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9
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Zhang-James Y, Wyon E, Grapsas D, Johnson B. Daily cannabis use may cause cannabis-induced hyperalgesia. Am J Addict 2023; 32:532-538. [PMID: 37550852 DOI: 10.1111/ajad.13456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/28/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Public opinion about cannabis as a medical treatment is generally favorable. As many as 35% of primary care patients report medical use of cannabis, most commonly for pain treatment. We designed a way to test whether cannabis helps chronic pain. METHODS A retrospective cohort study was conducted to explore whether daily long-term cannabis use was associated with increased pain sensitivity using the cold pressor test (CPT) to measure pain tolerance. Patients who used cannabis every day were compared to patients who inhaled tobacco and control patients who never used tobacco or cannabis. The effect of cannabis use on CPT was assessed using a generalized linear model. RESULTS Patients using cannabis daily had a median CPT of 46 s, similar to those who did not use cannabis but who inhaled tobacco (median CPT 45 s). Patients who used both cannabis and tobacco had the lowest CPT (median 26 s). The control group had a median CPT of 105 s. Cannabis use was associated with a significantly decreased pain tolerance (χ²(1) = 8.0, p = .004). The effect of tobacco on CPT was only marginally significant (χ²(1) = 3.8, p = .052). CONCLUSION AND SCIENTIFIC SIGNIFICANCE This suggests a phenomenon similar to opioid-induced hyperalgesia; a drug that reduces pain short term, induces pain long term-opponent process. Daily cannabis use may make chronic pain worse over time by reducing pain tolerance. In terms of risk/benefit, daily cannabis users risk addiction without any long-term benefit for chronic pain.
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Affiliation(s)
- Yanli Zhang-James
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Evelyn Wyon
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Dennis Grapsas
- State University of New York Upstate Medical University, Norton School of Medicine, Syracuse, New York, USA
| | - Brian Johnson
- Department of Psychiatry and Behavioral Sciences, State University of New York Upstate Medical University, Syracuse, New York, USA
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10
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Bahji A, Socias ME, Bach P, Milloy M. Implications of Cannabis Legalization on Substance-Related Benefits and Harms for People Who Use Opioids: A Canadian Perspective. Cannabis Cannabinoid Res 2023; 8:699-702. [PMID: 37001172 PMCID: PMC10623062 DOI: 10.1089/can.2023.0031] [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] [Indexed: 04/03/2023] Open
Abstract
In 2018, Canada enacted the Cannabis Act, becoming only the second country (after Uruguay) to legalize the recreational consumption of cannabis. Although there is ongoing global disagreement on the risk-benefit profile of cannabis with increasing legalization in many parts of the world, the evidence of rising cannabis use prevalence postlegalization has been consistent. In contrast, postlegalization changes in various cannabis-related metrics have been inconsistent in Canada and other parts of the world. Furthermore, the implications of cannabis legalization on substance-related harms and benefits for people who use unregulated drugs, particularly opioids, remain unclear. Finally, although Canada did not legalize cannabis to address the opioid crisis, there is rising scientific and popular interest in the therapeutic potential of cannabis to mitigate opioid-related harms. This perspective highlights the implications of cannabis legalization on substance-related benefits and harms for people who use opioids, the current state of Canadian research, and suggestions for future directions.
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Affiliation(s)
- Anees Bahji
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - M. Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - M.J. Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
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11
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Storey DP, Keeler-Villa NR, Harris N, Anthonypillai J, Tippin GK, Parihar V, Rash JA. Views on and experiences with medicinal cannabis among Canadian veterans who live with pain: A qualitative study. Can J Pain 2023; 7:2232838. [PMID: 37701550 PMCID: PMC10494725 DOI: 10.1080/24740527.2023.2232838] [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: 04/08/2023] [Revised: 06/27/2023] [Accepted: 06/30/2023] [Indexed: 09/14/2023]
Abstract
Background During fiscal year 2021-2022, Veterans Affairs Canada (VAC) reimbursed 18,388 veterans for medicinal cannabis at a cost of $153 million. Yet, it is not known whether the reimbursement program is producing a net benefit for veterans. Aims This study investigated the views and experiences Canadian that veterans who live with pain have about medicinal cannabis use, including its use for the management of chronic pain, poor sleep, and emotional distress. Methods Twelve Canadian veterans who live with pain-eight men, four women; split across four focus groups-were recruited to participate in a semistructured discussion around their experiences with medicinal cannabis use. Results Using inductive thematic analysis, seven broad categories were identified: (1) cannabis use behaviors, (2) reasons for cannabis use, (3) outcomes from cannabis use, (4) facilitators of cannabis use, (5) barriers to cannabis use, (6) stigma around cannabis use, and (7) questions and concerns about cannabis use. Conclusions Most veterans initiated cannabis use to manage the symptoms of preexisting medical and/or mental health conditions. Despite some negative side effects, most veterans reported improvements in their overall quality of life, sleep, relationships, mood, and pain. Concern remains around the discrepancy between veterans' qualitative reports of beneficial outcomes from medicinal cannabis use and equivocal findings around the benefit-to-harm ratio in the wider literature. Currently, the VAC reimbursement program remains challenged by unclear indication for which veterans, with what condition(s), at what dose, and in what form medical cannabis is most beneficial.
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Affiliation(s)
- David P. Storey
- Department of Psychology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Natalie R. Keeler-Villa
- Department of Psychology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | - Nick Harris
- Department of Psychology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
| | | | - Gregory K. Tippin
- Michael G. DeGroote Pain Clinic, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Vikas Parihar
- Michael G. DeGroote Pain Clinic, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Joshua A. Rash
- Department of Psychology, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada
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12
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Hammaker K, Weathington N, Maroon J, Tang LW, Donohue B, Yehuda R, Ford KM, Figura M, Kelmendi B, Tan B, Cook MW, Factor SD, Lagano L, Driscoll HP, Howe AS, Cho EG, Rabin DM. An answered call for aid? Cannabinoid clinical framework for the opioid epidemic. Harm Reduct J 2023; 20:110. [PMID: 37587466 PMCID: PMC10428550 DOI: 10.1186/s12954-023-00842-6] [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: 09/13/2022] [Accepted: 07/24/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND The opioid crisis continues in full force, as physicians and caregivers are desperate for resources to help patients with opioid use and chronic pain disorders find safer and more accessible non-opioid tools. MAIN BODY The purpose of this article is to review the current state of the opioid epidemic; the shifting picture of cannabinoids; and the research, policy, and current events that make opioid risk reduction an urgent public health challenge. The provided table contains an evidence-based clinical framework for the utilization of cannabinoids to treat patients with chronic pain who are dependent on opioids, seeking alternatives to opioids, and tapering opioids. CONCLUSION Based on a comprehensive review of the literature and epidemiological evidence to date, cannabinoids stand to be one of the most interesting, safe, and accessible tools available to attenuate the devastation resulting from the misuse and abuse of opioid narcotics. Considering the urgency of the opioid epidemic and broadening of cannabinoid accessibility amidst absent prescribing guidelines, the authors recommend use of this clinical framework in the contexts of both clinical research continuity and patient care.
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Affiliation(s)
- Krista Hammaker
- Northeast Ohio Medical University, 4209 St Rt 44, PO Box 95, Rootstown, OH, 44272, USA
| | - Nathaniel Weathington
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 200 Delafield Rd, Ste 2040, Pittsburgh, PA, 15215, USA
| | - Joseph Maroon
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 1218 Scaife Hall, 3550 Terrace St, Pittsburgh, PA, 15261, USA
| | - Lawton W Tang
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Huntington Hospital, 100 West California Blvd, Pasadena, CA, 91105, USA
| | - Brian Donohue
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of Pittsburgh Medical Center, 1300 Oxford Dr, Bethel Park, PA, 15102, USA
| | - Rachel Yehuda
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Kenneth M Ford
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Institute for Human and Machine Cognition (IHMC), 40 South Alcaniz, Pensacola, FL, 32502, USA
| | - Myro Figura
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- University of California Los Angeles, 757 Westwood Plaza, Ste 3325, Los Angeles, CA, 90095-7403, USA
| | - Ben Kelmendi
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Yale University, 300 George St, Ste 901, New Haven, CT, 06511, USA
| | - Belinda Tan
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- People Science, Inc, 3870 Del Amo Blvd, Unit 507, Torrance, CA, 90503, USA
| | - Matthew W Cook
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- BioReset Medical, 3803 S Bascom Ave, Ste 203, Campbell, CA, 95008, USA
| | - Steven D Factor
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Abington Neurological Associates, 1151 Old York Rd, Ste 200, Abington, PA, 19001, USA
| | - Laura Lagano
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
| | | | - Adam S Howe
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
- Albany Medical Center, 23 Hackett Blvd, MC-108, Albany, NY, 12208, USA
| | - EunBit G Cho
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA
| | - David M Rabin
- The Board of Medicine, 1942 5th Ave, Pittsburgh, PA, 15219, USA.
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13
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Davis MP, Case AA, Cyr C. Do We Have Structure, Process and Outcomes to Support Cannabis as Supportive Therapy in Cancer? Am J Hosp Palliat Care 2023; 40:341-350. [PMID: 35532011 DOI: 10.1177/10499091221101561] [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] [Indexed: 11/15/2022] Open
Abstract
Cannabis is becoming more popular and more available in the United States. It has been approved for use by multiple states for various conditions and several states now allow recreational cannabis. We explore the structure of cannabis distribution, the process of acquisition, outcomes, and the safety of cannabis in the United States.
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Affiliation(s)
- Mellar P Davis
- 2780Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Amy A Case
- Department of Medicine, Department of Supportive and Palliative Care, 2074Roswell Park Comprehensive Cancer Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Claude Cyr
- Supportive and Palliative Care Division, 12367McGill University Health Center, Montreal, QC, Canada
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14
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Clarke H, Fitzcharles M. The evolving culture of medical cannabis in Canada for the management of chronic pain. Front Pharmacol 2023; 14:1153584. [PMID: 37089954 PMCID: PMC10119390 DOI: 10.3389/fphar.2023.1153584] [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: 01/29/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023] Open
Abstract
Although used therapeutically for millennia, cannabis has been a prohibited substance worldwide for most of the 20th Century. With revision of prohibitive regulations in many jurisdictions during the past 2 decades, cannabis is increasingly available to patients as a potential treatment option for various symptoms. Pain relief, sleep promotion and alleviation of distress, depression and anxiety are the most common reasons for cannabis use. Canada has been at the forefront of medical cannabis (MC) legislation revisions to enable and facilitate access for therapeutic use. Although initially viewed with caution and stigma, attitudes to cannabis in general have changed. Medical cannabis is identified as the herbal plant product sourced from a grower/producer and is not at present a regulated pharmaceutical product. Medical cannabis use is currently prevalent in Canada but has bypassed the rigorous study required for usual drug approval. Although uptake has been enthusiastic by patients, the medical community has voiced cautions and concerns. Access to medical cannabis is fairly easy once an approval document is obtained from a healthcare professional, but without obligation for medical or pharmacy oversight. The greatest concern is a dearth of sound clinical evidence for effects and harms. Emerging concerns include prevalent patient self-management with information based on personal research, an abundance of on-line information which may not always be accurate, the emergence of designated "cannabis clinics," potential risks to society due to accidents, and high cost of the legal medical product leading to access via the recreational market. With cannabis now entrenched in Canadian healthcare, physicians must be sufficiently knowledgeable to provide guidance that is evidence-based and will ensure personal and societal harm reduction. Examination of the changing culture of medical cannabis in Canada will provide insight for countries that may be anticipating similar revisions of cannabis regulations to allow cannabis access for their patient population and learn from the issues created by recreational legalization.
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Affiliation(s)
- H. Clarke
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management Pain Research Unit, Toronto General Hospital, Toronto, ON, Canada
- Transitional Pain Service, Toronto General Hospital, Toronto, ON, Canada
| | - M. Fitzcharles
- Department of Rheumatology, McGill University, Montreal, QC, Canada
- Alan Edwards Pain Management Unit, McGill University, Montreal, QC, Canada
- *Correspondence: M. Fitzcharles,
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15
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Boehnke KF, Clauw DJ. Cannabinoids for Chronic Pain: Translating Systematic Review Findings Into Clinical Action. Ann Intern Med 2022; 175:1191-1192. [PMID: 35667063 DOI: 10.7326/m22-1512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Kevin F Boehnke
- Anesthesiology Department, University of Michigan Medical School, Ann Arbor, Michigan
| | - Daniel J Clauw
- Anesthesiology Department, University of Michigan Medical School, Ann Arbor, Michigan
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16
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Minhas M, Lunn SE. Letter to the Editor: The Need for Equitable Health Care Among Medical Cannabis Patients in Canada. Cannabis Cannabinoid Res 2022; 7:719-721. [PMID: 35532992 PMCID: PMC9587788 DOI: 10.1089/can.2022.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Meenu Minhas
- Department of Medical Affairs, Aurora Cannabis Inc., Edmonton, Alberta, Canada
| | - Stephanie E Lunn
- Department of Medical Affairs, Aurora Cannabis Inc., Edmonton, Alberta, Canada
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17
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Lazris D, Gaur D, Curseen K, Kavalieratos D, Maxwell M, Quest T, Zarrabi AJ. Integrated Medical Cannabis Consultations in a Palliative Care Program: Policies, Procedures, and Progress after Six Years of Practice. J Palliat Med 2022; 25:802-806. [PMID: 35319304 DOI: 10.1089/jpm.2021.0577] [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: 11/12/2022] Open
Abstract
Introduction: Our academic ambulatory palliative care program has counseled, monitored, and certified patients for cannabis as part of routine palliative care practice for six years. Objective: We describe the population certified for cannabis and policies, procedures, and medicolegal challenges in our palliative care clinic. Methods: We performed a retrospective review of patients, qualifying diagnoses for cannabis certification, reasons for referral, and number of annual certifications. Results: Between 2015 and 2021, we certified 1711 patients for cannabis. The most common indications were cancer (64%), pain (24%), and neuropathy (9%). Other three months in 2021, 28% of new referrals to our practice were certified for cannabis and 15% of patients were referred explicitly for cannabis certification. Conclusion: Despite legal and practical challenges to implementing a medical cannabis program, our palliative care program has fully integrated cannabis as part of our standard outpatient clinical practice.
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Affiliation(s)
- David Lazris
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dhruv Gaur
- Brown University, Providence, Rhode Island, USA
| | - Kimberly Curseen
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Meredith Maxwell
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tammie Quest
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali John Zarrabi
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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18
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Price RL, Charlot KV, Frieler S, Dettori JR, Oskouian R, Chapman JR. The Efficacy of Cannabis in Reducing Back Pain: A Systematic Review. Global Spine J 2022; 12:343-352. [PMID: 35128969 PMCID: PMC8907633 DOI: 10.1177/21925682211065411] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To critically analyze the evidence and efficacy of cannabis to treat surgical and nonsurgical back pain via a Systematic Review. METHODS We conducted a systematic review to investigate the efficacy of cannabis to treat non-surgical and surgical back pain. A literature search was performed with MEDLINE and Embase databases. Only RCTs and prospective cohort studies with concurrent control were included in this study. Risk of bias and quality grading was assessed for each included study. RESULTS Database searches returned 1738 non-duplicated results. An initial screening excluded 1716 results. Twenty-two full text articles were assessed for eligibility. Four articles ultimately met pre-determined eligibility and were included in the study. Two studies addressed post-SCI pain while other two studies addressed low back pain. No studies specifically examined the use of cannabis for surgical back pain. The type of cannabis varied between study and included THC, dronabinol, and Nabilone. A total of 110 patients were included in the four studies reviewed. In each study, there was a quantifiable advantage of cannabis therapy for alleviating back pain. There were no serious adverse effects reported. CONCLUSIONS In all articles, cannabis was shown to be effective to treat back pain with an acceptable side effect profile. However, long-term follow up is lacking. As medicinal cannabis is being used more commonly for analgesic effect and patients are "self-prescribing" cannabis for back pain, additional studies are needed for healthcare providers to confidently recommend cannabis therapy for back pain. STUDY DESIGN Systematic review.
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Affiliation(s)
- Richard L. Price
- Swedish Neuroscience
Institute, Seattle, WA, USA,Department of Neurosurgery, Washington University in St.
Louis, St. Louis, MO, USA,Richard L. Price, Swedish Neuroscience
Institute 500 17th Avenue, Suite 500, Seattle, WA 98122, USA.
| | | | - Sven Frieler
- Swedish Neuroscience
Institute, Seattle, WA, USA
| | | | - Rod Oskouian
- Swedish Neuroscience
Institute, Seattle, WA, USA
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19
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Kalaba M, Eglit GML, Feldner MT, Washer PD, Ernenwein T, Vickery AW, Ware MA. Longitudinal Relationship between the Introduction of Medicinal Cannabis and Polypharmacy: An Australian Real-World Evidence Study. Int J Clin Pract 2022; 2022:8535207. [PMID: 36448002 PMCID: PMC9663249 DOI: 10.1155/2022/8535207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/15/2022] [Accepted: 10/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recent studies recommend medicinal cannabis (MC) as a potential treatment for chronic pain (CP) when conventional therapies are not successful; however, data from Australia is limited. This real-world evidence study explored how the introduction of MC related to concomitant medication use over time. Long-term safety also was examined. METHODS Data were collected by the Emerald Clinics (a network of seven clinics located across Australia) as part of routine practice from Jan 2020 toJan 2021. Medications were classified by group: antidepressants, benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and total number of medications. Adverse events (AEs) were collected at each visit and subsequently coded using the Medical Dictionary for Regulatory Activities version 23 into the system organ class (SOC) and preferred term (PT). A total of 535 patients were analyzed. RESULTS The most common daily oral dose was 10 mg for delta-9-tetrahydrocannabinol (THC) and 15 mg for cannabidiol (CBD). With the introduction of MC, patients' total number of medications consumed decreased over the course of one year; significant reductions in NSAIDs, benzodiazepines, and antidepressants were observed (p < .001). However, the number of prescribed opioid medications did not differ from baseline to the end of one year (p = .49). Only 6% of patients discontinued MC treatment during the study. A total of 600 AEs were reported in 310 patients during the reporting period and 97% of them were classified as nonserious. Discussion. Though observational in nature, these findings suggest MC is generally well-tolerated, consistent with the previous literature, and may reduce concomitant use of some medications. Due to study limitations, concomitant medication reductions cannot be causally attributed to MC. Nevertheless, these data underscore early signals that warrant further exploration in randomized trials.
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Affiliation(s)
- Maja Kalaba
- Canopy Growth Corporation, 1 Hershey Drive, Smiths Falls, ON K7A 3K8, Canada
| | - Graham M. L. Eglit
- Canopy Growth Corporation, 1 Hershey Drive, Smiths Falls, ON K7A 3K8, Canada
| | - Matthew T. Feldner
- Canopy Growth Corporation, 1 Hershey Drive, Smiths Falls, ON K7A 3K8, Canada
| | - Patrizia D. Washer
- Emyria Limited, D2 661 Newcastle Street, Leederville WA 6007, PO Box 1442, West Leederville, WA 6901, Australia
| | - Tracie Ernenwein
- Emyria Limited, D2 661 Newcastle Street, Leederville WA 6007, PO Box 1442, West Leederville, WA 6901, Australia
| | - Alistair W. Vickery
- Emyria Limited, D2 661 Newcastle Street, Leederville WA 6007, PO Box 1442, West Leederville, WA 6901, Australia
| | - Mark A. Ware
- Canopy Growth Corporation, 1 Hershey Drive, Smiths Falls, ON K7A 3K8, Canada
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20
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Lou K, Murphy S, Talbot C. Cannabinoids for the treatment of refractory neuropathic pruritus in amyotrophic lateral sclerosis: A case report. Palliat Med 2022; 36:208-211. [PMID: 34510973 PMCID: PMC8796147 DOI: 10.1177/02692163211045314] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neuropathic symptoms have a wide variety of manifestations, ranging from pain to pruritus. Neuropathic pruritus is a type of chronic pruritus related to damaged small fibers. Cannabinoids have evidence to manage neuropathic symptoms. We present a case of refractory neuropathic pruritus that was successfully managed with the use of oral cannabinoids. CASE PRESENTATION A 60-year-old male with amyotrophic lateral sclerosis with ongoing pruritus despite the use of standard neuropathic therapies. POSSIBLE COURSE OF ACTION Sodium channel and N-methyl-D-aspartate receptor antagonists have evidence for neuropathic symptoms but can cause significant gastrointestinal side effects. Prescription cannabinoids such as nabiximol can be cost prohibitive to use in practice. Synthetic tetrahydrocannabinol products are dose limited by psychoactive side effects. FORMULATION OF A PLAN A balanced oral cannabinoid from a licensed producer was preferred as it has evidence for neuropathic symptoms and is generally well tolerated. OUTCOME The patient showed improvement to his pruritus score from 7/10 to 3/10. There was initial increased sedation but tolerance developed quickly. LESSONS LEARNED FROM CASE Cannabinoids are possibly safe and effective in management of neuropathic pruritus. VIEW ON RESEARCH PROBLEMS Additional research is needed to establish efficacy and safety.
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Affiliation(s)
- Kelvin Lou
- Palliative Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Shane Murphy
- Palliative Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Clair Talbot
- Palliative Medicine, The University of British Columbia, Vancouver, BC, Canada
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21
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Holman A, Boehnke KF. Tackling the taboo: a sensible prescription for appropriate cannabis use in fibromyalgia. Pain Manag 2021; 12:117-122. [PMID: 34743594 DOI: 10.2217/pmt-2021-0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Alexis Holman
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kevin F Boehnke
- Anesthesiology Department, Chronic Pain & Fatigue Research Center, University of Michigan, Ann Arbor, MI 48106, USA
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22
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Busse JW, Vankrunkelsven P, Zeng L, Heen AF, Merglen A, Campbell F, Granan LP, Aertgeerts B, Buchbinder R, Coen M, Juurlink D, Samer C, Siemieniuk RAC, Kumar N, Cooper L, Brown J, Lytvyn L, Zeraatkar D, Wang L, Guyatt GH, Vandvik PO, Agoritsas T. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. BMJ 2021; 374:n2040. [PMID: 34497062 DOI: 10.1136/bmj.n2040] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CLINICAL QUESTION What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes? CURRENT PRACTICE Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries. RECOMMENDATION The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. HOW THIS GUIDELINE WAS CREATED An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective. THE EVIDENCE This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain. UNDERSTANDING THE RECOMMENDATION The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.
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Affiliation(s)
- Jason W Busse
- Michael G DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada
| | - Patrick Vankrunkelsven
- Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium
- Department of Public Health and Primary Care, Katholieke Universiteiti Leuven, Leuven, Belgium
| | - Linan Zeng
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Pharmacy Department/Evidence-based Pharmacy Centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Anja Fog Heen
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Arnaud Merglen
- Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Fiona Campbell
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Lars-Petter Granan
- Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia
| | - Matteo Coen
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
- Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Juurlink
- Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals
- Faculty of Medicine, University of Geneva, Switzerland
| | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nimisha Kumar
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lynn Cooper
- Canadian Injured Workers' Alliance, Thunder Bay, ON, Canada
| | - John Brown
- Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
| | - Li Wang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Per O Vandvik
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland
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23
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Sihota A, Smith BK, Ahmed S, Bell A, Blain A, Clarke H, Cooper ZD, Cyr C, Daeninck P, Deshpande A, Ethans K, Flusk D, Le Foll B, Milloy M, Moulin DE, Naidoo V, Ong M, Perez J, Rod K, Sealey R, Sulak D, Walsh Z, O’Connell C. Consensus-based recommendations for titrating cannabinoids and tapering opioids for chronic pain control. Int J Clin Pract 2021; 75:e13871. [PMID: 33249713 PMCID: PMC8365704 DOI: 10.1111/ijcp.13871] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/24/2020] [Accepted: 11/20/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. RESULTS In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events. CONCLUSIONS This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.
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Affiliation(s)
- Aaron Sihota
- Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBCCanada
| | | | - Sana‐Ara Ahmed
- Medical Director, Anesthesiology and Interventional Chronic PainAhmed Institute for Pain and Cannabinoid ResearchCalgaryABCanada
| | - Alan Bell
- Department of Family and Community MedicineUniversity of TorontoTorontoONCanada
| | - Allison Blain
- Department of AnesthesiaMichael G DeGroote Pain ClinicHamilton Health SciencesMcMaster UniversityHamiltonONCanada
| | - Hance Clarke
- Department of Anesthesia and Pain MedicineToronto General HospitalUniversity Health NetworkUniversity of TorontoTorontoONCanada
| | - Ziva D. Cooper
- Department of Psychiatry and Biobehavioral ScienceUCLA Cannabis Research InitiativeJane and Terry Semel Institute for Neuroscience and Human Behavior University of CaliforniaLos AngelesCAUSA
| | - Claude Cyr
- Department of Family MedicineMcGill UniversityMontrealQCCanada
| | - Paul Daeninck
- Max Rady College of MedicineRady Faculty of Health SciencesUniversity of Manitoba, and CancerCare ManitobaWinnipegMBCanada
| | - Amol Deshpande
- Comprehensive Interdisciplinary Pain ProgramDivision of Physical MedicineToronto Rehabilitation InstituteTorontoONCanada
| | - Karen Ethans
- Department of MedicineSection of Physical Medicine and RehabilitationUniversity of ManitobaWinnipegMBCanada
| | - David Flusk
- Faculty of MedicineMemorial University of NewfoundlandSt John’s NLCanada
| | - Bernard Le Foll
- Translational Addiction Research LaboratoryCentre for Addiction and Mental HealthTorontoONCanada
- Alcohol Research and Treatment ClinicAcute Care ProgramCentre for Addiction and Mental HealthTorontoONCanada
- Campbell Family Mental Health Research InstituteCentre for Addiction and Mental HealthTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
- Institute of Medical SciencesUniversity of TorontoTorontoONCanada
- British Columbia Centre on Substance UseVancouverBCCanada
| | - M‐J Milloy
- British Columbia Centre on Substance UseVancouverBCCanada
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Dwight E. Moulin
- Departments of Clinical Neurological Sciences and OncologyEarl Russell Chair in Pain MedicineWestern UniversityLondonONCanada
| | | | - May Ong
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Jordi Perez
- Department of AnesthesiaMcGill UniversityMontrealQCCanada
| | - Kevin Rod
- FCFP Director Toronto Poly ClinicLecturer DFCM University of TorontoTorontoONCanada
| | | | | | - Zachary Walsh
- Department of PsychologyUniversity of British ColumbiaVancouverBCCanada
| | - Colleen O’Connell
- Department of Physical Medicine and RehabilitationStan Cassidy Centre for RehabilitationFrederictonNBCanada
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24
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Bhaskar A, Bell A, Boivin M, Briques W, Brown M, Clarke H, Cyr C, Eisenberg E, de Oliveira Silva RF, Frohlich E, Georgius P, Hogg M, Horsted TI, MacCallum CA, Müller-Vahl KR, O'Connell C, Sealey R, Seibolt M, Sihota A, Smith BK, Sulak D, Vigano A, Moulin DE. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. J Cannabis Res 2021; 3:22. [PMID: 34215346 PMCID: PMC8252988 DOI: 10.1186/s42238-021-00073-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed. METHODS Using a multistage modified Delphi process, twenty global experts across nine countries developed consensus-based recommendations on how to dose and administer medical cannabis in patients with chronic pain. RESULTS There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed. A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC. A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every 7 days until a maximum daily dose of 40 mg/day of THC. A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day. CONCLUSIONS In summary, using a modified Delphi process, expert consensus-based recommendations were developed on how to dose and administer medical cannabis for the treatment of patients with chronic pain.
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Affiliation(s)
- Arun Bhaskar
- Pain Management Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Alan Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Matthew Brown
- Department of Pain Medicine, The Royal Marsden Hospital, London, UK
- The Institute of Cancer Research, London, UK
| | - Hance Clarke
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Claude Cyr
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Elon Eisenberg
- Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel
| | | | - Eva Frohlich
- Department of Anaesthesiology and Pain Management, Helen Joseph Hospital, Johannesburg, South Africa
| | | | - Malcolm Hogg
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | | | | | - Kirsten R Müller-Vahl
- Hannover Medical School, Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany
| | - Colleen O'Connell
- Department of Physical Medicine and Rehabilitation, Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada
| | - Robert Sealey
- Cannabinoid Medicine Specialist, Victoria, BC, Canada
| | - Marc Seibolt
- Algesiologikum- Centers for Pain Medicine, Day Clinic for Pain Medicine, Munich, Germany
| | - Aaron Sihota
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Brennan K Smith
- CTC Communications, Medical Division, Mississauga, ON, Canada
| | | | - Antonio Vigano
- Department of Oncology, McGill University, Montreal, QC, Canada
| | - Dwight E Moulin
- Departments of Clinical Neurological Sciences and Oncology, Earl Russell Chair of Pain Medicine, Western University, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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Steardo L, Carbone EA, Menculini G, Moretti P, Steardo L, Tortorella A. Endocannabinoid System as Therapeutic Target of PTSD: A Systematic Review. Life (Basel) 2021; 11:life11030214. [PMID: 33803374 PMCID: PMC8000573 DOI: 10.3390/life11030214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/20/2021] [Accepted: 03/05/2021] [Indexed: 11/23/2022] Open
Abstract
Post-Traumatic Stress Disorder (PTSD) is a complex disorder involving dysregulation of stress-related hormones and neurotransmitter systems. Research focused on the endocannabinoid system (eCBS) for anxiety and stress regulation, cognitive and emotional responses modulation and aversive memories extinction, leading to the hypothesis that it could represent a possible alternative treatment target for PTSD. In this systematic review, we summarize evidence about the efficacy and safety of medicinal cannabidiol (CBD), Δ9-tetrahydrocannabinol (Δ9-THC), and nabilone in PTSD treatment. The PRISMA statement guidelines were followed. A systematic literature search was conducted in MEDLINE/PubMed, Scopus and Web of Science by two independent researchers, who also performed data extraction and quality assessment. Among the initial 495 papers, 234 were screened for eligibility and 10 were included. Studies suggested that different medicinal cannabinoids at distinct doses and formulations could represent promising treatment strategies for the improvement of overall PTSD symptomatology as well as specific symptom domains (e.g., sleep disorders, arousal disturbances, suicidal thoughts), also influencing quality of life, pain and social impact. Although there is a robust rationale for treatment with drugs that target the eCBS and the results are promising, further studies are needed to investigate the safety and efficacy profile of their prolonged use.
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Affiliation(s)
- Luca Steardo
- Psychiatric Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Viale Tommaso Campanella, 115, 88100 Catanzaro, Italy
- Correspondence:
| | - Elvira Anna Carbone
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Viale Tommaso Campanella, 115, 88100 Catanzaro, Italy;
| | - Giulia Menculini
- Department of Psychiatry, University of Perugia, Piazzale Lucio Severi, 1, 06132 Perugia, Italy; (G.M.); (P.M.); (A.T.)
| | - Patrizia Moretti
- Department of Psychiatry, University of Perugia, Piazzale Lucio Severi, 1, 06132 Perugia, Italy; (G.M.); (P.M.); (A.T.)
| | - Luca Steardo
- Department of Physiology and Pharmacology, Faculty of Pharmacy and Medicine, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Rome, Italy;
- Department of Psychiatry, Giustino Fortunato University, 12, 82100 Benevento, Italy
| | - Alfonso Tortorella
- Department of Psychiatry, University of Perugia, Piazzale Lucio Severi, 1, 06132 Perugia, Italy; (G.M.); (P.M.); (A.T.)
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