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Zanker T, Sacco J, Prota J, Palma M, Viola Lee KA, Wang RR, Liang Y, Cunningham J, Mackary M, Ovchinnikova P. Medical Marijuana for Pain Management in Hospice Care as a Complementary Approach to Scheduled Opioids: A Single Arm Study. Am J Hosp Palliat Care 2024; 41:1002-1010. [PMID: 38100655 DOI: 10.1177/10499091231213359] [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: 12/17/2023] Open
Abstract
Background: Opioid therapy is critical for pain relief for most hospice patients but may be limited by adverse side effects. Combining medical cannabis with opioids may help mitigate adverse effects while maintaining effective pain relief. Aim: This single-arm study investigated the impact of combined medical cannabis/opioid therapy on pain relief, opioid dose, appetite, respiratory function, well-being, nausea, and adverse events in hospice inpatients. Design: Adult hospice inpatients using scheduled oral, parenteral, or transdermal opioids for pain were administered standardized oral medical cannabis, 40 mg CBD/1.5 mg THC or 80 mg CBD/3 mg THC. Descriptive statistics detailed demographic and clinical baseline characteristics, the Mann-Whitney test compared outcomes, and the longitudinal mixed effects regression model analyzed longitudinal effects of combined therapy. Setting/Participants: Sixty-six inpatients at The Connecticut Hospital, Inc. were assessed over 996 treatment days; average age was 68.2 ± 12.9 years, 90.9% were white. Cancer was the most common diagnosis. Results: The medical cannabis/opioid combination showed a significant longitudinal reduction in pain intensity (P = .0029) and a non-significant trend toward lower opioid doses. Well-being, appetite, nausea, and respiratory function showed non-statistically significant changes. Three patients (4.5%) experienced minor, reversible adverse events potentially related to medical cannabis. No serious or life-threatening adverse events were seen. Conclusion: Combination medical cannabis/opioid therapy showed statistically significant pain relief and may have the potential for reducing opioid dose and mitigating opioid toxicity, offering a safe pain management alternative to opioids alone for patients in end-of-life care settings, and warrants further investigation in larger controlled trials.
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Affiliation(s)
- Theodore Zanker
- Department of Medicine, The Connecticut Hospice, Branford, CT, USA
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, CT, USA
- Department of Psychiatry, Yale-New Haven Hospital, New Haven, CT, USA
| | - Joseph Sacco
- Department of Medicine, The Connecticut Hospice, Branford, CT, USA
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, CT, USA
- Department of Internal Medicine, Hospice and Palliative Medicine, Yale School of Medicine, New Haven, CT, USA
- Palliative and End-of-Life Care Education, Yale School of Medicine, New Haven, CT, USA
| | - James Prota
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, CT, USA
- Department of Pharmacy, The Connecticut Hospice, Inc., Branford, CT, USA
| | - Michelle Palma
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, CT, USA
- Department of Pharmacy, The Connecticut Hospice, Inc., Branford, CT, USA
| | - Kyoung A Viola Lee
- Yale School of Medicine,Systems Biology Institute, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - Ruixiao Rachel Wang
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT USA
| | - Yixuan Liang
- Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
| | - James Cunningham
- Department of Medicine, The Connecticut Hospice, Branford, CT, USA
- The John D. Thompson Hospice Institute for Education, Training, and Research, Inc, Branford, CT, USA
| | - Mona Mackary
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT USA
| | - Polina Ovchinnikova
- Department of Health Informatics, Yale School of Public Health, New Haven, CT USA
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Thompson ES, Alcorn J, Neary JP. Cannabinoid Therapy in Athletics: A Review of Current Cannabis Research to Evaluate Potential Real-World Cannabinoid Applications in Sport. Sports Med 2024:10.1007/s40279-024-02094-1. [PMID: 39168949 DOI: 10.1007/s40279-024-02094-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 08/23/2024]
Abstract
The increasing legalization of Cannabis sativa plant products has sparked growing interest in their therapeutic applications. Prohibition laws established in 1937 hindered formal research on cannabis, a plant with cultural and medicinal roots dating back to 2700 BC in Chinese history. Despite regulatory hurdles, published research on cannabis has emerged; yet elite athletes remain an underrepresented population in these studies. Athletes, known for exploring diverse substances to optimize performance, are drawn to the potential benefits of cannabinoid therapy, with anecdotal reports suggesting positive effects on issues ranging from anxiety to brain injuries. This review aims to evaluate empirical published cannabis research with a specific focus on its potential applications in athletics. The changing legal landscape, especially the removal of cannabis from drug testing programs in leagues such as the National Basketball Association (NBA), and endorsements by Major League Baseball (MLB) for cannabinoid products and the National Football League (NFL) for cannabis research, reflects a shift in the acceptability of such substances in sports. However, stigma, confusion, and a lack of education persist, hindering a cohesive understanding among sports organizations, including business professionals, policymakers, coaches, and medical/training staff, in addition to athletes themselves. Adding to the confusion is the lack of consistency with cannabinoid regulations from sport to sport, within or out of competition, and with cannabis bioactive compounds. The need for this review is underscored by the evolving attitudes toward cannabinoids in professional sports and the potential therapeutic benefits or harms they may offer. By synthesizing current cannabis research, this review aims to provide a comprehensive understanding of the applications and implications of cannabinoid use in the realm of athletics.
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Affiliation(s)
| | - Jane Alcorn
- University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada
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Guy D, Wootten JC, Wong M, Turski D, Lukewich M, Alboog A, Kandasamy AR, Gregory J, Poolacherla R. Pharmacodynamic effects following co-administration of cannabinoids and opioids: a scoping review of human experimental studies. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:423-434. [PMID: 38561178 DOI: 10.1093/pm/pnae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/29/2023] [Accepted: 03/07/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Cannabinoids are increasingly used in the management of chronic pain. Although analgesic potential has been demonstrated, cannabinoids interact with a range of bodily functions that are also influenced by chronic pain medications, including opioids. OBJECTIVE We performed a scoping review of literature on the pharmacodynamic effects following the co-administration of cannabinoids and opioids. METHODS We systematically searched EMBASE, PubMed, and PsycINFO for studies that experimentally investigated the co-effects of cannabinoids and opioids in human subjects. Available evidence was summarized by clinical population and organ system. A risk of bias assessment was performed. RESULTS A total of 16 studies met the inclusion criteria. Study populations included patients with chronic non-cancer and cancer pain on long-term opioid regimens and healthy young adults without prior exposure to opioids who were subject to experimental nociceptive stimuli. Commonly administered cannabinoid agents included Δ9-tetrahydrocannabinol and/or cannabidiol. Co-administration of cannabinoids and opioids did not consistently improve pain outcomes; however, sleep and mood benefits were observed in chronic pain patients. Increased somnolence, memory and attention impairment, dizziness, gait disturbance, and nauseousness and vomiting were noted with co-administration of cannabinoids and opioids. Cardiorespiratory effects following co-administration appeared to vary according to duration of exposure, population type, and prior exposure to cannabinoids and opioids. CONCLUSIONS The available evidence directly investigating the pharmacodynamic effects following co-administration of cannabinoids and opioids for non-analgesic outcomes is scarce and suffers from a lack of methodological reporting. As such, further research in this area with comprehensive methodologic reporting is warranted.
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Affiliation(s)
- David Guy
- Department of Anesthesiology, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Jared C Wootten
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Michael Wong
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Daniel Turski
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Mark Lukewich
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Abdulrahman Alboog
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Anesthesia and ICU, University of Jeddah, College of Medicine Jeddah, Saudi Arabia
| | - Abirami R Kandasamy
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Children's Hospital-London's Health Science Center, London, ON, Canada
- Children's Health Research Institute, London, ON, Canada
| | - Jonathan Gregory
- First Episode Mood & Anxiety Program, Emergency Diversion Clinic for Children's Hospital, and Ambulatory Child & Adolescent Mental Health Care Program, London, ON, Canada
| | - Raju Poolacherla
- Pediatric Chronic Pain Program, London Health Sciences Centre, London, ON, Canada
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Carrascosa AJ, Navarrete F, Saldaña R, García-Gutiérrez MS, Montalbán B, Navarro D, Gómez-Guijarro FM, Gasparyan A, Murcia-Sánchez E, Torregrosa AB, Pérez-Doblado P, Gutiérrez L, Manzanares J. Cannabinoid Analgesia in Postoperative Pain Management: From Molecular Mechanisms to Clinical Reality. Int J Mol Sci 2024; 25:6268. [PMID: 38892456 PMCID: PMC11172912 DOI: 10.3390/ijms25116268] [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: 04/26/2024] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Postoperative pain (POP) is a challenging clinical phenomenon that affects the majority of surgical patients and demands effective management to mitigate adverse outcomes such as persistent pain. The primary goal of POP management is to alleviate suffering and facilitate a seamless return to normal function for the patient. Despite compelling evidence of its drawbacks, opioid analgesia remains the basis of POP treatment. Novel therapeutic approaches rely on multimodal analgesia, integrating different pharmacological strategies to optimize efficacy while minimizing adverse effects. The recognition of the imperative role of the endocannabinoid system in pain regulation has prompted the investigation of cannabinoid compounds as a new therapeutic avenue. Cannabinoids may serve as adjuvants, enhancing the analgesic effects of other drugs and potentially replacing or at least reducing the dependence on other long-term analgesics in pain management. This narrative review succinctly summarizes pertinent information on the molecular mechanisms, clinical therapeutic benefits, and considerations associated with the plausible use of various cannabinoid compounds in treating POP. According to the available evidence, cannabinoid compounds modulate specific molecular mechanisms intimately involved in POP. However, only two of the eleven clinical trials that evaluated the efficacy of different cannabinoid interventions showed positive results.
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Affiliation(s)
- Antonio J. Carrascosa
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Francisco Navarrete
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Raquel Saldaña
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - María S. García-Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Belinda Montalbán
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Daniela Navarro
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Fernando M. Gómez-Guijarro
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Ani Gasparyan
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Elena Murcia-Sánchez
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Abraham B. Torregrosa
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Paloma Pérez-Doblado
- Servicio de Anestesiologia y Reanimación, Hospital Universitario 12 de Octubre, Avda. Córdoba s/n, 28041 Madrid, Spain; (A.J.C.); (R.S.); (B.M.); (F.M.G.-G.); (E.M.-S.); (P.P.-D.)
| | - Luisa Gutiérrez
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
| | - Jorge Manzanares
- Instituto de Neurociencias, Universidad Miguel Hernández-CSIC, Avda de Ramón y Cajal s/n, San Juan de Alicante, 03550 Alicante, Spain; (F.N.); (M.S.G.-G.); (D.N.); (A.G.); (A.B.T.); (L.G.)
- Redes de Investigación Cooperativa Orientada a Resultados en Salud (RICORS), Red de Investigación en Atención Primaria de Adicciones (RIAPAd), Instituto de Salud Carlos III, MICINN and FEDER, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), 03010 Alicante, Spain
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Yang L, Tibbo PG, Stewart SH, Simon P, Bullerwell M, Wang J. A cross-sectional study of the relationship between frequency of cannabis use and psychiatric symptoms among people seeking mental health and addiction services in Nova Scotia (2019-21). J Psychiatr Res 2024; 173:104-110. [PMID: 38518571 DOI: 10.1016/j.jpsychires.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/13/2024] [Accepted: 03/15/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Cannabis use may be a modifiable risk factor for mental health problems; however, the role of cannabis use frequency in population seeking mental health and addiction services remains unclear. This study aimed to: 1) compare the prevalence and functional impact of psychiatric symptoms among frequent, infrequent, and non-users of cannabis; and 2) evaluate the associations between cannabis use frequency and functional impact of psychiatric symptoms in help-seeking individuals. METHODS Data from the Mental Health and Addictions (MHA) Central Intake system in Nova Scotia, Canada was used. Participants aged 19-64 who received MHA Intake assessments from September 2019 to December 2021 with complete information about substance use were included (N = 20,611). Cannabis use frequency over past 30 days was categorized into frequent (>4 times a month), infrequent (≤4 times a month), and non-use. Psychiatric symptomatology consists of five domains: mood, anxiety, psychosis, cognition, and externalizing behaviors. Multivariate ordinal logistic regression was used to examine the associations between cannabis use frequency and functional impact of psychiatric symptoms. RESULTS Frequent and infrequent cannabis users had a higher prevalence of psychiatric symptoms in each domain than non-users, while no significant differences were found between frequent and infrequent users. Frequent cannabis use was associated with greater functional impact of psychiatric symptoms in each domain compared to non-users, while infrequent use was only associated with greater functional impact of externalizing behaviors. CONCLUSION Frequent cannabis use is associated with increased prevalence and functional impact of psychiatric symptoms among adults seeking mental health services.
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Affiliation(s)
- Lu Yang
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Canada
| | - Philip G Tibbo
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, Canada; Early Psychosis Intervention Nova Scotia, Nova Scotia Health, Canada
| | - Sherry H Stewart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Canada; Department of Psychiatry, Faculty of Medicine, Dalhousie University, Canada; Department of Psychology and Neuroscience, Faculty of Science, Dalhousie University, Canada
| | - Patryk Simon
- Mental Health and Addiction Program, Nova Scotia Health, Canada
| | | | - JianLi Wang
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Canada; Department of Psychiatry, Faculty of Medicine, Dalhousie University, Canada.
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Cuñetti L, Oricchio F, Vázquez M, Peyraube R, Manzo L, Nalerio C, Curi L, Maldonado C. Drug-Drug Interaction Between Cannabidiol, Cyclosporine, and Mycophenolate Mofetil: A Case Report. Transplant Proc 2024; 56:252-256. [PMID: 38212169 DOI: 10.1016/j.transproceed.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 01/13/2024]
Abstract
Kidney transplantation remains the optimal therapy for many patients with end-stage kidney disease (ESKD). Chronic pain is one of the most common and distressing symptoms among patients with ESKD, and its treatment is a complex and challenging task to accomplish. The benefits of cannabidiol (CBD) in chronic pain treatment have been reported recently. Cannabidiol is metabolized by cytochrome P450, mainly CYP3A4 and CYP2C19, and can also undergo direct conjugation via UDP-glucuronosyltransferase enzymes, with a growing body of evidence suggesting it is also a potent inhibitor or inducer of these pathways. Cannabidiol was also found to be a potent inhibitor of carboxylesterases in vitro. Because cytochrome P450 enzymes and carboxylesterases are also responsible for the clearance and activation of immunosuppressants, respectively, drug-drug interactions are likely to occur. Here, we report a pharmacokinetic drug interaction between CBD and cyclosporine and mycophenolate mofetil in a patient with ESKD with a kidney transplantation. It is thus crucial to take into account these interactions and monitor drug levels to avoid drug toxicity or a lack of efficacy. This study is in accordance with the guidelines of the Declaration of Helsinki and the Declaration of Istanbul.
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Affiliation(s)
- Leticia Cuñetti
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Florencia Oricchio
- Graduate Program in Chemistry, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Marta Vázquez
- Pharmaceutical Sciences Department, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Raquel Peyraube
- International Diploma in Endocannabinology Cannabis and Cannabinoids, Instituto de Investigaciones Biológicas Clemente Estable-MEC, Montevideo, Uruguay
| | - Laura Manzo
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Catheryn Nalerio
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Lilian Curi
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Cecilia Maldonado
- Pharmaceutical Sciences Department, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay.
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Maldonado C, Peyraube R, Fagiolino P, Oricchio F, Cuñetti L, Vázquez M. Human Data on Pharmacokinetic Interactions of Cannabinoids: A Narrative Review. Curr Pharm Des 2024; 30:241-254. [PMID: 38288797 DOI: 10.2174/0113816128288510240113170116] [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: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 05/08/2024]
Abstract
Concomitant use of cannabinoids with other drugs may result in pharmacokinetic drug-drug interactions, mainly due to the mechanism involving Phase I and Phase II enzymes and/or efflux transporters. Cannabinoids are not only substrates but also inhibitors or inducers of some of these enzymes and/or transporters. This narrative review aims to provide the available information reported in the literature regarding human data on the pharmacokinetic interactions of cannabinoids with other medications. A search on Pubmed/Medline, Google Scholar, and Cochrane Library was performed. Some studies were identified with Google search. Additional articles of interest were obtained through cross-referencing of published literature. All original research papers discussing interactions between cannabinoids, used for medical or recreational/adult-use purposes, and other medications in humans were included. Thirty-two studies with medicinal or recreational/adult-use cannabis were identified (seventeen case reports/series, thirteen clinical trials, and two retrospective analyses). In three of these studies, a bidirectional pharmacokinetic drug-drug interaction was reported. In the rest of the studies, cannabinoids were the perpetrators, as in most of them, concentrations of cannabinoids were not measured. In light of the widespread use of prescribed and non-prescribed cannabinoids with other medications, pharmacokinetic interactions are likely to occur. Physicians should be aware of these potential interactions and closely monitor drug levels and/or responses. The existing literature regarding pharmacokinetic interactions is limited, and for some drugs, studies have relatively small cohorts or are only case reports. Therefore, there is a need for high-quality pharmacological studies on cannabinoid-drug interactions.
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Affiliation(s)
- Cecilia Maldonado
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Raquel Peyraube
- Instituto de Investigaciones Biológicas Clemente Estable - MEC, Montevideo, Uruguay
| | - Pietro Fagiolino
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Florencia Oricchio
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Leticia Cuñetti
- Kidney Transplant Unit, Nephrology and Urology Institute, Montevideo, Uruguay
| | - Marta Vázquez
- Department of Pharmaceutical Sciences, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
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Czigle S, Nagy M, Mladěnka P, Tóth J. Pharmacokinetic and pharmacodynamic herb-drug interactions-part I. Herbal medicines of the central nervous system. PeerJ 2023; 11:e16149. [PMID: 38025741 PMCID: PMC10656908 DOI: 10.7717/peerj.16149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023] Open
Abstract
Unlike conventional drug substances, herbal medicines are composed of a complex of biologically active compounds. Therefore, the potential occurrence of herb-drug interactions is even more probable than for drug-drug interactions. Interactions can occur on both the pharmacokinetic and pharmacodynamic level. Herbal medicines may affect the resulting efficacy of the concomitantly used (synthetic) drugs, mainly on the pharmacokinetic level, by changing their absorption, distribution, metabolism, and excretion. Studies on the pharmacodynamic interactions of herbal medicines and conventional drugs are still very limited. This interaction level is related to the mechanism of action of different plant constituents. Herb-drug interactions can cause changes in drug levels and activities and lead to therapeutic failure and/or side effects (sometimes toxicities, even fatal). This review aims to provide a summary of recent information on the potential drug interactions involving commonly used herbal medicines that affect the central nervous system (Camellia, Valeriana, Ginkgo, Hypericum, Humulus, Cannabis) and conventional drugs. The survey databases were used to identify primary scientific publications, case reports, and secondary databases on interactions were used later on as well. Search keywords were based on plant names (botanical genera), officinal herbal drugs, herbal drug preparations, herbal drug extracts.
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Affiliation(s)
- Szilvia Czigle
- Department of Pharmacognosy and Botany, Faculty of Pharmacy, Comenius University Bratislava, Bratislava, Slovak Republic
| | - Milan Nagy
- Department of Pharmacognosy and Botany, Faculty of Pharmacy, Comenius University Bratislava, Bratislava, Slovak Republic
| | - Přemysl Mladěnka
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Charles University, Hradec Králové, Czech Republic
| | - Jaroslav Tóth
- Department of Pharmacognosy and Botany, Faculty of Pharmacy, Comenius University Bratislava, Bratislava, Slovak Republic
| | - the OEMONOM.
- Department of Pharmacognosy and Botany, Faculty of Pharmacy, Comenius University Bratislava, Bratislava, Slovak Republic
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Charles University, Hradec Králové, Czech Republic
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9
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Cheng W, Parker N, Karadag N, Koch E, Hindley G, Icick R, Shadrin A, O'Connell KS, Bjella T, Bahrami S, Rahman Z, Tesfaye M, Jaholkowski P, Rødevand L, Holen B, Lagerberg TV, Steen NE, Djurovic S, Dale AM, Frei O, Smeland OB, Andreassen OA. The relationship between cannabis use, schizophrenia, and bipolar disorder: a genetically informed study. Lancet Psychiatry 2023; 10:441-451. [PMID: 37208114 PMCID: PMC10311008 DOI: 10.1016/s2215-0366(23)00143-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND The relationship between psychotic disorders and cannabis use is heavily debated. Shared underlying genetic risk is one potential explanation. We investigated the genetic association between psychotic disorders (schizophrenia and bipolar disorder) and cannabis phenotypes (lifetime cannabis use and cannabis use disorder). METHODS We used genome-wide association summary statistics from individuals with European ancestry from the Psychiatric Genomics Consortium, UK Biobank, and International Cannabis Consortium. We estimated heritability, polygenicity, and discoverability of each phenotype. We performed genome-wide and local genetic correlations. Shared loci were identified and mapped to genes, which were tested for functional enrichment. Shared genetic liabilities to psychotic disorders and cannabis phenotypes were explored using causal analyses and polygenic scores, using the Norwegian Thematically Organized Psychosis cohort. FINDINGS Psychotic disorders were more heritable than cannabis phenotypes and more polygenic than cannabis use disorder. We observed positive genome-wide genetic correlations between psychotic disorders and cannabis phenotypes (range 0·22-0·35) with a mixture of positive and negative local genetic correlations. Three to 27 shared loci were identified for the psychotic disorder and cannabis phenotype pairs. Enrichment of mapped genes implicated neuronal and olfactory cells as well as drug-gene targets for nicotine, alcohol, and duloxetine. Psychotic disorders showed a causal effect on cannabis phenotypes, and lifetime cannabis use had a causal effect on bipolar disorder. Of 2181 European participants from the Norwegian Thematically Organized Psychosis cohort applied in polygenic risk score analyses, 1060 (48·6%) were females and 1121 (51·4%) were males (mean age 33·1 years [SD 11·8]). 400 participants had bipolar disorder, 697 had schizophrenia, and 1044 were healthy controls. Within this sample, polygenic scores for cannabis phenotypes predicted psychotic disorders independently and improved prediction beyond the polygenic score for the psychotic disorders. INTERPRETATION A subgroup of individuals might have a high genetic risk of developing a psychotic disorder and using cannabis. This finding supports public health efforts to reduce cannabis use, particularly in individuals at high risk or patients with psychotic disorders. Identified shared loci and their functional implications could facilitate development of novel treatments. FUNDING US National Institutes of Health, the Research Council Norway, the South-East Regional Health Authority, Stiftelsen Kristian Gerhard Jebsen, EEA-RO-NO-2018-0535, European Union's Horizon 2020 Research and Innovation Programme, the Marie Skłodowska-Curie Actions, and University of Oslo Life Science.
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Affiliation(s)
- Weiqiu Cheng
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Nadine Parker
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Naz Karadag
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Elise Koch
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Guy Hindley
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Romain Icick
- INSERM UMR-S1144, University of Paris, Paris, France
| | - Alexey Shadrin
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; KG Jebsen Centre for Neurodevelopmental disorders, University of Oslo, Oslo, Norway
| | - Kevin S O'Connell
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Thomas Bjella
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Shahram Bahrami
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Zillur Rahman
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Markos Tesfaye
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; Department of Psychiatry, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Piotr Jaholkowski
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Linn Rødevand
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Børge Holen
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Trine Vik Lagerberg
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Nils Eiel Steen
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Srdjan Djurovic
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway; NORMENT, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anders M Dale
- Department of Psychiatry, and Department of Neurosciences, and Department of Radiology, University of California San Diego, La Jolla, CA, USA
| | - Oleksandr Frei
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; Center for Bioinformatics, Department of Informatics, University of Oslo, Oslo, Norway
| | - Olav B Smeland
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway
| | - Ole A Andreassen
- NORMENT, Centre for Mental Disorders Research, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway.
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10
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To J, Davis M, Sbrana A, Alderman B, Hui D, Mukhopadhyay S, Bouleuc C, Case AA, Amano K, Crawford GB, de Feo G, Tanco K, Garsed J. MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse events. Support Care Cancer 2023; 31:202. [PMID: 36872397 DOI: 10.1007/s00520-023-07662-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/24/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Approximately 18% of patients with cancer use cannabis at one time as palliation or treatment for their cancer. We performed a systematic review of randomized cannabis cancer trials to establish a guideline for its use in pain and to summarize the risk of harm and adverse events when used for any indication in cancer patients. METHODS A systematic review of randomized trials with or without meta-analysis was carried out from MEDLINE, CCTR, Embase, and PsychINFO. The search involved randomized trials of cannabis in cancer patients. The search ended on November 12, 2021. The Jadad grading system was used for grading quality. Inclusion criteria for articles were randomized trials or systematic reviews of randomized trials of cannabinoids versus either placebo or active comparator explicitly in adult patients with cancer. RESULTS Thirty-four systematic reviews and randomized trials met the eligibility criteria for cancer pain. Seven were randomized trials involving patients with cancer pain. Two trials had positive primary endpoints, which could not be reproduced in similarly designed trials. High-quality systematic reviews with meta-analyses found little evidence that cannabinoids are an effective adjuvant or analgesic to cancer pain. Seven systematic reviews and randomized trials related to harms and adverse events were included. There was inconsistent evidence about the types and levels of harm patients may experience when using cannabinoids. CONCLUSION The MASCC panel recommends against the use of cannabinoids as an adjuvant analgesic for cancer pain and suggests that the potential risk of harm and adverse events be carefully considered for all cancer patients, particularly with treatment with a checkpoint inhibitor.
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Affiliation(s)
- Josephine To
- Division of Aged Care, Rehabilitation and Palliative Care, Northern Adelaide Local Health Network, Adelaide, Australia
| | - Mellar Davis
- Palliative Care Department, Geisinger Medical System, Danville, USA.
| | | | | | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Carole Bouleuc
- Department of Supportive and Palliative Care, P.S.L. University, Institut Curie, Paris, France
| | - Amy A Case
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Division of Geriatrics and Palliative Medicine, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Koji Amano
- Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Gregory B Crawford
- Northern Adelaide Local Health Network, South Australia, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | | | - Kimberson Tanco
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Guerra J, Naidoo V, Cacabelos R. Potential effects of cannabinoids on audiovestibular function: A narrative review. Front Pharmacol 2022; 13:1010296. [PMID: 36605398 PMCID: PMC9807921 DOI: 10.3389/fphar.2022.1010296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
The growing interest in the development of drugs that target the endocannabinoid system has extended to conditions that affect the audiovestibular pathway. The expression of cannabinoid (CB) receptors in that pathway has been widely demonstrated, indicating a therapeutic potential for drug development at this level. These medications may be beneficial for conditions such as noise-induced hearing loss, ototoxicity, or various forms of vertigo of central or peripheral origin. The therapeutic targets of interest include natural or synthetic compounds that act as CB1/CB2 receptor agonists/antagonists, and inhibitors of the endocannabinoid-degrading enzymes FAAH and MAGL. Furthermore, genetic variations implicated in the response to treatment and the development of related disorders such as epilepsy or migraine have been identified. Direct methods of administering these medications should be examined beyond the systemic strategy.
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Affiliation(s)
- Joaquin Guerra
- Neuro-Otolaryngology Unit, EuroEspes Biomedical Research Center, Institute of Medical Science and Genomic Medicine, Bergondo, Corunna, Spain,*Correspondence: Joaquin Guerra,
| | - Vinogran Naidoo
- Department of Neuroscience, International Center of Neuroscience and Genomic Medicine, EuroEspes Biomedical Research Center, Bergondo, Corunna, Spain
| | - Ramon Cacabelos
- Genomic Medicine, EuroEspes Biomedical Research Center, Institute of Medical Science and Genomic Medicine, Bergondo, Corunna, Spain
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12
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Synergistic action between a synthetic cannabinoid compound and tramadol in neuropathic pain rats. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2022; 72:509-527. [PMID: 36651363 DOI: 10.2478/acph-2022-0037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 02/01/2023]
Abstract
In the present study the interaction of cannabinoid, PhAR-DBH-Me [(R, Z)-18-((1S,4S)-5-methyl-2,5-diazabicyclo[2.2.1]heptan-2-yl)-18-oxooctadec-9-en-7-ylphenyl-acetate] and tramadol in two neuropathy models, as well as their possible toxic effects, was analyzed. The anti-allodynic effect of PhAR-DBH-Me, tramadol, or their combination, were evaluated in neuropathic rats. Furthermore, the effective dose 35 (as the 35 % of the anti allodynic effect) was calculated from the maximum effect of each drug. Moreover, the isobolographic analysis was performed to determine the type of interaction between the drugs. A plasma acute toxicity study was carried out to assess the hepatic, renal, and heart functions after an individual or combined administration of the drugs, as well as histology using the hematoxylin-eosin or Masson-trichome method. PhAR-DBH-Me, tramadol, and their combination produced an antiallodynic effect on spinal nerve ligation (SNL) and cisplatin-induced neuropathic pain in rats. Moreover, PhAR-DBH-Me and tramadol combination showed a synergistic interaction in neuropathic pain rats induced by SNL but not for cisplatin-induced neuropathy. On the other hand, changes in renal and hepatic functions were not observed. Likewise, analysis of liver, kidney and heart histology showed no alterations compared with controls. Results show that the combination of PhAR-DBH-Me and tramadol attenuates the allodynia in SNL rats; the acute toxicology analysis suggests that this combination could be considered safe in administered doses.
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13
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Klein TA, Clark CS. Therapeutic use of cannabis in the US. Nurse Pract 2022; 47:16-25. [PMID: 36399143 PMCID: PMC9674439 DOI: 10.1097/01.npr.0000884880.81603.c5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT NPs are likely to encounter patients using cannabis with therapeutic intent, with or without legal authorization. During the clinical history and assessment process, NPs need to engage in frank discussion about cannabis therapeutics, including the risks and benefits, evidence for use, dosing considerations, potential drug interactions, and harm reduction.
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14
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Shehata I, Hashim A, Elsaeidy A, Nair A, Urits I, Viswanath O, Kaye A, Habib M. Cannabinoids and Their Role in Chronic Pain Treatment: Current Concepts and a Comprehensive Review. Health Psychol Res 2022; 10:35848. [PMID: 36628124 PMCID: PMC9820704 DOI: 10.52965/001c.35848] [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: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/22/2022] Open
Abstract
For decades, chronic pain was managed with an almost conventional approach of using a wide range of analgesic spectrum, surgical approaches and complex interventional pain techniques to modulate or even interrupt pain pathways. These different approaches carry many pharmacological hazards together with the lack of efficacy and safety of many interventional and surgical management techniques for chronic pain have mandated searching for other effective therapies including alternative treatments. Cannabinoids are naturally occurring substances that are derived from Cannabis sativa L. The usage of cannabinoids and their related synthetic chemical compounds has emerged as a choice in the management of different chronic pain conditions is being evaluated, however, the efficacy is still not consistently established. In the present investigation, therefore, we discuss the different aspects related to cannabinoids and their implications in the management of chronic pain conditions. This review will also discuss the safety profile of the cannabinoids together with the legal considerations that hinder their use in different countries.
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Affiliation(s)
| | | | | | | | - Ivan Urits
- Louisiana State University Health Sciences Center
| | | | - Alan Kaye
- Louisiana State University Health Sciences Center
| | - Marian Habib
- Hurghada General Hospital, Department of Cardiology, Hurghada, Egypt
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15
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Sandson N. Important Drug-Drug Interactions for the Addiction Psychiatrist. Psychiatr Clin North Am 2022; 45:431-450. [PMID: 36055731 DOI: 10.1016/j.psc.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The misuse of illicit substances, prescribed medications, and alcohol poses obvious health risks to afflicted individuals. When addressing these health risks, the overarching concerns generally relate to the direct effects that various substances can have on the functioning of multiple organ systems: cardiac, pulmonary, central nervous system, and others. What is not always evident, but potentially equally or even more dire, are the risks arising from drug-drug interactions involving illicit drugs and alcohol, whether with each other, or with prescribed medications. This review provides some basics that enable the reader to fruitfully approach the broad topic of drug-drug interactions.
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Affiliation(s)
- Neil Sandson
- Department of Psychiatry, University of Maryland, 126 East Aylesbury Road, Timonium, MD, USA; VA Maryland Health Care System, 10 North Greene St, Baltimore, MD 21201, USA.
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16
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Zongo A, Lee C, El-Mourad J, Dyck JRB, Hyshka E, Hanlon JG, Eurich DT. Substance Use Disorders and Psychoactive Drug Poisoning in Medically Authorized Cannabis Patients: Longitudinal Cohort Study. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:544-552. [PMID: 34806435 PMCID: PMC9234898 DOI: 10.1177/07067437211060597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Poisoning from psychoactive drugs and substance use disorders (SUD) have been reported among non-medical cannabis users. However, little is known about medical cannabis users and their risk for poisoning and/or development of SUD. This study assessed the risk of emergency department (ED) visits or hospitalization for 1) poisoning by psychoactive drugs and 2) mental/behavioural disorders due to the use of psychoactive drugs and other substances, in medically authorized cannabis patients in Ontario, Canada from 2014-2017. METHODS A cohort study of adult patients authorized for medical cannabis that were matched to population-based controls. ED visit/hospitalization were assessed with a main diagnostic code for: 1) poisoning by psychoactive drugs; 2) mental and behavioural disorder due to psychoactive drugs or other substance use. Conditional Cox proportional hazards regressions were conducted. RESULTS 18,653 cannabis patients were matched to 51,243 controls. During a median follow-up of 243 days, the incidence rate for poisoning was 4.71 per 1,000 person-years (95%CI: 3.71-5.99) for cases and 1.73 per 1,000 person-years (95% CI: 1.36-2.19) for controls. The adjusted hazard ratio (aHR) was 2.45 (95%CI: 1.56-3.84). For mental/behavioural disorders, the incident rates were 8.89 (95% CI: 7.47-10.57) and 5.01 (95% CI: 4.36-5.76) in the cannabis and the controls group. The aHR was 2.27 (95%CI: 1.66-3.11). No difference was observed between males and females (P-value for interaction > 0.05). CONCLUSIONS Our study observed a short-term increased risk of ED visit/hospitalization for poisoning or for mental/behavioural disorders (from use of psychoactive drugs and other substances)- in medically authorized cannabis patients.
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Affiliation(s)
- Arsène Zongo
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Canada.,Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Quebec City, Canada
| | - Cerina Lee
- School of Public Health, 3158University of Alberta, Edmonton, Canada
| | - Jihane El-Mourad
- Faculty of Pharmacy, 4440Université Laval, Quebec City, Canada.,Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Quebec City, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Department of Pediatrics, Faculty of Medicine and Dentistry, 3158University of Alberta, Edmonton, Canada
| | - Elaine Hyshka
- School of Public Health, 3158University of Alberta, Edmonton, Canada
| | - John G Hanlon
- St. Michael's Hospital Department of Anesthesia, 177410University of Toronto, Ontario, Canada.,Department of Anaesthesiology and Pain Medicine, University of Toronto, Ontario, Canada
| | - Dean T Eurich
- School of Public Health, 3158University of Alberta, Edmonton, Canada
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17
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Asselin A, Lamarre OB, Chamberland R, McNeil SJ, Demers E, Zongo A. A description of self-medication with cannabis among adults with legal access to cannabis in Quebec, Canada. J Cannabis Res 2022; 4:26. [PMID: 35619155 PMCID: PMC9134718 DOI: 10.1186/s42238-022-00135-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Cannabis is increasingly used for medical purposes, particularly in countries like Canada where cannabis was recently legalized for recreational use. We aimed to assess self-medication with cannabis post-cannabis legalization among adults in the Canadian province of Quebec. Methods This is a cross-sectional online survey of a self-selected convenience sample conducted in Quebec, Canada, from November 2020 to January 2021. Individuals aged ≥ 21 years who endorsed using cannabis bought in legal recreational cannabis stores to self-medicate a health condition were included. Data were analyzed using descriptive statistics and stratified according to sex, age, and the type of cannabis use (exclusively medical versus medical and recreational use). Results Four hundred eighty-nine participants were included. The median age was 34 years, and 48% were women. About 25% reported exclusive medical use of cannabis. Treated conditions included anxiety (70%), insomnia (56%), pain (53%), depression (37%), and many others. Reasons for not consulting in cannabis clinics included lack of information (52%), the complexity of the process (39%), accessibility of cannabis clinics (23%), and others. Tetrahydrocannabinol (THC) dosage > 20% was reported by 32%. Smoking was the main route of use (81%). Possession of prescribed drugs was reported by 56%. Professionals consulted for information on cannabis included recreational cannabis store agents (36%), physicians (29%), and others. Overall, significant differences were observed for many of the comparisons according to sex, age, and the type of cannabis use. Conclusions Many conditions are self-medicated with cannabis. The use of high doses of cannabis, smoking as a preferred method of use, and concurrent use of other medications may pose some risks to individuals. Addressing the reported barriers to medical access to cannabis is urgently needed. Supplementary Information The online version contains supplementary material available at 10.1186/s42238-022-00135-y.
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Affiliation(s)
- Antoine Asselin
- Faculty of Pharmacy, Unversité Laval, Quebec City, QC, Canada
| | | | | | | | - Eric Demers
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, 1050 Chemin Ste-Foy (J1-14B), QC, G1S 4L8, Quebec City, Canada
| | - Arsène Zongo
- Faculty of Pharmacy, Unversité Laval, Quebec City, QC, Canada. .,Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, 1050 Chemin Ste-Foy (J1-14B), QC, G1S 4L8, Quebec City, Canada.
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18
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Lopera V, Rodríguez A, Amariles P. Clinical Relevance of Drug Interactions with Cannabis: A Systematic Review. J Clin Med 2022; 11:jcm11051154. [PMID: 35268245 PMCID: PMC8911401 DOI: 10.3390/jcm11051154] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 12/29/2022] Open
Abstract
Concomitant use of cannabis with other drugs may lead to cannabis–drug interactions, mainly due to the pharmacokinetic mechanism involving the family of CYP450 isoenzymes. This narrative systematic review aimed to systematize the available information regarding clinical relevance of cannabis–drug interactions. We utilized the PubMed/Medline database for this systematic review, using the terms drug interactions and cannabis, between June 2011 and June 2021. Articles with cannabis–drug interactions in humans, in English or Spanish, with full-text access were selected. Two researchers evaluated the article’s inclusion. The level of clinical relevance was determined according to the severity and probability of the interaction. Ninety-five articles were identified and twenty-six were included. Overall, 19 pairs of drug interactions with medicinal or recreational cannabis were identified in humans. According to severity and probability, 1, 2, 12, and 4 pairs of cannabis–drug interactions were classified at levels 1 (very high risk), 2 (high risk), 3 (medium risk), and 5 (without risk), respectively. Cannabis–warfarin was classified at level 1, and cannabis–buprenorphine and tacrolimus at level 2. This review provides evidence for both the low probability of the occurrence of clinically relevant drug interactions and the lack of evidence regarding cannabis–drug interactions.
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19
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Laudanski K, Wain J. Considerations for Cannabinoids in Perioperative Care by Anesthesiologists. J Clin Med 2022; 11:jcm11030558. [PMID: 35160010 PMCID: PMC8836924 DOI: 10.3390/jcm11030558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: (K.L.); (J.W.)
| | - Justin Wain
- School of Osteopathic Medicine, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: (K.L.); (J.W.)
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20
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Drug Interactions. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00003-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Ruan LH, Fan LL, Wang K, Zhang WQ, Wang XJ, Qiu XJ. The Effect of Posaconazole and Isavuconazole on the Pharmacokinetics of Erdafitinib in Beagle Dogs by UPLC-MS/MS. Front Pharmacol 2021; 12:749169. [PMID: 34912218 PMCID: PMC8666568 DOI: 10.3389/fphar.2021.749169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/29/2021] [Indexed: 01/12/2023] Open
Abstract
Objective: A robust, quick, and reliable ultra-performance liquid chromatography–tandem mass spectrometry (UPLC-MS/MS) method for the quantification of erdafitinib in beagle dog plasma was developed and validated to evaluate the changes of posaconazole and isavuconazole on the pharmacokinetics of erdafitinib in beagle dogs, respectively. Methods: This experiment adopted a three-period self-control experimental design. In the first period (group A), erdafitinib was orally administered to six beagle dogs at a dose of 4 mg/kg. In the second period (group B), the same six beagle dogs were orally given posaconazole at a dose of 7 mg/kg, and after 30 min, erdafitinib was orally given. In the third period (group C), isavuconazole at a dose of 7 mg/kg was given orally, and then, erdafitinib was orally given. At the different time points after erdafitinib was given in the three periods, the blood samples were collected. The concentration of erdafitinib was detected by the developed UPLC-MS/MS method. DAS 2.0 was used to calculate the pharmacokinetic parameters of erdafitinib. Results: Erdafitinib had a good linear relationship in the range of 1–500 ng/ml, and the lower limit of quantification was 1 ng/ml. The precision, accuracy, extraction recovery, matrix effect, and stability meet the requirements of the guiding principles. After erdafitinib was combined with posaconazole, the Cmax and AUC0→t of erdafitinib increased by 27.19% and 47.62%, respectively, and the t1/2 was prolonged to 6.33 h. After erdafitinib was combined with isavuconazole, the Cmax and AUC0→t of erdafitinib increased by 23.13% and 54.46%, respectively, and the t1/2 was prolonged to 6.31 h. Conclusion: A robust and reliable UPLC-MS/MS method was fully optimized and developed to detect the plasma concentration of erdafitinib in beagle dogs. Posaconazole and isaconazole could inhibit the metabolism of erdafitinib in beagle dogs and increase the plasma exposure of erdafitinib.
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Affiliation(s)
- Lan-Hong Ruan
- The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China.,School of Nursing of Henan University of Science and Technology, Luoyang, China
| | - Ling-Ling Fan
- School of Nursing of Henan University of Science and Technology, Luoyang, China
| | - Kun Wang
- School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Wan-Qi Zhang
- School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Xiao-Jun Wang
- School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
| | - Xiang-Jun Qiu
- School of Basic Medical Sciences, Henan University of Science and Technology, Luoyang, China
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22
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Vázquez M, Fagiolino P. The role of efflux transporters and metabolizing enzymes in brain and peripheral organs to explain drug-resistant epilepsy. Epilepsia Open 2021; 7 Suppl 1:S47-S58. [PMID: 34560816 PMCID: PMC9340310 DOI: 10.1002/epi4.12542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 11/08/2022] Open
Abstract
Drug‐resistant epilepsy has been explained by different mechanisms. The most accepted one involves overexpression of multidrug transporters proteins at the blood brain barrier and brain metabolizing enzymes. This hypothesis is one of the main pharmacokinetic reasons that lead to the lack of response of some antiseizure drug substrates of these transporters and enzymes due to their limited entrance into the brain and limited stay at the sites of actions. Although uncontrolled seizures can be the cause of the overexpression, some antiseizure medications themselves can cause such overexpression leading to treatment failure and thus refractoriness. However, it has to be taken into account that the inductive effect of some drugs such as carbamazepine or phenytoin not only impacts on the brain but also on the rest of the body with different intensity, influencing the amount of drug available for the central nervous system. Such induction is not only local drug concentration but also time dependent. In the case of valproic acid, the deficient disposition of ammonia due to a malfunction of the urea cycle, which would have its origin in an intrinsic deficiency of L‐carnitine levels in the patient or by its depletion caused by the action of this antiseizure drug, could lead to drug‐resistant epilepsy. Many efforts have been made to change this situation. In order to name some, the administration of once‐daily dosing of phenytoin or the coadministration of carnitine with valproic acid would be preferable to avoid iatrogenic refractoriness. Another could be the use of an adjuvant drug that down‐regulates the expression of transporters. In this case, the use of cannabidiol with antiseizure properties itself and able to diminish the overexpression of these transporters in the brain could be a novel therapy in order to allow penetration of other antiseizure medications into the brain.
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Affiliation(s)
- Marta Vázquez
- Pharmaceutical Sciences Department, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
| | - Pietro Fagiolino
- Pharmaceutical Sciences Department, Faculty of Chemistry, Universidad de la República, Montevideo, Uruguay
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23
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Serum Proteomic Analysis of Cannabis Use Disorder in Male Patients. Molecules 2021; 26:molecules26175311. [PMID: 34500744 PMCID: PMC8434053 DOI: 10.3390/molecules26175311] [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: 06/27/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 12/18/2022] Open
Abstract
Cannabis use has been growing recently and it is legally consumed in many countries. Cannabis has a variety of phytochemicals including cannabinoids, which might impair the peripheral systems responses affecting inflammatory and immunological pathways. However, the exact signaling pathways that induce these effects need further understanding. The objective of this study is to investigate the serum proteomic profiling in patients diagnosed with cannabis use disorder (CUD) as compared with healthy control subjects. The novelty of our study is to highlight the differentially changes proteins in the serum of CUD patients. Certain proteins can be targeted in the future to attenuate the toxicological effects of cannabis. Blood samples were collected from 20 male individuals: 10 healthy controls and 10 CUD patients. An untargeted proteomic technique employing two-dimensional difference in gel electrophoresis coupled with mass spectrometry was employed in this study to assess the differentially expressed proteins. The proteomic analysis identified a total of 121 proteins that showed significant changes in protein expression between CUD patients (experimental group) and healthy individuals (control group). For instance, the serum expression of inactive tyrosine protein kinase PEAK1 and tumor necrosis factor alpha-induced protein 3 were increased in CUD group. In contrast, the serum expression of transthyretin and serotransferrin were reduced in CUD group. Among these proteins, 55 proteins were significantly upregulated and 66 proteins significantly downregulated in CUD patients as compared with healthy control group. Ingenuity pathway analysis (IPA) found that these differentially expressed proteins are linked to p38MAPK, interleukin 12 complex, nuclear factor-κB, and other signaling pathways. Our work indicates that the differentially expressed serum proteins between CUD and control groups are correlated to liver X receptor/retinoid X receptor (RXR), farnesoid X receptor/RXR activation, and acute phase response signaling.
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24
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Choi NG, Choi BY, Marti CN, DiNitto DM. Is cannabis use associated with prescription psychotropic and pain reliever medication and other substance use among individuals aged 50+ with mental illness? Drug Alcohol Depend 2021; 225:108842. [PMID: 34186443 DOI: 10.1016/j.drugalcdep.2021.108842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Despite increasing rates of nonmedical and/or medical cannabis use in the 50+ age group, scant research exists on the associations between cannabis use and prescription medication use. In this study, we examined associations of use of prescription tranquilizers, sedatives, stimulants, and pain relievers, tobacco products, any/binge/heavy alcohol, and illicit drugs with cannabis use and use characteristics among U.S. adults aged 50+ years with past-year mental illness (n = 6454). METHODS Data are from the 2015-2019 National Survey on Drug Use and Health (NSDUH). We used logistic regression models to examine associations of past-month use of each substance with (1) cannabis use among all those with past-year mental illness, and (2) cannabis use characteristics among cannabis users, controlling for severity of mental illness and sociodemographic and health characteristics. RESULTS Of individuals aged 50+, 14.1 % had any past-year mental illness, and 9.7 % of those with mental illness, compared to 4.0 % of those without, reported past-month cannabis use. Compared to nonusers, cannabis users had higher odds of using each substance except antidepressants, with adjusted odds ratios ranging from 1.3 (sedatives) to 3.6 (illicit drugs). Compared to nonmedical cannabis users, medical users had 2-2.5 times higher likelihood of co-use of tranquilizers, sedatives, and prescription pain relievers but lower odds of binge and heavy alcohol use. CONCLUSIONS Cannabis users, especially medical cannabis users, are significantly more likely to use prescription psychotropic or pain medications. Healthcare professionals should assess for poly-substance use and potential adverse effects among older adults with mental illness.
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Affiliation(s)
- Namkee G Choi
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, 78702, USA.
| | - Bryan Y Choi
- Department of Emergency Medicine, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA; Bayhealth Medical Center, Dover, DE, 19901, USA
| | - C Nathan Marti
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, 78702, USA
| | - Diana M DiNitto
- Steve Hicks School of Social Work, University of Texas at Austin, Austin, TX, 78702, USA
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25
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Coulter C, Wagner JR. Cannabinoids in Oral Fluid: Limiting Potential Sources of Cannabidiol Conversion to Δ9- and Δ8-Tetrahydrocannabinol. J Anal Toxicol 2021; 45:807-812. [PMID: 34137890 DOI: 10.1093/jat/bkab074] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 12/20/2022] Open
Abstract
In late 2019 the National Laboratory Certification Program (NLCP) published an article reporting on the potential analytical conversion of 7-carboxy-cannabidiol (CBD-COOH) to 11-nor-9-carboxy-Δ9-tetrahydrocannabinol-9-carboxylic acid (THC-COOH) in urine samples. (1) The same conversion is possible in oral fluid with the parent analyte cannabidiol (CBD) converting to Δ9-tetrahydrocannabinol (Δ9-THC) and Δ8-tetrahydrocannabinol (Δ8-THC) under strong acidic conditions. With the recent rise in states legalizing the use of THC and the availability of products containing only CBD, unless the analytical in vitro conversions are controlled, the detection of Δ9-THC or Δ8-THC in oral fluid may not clarify whether the donor was using a CBD product, licit or illicit THC product. Authentic oral fluid samples submitted for cannabinoid analysis were subjected to multiple sample preparation procedures and extraction methods to determine the conditions that allow CBD to convert to THC. CBD single analyte controls prepared from a certified THC-free source were added to the batch to monitor the rate of conversion. Samples were prepared using a base hydrolysis, solid phase extraction, derivatization, and analysis by liquid chromatography with tandem mass spectrometry (LC-MS-MS). The base hydrolysis and derivatization were tested independently and did not contribute to the conversion rate. Adjusting the pH of the sample preparation and extraction from pH 2.0 to pH 5.0 changed the conversion rate from 5% to 1%. A pH of 6.0 was not strong enough to extract the cannabinoids efficiently. Removing the acid component of the preparation and extraction procedure eliminated the conversion to THC; however, this did reduce the analyte recovery depending on which extraction column was used. Processing time also contributed to the conversion rate. With smaller trial runs, conversion was not always seen but with larger validation batches low level conversion of 1-2% was observed. A fully validated LC-MS-MS method utilizing solid-phase extraction was developed for CBD, Δ9-THC, Δ8-THC, and cannabinol (CBN). The method specifically targets those analytes found in oral fluid after CBD administration and those that are seen during in vitro CBD conversion. CBD administration was performed using a certified THC-free CBD control.
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Affiliation(s)
- Cynthia Coulter
- School of Forensic Sciences, Oklahoma State University Center for Health Sciences, 1111 W. 17th St., Tulsa, OK 74107 USA
| | - Jarrad R Wagner
- School of Forensic Sciences, Oklahoma State University Center for Health Sciences, 1111 W. 17th St., Tulsa, OK 74107 USA
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