Cannabis use in patients with multiple sclerosis

Cannabis Use: A New Risk Behaviour Among Adults With Congenital Heart Disease

Background

Cannabis use has increased in Canada and can be associated with adverse cardiovascular events. Given increased use and accessibility to cannabis, there is a need among clinicians to better understand cannabis use in adults with congenital heart disease.

Methods

A cross-sectional survey (May to September 2018) was used to investigate cannabis use among 252 patients with adult congenital heart disease in a quaternary care centre.

Results

Of the 252 patients, 53 (21%) reported using cannabis. The majority of cannabis users were men (62%), between the ages of 25 and 39 years (mean age = 32 ± 16 years), and more likely to use tobacco (n = 9, 17%; P = 0.001) and alcohol (n = 37, 60%; P = 0.001). Significant differences (P = 0.011) were found between the age of onset for tobacco use among cannabis users (mean age: 16 ± 8 years) and non-cannabis users (mean age: 20 ± 3 years). Users reported consuming cannabis for recreational purposes (n = 29, 55%), anxiety (n = 22, 42%), depression (n = 15, 28%), and pain management (n = 4, 8%).

Conclusions

This study supports our clinical experience that a high proportion of patients with adult congenital heart disease use cannabis. Cannabis users represent a patient population who may demonstrate less optimal health behaviours, including tobacco and alcohol use. Assessment of cannabis use should be an integral part of risk behaviour and cardiovascular risk profile at each clinic visit. Given the current legalization of cannabis in Canada and the growing increase of cannabis use, educational support should be provided to patients and caregivers.

Symptom severity is a major determinant of cannabis-based products use among people with multiple sclerosis

AIMS AND OBJECTIVES

We aimed to identify correlates of cannabinoid-based products (CBP) use in patients with multiple sclerosis (MS) in France and Spain.

BACKGROUND

MS is responsible for a wide range of symptoms, including pain. Access to CBP differs according to local legislation. The French context is more restrictive than the Spanish one, and no data regarding cannabis use among MS patients has yet been published. Characterizing MS patients who use CBP constitutes a first step toward identifying persons most likely to benefit from them.

DESIGN

An online cross-sectional survey was submitted to MS patients who were members of a social network for people living with chronic diseases and were living in France or Spain.

METHODS

Two study outcomes measured therapeutic CBP use and daily therapeutic CBP use. Seemingly unrelated bivariate probit regression models were used to test for associations between the outcomes and patients' characteristics while accounting for country-related differences. STROBE guidelines were followed in reporting this study.

RESULTS

Among 641 study participants (70% from France), the prevalence of CBP use was similar in both countries (23.3% in France vs. 20.1% in Spain). MS-related disability was associated with both outcomes, with a gradient observed between different degrees of disability. MS-related pain level was associated with CBP use only.

CONCLUSIONS

CBP use is common in MS patients from both countries. The more severe the MS, the more participants turned to CBP to alleviate their symptoms. Easier access to CBP should be ensured for MS patients in need of relief, especially from pain.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the characteristics of MS patients using CBP. Such practices should be discussed by healthcare professional with MS patients.

Characterizing cannabis use in a sample of adults with multiple sclerosis and chronic pain: An observational study

BACKGROUND

Although cannabis has become an increasingly common method for pain management among people with multiple sclerosis (PwMS), there is a dearth of knowledge regarding the types of cannabis products used as well as the characteristics of cannabis users. The current study aimed to (1) describe the prevalence of cannabis use and the routes of administration of cannabis products in adults with an existing chronic pain condition and MS, (2) to examine differences in demographic and disease-related variables between cannabis users and non-users, and (3) to examine differences between cannabis users and non-users in pain-related variables, including pain intensity, pain interference, neuropathic pain, pain medication use, and pain-related coping.

METHODS

Secondary analysis of baseline data from participants with multiple sclerosis (MS) and chronic pain (N = 242) enrolled in an RCT comparing mindfulness-based cognitive therapy (MBCT), cognitive-behavioral therapy (CBT), and usual care for chronic pain. Statistical methods included t-tests, Mann-Whitney tests, chi-square tests, and Fisher's exact tests to assess for differences in demographic, disease-related, and pain-related variables between cannabis users and non-users.

RESULTS

Of the 242 participants included in the sample, 65 (27%) reported the use of cannabis for pain management. The most common route of administration was oil/tincture (reported by 42% of cannabis users), followed by vaped (22%) and edible (17%) products. Cannabis users were slightly younger than non-users (Medage 51.0 vs 55.0, p = .019) and reported higher median pain intensity scores (6.0 vs 5.0, p = .022), higher median pain interference scores (5.9 vs 5.4, p = .027), and higher median levels of neuropathic pain (20.0 vs 16.0, p = .001).

CONCLUSIONS

The current study identified factors that may intersect with cannabis use for pain management and adds to our current knowledge of the types of cannabis products used by PwMS. Future research should continue to investigate trends in cannabis use for pain management, especially as the legality and availability of products continue to shift. Additionally, longitudinal studies are needed to examine the effects of cannabis use on pain-related outcomes over time.

Views on Using Psychoactive Substances to Self-Manage Functional Neurological Disorder: Online Patient Survey Results

Objective: Functional neurological disorder (FND) causes a high burden of disability and distress. Although it is a common disorder, there is a pressing need for improved access to evidence-based treatments. With difficulties in finding effective treatment, some people with FND may seek alternative means of symptom relief, such as legal and illicit psychoactive substances, although the prevalence and nature of such self-management strategies are currently unclear. Additionally, psychoactive substances may represent novel treatment research opportunities, particularly for those with suboptimal improvement. The investigators examined the use of self-management techniques, as well as perspectives on novel therapies, in this patient population. Methods: An online survey was created to assess self-management strategies and views on novel treatments for FND, including psychedelic therapy. The survey was accessible for 1 month, and respondents were recruited internationally through social media and patient groups. A total of 1,048 respondents from 16 countries completed the survey. Results: Almost half (46%) of 980 respondents reported having tried legal psychoactive substances for the management of their FND symptoms and, on average, nicotine, alcohol, and cannabidiol were reported as modestly effective. Additionally, 15% of respondents reported having used illicit substances, mostly cannabis, to manage FND, with the majority reporting moderate effectiveness and experiencing no or minimal physical (90%) and psychological (95%) sequelae. Many respondents (46%) reported that they would be willing to try medically supervised psychedelic therapy (with 19% of respondents ambivalent) if it were found to be safe and effective. Conclusions: Many people with FND seek alternative means of symptom management outside usual medical care, including legal and illicit psychoactive substances. Further research exploring novel treatment options, such as psychedelics, in FND may be warranted.

The Efficacy of Cannabis on Multiple Sclerosis-Related Symptoms

Multiple sclerosis (MS) is known as an autoimmune disease that damages the neurons in the central nervous system. MS is characterized by its most common symptoms of spasticity, muscle spasms, neuropathic pain, tremors, bladder dysfunction, dysarthria, and some intellectual problems, including memory disturbances. Several clinical studies have been conducted to investigate the effects of cannabis on the relief of these symptoms in MS patients. The efficacy of Cannabis sativa (C. Sativa) in the management of MS outcomes such as spasticity, pain, tremors, ataxia, bladder functions, sleep, quality of life, and adverse effects were assessed in this review. Most clinical studies showed the positive effects of cannabinoids with their different routes of administration, such as oromucosal spray and oral form, in reducing most MS symptoms. The oromucosal spray Nabiximols demonstrated an improvement in reducing MS spasticity, pain, and quality of life with a tolerated adverse effect. Oral cannabinoids are significantly effective for treating MS pain and spasticity, while the other symptoms indicate slight improvement and the evidence is quite inconsistent. Oromucosal spray and oral cannabis are mainly used for treating patients with MS and have positive effects on treating the most common symptoms of MS, such as pain and spasticity, whereas the other MS symptoms indicated slight improvement, for which further studies are needed.

Comparison of Medical Cannabis Use Reported on a Confidential Survey vs Documented in the Electronic Health Record Among Primary Care Patients

Importance

Patients who use cannabis for medical reasons may benefit from discussions with clinicians about health risks of cannabis and evidence-based treatment alternatives. However, little is known about the prevalence of medical cannabis use in primary care and how often it is documented in patient electronic health records (EHR).

Objective

To estimate the primary care prevalence of medical cannabis use according to confidential patient survey and to compare the prevalence of medical cannabis use documented in the EHR with patient report.

Design, Setting, and Participants

This study is a cross-sectional survey performed in a large health system that conducts routine cannabis screening in Washington state where medical and nonmedical cannabis use are legal. Among 108 950 patients who completed routine cannabis screening (between March 28, 2019, and September 12, 2019), 5000 were randomly selected for a confidential survey about cannabis use, using stratified random sampling for frequency of past-year use and patient race and ethnicity. Data were analyzed from November 2020 to December 2021.

Exposures

Survey measures of patient-reported past-year cannabis use, medical cannabis use (ie, explicit medical use), and any health reason(s) for use (ie, implicit medical use).

Main Outcomes and Measures

Survey data were linked to EHR data in the year before screening. EHR measures included documentation of explicit and/or implicit medical cannabis use. Analyses estimated the primary care prevalence of cannabis use and compared EHR-documented with patient-reported medical cannabis use, accounting for stratified sampling and nonresponse.

Results

Overall, 1688 patients responded to the survey (34% response rate; mean [SD] age, 50.7 [17.5] years; 861 female [56%], 1184 White [74%], 1514 non-Hispanic [97%], and 1059 commercially insured [65%]). The primary care prevalence of any past-year patient-reported cannabis use on the survey was 38.8% (95% CI, 31.9%-46.1%), whereas the prevalence of explicit and implicit medical use were 26.5% (95% CI, 21.6%-31.3%) and 35.1% (95% CI, 29.3%-40.8%), respectively. The prevalence of EHR-documented medical cannabis use was 4.8% (95% CI, 3.45%-6.2%). Compared with patient-reported explicit medical use, the sensitivity and specificity of EHR-documented medical cannabis use were 10.0% (95% CI, 4.4%-15.6%) and 97.1% (95% CI, 94.4%-99.8%), respectively.

Conclusions and Relevance

These findings suggest that medical cannabis use is common among primary care patients in a state with legal use, and most use is not documented in the EHR. Patient report of health reasons for cannabis use identifies more medical use compared with explicit questions about medical use.

Increased 2-arachidonoyl-sn-glycerol levels normalize cortical responses to sound and improve behaviors in Fmr1 KO mice

Background

Individuals with Fragile X syndrome (FXS) and autism spectrum disorder (ASD) exhibit an array of symptoms, including sociability deficits, increased anxiety, hyperactivity, and sensory hyperexcitability. It is unclear how endocannabinoid (eCB) modulation can be targeted to alleviate neurophysiological abnormalities in FXS as behavioral research reveals benefits to inhibiting cannabinoid (CB) receptor activation and increasing endocannabinoid ligand levels. Here, we hypothesize that enhancement of 2-arachidonoyl-sn-glycerol (2-AG) in Fragile X mental retardation 1 gene knock-out (Fmr1 KO) mice may reduce cortical hyperexcitability and behavioral abnormalities observed in FXS.

Methods

To test whether an increase in 2-AG levels normalized cortical responses in a mouse model of FXS, animals were subjected to electroencephalography (EEG) recording and behavioral assessment following treatment with JZL-184, an irreversible inhibitor of monoacylglycerol lipase (MAGL). Assessment of 2-AG was performed using lipidomic analysis in conjunction with various doses and time points post-administration of JZL-184. Baseline electrocortical activity and evoked responses to sound stimuli were measured using a 30-channel multielectrode array (MEA) in adult male mice before, 4 h, and 1 day post-intraperitoneal injection of JZL-184 or vehicle. Behavior assessment was done using the open field and elevated plus maze 4 h post-treatment.

Results

Lipidomic analysis showed that 8 mg/kg JZL-184 significantly increased the levels of 2-AG in the auditory cortex of both Fmr1 KO and WT mice 4 h post-treatment compared to vehicle controls. EEG recordings revealed a reduction in the abnormally enhanced baseline gamma-band power in Fmr1 KO mice and significantly improved evoked synchronization to auditory stimuli in the gamma-band range post-JZL-184 treatment. JZL-184 treatment also ameliorated anxiety-like and hyperactivity phenotypes in Fmr1 KO mice.

Conclusions

Overall, these results indicate that increasing 2-AG levels may serve as a potential therapeutic approach to normalize cortical responses and improve behavioral outcomes in FXS and possibly other ASDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-021-09394-x.

A cross-sectional survey of cannabis use by people with MS in Oregon and Southwest Washington

BACKGROUND

Evidence supports that cannabinoids reduce self-reported spasticity and neuropathic pain in people with MS (PwMS), and legal access to cannabis for medical and recreational use continues to rise. However, there are limited data regarding patterns of cannabis use and perceived benefits of cannabis among PwMS in the US. This study describes the prevalence of cannabis use, routes of administration, perceived benefit of cannabis for MS, and characteristics associated with cannabis use and perception of benefit among a population of PwMS living in two states where cannabis is legal for both medical and recreational use.

METHODS

A survey about treatments used by PwMS, focusing on complementary and alternative medicine (CAM), was sent to PwMS living in Oregon and Southwest Washington. This survey included questions about current and past cannabis use, route of cannabis administration, and perceived benefits, as well as personal demographics.

RESULTS

Of the 1188 returned surveys, 1000 had at least 75% complete survey responses and also completed the questions about current and past cannabis use. Thirty percent (n=303) of respondents reported currently using cannabis, 21% (n=210) used in the past but not currently, and 49% (n=487) had never used cannabis. Among current users, rates of use by smoking, vaping, topicals, tinctures and oils, or edibles were similar (35-46%), and most (59%) reported using multiple routes of administration. Most (64-78%, varying by route) current and past users reported cannabis being very or somewhat beneficial for their MS. The odds of current cannabis use were higher in PwMS who: 1) were younger (OR 2.24 [95% CI 1.39-3.61] for those age 18-40 compared with age >60]; 2) had lower household income (OR 3.94 [95% CI 2.55-6.09] with annual income <$25k compared with those with >$100k); 3) had secondary progressive MS (OR 1.77 [95% CI 1.07-2.92]); and 4) had more than minimal MS disability (OR 2.05 [95% CI 1.03-4.10] for those using a walker compared to those with none/minimal disability). The odds of perceiving cannabis as beneficial for MS were higher in: 1) younger individuals (OR 5.61 [95% CI 2.62-11.98] for those age 18-40 compared with age >60); 2) those with lower household income (OR 3.35 [95% CI 1.65-6.80] with annual income <$25k compared with those with >$100k), 3) those not currently using disease modifying therapies (OR 2.32 [95% CI 1.30-4.13]), and 4) those with the greatest disability (OR 17.96; [95% CI 2.00-161.22]).

CONCLUSION

In this survey, 30% of PwMS reported currently using cannabis for their MS, mostly by multiple routes of administration, and most of these people report this being helpful for their MS. People who were younger, had lower household income, had progressive disease, and had more than minimal disability were more likely to use cannabis and report it was beneficial for their MS. People who were not using disease modifying therapies were also more likely to report benefit from cannabis use.

Cannabinoids and bladder symptoms in multiple sclerosis

BACKGROUND

Research on the health benefits of cannabis has been limited because use remains restricted or illegal in most countries. Medical cannabis has been legal in Canada since 2001 and recreational use became legal in October 2018. While there are data that support a biological mechanism by which cannabinoids can impact various other symptoms of MS, the evidence of effectiveness of cannabis as a treatment for bladder symptoms remains unsettled. We conducted an exploratory study to describe the current trends of cannabis product consumption among people with MS (PwMS) and their association with perceived benefits on MS symptoms.

METHODS

A cross-sectional survey study of PwMS, recruited from the MS Clinic in Calgary, Alberta, Canada was undertaken. Logistic regression analyses were performed to assess the associations between cannabis consumption and improvement in bladder function symptoms.

RESULTS

There were 775 respondents out of 2899 PwMS contacted by email. Among respondents, 734 reported cannabis use in the past 3 months. There were 275 (37.5%) respondents who reported cannabis use in the prior 3 months, and 73.8% of these reported at least weekly use of cannabis. Among all users, 78.1% reported a primary medical or therapeutic indication for consumption. The most common modes of cannabis consumption were oral-edible (69.0%) and smoked (57.1%), while 59.3% used more than one mode of consumption and 2.6% used five different modes. The most common reasons for cannabis use were for sleep (58.3%), pain (51.5%), relaxation (44.4%), muscle spasms (40.2%), anxiety (33.8%) and depression (22.9%). Among the 19 participants who reported bladder symptoms as a main reason for cannabis use, 89.5% reported "better" bladder symptoms when using cannabis. Cannabis consumption in the past 3 months was associated with a two-fold increased odds of reporting improvement in urinary frequency, urinary urgency, bladder leakage and wetness, pad use and bladder emptying.

CONCLUSIONS

Cannabis is commonly used in this survey study of personal cannabis use among PwMS. Patterns of use, dosing, frequency and mode of delivery are diverse among survey respondents. This pilot study provides some initial glimpses into real world therapeutic use of cannabinoids among PwMS for bladder symptoms.

Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State

Importance

Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners' documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use.

Objectives

To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use.

Design, Setting, and Participants

This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use.

Exposures

Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening.

Main Outcomes and Measures

Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine's review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression.

Results

A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%).

Conclusions and Relevance

In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients.

Use of cannabis in patients with multiple sclerosis from Argentina

BACKGROUND

The use of cannabis to treat some symptoms of neurological diseases, including multiple sclerosis (MS), has increased worldwide. We aimed to assess the use of cannabis in patients with MS (PwMS) from Argentina, its reasons and patients' perceptions on the management of MS symptoms. Additionally, we assessed their association with socio-demographic and clinical aspects.

METHODS

A cross-sectional online survey that included 281 PwMS from Argentina was conducted. Screening instruments: Demographics and clinical data, health-related QoL (MS Impact Scale-29), Fatigue Severity Scale, The Hospital Anxiety and Depression Scale, sleep disorders, physical disability (self-administrated Expanded Disability Status Scale) and medical or recreational cannabis use were evaluated. A logistic regression model was carried out.

RESULTS

Current users (cannabis was used within the past year) was reported in 34.2% and former users (had tried cannabis but not used it within the past year) in 22.7%. Daily cannabis use was reported in 31.3% (current + former users) of the studied cohort, 41.9% started their use after MS diagnosis and 54.3% of them had never discussed about cannabis use with their neurologist. Recreational use was reported in 47.5%. Younger (age below 30 years) PwMS (OR = 2.39, p = 0.03), presence of chronic pain (OR = 2.42, p = 0.002) and current alcohol intake (OR = 3.33, p = 0.001) were predictors of current cannabis use in our multivariate model.

CONCLUSION

A high prevalence of use of cannabis in PwMS from Argentina was observed. Demographic, symptoms and lifestyle factors predict cannabis use. Identifying the presence and severity of these conditions would contribute to a better MS management and treatment.

The Effect of Cannabis on the Clinical and Cytokine Profiles in Patients with Multiple Sclerosis

Background

Multiple studies have reported that cannabis administration in multiple sclerosis patients is associated with decreased symptom severity. This study was conducted to evaluate the prevalence of cannabis abuse in multiple sclerosis cases and to evaluate the effect of cannabis on serum cytokines in such cases. Patients and Methods. A total of 150 multiple sclerosis cases along with 150 healthy controls were included during the study period. All cases were subjected to history taking, neurological examination, and routine investigations. Cases were asked about cannabis intake which was confirmed by a urine test. Serum cytokines including IL-1, IL-2, IL-4, IL-10, IL-12, IL-17, IL-22, IFN-γ, IFN-β1, and TNF-α were ordered for all cases and controls.

Results

Twenty-eight cases were cannabis abusers (MS/cannabis group, 18.67%). The remaining 122 cases represented the MS group. There was no significant difference between the three groups regarding age, disease duration, or MS type. Male gender was more predominant in the MS/cannabis group, and the number of relapses was significantly lower in the same group. Fifteen cases (53.6%) reported that their symptoms were improved by cannabis. Proinflammatory cytokines were significantly elevated in the MS group compared to the MS/cannabis and control groups. Additionally, anti-inflammatory cytokines had significantly lower values in the MS group compared to the MS/cannabis and control groups. Most clinical symptoms were significantly improved in the MS/cannabis group compared to the MS group apart from sexual dysfunction, bladder symptoms, and visual disturbances. Mild side effects of cannabis were also reported.

Conclusion

Cannabis may have a positive impact on the cytokine and clinical profiles in cases with multiple sclerosis.

Use of medical marijuana in cystic fibrosis patients

BACKGROUND

The usage and attitudes towards medical marijuana in Cystic Fibrosis (CF) patients is unknown. Through the use of a survey we aim to clarify rates and reasons for use.

METHODS

An anonymous survey was sent out to six centers in the Mid-Atlantic region of the United States. Use of and reason for medical marijuana was assessed, along with attitudes of the perceived utility of medical marijuana.

RESULTS

A total of 637 surveys were sent out, and 193 surveys were returned (30.3% return rate). Three did not give consent, and one was empty, for a total of 189 completed surveys. 31 subjects (16.5%) reported having used marijuana for medical purposes in their lifetime, with 29 (15.4%) of these in the past year. The most used forms were edible and vaporized. The most common indications for usage were pain and stress. 28 out of 31 found marijuana to be a great deal effective for their symptoms. 21 of the 31 rated marijuana very important or important to their health. There were two reported side effects, both mild. Of 156 subjects who responded to the question if they would be interested in medical marijuana if available, 72 (46.2%) replied yes.

CONCLUSION

The use of marijuana for medical reasons was 15.4% in the past year in this sample CF population, although more expressed interest if it was available through prescription. Side effects were rare. CF physicians are going to have to familiarize themselves with advantages and disadvantages of medical marijuana as there is a great deal of interest within the community, and legalization becomes more common.

CANUE: A Theoretical Model of Pain as an Antecedent for Substance Use

BACKGROUND

Pain and substance use are frequently comorbid and have been shown to exert bidirectional effects. Self-medication of pain and distress via substance use is common and can be understood via negative reinforcement, ultimately strengthening the pathway between pain to substance use over time. As such, a testable model of the potentially modifiable candidate mechanisms that underlie the pain to substance use pathway is needed.

PURPOSE

This review proposes a testable model of pain as an antecedent to substance use to guide future research and inform clinical practice.

METHODS

An integrative review of current evidence regarding pain, substance use, and associated risk factors (i.e., negative affect, pain-related attitudes, negative urgency, and substance use outcome expectancies) was conducted.

RESULTS

The Catastrophizing, Anxiety, Negative Urgency, and Expectancy (CANUE) model highlights modifiable risk factors for self-medicating pain with substance use, including increased negative affect and maladaptive pain-related attitudes (i.e., pain catastrophizing, pain anxiety, and fear of pain), negative urgency, and substance-related outcome expectancies for pain relief and enhanced pain coping.

CONCLUSIONS

Targeted behavioral and psychological interventions that address these factors may facilitate more adaptive pain-coping responses, thereby reducing the impacts of pain on substance use. Systematic research is needed to evaluate the validity and clinical utility of this model.

Coming off cannabis: a cognitive and magnetic resonance imaging study in patients with multiple sclerosis

Cognitive dysfunction affects 40-80% of patients with multiple sclerosis. Smoking cannabis may add to these deficits. It is unclear whether coming off cannabis results in cognitive improvement. To address this question, 40 patients with multiple sclerosis who started using cannabis after the onset of multiple sclerosis and who used it for at least 4 days a week over many years were divided by odd-even number selection into two groups: cannabis continuation and cannabis withdrawal. Assessments took place at baseline and after 28 days and included serial versions of the Brief Repeatable Neuropsychological Battery for multiple sclerosis containing tests of verbal and visual memory, processing speed and executive function; structural and functional MRI, the latter entailing a compatible version of the Symbol Digit Modalities Test; urine for cannabinoid metabolites to detect compliance with abstinence. Only those participants deemed globally impaired at baseline (failure on at least two cognitive domains) were enrolled. The results revealed that the two groups were well matched demographically and neurologically. One subject was removed from the withdrawal group because of failed abstinence. Urine analysis revealed the cannabinoid consumed was predominantly tetrahydrocannabinol (THC). There were no baseline between group cognitive differences, but by Day 28 the withdrawal group performed significantly better on every cognitive index (P < 0.0001 for all). Significant within group differences were present for every test over time, but only in the abstinent group (P < 0.0001 for all tests). There were no between group baseline or Day 28 differences in structural MRI indices (global atrophy, total T1 and T2 lesion volume). At index assessment the two groups had a similar performance on the functional MRI-compatible Symbol Digit Modalities Test and there were no group differences in brain activation. However, by Day 28, the withdrawal group completed more trials correctly (P < 0.012) and had a faster reaction time (P < 0.002), associated with significantly increased activation in brain regions known to be associated with performance of the test (bilateral inferior frontal gyri, caudate and declive/cerebellum, P < 0.001 for all regions). These results reveal that patients with multiple sclerosis who are frequent, long-term cannabis users can show significant improvements in memory, processing speed and executive function after 28 days of drug abstinence. The absence of similar improvements in a matched multiple sclerosis group that remained on cannabis shows that beneficial cognitive change after stopping cannabis is not solely attributable to the effects of practice.

A Review of Scientific Evidence for THC:CBD Oromucosal Spray (Nabiximols) in the Management of Chronic Pain

The 20% prevalence of chronic pain in the general population is a major health concern given the often profound associated impairment of daily activities, employment status, and health-related quality of life in sufferers. Resource utilization associated with chronic pain represents an enormous burden for healthcare systems. Although analgesia based on the World Health Organization’s pain ladder continues to be the mainstay of chronic pain management, aside from chronic cancer pain or end-of-life care, prolonged use of non-steroidal anti-inflammatory drugs or opioids to manage chronic pain is rarely sustainable. As the endocannabinoid system is known to control pain at peripheral, spinal, and supraspinal levels, interest in medical use of cannabis is growing. A proprietary blend of cannabis plant extracts containing delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) as the principal cannabinoids is formulated as an oromucosal spray (USAN name: nabiximols) and standardized to ensure quality, consistency and stability. This review examines evidence for THC:CBD oromucosal spray (nabiximols) in the management of chronic pain conditions. Cumulative evidence from clinical trials and an exploratory analysis of the German Pain e-Registry suggests that add-on THC:CBD oromucosal spray (nabiximols) may have a role in managing chronic neuropathic pain, although further precise clinical trials are required to draw definitive conclusions.

Cannabis use in people with multiple sclerosis and spasticity: A cross-sectional analysis

BACKGROUND

Growing evidence supports that cannabinoids relieve MS-related spasticity but little is known about cannabis use among people with MS (PwMS) and spasticity.

OBJECTIVE

To characterize cannabis use among PwMS and spasticity.

METHODS

As part of baseline data collection for a spasticity intervention trial in Oregon, PwMS and self-reported spasticity answered questions about cannabis use.

RESULTS

54% reported ever using cannabis and 36% currently use. 79% use multiple routes of administration, 58% use at least daily. 79% find cannabis helpful for spasticity and 26% use cannabis and prescribed oral antispasticity medications.

CONCLUSIONS

Many PwMS and spasticity use cannabis and report it helps their spasticity.

Neuropsychiatric Symptoms of Multiple Sclerosis: State of the Art

Multiple Sclerosis (MS) is a chronic disabling neuroinflammatory disease. Psychiatric manifestations have a high prevalence in MS patients and may worsen the illness progression and the patients' quality of life (QoL). Depression is a highly prevalent condition in MS patients, associated with poorer adherence to treatment, decreased functional status and QoL, and increased suicide risk. Diagnosis and treatment of this disorder is challenging because of symptom overlap. Other prevalent psychiatric comorbidities are anxiety disorders, bipolar disorder, psychotic disorders, substance misuse and personality disorders. As the illness progresses, personality changes can happen, as well as affect abnormalities. Cognitive changes occur frequently in MS patients, and affect features like processing speed, attention, learning, memory, visual spatial capabilities, and some language deficits. Disease-modifying treatments may reduce cognitive impairment because of their container action on the brain's lesion burden. Other QoL determinants such as fatigue, pain, sexual dysfunction, exercise, resilience and social support should be taken into account, in order to promote the individuals' well-being. Further studies are needed in order to elucidate the effectiveness of pharmacotherapy and more neuroimaging studies are required to clarify the relationship between structural changes and psychiatric comorbidities.

Caring for people with multiple sclerosis who use cannabis for symptom control

Research suggests that a large proportion of people living with multiple sclerosis (PwMS) are using cannabis to self-manage symptoms, or at least believe there are potential benefits in using this drug. Since community nurses are frontline caregivers, they are likely to encounter PwMS who use cannabis within the home setting. The literature base surrounding this topic is largely driven by quantitative research examining the effectiveness of cannabis as a medicine. This review found that qualitative research exploring the experiences of PwMS who use cannabis is lacking worldwide and is completely absent within UK nursing literature. PwMS using cannabis may not feel safe discussing this with health professionals, as they might fear being judged. This literature review discusses how people perceive the effectiveness of cannabis in helping symptoms associated with MS, while also considering the stigma and legal concerns people face. This review may help community nurses inform their practice and enhance person-centred relationships between them and PwMS.

A Cost-Effectiveness Model for Adjunctive Smoked Cannabis in the Treatment of Chronic Neuropathic Pain

Background: A recent meta-analysis affirmed the benefit of medicinal cannabis for chronic neuropathic pain, a disabling and difficult-to-treat condition. As medicinal cannabis use is becoming increasingly prevalent among Americans, an exploration of its economic feasibility is warranted. We present this cost-effectiveness analysis of adjunctive cannabis pharmacotherapy for chronic peripheral neuropathy.

Materials and Methods: A published Markov model comparing conventional therapies for painful diabetic neuropathy was modified to include arms for augmenting first-line, second-line (if first-line failed), or third-line (if first- and second-line failed) therapies with smoked cannabis. Microsimulation of 1,000,000 patients compared the cost (2017 U.S. dollars) and effectiveness (quality-adjusted life years [QALYs]) of usual care with and without adjunctive cannabis using a composite of third-party and out-of-pocket costs. Model efficacy inputs for cannabis were adapted from clinical trial data. Adverse event rates were derived from a prospective study of cannabis for chronic noncancer pain and applied to probability inputs for conventional therapies. Cannabis cost was derived from retail market pricing. Parameter uncertainty was addressed with one-way and probabilistic sensitivity analysis.

Results: Adding cannabis to first-line therapy was incrementally less effective and costlier than adding cannabis to second-line and third-line therapies. Third-line adjunctive cannabis was subject to extended dominance, that is, the second-line strategy was more effective with a more favorable incremental cost-effectiveness ratio of $48,594 per QALY gained, and therefore, third-line adjunctive cannabis was not as cost-effective. At a modest willingness-to-pay threshold of $100,000/QALY gained, second-line adjunctive cannabis was the strategy most likely to be cost-effective.

Conclusion: As recently proposed willingness-to-pay thresholds for the United States health marketplace range from $110,000 to $300,000 per QALY, cannabis appears cost-effective when augmenting second-line treatment for painful neuropathy. Further research is warranted to explore the long-term benefit of smoked cannabis and standardization of its dosing for chronic neuropathic pain.

Marijuana Use by Patients with Multiple Sclerosis

Background

With social attitudes about marijuana changing and patients sometimes seeking nonmainstream treatment options, the main goal of this study was to investigate the prevalence of, and factors associated with, marijuana use by patients with multiple sclerosis (MS).

Methods

Adult patients with MS (n = 521) and controls (n = 279) from a study of clinical, neuroimaging, genetic, and environmental factors in MS progression were included. Patients with MS stated whether they had ever used marijuana before MS diagnosis, after MS diagnosis, and in the preceding 3 months as part of an in-person questionnaire. The control group stated whether they had ever used marijuana and in the preceding 3 months.

Results

The percentage of patients with MS reporting ever use of marijuana was 39.9%, compared with 32.7% of controls. Marijuana use in the preceding 3 months was significantly more prevalent among patients with MS (9.4%) compared with controls (0.4%) (P < .001). Marijuana use was most prevalent in male patients with MS (P = .004) and in patients with MS who used complementary and alternative medicine (P = .045). Cigarette smoking was associated with marijuana use in patients with MS (P < .001) and controls (P = .001). Increasing age was associated with decreasing prevalence of marijuana use in the patients with MS (P < 0.001).

Conclusions

Patients with MS are more likely to report recent marijuana use than are people without MS. Owing to potential adverse effects, marijuana use by patients with MS may warrant vigilance by MS caregivers, given shifting social attitudes and the trend towards legalization of marijuana in the United States.

Cannabis and Its Secondary Metabolites: Their Use as Therapeutic Drugs, Toxicological Aspects, and Analytical Determination

Although the medicinal properties of Cannabis species have been known for centuries, the interest on its main active secondary metabolites as therapeutic alternatives for several pathologies has grown in recent years. This potential use has been a revolution worldwide concerning public health, production, use and sale of cannabis, and has led inclusively to legislation changes in some countries. The scientific advances and concerns of the scientific community have allowed a better understanding of cannabis derivatives as pharmacological options in several conditions, such as appetite stimulation, pain treatment, skin pathologies, anticonvulsant therapy, neurodegenerative diseases, and infectious diseases. However, there is some controversy regarding the legal and ethical implications of their use and routes of administration, also concerning the adverse health consequences and deaths attributed to marijuana consumption, and these represent some of the complexities associated with the use of these compounds as therapeutic drugs. This review comprehends the main secondary metabolites of Cannabis, approaching their therapeutic potential and applications, as well as their potential risks, in order to differentiate the consumption as recreational drugs. There will be also a focus on the analytical methodologies for their analysis, in order to aid health professionals and toxicologists in cases where these compounds are present.

Multiple sclerosis symptoms and spasticity management: new data

Spasticity, perceived by patients as muscle rigidity and spasms, is a common symptom in multiple sclerosis (MS). It is associated with functional impairment that can exacerbate other MS symptoms and reduce quality of life. Pharmacological treatment options are limited and frequently ineffective. Treatment adherence is a key issue to address in these patients. The efficacy and safety of 9-delta-tetrahydrocannabinol:cannabidiol (THC:CBD) oromucosal spray for treatment of MS spasticity were demonstrated in four Phase III trials. Observational studies and registry data subsequently confirmed the effectiveness and tolerability of THC:CBD oromucosal spray under everyday practice conditions. Among patients who respond to treatment, THC:CBD oromucosal spray has been shown to produce positive improvements in gait parameters and to normalize muscle fibers.

Cannabis for Chronic Pain: Challenges and Considerations

The National Academies of Sciences, Engineering, and Medicine has found substantial evidence that cannabis (plant) is effective for the treatment of chronic pain in adults, and moderate evidence that oromucosal cannabinoids (extracts, especially nabiximols) improve short-term sleep disturbances in chronic pain. The paradoxical superiority of the cannabis plant over cannabinoid molecules represents a challenge for the medical community and the established processes that define modern pharmacy. The expanding and variable legalization of cannabis in multiple states nationwide represents an additional challenge for patients and the medical community because recreational and medicinal cannabis are irresponsibly overlapped. Cannabis designed for recreational use (containing high levels of active ingredients) is increasingly available to patients with chronic pain who do not find relief with current pharmacologic entities, which exposes patients to potential harm. This article analyzes the available scientific evidence to address controversial questions that the current state of cannabis poses for health care professionals and chronic pain patients and sets the basis for a more open discussion about the role of cannabis in modern medicine for pain management. A critical discussion on these points, the legal status of cannabis, and considerations for health care providers is presented.

Complementary and alternative treatments of multiple sclerosis: a review of the evidence from 2001 to 2016

People with multiple sclerosis (PwMS) commonly use complementary and alternative medicines (CAM), but an understanding of their efficacy is lacking. Here, we quantitatively review the class I and class II studies of treatment efficacy for multiple sclerosis from January 2001 to January 2017, in order to assess the modern evidence for CAM use. The 38 studies included in this review are divided across five CAM types (cannabis, diet, exercise, psychological approaches and other). We found little evidence to support CAM efficacy. The studies contained little replication in intervention, primary outcomes or study design. Six of 16 CAMs included in this review were only researched in a single study. Future work in this area should build consensus around study methodologies and primary outcomes.

Cannabis use among patients at a comprehensive cancer center in a state with legalized medicinal and recreational use

BACKGROUND

Cannabis is purported to alleviate symptoms related to cancer treatment, although the patterns of use among cancer patients are not well known. This study was designed to determine the prevalence and methods of use among cancer patients, the perceived benefits, and the sources of information in a state with legalized cannabis.

METHODS

A cross‐sectional, anonymous survey of adult cancer patients was performed at a National Cancer Institute–designated cancer center in Washington State. Random urine samples for tetrahydrocannabinol provided survey validation.

RESULTS

Nine hundred twenty‐six of 2737 eligible patients (34%) completed the survey, and the median age was 58 years (interquartile range [IQR], 46‐66 years). Most had a strong interest in learning about cannabis during treatment (6 on a 1‐10 scale; IQR, 3‐10) and wanted information from cancer providers (677 of 911 [74%]). Previous use was common (607 of 926 [66%]); 24% (222 of 926) used cannabis in the last year, and 21% (192 of 926) used cannabis in the last month. Random urine samples found similar percentages of users who reported weekly use (27 of 193 [14%] vs 164 of 926 [18%]). Active users inhaled (153 of 220 [70%]) or consumed edibles (154 of 220 [70%]); 89 (40%) used both modalities. Cannabis was used primarily for physical (165 of 219 [75%]) and neuropsychiatric symptoms (139 of 219 [63%]). Legalization significantly increased the likelihood of use in more than half of the respondents.

CONCLUSIONS

This study of cancer patients in a state with legalized cannabis found high rates of active use across broad subgroups, and legalization was reported to be important in patients' decision to use. Cancer patients desire but are not receiving information about cannabis use during their treatment from oncology providers. Cancer 2017;123:4488‐97. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

Cannabis use is common among patients receiving treatment at a large cancer center in a state with legalized recreational and medical cannabis. Active use is reported across broad demographic and diagnostic cancer subgroups, and legalization is reported to be important in patients' decision to use.

Neuropsychiatric syndromes of multiple sclerosis

Neuropsychiatric signs and symptoms occur frequently in individuals with multiple sclerosis (MS), either as the initial presenting complaint prior to a definitive neurological diagnosis or more commonly with disease progression. However, the pathogenesis of these comorbid conditions remains unclear and it remains difficult to accurately elucidate if neuropsychiatric symptoms or conditions are indicators of MS illness severity. Furthermore, both the disease process and the treatments of MS can adversely impact an individual's mental health. In this review, we discuss the common neuropsychiatric syndromes that occur in MS and describe the clinical symptoms, aetiology, neuroimaging findings and management strategies for these conditions.

Prevalence, reasons, perceived effects, and correlates of medical marijuana use: A review

BACKGROUND

The use of marijuana for medical purposes is now legal in some U.S. states and other jurisdictions, such as Canada, and Israel. Despite the widespread legalization of medical marijuana globally, there is limited information on patterns and correlates of medical marijuana use (MMU). We conducted a literature review to assess prevalence, reasons, perceived effects, and correlates of MMU among adolescents and adults.

METHODS

We searched peer-reviewed articles in English between January 1996 and August 2016 from several databases (PubMed, Google Scholar, Embase, CINAHL, and PsycINFO) using different combinations of keywords.

RESULTS

A total of 25 articles met the inclusion criteria. In the U.S., national survey estimates of prescribed MMU was 1.1% among 12th graders and 17% among adults who reported past-year marijuana use. The reported prevalence of prescribed MMU ranged from <1.7% in Israeli cancer patients to 17.4% in American health care patients. The reported prevalence of self-medication with marijuana ranged from 15% in Canadian patients with chronic pain to 30% in British patients with multiple sclerosis. Pain was the most frequently endorsed reason for use. MMU appeared to provide symptom relief for a range of pain conditions, sleep disturbance, and anxiety symptoms, but it did not appear to provide sufficient relief of cluster headache symptoms. Non-medical marijuana use was a common factor associated with MMU across studies.

CONCLUSION

Either MMU or self-medication with marijuana was common, mainly due to pain management. Additional research is needed to evaluate temporal and causal associations of non-medical marijuana use with MMU.

Perspectives on marijuana use and effectiveness: A survey of NARCOMS participants

Background

Interest in and use of marijuana by persons with multiple sclerosis (MS) has increased. While potential benefits have been reported, so have concerns about potential risks. Few large studies have been conducted about the perceptions and current usage of marijuana and medical cannabinoids in persons with MS.

Methods

Participants in the North American Research Committee on Multiple Sclerosis (NARCOMS) registry were surveyed in 2014 regarding legality and history of marijuana usage, both before and after diagnosis with MS.

Results

A total of 5,481 participants responded, with 78.2% female, 90% relapsing disease at onset, and a current mean age of 55.5 (10.2) years. Sixty-four percent had tried marijuana prior to their MS diagnosis, 47% have considered using for their MS, 26% have used for their MS, 20% have spoken with their physician about use, and 16% are currently using marijuana. Ninety-one percent think marijuana should be legal in some form. Men, those with higher disability, current and past nicotine smokers, and younger age were associated with a higher likelihood of current use.

Conclusions

The majority of responders favor legalization and report high interest in the use of marijuana for treatment of MS symptoms, but may be reluctant to discuss this with health care providers. Health care providers should systematically inquire about use of marijuana.

Attitudes to cannabis and patterns of use among Canadians with multiple sclerosis

BACKGROUND

Canada has the highest incidence of MS worldwide. Anecdotal evidence reveals that people with MS smoke, ingest or vaporize cannabis for a multiplicity of reasons. With the legal situation in relation to use currently in flux, we undertook a study investigating patterns of use amongst people with MS and their attitudes towards the drug.

METHODS

A consecutive sample of people with MS (n=246) attending a neurology (n=118) and a neuropsychiatry (n=107) clinic was enrolled and asked to complete a questionnaire containing demographic, disease and cannabis related variables.

RESULTS

Of the 246 people approached, 225 (91.8%) agreed to participant. Attitude towards cannabis revealed that 122 (54.3%) participants approved of the drug while 75 (33.2%) were neutral. Legalization was endorsed by 98 (43.7%) participants, while 98 (43.7%) were in favour of legalization for medical use only. Current use was endorsed by 44 (19.5%) people with 125 (56.1%) reporting lifetime use. If cannabis were legal, 113 (50.2%) participants would use it. The most common symptoms for which cannabis was being used were: sleep (86%), pain (75%), anxiety (73%) and spasticity (68%). Participants attending the neuropsychiatry clinic were more likely to use cannabis for managing depression (χ²=4.99; p=0.03) and pain (χ²=3.85; p=0.05).

CONCLUSION

There is a wide acceptance of cannabis within the MS patient community. One in five people currently use the drug for reasons that differ between neuropsychiatry and neurology clinics. Use could potentially more than double if the drug were legalized.

Use of herbal remedies by multiple sclerosis patients: a nation-wide survey in Italy

Though recent progress in multiple sclerosis (MS) treatment is remarkable, numerous unmet needs remain to be addressed often inducing patients to look for complementary and alternative medicines (CAM), especially herbal remedies (HR). HR use, scarcely investigated in MS, may cause adverse reactions (AR) and interfere with conventional treatment. We performed a survey aimed at evaluating use and attitudes towards HR and factor associated to HR use. Other CAM use and attitudes have been investigated as well. Multiple-choice questionnaires were distributed to MS out patients attending 14 Italian referral Centers. Multivariable logistic regression was used to identify HR use determinants. Present/past HR use for either MS or other diseases was reported in 35.6 % of 2419 cases (95 % CI 36.0-40.0 %). CAM use was reported in 42.5 % of cases. Independent predictors of HR use were represented by higher education, geographic area, dissatisfaction with conventional treatment of diseases other than MS and benefit perception from CAM use. Both HR and CAM use were not always disclosed to the healthcare professional. In conclusion, HR and other CAM appear to be popular among MS patients. The involvement of the healthcare professionals appears to be scarce with potential risk of AR or interference with conventional treatments.

What to make of cannabis and cognition in MS: In search of clarity amidst the haze

Given data showing that cannabis (herbal drug from the Cannabis sativa plant) can impair cognition in healthy subjects, the possibility that it may also do so in people with multiple sclerosis (MS) should be cause for concern. Approximately 20% of people with MS inhale or ingest cannabis for a variety of symptoms, or as a lifestyle choice. In addition, pharmaceutically manufactured cannabis (in capsules or spray) is prescribed most often for pain and spasticity; however, there is a dearth of literature on the cognitive effects of cannabis. Furthermore, methodological limitations introduce a cautionary note when interpreting the data. The evidence, which must therefore be considered preliminary, suggests that smoked cannabis may further compromise information processing speed and memory, with magnetic resonance imaging (fMRI) demonstrating more inefficient patterns of cerebral activation during task performance. The findings related to pharmaceutically manufactured cannabis are equivocal. There is a pressing need for further research to inform clinical opinion, which at present reflects a combination of uncertainty and dogma.

Cannabis-induced alterations in brain activation during a test of information processing speed in patients with MS

Objective

The objective of this article is to determine the functional brain correlates of information processing speed in multiple sclerosis (MS) patients who smoke cannabis and those who are drug naïve.

Methods

Two neurologically and demographically matched samples of MS patients were enrolled, those who smoked cannabis daily (n = 20) and those who were cannabis naïve (n = 19). All participants completed the Brief Repeatable Battery of Neuropsychological Tests and underwent fMRI testing during which they were administered a modified version of the Symbol Digit Modalities Test (mSDMT).

Results

The cannabis group responded slower in nine of 11 blocks of the mSDMT (p < 0.001), showing a trend toward a slower response time (p < 0.08), but did not differ in the accuracy of response (p < 0.18). Both groups displayed activation in a prefrontal cortex-parietal network associated with information processing speed. When compared to the cannabis-naïve group, cannabis users showed less activation in the right (p = 0.009) and left (p = 0.001) thalami and increased activation in the anterior cingulate (p = 0.006).

Conclusion

Regular cannabis use in MS patients is associated with slower information processing speed and a pattern of cerebral activity that differs from cannabis-naïve individuals, most notably in a bilateral reduction of thalamic activity.

Comprehensive Review of Medicinal Marijuana, Cannabinoids, and Therapeutic Implications in Medicine and Headache: What a Long Strange Trip It's Been …

BACKGROUND

The use of cannabis, or marijuana, for medicinal purposes is deeply rooted though history, dating back to ancient times. It once held a prominent position in the history of medicine, recommended by many eminent physicians for numerous diseases, particularly headache and migraine. Through the decades, this plant has taken a fascinating journey from a legal and frequently prescribed status to illegal, driven by political and social factors rather than by science. However, with an abundance of growing support for its multitude of medicinal uses, the misguided stigma of cannabis is fading, and there has been a dramatic push for legalizing medicinal cannabis and research. Almost half of the United States has now legalized medicinal cannabis, several states have legalized recreational use, and others have legalized cannabidiol-only use, which is one of many therapeutic cannabinoids extracted from cannabis. Physicians need to be educated on the history, pharmacology, clinical indications, and proper clinical use of cannabis, as patients will inevitably inquire about it for many diseases, including chronic pain and headache disorders for which there is some intriguing supportive evidence.

OBJECTIVE

To review the history of medicinal cannabis use, discuss the pharmacology and physiology of the endocannabinoid system and cannabis-derived cannabinoids, perform a comprehensive literature review of the clinical uses of medicinal cannabis and cannabinoids with a focus on migraine and other headache disorders, and outline general clinical practice guidelines.

CONCLUSION

The literature suggests that the medicinal use of cannabis may have a therapeutic role for a multitude of diseases, particularly chronic pain disorders including headache. Supporting literature suggests a role for medicinal cannabis and cannabinoids in several types of headache disorders including migraine and cluster headache, although it is primarily limited to case based, anecdotal, or laboratory-based scientific research. Cannabis contains an extensive number of pharmacological and biochemical compounds, of which only a minority are understood, so many potential therapeutic uses likely remain undiscovered. Cannabinoids appear to modulate and interact at many pathways inherent to migraine, triptan mechanisms ofaction, and opiate pathways, suggesting potential synergistic or similar benefits. Modulation of the endocannabinoid system through agonism or antagonism of its receptors, targeting its metabolic pathways, or combining cannabinoids with other analgesics for synergistic effects, may provide the foundation for many new classes of medications. Despite the limited evidence and research suggesting a role for cannabis and cannabinoids in some headache disorders, randomized clinical trials are lacking and necessary for confirmation and further evaluation.

Multiple sclerosis, cannabis, and cognition: A structural MRI study

Objective

A subset of patients with multiple sclerosis (MS) smoke cannabis to relieve symptoms including spasticity and pain. Recent evidence suggests that smoking cannabis further impairs cognition in people with MS and is linked to impaired functional brain changes. No such association, however, has been reported between cannabis use and structural brain changes, hence the focus of the present study.

Methods

Twenty patients with MS who smoke cannabis for symptom relief, and 19 matched non-cannabis-smoking MS patients were given the Brief Repeatable Neuropsychological Battery and structural MRI scans. Images were segmented into gray matter and white matter, and subsequently analysed with Partial Least Squares, a data-driven multivariate technique that explores brain–behaviour associations.

Results

In both groups, the Partial Least Squares analysis yielded significant correlations between cognitive scores and both gray matter (33% variance, p < .0001) and white matter (17% variance, p < .05) volume. Gray matter volume in the thalamus, basal ganglia, medial temporal, and medial prefrontal regions, and white matter volume in the fornix correlated with cognitive deficits. Crucially, the analysis indicated that brain volume reductions were associated with more extensive cognitive impairment in the cannabis versus the non-cannabis MS group.

Interpretation

These results suggest that cannabis use in MS results in more widespread cognitive deficits, which correlate with tissue volume in subcortical, medial temporal, and prefrontal regions. These are the first findings demonstrating an association between cannabis use, cognitive impairment and structural brain changes in MS patients.

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In MS, cannabis use moderates the association between cognition and brain integrity.

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Gray matter correlates with more widespread cognitive deficits in cannabis users.

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Hippocampal volume & white matter are correlated with memory only in cannabis users.

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Such differential patterns suggest that cannabis use has negative effects in MS patients.

Neuroprotection in Experimental Autoimmune Encephalomyelitis and Progressive Multiple Sclerosis by Cannabis-Based Cannabinoids

Multiple sclerosis (MS) is the major immune-mediated, demyelinating, neurodegenerative disease of the central nervous system. Compounds within cannabis, notably Δ9-tetrahydrocannabinol (Δ9-THC) can limit the inappropriate neurotransmissions that cause MS-related problems and medicinal cannabis is now licenced for the treatment of MS symptoms. However, the biology indicates that the endocannabinoid system may offer the potential to control other aspects of disease. Although there is limited evidence that the cannabinoids from cannabis are having significant immunosuppressive activities that will influence relapsing autoimmunity, we and others can experimentally demonstrate that they may limit neurodegeneration that drives progressive disability. Here we show that synthetic cannabidiol can slow down the accumulation of disability from the inflammatory penumbra during relapsing experimental autoimmune encephalomyelitis (EAE) in ABH mice, possibly via blockade of voltage-gated sodium channels. In addition, whilst non-sedating doses of Δ9-THC do not inhibit relapsing autoimmunity, they dose-dependently inhibit the accumulation of disability during EAE. They also appear to slow down clinical progression during MS in humans. Although a 3 year, phase III clinical trial did not detect a beneficial effect of oral Δ9-THC in progressive MS, a planned subgroup analysis of people with less disability who progressed more rapidly, demonstrated a significant slowing of progression by oral Δ9-THC compared to placebo. Whilst this may support the experimental and biological evidence for a neuroprotective effect by the endocannabinoid system in MS, it remains to be established whether this will be formally demonstrated in further trials of Δ9-THC/cannabis in progressive MS.

Pathophysiology, assessment and management of multiple sclerosis spasticity: an update

Spasticity is one of the most common and disabling symptoms associated with multiple sclerosis (MS). MS spasticity occurs through both myelin and nerve fiber (axonal) degradation, which commence in the early stages of the disease. More than 80% of MS patients experienced spasticity in a large UK survey, with more than 50% of patients reporting their spasticity to be `moderate' or `severe'. Data from a large US registry show that patients with moderate-to-severe MS spasticity experience levels of disability that correlate closely with being wheelchair-bound and/or bedridden. The Ashworth scale is the most commonly used scale for assessing the degree of MS spasticity. However, the validity, reliability and sensitivity of this scale have been challenged and it is not considered an ideal scale for assessing the severity of MS spasticity. The numerical rating scale, a well-established standard pain assessment tool, provides a reliable, valid and simplified scale for patient self-rated assessment of the mean level of spasticity over the previous 24 h (0 = no spasticity, 10 = worst possible spasticity). According to data from the German MS Register, almost a third of MS patients with spasticity were untreated. Despite the availability of oral agents for generalized spasticity (often used in conjunction with physical/rehabilitation management strategies), including baclofen, tizanidine, dantrolene and gabapentin, there is limited clinical evidence to support their use and there is a need for improved and better tolerated pharmacological therapies for MS spasticity. The endocannabinoid system modulator, Sativex(®) (nabiximols, USAN name), provides an alternative therapeutic approach in the management of MS spasticity.

The effect of whole-body, repetitive, inhomogeneous static magnetic field-exposure on the symptoms of experimental autoimmune encephalomyelitis in mice

Experimental autoimmune encephalomyelitis (EAE) is a model for human multiple sclerosis (MS) in rodents. Static magnetic field (SMF)-exposure was shown to be beneficial in specific cases of inflammatory background, where it suppresses symptoms. The null-hypothesis was that animals with induced EAE exposed to SMF would show different seriousness of symptoms, than those in the sham-exposed control group. Three replicated series of repetitive, 30 min/day whole-body exposure to SMF with 477 mT peak-to-peak magnetic induction and 48 T/m lateral induction gradient was tested on female CSJLF1 mice with a mild, mouse spinal cord homogenate emulsion-induced EAE. Conventional scores of the animal response to EAE were compared between sham- and SMF-exposed groups of animals. Following pilot test we used 18 animals per group. Primary outcome measure was the daily group average of standard EAE scores. Results show that SMF-exposure has a strong, reproducible, and significantly beneficial effect up to 51.82% (p<0.001) over sham-exposure on the symptoms of EAE in the course of the 25 days of the experiment. This study aimed to build experimental research foundation for a later therapy option by applying SMF-exposure in the clinical management of MS.

Nabiximols in the treatment of spasticity, pain and urinary symptoms due to multiple sclerosis

INTRODUCTION

Over the last two decades, experimental and clinical data suggest a therapeutic benefit of cannabis-based medicines for a variety of multiple sclerosis (MS) symptoms. Clinical trials, both with synthetic or plant-derived cannabinoids, have demonstrated clinical efficacy of cannabinoids for the treatment of spasticity, neuropathic pain and bladder dysfunction. Nabiximols, a 1:1 mix of delta-9-tetrahydrocanabinol and cannabidiol extract from cloned chemovars, was licensed in the UK in 2010 and has also been approved in other European countries and Canada. The European Federation of Neurological Societies recommends that cannabis should be used only as a second or third line treatment in central neuropathic pain.

AREAS COVERED

After a brief discussion of the endocannabinoid system, this review focuses on the use of cannabis to improve MS symptoms. More specifically, the authors have analyzed clinical studies on cannabis-based medicine extract (CBME), in particular nabiximols, in spasticity, as well as pain, and bladder dysfunction in MS. The authors have considered the large randomized controlled trials examining the psychological effects associated with cannabinoids use as well as long-term follow-up studies.

EXPERT OPINION

Despite a number of trials with very promising results, there are still concerns related to relative paucity of data on long-term safety. Also, the long-term efficacy information in terms of the control of symptoms of a disease in which the natural history is progression is sparse. Therefore, further studies are required to improve the current knowledge of nabiximols.

Clinical efficacy and effectiveness of Sativex, a combined cannabinoid medicine, in multiple sclerosis-related spasticity

Multiple sclerosis (MS) is associated with a wide range of disease symptoms and amongst these, spasticity is one of the most disabling and has the greatest impact on patient well-being and quality of life. Until now, available drug therapies for spasticity appear to have limited benefit and are often associated with poor tolerability. In a recent Spanish survey it was noted that multidrug therapy and a low control rate were common features for a large proportion of patients with MS-related spasticity, suggesting that currently available monotherapies lack significant activity. Sativex is a 1:1 mixture of δ-9-tetrahydrocannabinol and cannabidiol derived from Cannabis sativa chemovars, which is available as an oromucosal spray. Clinical experience with Sativex in patients with MS-related spasticity is steadily accumulating. Results from randomized, controlled trials have reported a reduction in the severity of symptoms associated with spasticity, leading to a better ability to perform daily activities and an improved perception of patients and their carers regarding functional status. These are highly encouraging findings that provide some much needed optimism for the treatment of this disabling and often painful symptom of MS.