Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study

The Association of Medical Cannabis Use with Pain Levels and Opioid Use in Illinois' Opioid Alternative Pilot Program

OBJECTIVE

The state of Illinois' Opioid Alternative Pilot Program (OAPP) is the first and only official harm-reduction program in the US to address the opioid crisis via facilitation of safe and legal access to medical cannabis. This study evaluates the association of medical cannabis use with pain level and frequency of opioid use in the first cohort of OAPP participants in 2019.

METHODS

A survey was sent OAPP enrollees between February and July 2019. Cannabis users (n = 626) were compared to non-users (n = 234) to determine whether there was an association between cannabis use and self-reported (a) pain level and (b) frequency of opioid use. Backward stepwise regression models were used.

RESULTS

A total of 860 participants was included in the analysis. Overall, 75% of the study sample reported pain as their primary medical symptom, and 67% of cannabis users reported having a disability. The mean difference in pain level between cannabis users and non-users was 4.5 units (on a 100-point scale) higher among cannabis users than non-users (p = 0.03); and cannabis use was statistically associated with pain level. High-frequency opioid users had lower odds of reporting cannabis use within the past year than low/no opioid users.

CONCLUSIONS

Although there was a statistical association between cannabis use and pain, the difference of 4.5 points in pain level between users and non-users was too small to reflect a clinically meaningful relative difference. This study may provide useful information to providers and clinicians about how the OAPP and similar programs may reduce opioid use and improve health outcomes.

Pierre M, Belle-Isle L, Gagnon M, Bevan S, Sanchez T, Arlt S, Monahan-Ellison M, O'Hara J, Boivin M, Costiniuk C. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions

Background: One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual. Systematic Review Registration: PROSPERO no. 135886.

The Interaction of Opiate Misuse and Marijuana Use on Behavioral Health Outcomes Using the Traumatic Brain Injury Model Systems Pain Collaborative Dataset

OBJECTIVE

To determine if the interaction of opiate misuse and marijuana use frequency is associated with behavioral health outcomes.

SETTING

Community.

PARTICIPANTS

Three thousand seven hundred fifty participants enrolled in the Traumatic Brain Injury Model Systems who completed the Pain Survey and had complete opioid use and marijuana use information.

DESIGN

Cross-sectional, secondary analysis from a multisite observational cohort.

MAIN OUTCOME MEASURES

Clinically significant behavioral health symptoms for posttraumatic stress disorder (PTSD), depression, anxiety, and sleep quality.

RESULTS

Three thousand five hundred thirty-five (94.3%) participants did not misuse opiates, 215 (5.7%) did misuse opiates (taking more opioid pain medication than prescribed and/or using nonprescription opioid pain medication); 2683 (70.5%) participants did not use marijuana, 353 (9.3%) occasionally used marijuana (less than once a week), and 714 (18.8%) regularly used marijuana (once a week or more frequently). There was a statistically significant relationship (P < .05) between the interaction of opiate misuse and marijuana use frequency and all behavioral health outcomes and several covariates (age, sex, cause of injury, severity of injury, and pain group category). Pairwise comparisons confirm that statistically significant associations on behavioral health outcomes are driven by endorsing opiate misuse and/or regular marijuana use, but occasional marijuana use was not associated.

CONCLUSIONS

Higher odds of clinically significant PTSD, depression, anxiety, and poor sleep quality are present in people with traumatic brain injury (TBI) who misuse opiates and/or who use marijuana regularly. In the absence of opiate misuse, regular marijuana use had higher odds of worse behavioral health outcomes than occasional and no use. The interaction of opiate misuse and regular marijuana use yielded the highest odds. Individuals with TBI should be informed of the relationship of substance use and behavioral health outcomes and that current chronic pain may mediate the association.

Medical Cannabis and Its Efficacy/Effectiveness for the Treatment of Low-Back Pain: a Systematic Review

PURPOSE OF REVIEW

This systematic review aims to inform the current state of evidence about the efficacy and effectiveness of medical cannabis use for the treatment of LBP, specifically on pain levels and overall opioid use for LBP. Searches were conducted in MEDLINE (PubMed), Embase, and CINAHL. The search was limited to the past 10 years (2011-2021). Study inclusion was determined by the critical appraisal process using the Joanna Briggs Institute framework. Only English language articles were included. Participant demographics included all adult individuals with LBP who were prescribed medical cannabis for LBP and may be concurrently using opioids for their LBP. Study quality and the risk of bias were both evaluated. A narrative synthesis approach was used.

RECENT FINDINGS

A total of twelve studies were included in the synthesis: one randomized controlled trial (RCT), six observational studies (one prospective, four retrospective, and one cross-over), and five case studies. All study results, except for the RCT, indicated a decrease in LBP levels or opioid use over time after medical cannabis use. The RCT reported no statistically significant difference in LBP between cannabis and placebo groups. Low back pain (LBP) affects 568 million people worldwide. In the United States, LBP treatment represents more than half of regular opioid users. With the opioid epidemic, alternative methods, particularly medical cannabis, is now increasingly sought by practicing physicians and patients. Due to its infancy, there is minimal high-quality evidence to support medical cannabis use as a first line treatment for LBP.

Health, safety, and socioeconomic impacts of cannabis liberalization laws: An evidence and gap map

Background

Globally, cannabis laws and regulations are rapidly changing. Countries are increasingly permitting access to cannabis under various decriminalization, medicalization, and legalization laws. With strong economic, public health, and social justice incentives driving these domestic cannabis policy reforms, liberalization trends are bound to continue. However, despite a large and growing body of interdisciplinary research addressing the policy-relevant health, safety, and socioeconomic consequences of cannabis liberalization, there is a lack of robust primary and systematic research that comprehensively investigates the consequences of these reforms.

Objectives

This evidence and gap map (EGM) summarizes the empirical evidence on cannabis liberalization policies. Primary objectives were to develop a conceptual framework linking cannabis liberalization policies to relevant outcomes, descriptively summarize the empirical evidence, and identify areas of evidence concentration and gaps.

Search Methods

We comprehensively searched for eligible English-language empirical studies published across 23 academic databases and 11 gray literature sources through August 2020. Additions to the pool of potentially eligible studies from supplemental sources were made through November 2020.

Selection Criteria

The conceptual framework for this EGM draws upon a legal epidemiological perspective highlighting the causal effects of law and policy on population-level outcomes. Eligible interventions include policies that create or expand access to a legal or decriminalized supply of cannabis: comprehensive medical cannabis laws (MCLs), limited medical cannabidiol laws (CBDLs), recreational cannabis laws (RCLs), industrial hemp laws (IHLs), and decriminalization of cultivations laws (DCLs). Eligible outcomes include intermediate responses (i.e., attitudes/behaviors and markets/environments) and longer-term consequences (health, safety, and socioeconomic outcomes) of these laws.

Data Collection and Analysis

Both dual screening and dual data extraction were performed with third person deconfliction. Primary studies were appraised using the Maryland Scientific Methods Scale and systematic reviews were assessed using AMSTAR 2.

Main Results

The EGM includes 447 studies, comprising 438 primary studies and nine systematic reviews. Most research derives from the United States, with little research from other countries. By far, most cannabis liberalization research focuses on the effects of MCLs and RCLs. Studies targeting other laws-including CBDLs, IHLs, and DCLs-are relatively rare. Of the 113 distinct outcomes we documented, cannabis use was the single most frequently investigated. More than half these outcomes were addressed by three or fewer studies, highlighting substantial evidence gaps in the literature. The systematic evidence base is relatively small, comprising just seven completed reviews on cannabis use (3), opioid-related harms (3), and alcohol-related outcomes (1). Moreover, we have limited confidence in the reviews, as five were appraised as minimal quality and two as low quality.

Authors’ Conclusions

More primary and systematic research is needed to better understand the effects of cannabis liberalization laws on longer-term-and arguably more salient-health, safety, and socioeconomic outcomes. Since most research concerns MCLs and RCLs, there is a critical need for research on the societal impacts of industrial hemp production, medical CBD products, and decriminalized cannabis cultivation. Future research should also prioritize understanding the heterogeneous effects of these laws given differences in specific provisions and implementation across jurisdictions.

The holistic effects of medical cannabis compared to opioids on pain experience in Finnish patients with chronic pain

BACKGROUND

Medical cannabis (MC) is increasingly used for chronic pain, but it is unclear how it aids in pain management. Previous literature suggests that MC could holistically alter the pain experience instead of only targeting pain intensity. However, this hypothesis has not been previously systematically tested.

METHOD

A retrospective internet survey was used in a sample of Finnish chronic pain patients (40 MC users and 161 opioid users). The patients evaluated statements describing positive and negative phenomenological effects of the medicine. The two groups were propensity score matched to control for possible confounding factors.

RESULTS

Exploratory factor analysis revealed three experience factors: Negative Side Effects, Positive Holistic Effects, and Positive Emotional Effects. The MC group (matched n = 39) received higher scores than the opioid group (matched n = 39) in Positive Emotional Effects with large effect size (Rank-Biserial Correlation RBC = .71, p < .001), and in Holistic Positive Effects with medium effect size (RBC = .47, p < .001), with no difference in Negative Side Effects (p = .13). MC and opioids were perceived as equally efficacious in reducing pain intensity. Ratings of individual statements were exploratively examined in a post hoc analysis.

CONCLUSION

MC and opioids were perceived to be equally efficacious in reducing pain intensity, but MC additionally positively affected broader pain-related factors such as emotion, functionality, and overall sense of wellbeing. This supports the hypothesis that MC alleviates pain through holistically altering the pain experience.

Cannabis Use Does Not Increase Risk of Perioperative Complications Following Primary Total Hip Arthroplasty: A Cohort-Matched Comparison

Introduction: Cannabis use among arthroplasty patients has dramatically increased throughout the United States. Despite this trend, knowledge remains particularly limited regarding the effects of cannabis use on perioperative outcomes in total hip arthroplasty (THA). Therefore, the goal of this research was to investigate how cannabis use affects risk of perioperative outcomes, cost and length of stay (LOS) after THA. Materials and Methods: The National Inpatient Sample was used to identify 331,825 patients who underwent primary THA between 2010 and 2014 using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) procedure code 81.51. Patients with an ICD-9 diagnosis code correlating to history of thromboembolic events, cardiac events, or active substance use other than cannabis were eliminated. The ICD-9 diagnosis codes for cannabis use (304.3-304.32, 305.2-305.22) were used to identify 538 patients with active use. Cannabis users were matched 1:1 to nonusers on age, sex, tobacco use, and comorbidities. The chi-square test was used to determine risk of major and minor complications, whereas the Kruskal-Wallis H test was used to compare hospital charges and LOS. Results: A total of 534 (99.3%) patients with cannabis use were successfully matched with 534 patients without cannabis use. Risk of major complications among cannabis users (25, 4.68%) was similar to that of nonusers (20, 3.74%, p=0.446). Minor complications also occurred at similar rates between cannabis users (77, 14.4%) and nonusers (87, 16.3%, p=0.396). LOS for cannabis users (3.07±2.40) did not differ from nonusers (3.10±1.45, p=0.488). Mean hospital charges were higher for cannabis users ($17,847±10,024) compared with nonusers ($16,284±7025, p<0.001). Conclusion: Utilizing statistically matched cohorts within a nationally representative database demonstrated that cannabis use is not associated with increased risk of complications or prolonged LOS after primary THA. However, cannabis use is associated with higher hospital charges.

Assessment of Medical Cannabis and Health-Related Quality of Life

Importance

The use of cannabis as a medicine is becoming increasingly prevalent. Given the diverse range of conditions being treated with medical cannabis, as well as the vast array of products and dose forms available, clinical evidence incorporating patient-reported outcomes may help determine safety and efficacy.

Objective

To assess whether patients using medical cannabis report improvements in health-related quality of life over time.

Design, Setting, and Participants

This retrospective case series study was conducted at a network of specialist medical clinics (Emerald Clinics) located across Australia. Participants were patients who received treatment for any indication at any point between December 2018 and May 2022. Patients were followed up every mean (SD) 44.6 (30.1) days. Data for up to 15 follow-ups were reported. Statistical analysis was conducted from August to September 2022.

Exposure

Medical cannabis. Product types and cannabinoid content varied over time in accordance with the treating physician's clinical judgement.

Main Outcomes and Measures

The main outcome measure was health-related quality of life as assessed using the 36-Item Short Form Health Survey (SF-36) questionnaire.

Results

In this case series of 3148 patients, 1688 (53.6%) were female; 820 (30.2%) were employed; and the mean (SD) age was 55.9 (18.7) years at baseline before treatment. Chronic noncancer pain was the most common indication for treatment (68.6% [2160 of 3148]), followed by cancer pain (6.0% [190 of 3148]), insomnia (4.8% [152 of 3148]), and anxiety (4.2% [132 of 3148]). After commencing treatment with medical cannabis, patients reported significant improvements relative to baseline on all 8 domains of the SF-36, and these improvements were mostly sustained over time. After controlling for potential confounders in a regression model, treatment with medical cannabis was associated with an improvement of 6.60 (95% CI, 4.57-8.63) points to 18.31 (95% CI, 15.86-20.77) points in SF-36 scores, depending on the domain (all P < .001). Effect sizes (Cohen d) ranged from 0.21 to 0.72. A total of 2919 adverse events were reported, including 2 that were considered serious.

Conclusions and Relevance

In this case series study, patients using medical cannabis reported improvements in health-related quality of life, which were mostly sustained over time. Adverse events were rarely serious but common, highlighting the need for caution with prescribing medical cannabis.

Systematic combinations of major cannabinoid and terpene contents in Cannabis flower and patient outcomes: a proof-of-concept assessment of the Vigil Index of Cannabis Chemovars

BACKGROUND

Little is known about the frequency with which different combinations of phytochemicals (chemovars) arise in Cannabis flower or whether common chemovars are associated with distinct pharmacodynamics and patient health outcomes. This study created a clinically relevant, user-friendly, scalable chemovar indexing system summarizing primary cannabinoid and terpene contents and tested whether the most frequently consumed chemovars differ in their treatment effectiveness and experienced side effects.

METHODS

Between 09/10/2016 and 03/11/2021, 204 people used the freely available, educational mobile software application, Releaf App, to record 6309 real-time consumption sessions using 633 distinct Cannabis flower products, unique at the user level, with terpene and cannabinoid potency information. The indexing system is based on retrospective data analysis of the products' primary and secondary terpene contents and tetrahydrocannabinol (THC) and cannabidiol (CBD) potencies and yielded a total of 478 distinct chemovars. Analyses of covariances (ANCOVAs) were used to compare symptom levels and side effects experienced across the five most common chemovars before and after cannabis consumption for app users overall and for those treating chronic pain and depression or anxiety.

RESULTS

Examination of the five most frequently consumed chemovars showed significant differences in symptom treatment effectiveness for chronic pain and for depression and anxiety (ps < .001). While the effects varied in magnitude, the five chemovars were effective across conditions except for MC61 (mercene .01-0.49%/beta-caryophyllene .01 to 0.49%/THC 20-25%/CBD 0.01-1.0%), which exacerbated feelings of anxiety or depression. The chemovars also differed in their association with experiencing positive, negative, and context-specific side effects, with two chemovars, MC61 and MC62 (mercene .01-0.49%/beta-caryophyllene .01-0.49%/THC 20-25%/CBD 1-5%), generating two to three fewer positive side effects and as much as one more negative and two more context-specific side effects than the other three chemovars.

CONCLUSIONS

The findings provide "proof-of-concept" that a simple, yet comprehensive chemovar indexing system can be used to identify systematic differences in clinically relevant patient health outcomes and other common experiences across Cannabis flower products, irrespective of the product's commercial or strain name. This study was limited by self-selection into cannabis and app use and a lack of user-specific information. Further research using this chemovar indexing system should assess how distinct combinations of phytochemicals interact with user-level characteristics to produce general and individualized Cannabis consumption experiences and health outcomes, ideally using randomized methods to assess differences in effects across chemovars.

Changes in Prescribed Opioid Dosages Among Patients Receiving Medical Cannabis for Chronic Pain, New York State, 2017-2019

IMPORTANCE

Patients with chronic pain often receive long-term opioid therapy (LOT), which places them at risk of opioid use disorder and overdose. This presents the need for alternative or companion treatments; however, few studies on the association of medical cannabis (MC) with reducing opioid dosages exist.

OBJECTIVE

To assess changes in opioid dosages among patients receiving MC for longer duration compared with shorter duration.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of New York State Prescription Monitoring Program data from 2017 to 2019 included patients receiving MC for chronic pain while also receiving opioid treatment. Of these, patients receiving LOT prior to receiving MC were selected. Individuals were studied for 8 months after starting MC. Data were analyzed from November 2021 to February 2022.

EXPOSURES

Selected patients were divided into 2 groups based on the duration of receiving MC: the nonexposure group received MC for 30 days or fewer, and the exposure group received MC for more than 30 days.

MAIN OUTCOMES AND MEASURES

The main outcome was opioid dosage, measured by mean daily morphine milligram equivalent (MME). Analyses were conducted for 3 strata by opioid dosage prior to receiving MC: MME less than 50, MME of 50 to less than 90, and MME of 90 or greater.

RESULTS

A total of 8165 patients were included, with 4041 (median [IQR] age, 57 [47-65] years; 2376 [58.8%] female) in the exposure group and 4124 (median [IQR] age, 54 (44-62) years; 2370 [57.5%] female) in the nonexposure group. Median (IQR) baseline MMEs for the exposure vs nonexposure groups were 30.0 (20.0-40.0) vs 30.0 (20.0-40.0) in the lowest stratum, 60.0 (60.0-70.0) vs 60.0 (60.0-90.0) in the middle stratum, and 150.0 (100.0-216.2) vs 135.0 (100.0-218.0) in the highest stratum. During follow-up, significantly greater reductions in opioid dosage were observed among the exposure group. A dose-response association of patients' opioid dosage at baseline was observed with the differences in the monthly MME reductions between exposure and nonexposure groups, with a difference of -1.52 (95% CI, -1.67 to -1.37) MME for the lowest stratum, -3.24 (95% CI, -3.61 to -2.87) MME for the middle stratum, and -9.33 (95% CI, -9.89 to -8.77) MME for the highest stratum. The daily MME for the last month of the follow-up period among patients receiving longer MC was reduced by 48% in the lowest stratum, 47% in the middle stratum, and 51% in the highest stratum compared with the baseline dosages. Among individuals in the nonexposure group, daily MME was reduced by only 4% in the lowest stratum, 9% in the middle stratum, and 14% in the highest stratum.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients receiving LOT, receiving MC for a longer duration was associated with reductions in opioid dosages, which may lower their risk of opioid-related morbidity and mortality.

Protocol of a Combined Cohort and Cross-Sectional Study of Persons Receiving Medical Cannabis in Florida, USA: The Medical Marijuana and Me (M3) Study

Significant knowledge gaps regarding the effectiveness and safety of medical cannabis (MC) create clinical challenges for MC physicians, making treatment recommendations and patients choosing treatment among the growing number of options offered in dispensaries. Additionally, data describing the characteristics of people who use MC and the products and doses they receive are lacking. The Medical Marijuana and Me (M³) Study was designed to collect patient-centered data from MC users. We aim to describe preferred MC use patterns that patients report as "most effective" for specific health conditions and symptoms, identify user characteristics associated with such use patterns, characterize adverse effects, including cannabis use disorder, identify products and patient characteristics associated with adverse effects, describe concurrent prescription medication use, and identify concomitant medication use with potential drug-MC interaction risk. Among MC initiators, we also aim to quantify MC use persistence and identify reasons for discontinuation, assess MC utilization pattern trajectories over time, describe outcome trajectories of primary reasons for MC use and determine factors associated with different trajectories, track changes in concomitant substance and medication use after MC initiation, and identify factors associated with such changes. M³ is a combined study comprised of: (1) a prospective cohort of MC initiators completing surveys at enrollment, 3 months, and 9 months after MC initiation and (2) a cross-sectional study of current MC users. A multidisciplinary committee including researchers, physicians, pharmacists, patients, and dispensary personnel designed and planned study protocols, established study measures, and created survey questionnaires. M³ will recruit 1,000-1,200 participants aged ≥18 years, with ∼50% new and ∼50% current MC patients from MC clinics across Florida, USA. Study enrollment started in May 2022 and will continue until the target number of patients is achieved. Survey domains include sociodemographic characteristics, physical and mental health, cannabis use history, reasons for MC use and discontinuation, MC products and use patterns, concurrent use of prescription medications and other substances, and side effects. Data collected in the M³ Study will be available for interested researchers affiliated with the Consortium for Medical Marijuana Clinical Outcomes Research. The M³ Study and Databank will be the largest cohort of current and new MC users in Florida, USA, which will provide data to support MC-related health research necessary to inform policy and clinical practice and ultimately improve patient outcomes.

Co-use of cannabis and prescription opioids in adults in the USA: a population-based, cross-sectional analysis of the NHANES from 2009 to 2018

INTRODUCTION

Cannabis and cannabinoids continue to gain popularity as adjuncts or alternatives to opioids in pain management, with evolving evidence of effectiveness. The relationship between cannabis and opioid use has previously been investigated in smaller cohorts or ecological samples, but not yet in a nationally representative sample.

METHODS

A cross-sectional analysis of adults in the USA was undertaken using National Health and Nutrition Examination Survey (NHANES) data from 2009 to 2018. The primary exposure was self-reported use of at least one opioid-containing prescription medication in the 30 days prior to survey administration. The outcome of interest was self-reported cannabis use in the same period. Multivariable logistic regression was used to adjust for sociodemographic and health-related covariates, and NHANES survey sample weights were included in modeling. Prescription opioid users were then subclassified as short-term users (<90 days) or chronic users (≥90 days) in secondary analysis.

RESULTS

A total 10,928 survey respondents were included in analyses, representing 110 million adults in the USA aged 18-59. In this weighted cohort, 5.6%±0.4% reported a recent opioid prescription. Among prescription opioid users, 18.4%±3.1% reported recent cannabis use, not significantly different from 17.7%±0.7% among non-users (OR 1.05, 95% CI 0.81 to 1.36, p=0.714). After adjustment for covariates, opioid users were significantly less likely to have recently used cannabis (adjusted OR, aOR 0.70, 95% CI 0.51 to 0.97, p=0.032). When opioid users were subclassified by duration of prescription, there was no detectable difference in recent cannabis use between chronic opioid users and short-term opioid users (aOR 1.11, 95% CI 0.70 to 1.78, p=0.649).

CONCLUSION

Recent prescription opioid use was associated with decreased odds of cannabis use in this cross-sectional analysis of a nationally representative cohort. These findings suggest that use of cannabis or prescription opioids may not independently promote use of the other.

Making a joint decision: Cannabis as a potential substitute for opioids in obstetrics and gynecology

There is a growing body of evidence that cannabis may be effective as an analgesic with potential to reduce opioid usage in chronic pain. This review synthesizes the available literature to elucidate the possible role that cannabis might play in reducing opioid use in gynecological disorders that may potentially lead to a recommendation of substituting opioids with cannabis. With reports of a decrease in opioid use after cannabis initiation, an opioid-sparing effect has been seen in gynecologic malignancies such as ovarian, uterine, endometrial, and cervical cancers, in addition to chronic pelvic pain (CPP). Though many studies have found an association between cannabis and various adverse maternal and neonatal outcomes, there is a lack of randomized controlled trials making it difficult to claim a directly causal relationship between cannabis and these adverse outcomes. Additionally, with increased use of cannabis during pregnancy, the evidence of possible benefits and risks to mothers and fetuses is examined.

Synergistic action between a synthetic cannabinoid compound and tramadol in neuropathic pain rats

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.

Association of cannabis and/or opioid with quality of life and healthcare utilization in patients with chronic pain

Background

Opioids have been commonly used to treat chronic pain, but they are associated with significant morbidity and mortality. Cannabis has been advocated as an alternative; however, a growing number of patients are now using a combination of opioid and cannabis and the impact of this combination is not well-studied.

Aim

We characterized use of opioid and/or cannabis in patients with chronic pain; and compared utilization of healthcare resources.

Methods

We conducted a cross-sectional study to determine if measures of physical, psychological and social functioning differed among patients according to whether they used opioids and/or cannabis. We used our learning healthcare system - CHOIR - to capture NIH Patient Reported Outcomes Measure Information System surveys, and legacy pain and treatment specific questions.

Results

Patients who report use of opioid and/or cannabis experience higher levels of physical, psychological and social distress. After adjusting for inversed weight of propensity scores, they have higher odds of visiting an emergency room, staying overnight at the hospital, and visiting a physician.

Conclusion

Our results show that use of opioid and/or cannabis is associated with worse baseline characteristics and outcomes. Our study however cannot determine if worse outcomes are due to the opioids and/or cannabis or simply that these patients are worse off before using opioids and/or cannabis. Thus, it is important to characterize the trajectory of these patients in a prospective longitudinal study.

A Spatiotemporal Analysis of the Association of California City and County Cannabis Policies with Cannabis Outlet Densities

BACKGROUND

Cannabis outlets may affect health and health disparities. Local governments can regulate outlets, but little is known about the effectiveness of local policies in limiting outlet densities and discouraging disproportionate placement of outlets in vulnerable neighborhoods.

METHODS

For 241 localities in California, we measured seven policies pertaining to density or location of recreational cannabis outlets. We geocoded outlets using web-scraped data from the online finder Weedmaps between 2018 and 2020. We applied Bayesian spatiotemporal models to evaluate associations of local cannabis policies with Census block group-level outlet counts, accounting for confounders and spatial autocorrelation. We assessed whether associations differed by block group median income or racial-ethnic composition.

RESULTS

Seventy-six percent of localities banned recreational cannabis outlets. Bans were associated with fewer outlets, particularly in block groups with higher median income, fewer Hispanic residents, and more White and Asian residents. Outlets were disproportionately located in block groups with lower median income [posterior RR (95% credible interval): 0.76 (0.70, 0.82) per $10,000], more Hispanic residents [1.05 (1.02, 1.09) per 5%], and fewer Black residents [0.91 (0.83, 0.98) per 5%]. For the six policies in jurisdictions permitting outlets, two policies were associated with fewer outlets and two with more; two policy associations were uninformative. For these policies, we observed no consistent heterogeneity in associations by median income or racial-ethnic composition.

CONCLUSIONS

Some local cannabis policies in California are associated with lower cannabis outlet densities, but are unlikely to deter disproportionate placement of outlets in racial-ethnic minority and low-income neighborhoods.

U.S. cannabis laws projected to cost generic and brand pharmaceutical firms billions

Legalization of cannabis by U.S. states is likely increasing the use of cannabis as an alternative to conventional pharmaceutical drugs. We examined how cannabis legalization between 1996 and 2019 affected stock market returns for listed generic and brand pharmaceutical companies and found that returns were 1.5-2% lower at 10 days after legalization. Returns decreased in response to both medical and recreational legalization, for both generic and brand drugmakers. Investors anticipate a single legalization event to reduce drugmaker annual sales by $3B on average.

Long-term and serious harms of medical cannabis and cannabinoids for chronic pain: a systematic review of non-randomised studies

OBJECTIVE

To establish the prevalence of long-term and serious harms of medical cannabis for chronic pain.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO and CENTRAL from inception to 1 April 2020.

STUDY SELECTION

Non-randomised studies reporting on harms of medical cannabis or cannabinoids in adults or children living with chronic pain with ≥4 weeks of follow-up.

DATA EXTRACTION AND SYNTHESIS

A parallel guideline panel provided input on the design and interpretation of the systematic review, including selection of adverse events for consideration. Two reviewers, working independently and in duplicate, screened the search results, extracted data and assessed risk of bias. We used random-effects models for all meta-analyses and the Grades of Recommendations, Assessment, Development and Evaluation approach to evaluate the certainty of evidence.

RESULTS

We identified 39 eligible studies that enrolled 12 143 adult patients with chronic pain. Very low certainty evidence suggests that adverse events are common (prevalence: 26.0%; 95% CI 13.2% to 41.2%) among users of medical cannabis for chronic pain, particularly any psychiatric adverse events (prevalence: 13.5%; 95% CI 2.6% to 30.6%). Very low certainty evidence, however, indicates serious adverse events, adverse events leading to discontinuation, cognitive adverse events, accidents and injuries, and dependence and withdrawal syndrome are less common and each typically occur in fewer than 1 in 20 patients. We compared studies with <24 weeks and ≥24 weeks of cannabis use and found more adverse events reported among studies with longer follow-up (test for interaction p<0.01). Palmitoylethanolamide was usually associated with few to no adverse events. We found insufficient evidence addressing the harms of medical cannabis compared with other pain management options, such as opioids.

CONCLUSIONS

There is very low certainty evidence that adverse events are common among people living with chronic pain who use medical cannabis or cannabinoids, but that few patients experience serious adverse events.

Cannabis-Based Products for Chronic Pain : A Systematic Review

BACKGROUND

Contemporary data are needed about the utility of cannabinoids in chronic pain.

PURPOSE

To evaluate the benefits and harms of cannabinoids for chronic pain.

DATA SOURCES

Ovid MEDLINE, PsycINFO, EMBASE, the Cochrane Library, and Scopus to January 2022.

STUDY SELECTION

English-language, randomized, placebo-controlled trials and cohort studies (≥1 month duration) of cannabinoids for chronic pain.

DATA EXTRACTION

Data abstraction, risk of bias, and strength of evidence assessments were dually reviewed. Cannabinoids were categorized by THC-to-CBD ratio (high, comparable, or low) and source (synthetic, extract or purified, or whole plant).

DATA SYNTHESIS

Eighteen randomized, placebo-controlled trials (n = 1740) and 7 cohort studies (n = 13 095) assessed cannabinoids. Studies were primarily short term (1 to 6 months); 56% enrolled patients with neuropathic pain, with 3% to 89% female patients. Synthetic products with high THC-to-CBD ratios (>98% THC) may be associated with moderate improvement in pain severity and response (≥30% improvement) and an increased risk for sedation and are probably associated with a large increased risk for dizziness. Extracted products with high THC-to-CBD ratios (range, 3:1 to 47:1) may be associated with large increased risk for study withdrawal due to adverse events and dizziness. Sublingual spray with comparable THC-to-CBD ratio (1.1:1) probably is associated with small improvement in pain severity and overall function and may be associated with large increased risk for dizziness and sedation and moderate increased risk for nausea. Evidence for other products and outcomes, including longer-term harms, were not reported or were insufficient.

LIMITATION

Variation in interventions; lack of study details, including unclear availability in the United States; and inadequate evidence for some products.

CONCLUSION

Oral, synthetic cannabis products with high THC-to-CBD ratios and sublingual, extracted cannabis products with comparable THC-to-CBD ratios may be associated with short-term improvements in chronic pain and increased risk for dizziness and sedation. Studies are needed on long-term outcomes and further evaluation of product formulation effects.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. (PROSPERO: CRD42021229579).

Medicinal Cannabis and Central Nervous System Disorders

Cannabinoids, including those found in cannabis, have shown promise as potential therapeutics for numerous health issues, including pathological pain and diseases that produce an impact on neurological processing and function. Thus, cannabis use for medicinal purposes has become accepted by a growing majority. However, clinical trials yielding satisfactory endpoints and unequivocal proof that medicinal cannabis should be considered a frontline therapeutic for most examined central nervous system indications remains largely elusive. Although cannabis contains over 100 + compounds, most preclinical and clinical research with well-controlled dosing and delivery methods utilize the various formulations of Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), the two most abundant compounds in cannabis. These controlled dosing and delivery methods are in stark contrast to most clinical studies using whole plant cannabis products, as few clinical studies using whole plant cannabis profile the exact composition, including percentages of all compounds present within the studied product. This review will examine both preclinical and clinical evidence that supports or refutes the therapeutic utility of medicinal cannabis for the treatment of pathological pain, neurodegeneration, substance use disorders, as well as anxiety-related disorders. We will predominately focus on purified THC and CBD, as well as other compounds isolated from cannabis for the aforementioned reasons but will also include discussion over those studies where whole plant cannabis has been used. In this review we also consider the current challenges associated with the advancement of medicinal cannabis and its derived potential therapeutics into clinical applications.

Medicinal Cannabis and Central Nervous System Disorders

Cannabinoids, including those found in cannabis, have shown promise as potential therapeutics for numerous health issues, including pathological pain and diseases that produce an impact on neurological processing and function. Thus, cannabis use for medicinal purposes has become accepted by a growing majority. However, clinical trials yielding satisfactory endpoints and unequivocal proof that medicinal cannabis should be considered a frontline therapeutic for most examined central nervous system indications remains largely elusive. Although cannabis contains over 100 + compounds, most preclinical and clinical research with well-controlled dosing and delivery methods utilize the various formulations of Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD), the two most abundant compounds in cannabis. These controlled dosing and delivery methods are in stark contrast to most clinical studies using whole plant cannabis products, as few clinical studies using whole plant cannabis profile the exact composition, including percentages of all compounds present within the studied product. This review will examine both preclinical and clinical evidence that supports or refutes the therapeutic utility of medicinal cannabis for the treatment of pathological pain, neurodegeneration, substance use disorders, as well as anxiety-related disorders. We will predominately focus on purified THC and CBD, as well as other compounds isolated from cannabis for the aforementioned reasons but will also include discussion over those studies where whole plant cannabis has been used. In this review we also consider the current challenges associated with the advancement of medicinal cannabis and its derived potential therapeutics into clinical applications.

The Effects of Consuming <b><i>Cannabis</i></b> Flower for Treatment of Fatigue

<b><i>Objectives:</i></b> We measure for the first time how commercially available <i>Cannabis</i> flower products affect feelings of fatigue. <b><i>Methods:</i></b> A total of 1,224 people recorded 3,922 <i>Cannabis</i> flower self-administration sessions between June 6, 2016, and August 7, 2019, using the Releaf App. Usage sessions included real-time subjective changes in fatigue intensity levels prior to and following <i>Cannabis</i> consumption, <i>Cannabis</i> flower characteristics (labeled phenotype, cannabinoid potency levels), combustion method, and any potential experienced side effects. <b><i>Results:</i></b> On average, 91.94% of people experienced decreased fatigue following consumption with an average symptom intensity reduction of 3.48 points on a 0–10 visual analog scale (SD = 2.70, <i>d</i> = 1.60, <i>p</i> &#x3c; 0.001). While labeled plant phenotypes (“<i>C. indica</i>,” “<i>C. sativa</i>,” or “hybrid”) did not differ in symptom relief, people that used joints to combust the flower reported greater symptom relief than pipe or vaporizer users. Across cannabinoid levels, tetrahydrocannabinol, and cannabidiol levels were generally not associated with changes in symptom intensity levels. <i>Cannabis</i> use was associated with several negative side effects that correspond to increased feelings of fatigue (e.g., feeling unmotivated, couch-locked) among a minority of users (&#x3c;24% of users), with slightly more users (up to 37%) experiencing a positive side effect that corresponds to increased energy (e.g., feeling active, energetic, frisky, or productive). <b><i>Conclusions:</i></b> The findings suggest that the majority of patients experience decreased fatigue from consumption of <i>Cannabis</i> flower consumed in vivo, although the magnitude of the effect and extent of side effects experienced likely vary with individuals’ metabolic states and the synergistic chemotypic properties of the plant.

Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis

OBJECTIVE

To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions.

DATA SOURCES

Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Original research in English. Case reports and cross sectional studies were excluded.

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation).

RESULTS

Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05).

CONCLUSIONS

Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed.

REVIEW REGISTRATION

PROSPERO CRD42020140943.

Pharmacologic Management of Persistent Pain in Cancer Survivors

Improvements in screening, diagnosis and treatment of cancer has seen cancer mortality substantially diminish in the past three decades. It is estimated there are almost 20 million cancer survivors in the USA alone, but some 40% live with chronic pain after completing treatment. While a broad definition of survivorship that includes all people living with, through and beyond a cancer diagnosis—including those with active cancer—is often used, this narrative review primarily focuses on the management of pain in people who are disease-free after completing primary cancer treatment as adults. Chronic pain in this population needs a different approach to that used for people with a limited prognosis. After describing the common chronic pain syndromes caused by cancer treatment, and the pathophysiologic mechanisms involved, the pharmacologic management of entities such as post-surgical pain, chemotherapy-induced neuropathy, aromatase inhibitor musculoskeletal syndrome and checkpoint inhibitor-related pain are described. The challenges  associated with opioid prescribing in this population are given special attention. Expert guidelines on pain management in cancer survivors now recommend a combination of pharmacologic and non-pharmacologic modalities, and these are also briefly covered.

Association of medical cannabis licensure with prescription opioid receipt: A population-based, individual-level retrospective cohort study

BACKGROUND

The endocannabinoid system has been implicated in physiological processes fundamental to pain, giving plausibility to the hypothesis that cannabis may be used as a substitute or complement to prescription opioids in the management of chronic pain. We examined the association of medical cannabis licensure with likelihood of prescription opioid receipt using administrative records.

METHODS

This study linked registry information for medical cannabis licensure with records from the prescription drug monitoring program from April 1, 2016 to March 31, 2019 to create a population-based, retrospective cohort in Rhode Island. We examined within-person changes in receipt of any opioid prescription and receipt of an opioid prescription with a morphine equivalent dose of 50 mg or more, and of 90 mg or more.

RESULTS

The sample included 5,296 participants with medical cannabis license. Medical cannabis licensure was not associated with the odds of filling any opioid prescription (OR: 0.99; 95% CI: 0.94-0.1.05) or the odds of filling a prescription with a morphine equivalent dose of 50 mg or more (OR: 0.93; 95% CI: 0.84-1.04) and 90 mg or more (OR: 0.99; 95% CI: 0.86-1.15).

CONCLUSION

Medical cannabis licensure was not associated with subsequent cessation and reduction in prescription opioid use. Re-scheduling of cannabis will allow for the conduct of randomized controlled trials to determine the efficacy of medical cannabis as an alternative to prescription opioid use or a complement to the use of lower doses of prescription opioids in patients with chronic pain.

Societal Costs and Outcomes of Medical and Recreational Marijuana Policies in the United States: A Systematic Review

Significant support exists in the United States for legalization of marijuana/cannabis. As of 2021, 36 states and four territories approved the legalization of medical cannabis via medical marijuana laws (MMLs), and 15 states and District of Columbia (DC) have adopted recreational marijuana laws (RMLs). We performed structured and systematic searches of articles published from 2010 through September 2021. We assess the literature pertaining to adolescent marijuana use; opioid use and opioid-related outcomes; alcohol use; tobacco use; illicit and other drug use; marijuana growing and cultivation; employment, earnings, and other workplace outcomes; academic achievement and performance; criminal activity; perceived harmfulness; traffic and road safety; and suicide and sexual activity. Overall, 113 articles satisfied our inclusion criteria. Except for opioids, studies on use of other substances (illicit drugs, tobacco, and alcohol) were inconclusive. MMLs and RMLs do not generate negative outcomes in the labor market, lead to greater criminal activity, or reduce traffic and road safety.

Opioid reduction for patients with chronic pain in primary care: systematic review

BACKGROUND

Long-term opioid treatment in patients with chronic pain is often ineffective and possibly harmful. These patients are often managed by general practitioners, who are calling for a clear overview of effective opioid reduction strategies for primary care.

AIM

Evaluate effectiveness of opioid reduction strategies applicable in primary care for patients with chronic pain on long-term opioid treatment.

DESIGN

Systematic review of controlled trials and cohort studies. Method Literature search conducted in Embase, Medline, Web of Science, Cochrane CENTRAL register of trials, CINAHL, Google Scholar and PsychInfo. Studies evaluating opioid reduction interventions applicable in primary care among adults with long-term opioid treatment for chronic non-cancer pain were included. Risk of bias was assessed using Cochrane risk of bias (RoB) 2.0 tool or Risk-of-Bias in Non-randomized studies of Interventions (ROBINS-I) tool. Narrative synthesis was performed due to clinical heterogeneity in study designs and types of interventions.

RESULTS

Five RCTs and five cohort studies were included (total n= 1717, range 35-985) exploring various opioid reduction strategies. Six studies had high RoB, three moderate RoB, and one low RoB. Three cohort studies investigating a GP supervised opioid taper (critical ROBINS-I), an integrative pain treatment (moderate ROBINS-I) and group medical visits (critical ROBINS-I) demonstrated significant between-group opioid reduction.

CONCLUSION

Results carefully point in the direction of a GP supervised tapering and multidisciplinary group therapeutic sessions to reduce long term opioid treatment. However, due to high risk of bias and small sample sizes, no firm conclusions can be made demonstrating need for more high-quality research.

Legal status of recreational cannabis and self-reported substitution of cannabis for opioids or prescription pain medication in Canada and the United States

Aims: With increased liberalization of cannabis policies in North America, there is growing interest in the use of cannabis to manage pain instead of opioids. The objectives of the study were to (1) examine the use of cannabis for pain relief in Canada and the United States (US) in 2018 and 2019; (2) examine the association between recreational cannabis laws and changes in the use of cannabis for pain relief, instead of opioids or prescription pain medication. Methods: Repeat cross-sectional survey data were used from Wave 1 and Wave 2 of the International Cannabis Policy Study conducted in 2018 and 2019 in Canada and the US. Respondents were recruited through commercial panels, aged 16-65, and had ever tried cannabis (N = 44,119). Weighted binary logistic regression models examined the association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication (n = 15,092). Results: Between 14-33% of cannabis consumers in Canada and the US reported using cannabis to manage headaches or pain. Of these consumers, 79% and 78% respondents in Canada; 80% and 83% in US illegal states; and 83% and 84% in US legal states, in 2018 and 2019, respectively, reported cannabis use for pain relief instead of opioids or prescription pain medication. There was little evidence of an association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication, among Canadian (AOR = 0.98, 95% CI: 0.78, 1.22) and US respondents (AOR = 1.11, 95% CI: 0.96, 1.28). Conclusions: Although substitution of cannabis for opioids or prescription pain medication is common among those who use cannabis for pain, there does not seem to be a significant difference according to cannabis legality. Future research should examine cannabis and opioid substitution using different research designs and time frames.

Medical Cannabis Patients Report Improvements in Health Functioning and Reductions in Opiate Use

Purpose: Opioid use rates have dropped as North American patients gain access to medical cannabis, indicating a harm reduction role, yet health outcomes remain mostly unexplored. This study presents self-reported medical cannabis use, perceptions of health functioning, and changes in opioid pain medication use in Florida medical cannabis patients.Methods: Patients (n = 2,183) recruited from medical dispensaries across Florida completed a 66-item cross-sectional survey that included demographic, health, and medication usage items, along with items from the Medical Outcomes Survey (SF-36) to assess health functioning before and after cannabis initiation.Results: Most participants were between the ages of 20 and 70 years of age (95%), over 54% were female, 47% were employed, and most (85%) were white. Commonly reported ailment groups were Pain and Mental Health combined (47.92%), Mental Health (28.86%) or Pain (9.07%). Health domains of bodily pain, physical functioning, and social functioning improved while limitations due to physical and emotional problems were unchanged. Most patients rated medical cannabis as being important to their quality of life. Many (60.98%) reported using pain medications prior to medical cannabis, 93.36% of these reported a change in pain medication after medical cannabis. The majority of participants (79%) reported either cessation or reduction in pain medication use following initiation of medical cannabis and 11.47% described improved functioning.Conclusions: The findings suggest that some medical cannabis patients decreased opioid use without harming quality of life or health functioning, soon after the legalization of medical cannabis. The public health implications of medical cannabis as an alternative pain medication are discussed.

Medical Cannabis Certification Is Associated With Decreased Opiate Use in Patients With Chronic Pain: A Retrospective Cohort Study in Delaware

Background

Opioid medications are commonly used to treat chronic pain around the world. While these medications are quite effective at reducing pain, they can create opioid dependence and lead to further drug addiction. Long-term opioid use has significantly contributed to the “opioid epidemic” that is currently ravaging the United States, leading to opioid overdoses and unintentional deaths, particularly in Delaware.

Objective

To determine if medical marijuana certification helps patients in Delaware with chronic pain reduce their opiate use.

Methods

In this study, we examined individuals who were provided with legal; medical cannabis certifications in the state of Delaware between June 2018 and October 2019 and were concurrently being treated with opioid medications for chronic pain at a private pain management practice. Using a posthoc analysis, we conducted a retrospective cohort study on the individuals (n = 81) to determine if there was a decrease in their opioid use following medical cannabis certification. Opioid use was measured in morphine milligram equivalent (MME) through the Delaware prescription monitoring program (PMP) database.

Results

Overall, the average change in prescribed opioid use was found to be -12.3 morphine milligram equivalent (MME) units when including all individuals (p < 0.00001). Among the included individuals with baseline opioid use, medical cannabis certification was associated with a 31.3% average decrease in opioid use (n = 63). When examining subgroups based upon pain location, individuals with neck pain displayed a 41.5% average decrease in MME (n = 27), while individuals with low back pain were observed to have a 29.4% decrease in opioid use (n = 58). Similarly, individuals with knee pain (n = 14) reduced their opioid use by 32.6%.

Conclusion

The results display an association between medical cannabis certification and a decrease in opiate use among the study group individuals. This study suggests that medical cannabis use may help individuals to reduce their opiate requirements along with physician intervention. More research is needed to validate these findings with appropriate controls and verification of cannabis use.

Real World Evidence in Medical Cannabis Research

BACKGROUND

Whilst access to cannabis-based medicinal products (CBMPs) has increased globally subject to relaxation of scheduling laws globally, one of the main barriers to appropriate patient access remains a paucity of high-quality evidence surrounding their clinical effects.

DISCUSSION

Whilst randomised controlled trials (RCTs) remain the gold-standard for clinical evaluation, there are notable barriers to their implementation. Development of CBMPs requires novel approaches of evidence collection to address these challenges. Real world evidence (RWE) presents a solution to not only both provide immediate impact on clinical care, but also inform well-conducted RCTs. RWE is defined as evidence derived from health data sourced from non-interventional studies, registries, electronic health records and insurance data. Currently it is used mostly to monitor post-approval safety requirements allowing for long-term pharmacovigilance. However, RWE has the potential to be used in conjunction or as an extension to RCTs to both broaden and streamline the process of evidence generation.

CONCLUSION

Novel approaches of data collection and analysis will be integral to improving clinical evidence on CBMPs. RWE can be used in conjunction or as an extension to RCTs to increase the speed of evidence generation, as well as reduce costs. Currently, there is an abundance of potential data however, whilst a number of platforms now exist to capture real world data it is important the right tools and analysis are utilised to unlock potential insights from these.

Demographics, Perceptions, and Use of Medical Marijuana among Patients in Florida

Medical marijuana (MMJ) is currently legal in 35 US states, with an estimated 3.6 million state-legal medical cannabis patients. Although there are currently over 440,000 MMJ patients in the state of Florida, there are limited data on their demographics, reasons and patterns of use, and successes or failures of treatment. The goal of this study is to examine the demographics, perceptions, and use of medical cannabis among patients in Florida, as well as their perceptions of the quality of information received from physicians and dispensaries. One hundred and fifty-seven MMJ patients completed an online survey regarding their characteristics and use. Patients in Florida shared many characteristics with patients in other states, such as race, use frequency, and administration technique. Patients most commonly used MMJ to treat their symptoms of anxiety, pain, and stress and reported great therapeutic effectiveness. A majority (65%) of patients also reported either a reduction or total discontinuation of at least one prescription or over-the-counter drug. The findings highlight the need to further investigate the use of MMJ as a viable treatment for pain and anxiety and to improve access of quality cannabis information to patients, physicians, and dispensary employees.

Medical Cannabis for Headache Pain: a Primer for Clinicians

PURPOSE OF REVIEW

Public acceptance of Cannabis sativa L. (cannabis) as a therapeutic option grows despite lags in both research and clinician familiarity. Cannabis-whether as a medical, recreational, or illicit substance-is and has been commonly used by patients. With ongoing decriminalization efforts, decreased perception of harms, and increased use of cannabis in the treatment of symptoms and disease, it is critical for clinicians to understand the rationale for specific therapies and their medical and practical implications for patients. In view of the opioid crisis, overall patient dissatisfaction, and lack of adherence to current chronic pain and headache therapies, this review provides up-to-date knowledge on cannabis as a potential treatment option for headache pain.

RECENT FINDINGS

Research into the use of cannabinoids for disease treatment have led to FDA-approved drugs for seizures, nausea, and vomiting caused by cancer chemotherapy; and for decreased appetite and weight loss in people with HIV/AIDS. For a wide variety of conditions and symptoms (including chronic pain), cannabis has gained increasing acceptance in society. The effects of cannabidiol (CBD) and tetrahydrocannabinol (THC) in pain pathways have been significantly elucidated. An increasing number of retrospective studies have shown a decrease in pain scores after administration of cannabinoids, as well as long-term benefits such as reduced opiate use. Yet, there is no FDA-approved cannabis product for headache or other chronic pain disorders. More is being done to determine who is likely to benefit from cannabis as well as to understand the long-term effects and limitations of the treatment. Cannabis can refer to a number of products derived from the plant Cannabis sativa L. Relatively well-tolerated, these products come in different configurations, types, and delivery forms. Specific formulations of the plant have been shown to be an effective treatment modality for chronic pain, including headache. It is important for clinicians to know which product is being discussed as well as the harms, benefits, contraindications, interactions, and unknowns in order to provide the best counsel for patients.

The Endocannabinoid System: A Potential Target for the Treatment of Various Diseases

The Endocannabinoid System (ECS) is primarily responsible for maintaining homeostasis, a balance in internal environment (temperature, mood, and immune system) and energy input and output in living, biological systems. In addition to regulating physiological processes, the ECS directly influences anxiety, feeding behaviour/appetite, emotional behaviour, depression, nervous functions, neurogenesis, neuroprotection, reward, cognition, learning, memory, pain sensation, fertility, pregnancy, and pre-and post-natal development. The ECS is also involved in several pathophysiological diseases such as cancer, cardiovascular diseases, and neurodegenerative diseases. In recent years, genetic and pharmacological manipulation of the ECS has gained significant interest in medicine, research, and drug discovery and development. The distribution of the components of the ECS system throughout the body, and the physiological/pathophysiological role of the ECS-signalling pathways in many diseases, all offer promising opportunities for the development of novel cannabinergic, cannabimimetic, and cannabinoid-based therapeutic drugs that genetically or pharmacologically modulate the ECS via inhibition of metabolic pathways and/or agonism or antagonism of the receptors of the ECS. This modulation results in the differential expression/activity of the components of the ECS that may be beneficial in the treatment of a number of diseases. This manuscript in-depth review will investigate the potential of the ECS in the treatment of various diseases, and to put forth the suggestion that many of these secondary metabolites of Cannabis sativa L. (hereafter referred to as "C. sativa L." or "medical cannabis"), may also have potential as lead compounds in the development of cannabinoid-based pharmaceuticals for a variety of diseases.

Opioid-sparing effects of medical cannabis or cannabinoids for chronic pain: a systematic review and meta-analysis of randomised and observational studies

OBJECTIVE

To assess the efficacy and harms of adding medical cannabis to prescription opioids among people living with chronic pain.

DESIGN

Systematic review.

DATA SOURCES

CENTRAL, EMBASE and MEDLINE.

MAIN OUTCOMES AND MEASURES

Opioid dose reduction, pain relief, sleep disturbance, physical and emotional functioning and adverse events.

STUDY SELECTION CRITERIA AND METHODS

We included studies that enrolled patients with chronic pain receiving prescription opioids and explored the impact of adding medical cannabis. We used Grading of Recommendations Assessment, Development and Evaluation to assess the certainty of evidence for each outcome.

RESULTS

Eligible studies included five randomised trials (all enrolling chronic cancer-pain patients) and 12 observational studies. All randomised trials instructed participants to maintain their opioid dose, which resulted in a very low certainty evidence that adding cannabis has little or no impact on opioid use (weighted mean difference (WMD) -3.4 milligram morphine equivalent (MME); 95% CI (CI) -12.7 to 5.8). Randomised trials provided high certainty evidence that cannabis addition had little or no effect on pain relief (WMD -0.18 cm; 95% CI -0.38 to 0.02; on a 10 cm Visual Analogue Scale (VAS) for pain) or sleep disturbance (WMD -0.22 cm; 95% CI -0.4 to -0.06; on a 10 cm VAS for sleep disturbance; minimally important difference is 1 cm) among chronic cancer pain patients. Addition of cannabis likely increases nausea (relative risk (RR) 1.43; 95% CI 1.04 to 1.96; risk difference (RD) 4%, 95% CI 0% to 7%) and vomiting (RR 1.5; 95% CI 1.01 to 2.24; RD 3%; 95% CI 0% to 6%) (both moderate certainty) and may have no effect on constipation (RR 0.85; 95% CI 0.54 to 1.35; RD -1%; 95% CI -4% to 2%) (low certainty). Eight observational studies provided very low certainty evidence that adding cannabis reduced opioid use (WMD -22.5 MME; 95% CI -43.06 to -1.97).

CONCLUSION

Opioid-sparing effects of medical cannabis for chronic pain remain uncertain due to very low certainty evidence.PROSPERO registration numberCRD42018091098.

Exploring the use of cannabis as a substitute for prescription drugs in a convenience sample

BACKGROUND

The use of cannabis as medicine (CaM) both prescribed and non-prescribed has increased markedly in the last decade, mirrored in a global shift in cannabis policy towards a more permissive stance. There is some evidence that cannabis functions as a substitute for prescription drugs, particularly opioids; however, more knowledge is needed on the motives of substitution users, their patterns of use, and perceived effects of substitution use.

AIMS

To explore who substitutes prescription drugs with cannabis, the type of prescription drugs substituted and the type of cannabis used, and the impact that substitution with cannabis has on prescription drug use as well as the motives for substitution in terms of experienced effects and side effects.

METHODS

A self-selected convenience sample was recruited through social media, public media, and patient organizations to take part in an anonymous online survey. Inclusion criteria were 18 years or older and use of cannabis (prescribed or non-prescribed) with a medical purpose.

RESULTS

The final sample included 2.841 respondents of which the majority (91%) used non-prescribed cannabis, and more than half (54.6%) had used CaM with the purpose of replacing a prescribed drug. Compared to non-substitution users, substitution users were more likely to be women and to use CaM in the treatment of chronic pain and other somatic conditions. Pain medication (67.2%), antidepressants (24.5%), and arthritis medication (20.7%) were the most common types of drugs replaced with CaM. Among substitution users, 38.1% reported termination of prescription drug use, and 45.9% a substantial decrease in prescription drug use. The most frequent type of cannabis used as a substitute was CBD-oil (65.2%), followed by 'hash, pot or skunk' (36.6%). More than half (65.8%) found CaM much more effective compared to prescription drugs, and 85.5% that the side effects associated with prescription drug use were much worse compared to use of CaM.

CONCLUSION

CaM is frequently used as a substitute for prescription drugs, particularly opioids. More research is needed on the long-term consequences of use of CaM, including the impact from low and high THC cannabis products on specific somatic and mental health conditions.

Opioid Prescribing in Canada following the Legalization of Cannabis: A Clinical and Economic Time-Series Analysis

PURPOSE

On 17 October 2018 recreational cannabis became legal in Canada, thereby increasing access and reducing the stigma associated with its use for pain management. This study assessed total opioid prescribing volumes and expenditures prior to and following cannabis legalization.

METHODS

National monthly claims data for public and private payers were obtained from January 2016 to June 2019. The drugs evaluated consisted of morphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, oxycodone, tramadol, and the non-opioids gabapentin and pregabalin. All opioid volumes were converted to a mean morphine equivalent dose (MED)/claim, which is analogous to a prescription from a physician. Gabapentin and pregabalin claims data were analyzed separately from the opioids. Time-series regression modelling was undertaken with dependent variables being mean MED/claim and total monthly spending. The slopes of the time-series curves were then compared pre- versus post-cannabis legalization.

RESULTS

Over the 42-month period, the mean MED/claim declined within public plans (p < 0.001). However, the decline in MED/claim was 5.4 times greater in the period following legalization (22.3 mg/claim post vs. 4.1 mg/claim pre). Total monthly opioid spending was also reduced to a greater extent post legalization ($Can267,000 vs. $Can95,000 per month). The findings were similar for private drug plans; however, the absolute drop in opioid use was more pronounced (76.9 vs. 30.8 mg/claim). Over the 42-month period, gabapentin and pregabalin usage also declined.

CONCLUSIONS

Our findings support the hypothesis that easier access to cannabis for pain may reduce opioid use for both public and private drug plans.

A Mapping Literature Review of Medical Cannabis Clinical Outcomes and Quality of Evidence in Approved Conditions in the USA from 2016 to 2019

In 2017, a National Academies of Sciences, Engineering, and Medicine (NASEM) report comprehensively evaluated the body of evidence regarding cannabis health effects through the year 2016. The objectives of this study are to identify and map the most recently (2016-2019) published literature across approved conditions for medical cannabis and to evaluate the quality of identified recent systematic reviews, published following the NASEM report. Following the literature search from 5 databases and consultation with experts, 11 conditions were identified for evidence compilation and evaluation: amyotrophic lateral sclerosis, autism, cancer, chronic noncancer pain, Crohn's disease, epilepsy, glaucoma, human immunodeficiency virus/AIDS, multiple sclerosis (MS), Parkinson's disease, and posttraumatic stress disorder. A total of 198 studies were included after screening for condition-specific relevance and after imposing the following exclusion criteria: preclinical focus, non-English language, abstracts only, editorials/commentary, case studies/series, and non-U.S. study setting. Data extracted from studies included: study design type, outcome definition, intervention definition, sample size, study setting, and reported effect size. Few completed randomized controlled trials (RCTs) were identified. Studies classified as systematic reviews were graded using the Assessing the Methodological Quality of Systematic Reviews-2 tool to evaluate the quality of evidence. Few high-quality systematic reviews were available for most conditions, with the exceptions of MS (9 of 9 graded moderate/high quality; evidence for 2/9 indicating cannabis improved outcomes; evidence for 7/9 indicating cannabis inconclusive), epilepsy (3 of 4 graded moderate/high quality; 3 indicating cannabis improved outcomes; 1 indicating cannabis inconclusive), and chronic noncancer pain (12 of 13 graded moderate/high quality; evidence for 7/13 indicating cannabis improved outcomes; evidence from 6/7 indicating cannabis inconclusive). Among RCTs, we identified few studies of substantial rigor and quality to contribute to the evidence base. However, there are some conditions for which significant evidence suggests that select dosage forms and routes of administration likely have favorable risk-benefit ratios (i.e., epilepsy and chronic noncancer pain). The body of evidence for medical cannabis requires more rigorous evaluation before consideration as a treatment option for many conditions, and evidence necessary to inform policy and treatment guidelines is currently insufficient for many conditions.

Evaluation of Patient Reported Safety and Efficacy of Cannabis From a Survey of Medical Cannabis Patients in Canada

With the medical use of cannabis permitted in Canada since 2001, patients seek to use this botanical drug to treat a range of medical conditions. However, many healthcare practitioners express the need for further scientific evidence around the use of medical cannabis. This real-world evidence study aimed to address the paucity of scientific data by surveying newly registered medical cannabis patients, before beginning medical cannabis treatment, and at one follow up 6 weeks after beginning medical cannabis treatment. The goal was to collect data on efficacy, safety and cannabis product type information to capture the potential impact medical cannabis had on patient-reported quality of life (QOL) and several medical conditions over a 6-week period using validated questionnaires. The 214 participants were mainly male (58%) and 57% of the population was older than 50. The most frequently reported medical conditions were recurrent pain, post-traumatic stress disorder (PTSD), anxiety, sleep disorders [including restless leg syndrome (RLS)], and arthritis and other rheumatic disorders. Here we report that over 60% of our medical cannabis cohort self-reported improvements in their medical conditions. With the use of validated surveys, we found significant improvements in recurrent pain, PTSD, and sleep disorders after 6 weeks of medical cannabis treatment. Our findings from patients who reported arthritis and other rheumatic disorders are complex, showing improvements in pain and global activity sub-scores, but not overall changes in validated survey scores. We also report that patients who stated anxiety as their main medical condition did not experience significant changes in their anxiety after 6 weeks of cannabis treatment, though there were QOL improvements. While these results show that patients find cannabis treatment effective for a broad range of medical conditions, cannabis was not a remedy for all the conditions investigated. Thus, there is a need for future clinical research to support the findings we have reported. Additionally, while real-world evidence has not historically been utilized by regulatory bodies, we suggest changes in public policy surrounding cannabis should occur to reflect patient reported efficacy of cannabis from real-world studies due to the uniqueness of medical cannabis's path to legalization.

The use of an integrated opioid and medical marijuana prescription drug monitoring program

OBJECTIVES

To (1) identify the reasons for which pharmacists in Connecticut use the CPMRS when dispensing opioid medications and medical marijuana products, (2) determine pharmacists' perceived value of the CPMRS when dispensing opioids or medical marijuana, and (3) compare practices and the perceived value of the CPMRS among community-based pharmacists (CBPs) and medical marijuana dispensary pharmacists (MMDPs).

METHODS

An online survey was administered from May 2019 to June 2019 to CBPs (n = 178) and MMDPs (n = 12). The survey included items about background, use, and attitudes about current and future use of the CPMRS.

RESULTS

Both pharmacist groups indicated that opioid use information was the most useful aspect of the CPMRS. Ninety percent of both groups checked patients' use of opioids using the CPMRS, and 81.2% of the MMDPs compared with 38.4% of the CBPs indicated that they checked for patients' use of medical marijuana. A greater percentage of MMDPs than CBPs felt that access to the marijuana use information was useful and needed for counseling. Several pharmacists recommended improvements in marijuana use information in the CPMRS and greater efficiencies for users of the system.

CONCLUSION

Access to both marijuana and opioid use information can allow pharmacists to make specific recommendations on the basis of potential drug interactions and dose adjustments. The results from the present study highlight how integrated systems of opioid and marijuana dispensing information can be further enhanced by resolving existing pharmacy barriers involving technology, workflow, and need for systems with more detailed marijuana product information.

Opioid-sparing effects of cannabinoids: Myth or reality?

A converging line of evidence is indicating that cannabinoids may have an opioid-sparing effect. This property, well validated in preclinical studies, allow when both drugs are co-administered to reduce the dose of opioids without loss of analgesic effects. A meta-analysis of pre-clinical studies indicated in 2017 that the median effective dose (ED₅₀) of morphine administered in combination with delta-9-tetrahydrocannabinol (delta-9-THC) is 3.6 times lower than the ED₅₀ of morphine alone (Nielsen et al., 2017). However, very few studies have been conducted in humans to validate this effect. This narrative review provides an update on whether or not cannabinoid drugs can be used to produce an opioid sparing effect. For this, various lines of evidence ranging from preclinical, epidemiological and human studies will be summarized. Overall, this review indicates that the preclinical results are strongly and consistently supportive of the presence of an opioid sparing effect of cannabinoid drugs. However, to date the clinical studies have been mostly negative; and, the evidence collected in humans so far is so limited that it is premature to conclude. Therefore, prospective high quality controlled clinical trials are still required to validate this. Priorities for future research are also discussed.

Community nurses' support for patients with fibromyalgia who use cannabis to manage pain

Supporting patients to manage chronic pain conditions, such as fibromyalgia (FM), remains a challenge for community nurses. Research suggests that despite the absence of a licensed cannabis-based product for medicinal use (CBPM) available for people with FM in the UK, there is an appetite for FM patients to use cannabis for pain management. Nurses have expressed anxieties when balancing tensions between helping patients and working within medical guidelines, as well as a need for further education about patient cannabis use. This article provides community nurses with insight into how cannabis use affects the pain experience for people living with FM. Despite potential harms, cannabis is perceived by users to have a positive impact on the lived experience of pain, and it may be preferred to prescribed opioid medication. This understanding can help to inform empathic practice and recommendations are made for reducing the risks of cannabis use to patient health.

The Clinical Conundrum of Cannabis: Current Practices and Recommendations for Transplant Clinicians: An Opinion of the Immunology/Transplantation PRN of the American College of Clinical Pharmacy

Cannabis, or marijuana, comprises many compounds with varying effects. It has become a treatment option for chronic diseases and debilitating symptoms, and evidence suggests that it has immunomodulatory and antiinflammatory properties. Transplant centers are more frequently facing issues about cannabis, as indications and legalization expand. As of February 2020, 33 states and the District of Columbia have legalized medical cannabis, and 14 have legalized recreational cannabis. Moreover, 8 states have passed legislation prohibiting the denial of transplant listing solely based on cannabis use. Studies demonstrate the potential for significant pharmacokinetic and pharmacodynamic interactions between cannabis and immunosuppression. Additionally, safety concerns include increased risk of myocardial infarction, ischemic stroke, tachyarrhythmias, malignancy, neurocognitive deficits, psychosis, other neuropsychiatric disorders, cannabis use disorder, respiratory symptoms, and infection. A recent retrospective database study found a negative association between documented cannabis use disorder and graft survival, but little additional evidence exists evaluating this relationship. In the absence of robust clinical data, transplant centers need a clear, reasoned, and systematic approach to cannabis. The results of our national survey, unfortunately, found little consensus among institutions. As both recreational and medicinal cannabis become more ubiquitous nationwide, transplant centers will need to develop comprehensive policies to address its use.

Cannabis for Restless Legs Syndrome

Restless legs syndrome (RLS) is a chronic sensorimotor disorder characterized by an urge to move the legs. This urge is often accompanied by pain or other uncomfortable and unpleasant sensations, it either occurs or worsens during rest, particularly in the evening and/or at night, and temporarily improves with activity. Affecting nearly 3% of the North American and European populations in its moderate-to-severe form, RLS has a considerable negative impact on the quality of life, and sleep and is associated with significant morbidity. Although new developments have deepened our understanding of the disorder, yet, the corresponding pathophysiologic features that underlie the sensorimotor presentation are still not fully understood. Usually, symptoms respond well to dopamine agonists (DA), anticonvulsants, or opiates, used either alone or in any combination, but still, a subset of patients remains refractory to medical therapy and serious side effects such as augmentation and impulse control disorder may occur in patients with RLS under DA. Convincing treatment alternative are lacking but recently patients' spontaneous reports of a remarkable and total remission of RLS symptoms following cannabis use has been reported. The antinociceptive effect of marijuana has been documented in many painful neurological conditions and the potential benefit of cannabis use in patients with refractory RLS should, therefore, be questioned by robust clinical trials. Here, we review basic knowledge of RLS and the putative mechanisms by which cannabis may exert its analgesic effects.

The effectiveness of inhaled Cannabis flower for the treatment of agitation/irritability, anxiety, and common stress

BACKGROUND

An observational research design was used to evaluate which types of commonly labeled Cannabis flower product characteristics are associated with changes in momentary feelings of distress-related symptoms.

METHODS

We used data from 2306 patient-directed cannabis administration sessions among 670 people who used the real-time Cannabis effects recording software, Releaf App, between June 6, 2016, and February 23, 2019, for tracking the effects of Cannabis flower consumption. Fixed effects multivariable panel regression techniques were used to establish overall relief by symptom type and to determine which labeled product characteristics (e.g., subspecies/subtype, inhalation method, and major cannabinoid contents) showed the strongest correlation with changes in momentary feelings of agitation/irritability, anxiety, and stress, along with experienced side effects.

RESULTS

In total, a decrease in symptom intensity levels was reported in 95.51% of Cannabis usage sessions, an increase in 2.32% of sessions, and no change in 2.16% of sessions. Fixed effects models showed, on average, respondents recorded a maximum symptom intensity reduction of 4.33 points for agitation/irritability (SE = 0.20, p < 0.01), 3.47 points for anxiety (SE = 0.13, p < 0.01), and 3.98 for stress (SE = 0.12, p < 0.01) on an 11-point visual analog scale. Fixed effects regressions showed that, controlling for time-invariant user characteristics, mid and high tetrahydrocannabinol (THC) levels were the primary independent predictor of increased symptom relief, and that when broken out by symptom type, this effect was only statistically significant for our largest sample of users, those reporting anxiety rather than agitation/irritability or stress. Cannabidiol (CBD) levels were generally not associated with changes in symptom intensity levels. In a minority of cannabis use sessions (< 13%), cannabis users reported anxiogenic-related negative side effects (e.g., feeling anxious, irritable, paranoid, rapid pulse, or restless), whereas in a majority of sessions (about 66%), users reported positive anxiolytic side effects (e.g., feeling chill, comfy, happy, optimistic, peaceful, or relaxed).

CONCLUSIONS

The findings suggest the majority of patients in our sample experienced relief from distress-related symptoms following consumption of Cannabis flower, and that among product characteristics, higher THC levels were the strongest predictors of relief.