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Chrobak AA, Woroń J, Siwek M. Green rush and red warnings: Retrospective chart review of adverse events of interactions between cannabinoids and psychotropic drugs. Front Pharmacol 2024; 15:1500312. [PMID: 39502532 PMCID: PMC11534596 DOI: 10.3389/fphar.2024.1500312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 10/09/2024] [Indexed: 11/08/2024] Open
Abstract
Aim Our objective was to systematically assess the prevalence and clinical features of adverse events related to interactions between cannabinoids and psychotropic drugs through a retrospective chart review. Methodology 1586 adverse event reports were assessed. Cases included in the analysis showed a high probability of a causal relationships between cannabinoid-psychotropic drug interactions and adverse events. Data extracted included age, sex, psychotropic drug, cannabinoid products, other medications, and the clinical outcomes and mechanisms of these interactions. Results Cannabinoids were involved in 8% of adverse events associated with the concomitant use of psychotropic drugs and other preparations. We identified 20 reports in which side effects presented a causal relationship with the use of psychotropic drugs and cannabinoids. Preparations containing 18% or more tetrahydrocannabinol (THC), presented significant side effects with the following antidepressants: mianserine (restless legs syndrome, urogenital pain, ventricular tachycardia), mirtazapine (pancreatitis, hyperhidrosis, arthralgia), quetiapine (myocarditis, renal failure, bradycardia, sialorrhea), haloperidol (ventricular arrhythmia, prolonged QTc), aripiprazole (prolonged QTc), ventricular tachycardia) and cariprazine (stomach pain, hepatotoxicity), sertraline (ataxia, hyperactivity, coma, hallucinations, anxiety, agitation, tachycardia, panic attacks, disorientation, headache, dizziness, blurry vision, severe emesis, xerostomia, dry eyes), trazodone (disorientation, memory impairment, sedation), fluvoxamine (tachycardia, tachypnoea, dysarthria, auditory hallucinations). Two out of 20 reports (10%) analyzed in our study was related with the simultaneous use of cannabidiol (CBD) oil and sertraline. Concomitant use of those substances was associated with the adverse events in form of diarrhea, emesis, fever and severe fatigue. Conclusion Clinicians need to closely monitor adverse events resulting from the combined use of cannabinoids and psychotropic medications. The accumulation of side effects and pharmacokinetic interactions (including CYP and p-glycoprotein inhibition) between these drugs can lead to clinically significant adverse outcomes.
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Affiliation(s)
- Adrian Andrzej Chrobak
- Department of Adult Psychiatry, Chair of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław Woroń
- Department of Clinical Pharmacology, Chair of Pharmacology, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
- Department of Anesthesiology and Intensive Care No. 1, Department of Internal Medicine and Geriatrics, University Hospital in Cracow, Kraków, Poland
- University Center for Monitoring and Research on Adverse Drug Effects in Krakow, Kraków, Poland
| | - Marcin Siwek
- Department of Affective Disorders, Chair of Psychiatry, Jagiellonian University Medical College, Kraków, Poland
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Shin YM, Moussa M, Akwe J. Exploring The Contours: Navigating Cannabis Use Among Older Adults. JOURNAL OF BROWN HOSPITAL MEDICINE 2024; 3:120951. [PMID: 40026396 PMCID: PMC11864428 DOI: 10.56305/001c.120951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/05/2024] [Indexed: 03/05/2025]
Abstract
Cannabis has been employed medicinally throughout history, with recent renewed interest for use due to media awareness and medical marijuana legislation. The geriatric population, identified as those 65 years of age and older, is increasingly using cannabis-derived products, has a higher likelihood of having multiple comorbidities, and is subject to polypharmacy. These individuals are at increased risk of psychiatric and other medical adverse events due to their decreased physical and cognitive reserve and changes in their physicality. Recreational use of cannabis in this population has not been well studied, but medical marijuana use has been investigated more frequently. Increased nonmedical use increases the risk of adverse health consequences. Heavy regular use can lead to cannabis use disorder (CUD), which is formerly known as cannabis abuse and dependence, and may also lead to impaired social functioning and psychiatric comorbidity. The pattern of patients admitted to hospitals has dramatically changed recently, with an increased number of elderly patients being frequently admitted. As such, due to the ease of accessing CBD, this vulnerable cohort is seen more frequently in the hospital, and we need to be more vigilant and inquire about cannabis use as we do, asking about routine medications and over-the-counter supplements. In the U.S., marijuana laws have been changing rapidly, and Americans increasingly favor legalizing cannabis for medical and recreational uses. Policymakers should ensure that training on cannabis screening and interventions for CUD are provided to clinicians to equip them better to monitor and treat patients with cannabis-related problems.
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Affiliation(s)
- Yoo Mee Shin
- Division of Hospital Medicine Emory University School of Medicine
| | - Mohamad Moussa
- Division of Hospital Medicine Emory University School of Medicine
| | - Joyce Akwe
- Division of Hospital Medicine Emory University School of Medicine
- Atlanta VAHCS/ VISN 7 Clinical Resource Hub
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Wang Y, Robinson KR, Fechtel H, Hartog A. Medical Cannabis Use and Its Impact on Health Among Older Adults: Recent Research Findings and Future Directions. CURRENT ADDICTION REPORTS 2023; 10:837-843. [PMID: 38586531 PMCID: PMC10997349 DOI: 10.1007/s40429-023-00519-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review With the rapidly changing landscape of state level legalization of cannabis, older adults have become one of the fastest growing populations seeking medical cannabis (MC). However, research evidence on the risks and benefits of MC use in this population remains limited. This review aims to synthesize recent literature on the impacts of MC use in older adults and identify critical knowledge gaps to be addressed in future research. Recent Findings Recent literature showed that older adults often face financial and/or educational barriers and stigma associated with MC access. Emerging data showed that MC may have therapeutic effects on symptoms of conditions such as chronic pain, insomnia, anxiety/depression, dementia, nausea, and vomiting. However, available evidence is inconsistent and tends to rely on self-report and uncontrolled studies. While some adverse events associated with MC use were reported, it is generally well tolerated in older adults. Neurocognitive and psychological consequences and cardiovascular risks have been reported but again only in limited studies with inconsistent findings. Summary There is a need for more systematic and rigorous research on MC in older adults to determine its safety and efficacy. Research on dosing procedures and product characteristics, as well as how these may impact health outcomes, is crucial. More consistent evidence is needed to inform policy changes and patient/physician education to minimize potential risks and optimize benefits among older adults seeking MC as an alternative treatment.
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Affiliation(s)
- Yan Wang
- Department of Epidemiology, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, USA
| | - Kendall R. Robinson
- Department of Epidemiology, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, USA
| | - Hannah Fechtel
- Department of Epidemiology, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, USA
| | - Alexis Hartog
- Department of Biology, University of Florida, 2004 Mowry Rd, Gainesville, FL 32610, USA
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Timler A, Bulsara C, Bulsara M, Vickery A, Jacques A, Codde J. Examining the use of cannabidiol and delta-9-tetrahydrocannabinol-based medicine among individuals diagnosed with dementia living within residential aged care facilities: Results of a double-blind randomised crossover trial. Australas J Ageing 2023; 42:698-709. [PMID: 37321847 DOI: 10.1111/ajag.13224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/28/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Dementia affects individuals older than 65 years. Currently, residential aged care facilities (RACF) use psychotropic medications to manage behavioural and neuropsychiatric symptoms of dementia (BPSD), which are recommended for short-term use and have substantial side effects, including increased mortality. Cannabinoid-based medicines (CBM) have some benefits that inhibit BPSD and cause minimal adverse effects (AEs), yet limited research has been considered with this population. The study aimed to determine a tolerable CBM dose (3:2 delta-9-tetrahydrocannabinol:cannabidiol), and assessed its effect on BPSD, quality of life (QoL) and perceived pain. METHODS An 18-week randomised, double-blinded, crossover trial was conducted. Four surveys, collected on seven occasions, were used to measure changes in BPSD, QoL and pain. Qualitative data helped to understand attitudes towards CBM. General linear mixed models were used in the analysis, and the qualitative data were synthesised. RESULTS Twenty-one participants (77% female participants, mean age 85) took part in the trial. No significant differences were seen between the placebo and CBM for behaviour, QOL or pain, except a decrease in agitation at the end of treatment in favour of CBM. The qualitative findings suggested improved relaxation and sleep among some individuals. Post hoc estimates on the data collected suggested that 50 cases would draw stronger conclusions on the Neuropsychiatric Inventory. CONCLUSIONS The study design was robust, rigorous and informed by RACF. The medication appeared safe, with minimal AEs experienced with CBM. Further studies incorporating larger samples when considering CBM would allow researchers to investigate the sensitivity of detecting BPSD changes within the complexity of the disease and concomitant with medications.
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Affiliation(s)
- Amanda Timler
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
| | - Caroline Bulsara
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
| | - Alistair Vickery
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
- Emerald Clinics, Fremantle, WA, USA
| | - Angela Jacques
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
| | - Jim Codde
- Institute for Health Research, University of Notre Dame Australia, Fremantle, WA, USA
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Abuhasira R, Schwartz L, Novack V. Medical Cannabis Is Not Associated with a Decrease in Activities of Daily Living in Older Adults. Biomedicines 2023; 11:2697. [PMID: 37893071 PMCID: PMC10604566 DOI: 10.3390/biomedicines11102697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/27/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023] Open
Abstract
The proportion of older adults using medical cannabis is rising. Therefore, we aimed to assess the effects of herbal medical cannabis on the functional status of older adults. We conducted a prospective observational study of patients aged 65 years or older that initiated cannabis treatment for different indications, mostly chronic non-cancer pain, during 2018-2020 in a specialized geriatric clinic. The outcomes assessed were activities of daily living (ADL), instrumental activities of daily living (IADL), pain intensity, geriatric depression scale, chronic medication use, and adverse events at six months. A cohort of 119 patients began cannabis treatment: the mean age was 79.3 ± 8.5 and 74 (62.2%) were female. Of the cohort, 43 (36.1%) experienced adverse effects due to cannabis use and 2 (1.7%) required medical attention. The mean ADL scores before and after treatment were 4.4 ± 1.8 and 4.5 ± 1.8, respectively (p = 0.27), and the mean IADL scores before and after treatment were 4.1 ± 2.6 and 4.7 ± 3, respectively (p = 0.02). We concluded that medical cannabis in older adults has a number of serious adverse events, but was not associated with a decrease in functional status, as illustrated by ADL and IADL scores after six months of continuous treatment.
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Affiliation(s)
- Ran Abuhasira
- Clinical Research Center, Soroka University Medical Center, Be’er-Sheva 8410501, Israel;
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva 8410501, Israel
| | - Lihi Schwartz
- Clalit Health Services, Department of Family Medicine, Dan-Petah Tikva District, Petah Tikva 5239530, Israel;
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv 6139001, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center, Be’er-Sheva 8410501, Israel;
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er-Sheva 8410501, Israel
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Trojan V, Landa L, Šulcová A, Slíva J, Hřib R. The Main Therapeutic Applications of Cannabidiol (CBD) and Its Potential Effects on Aging with Respect to Alzheimer's Disease. Biomolecules 2023; 13:1446. [PMID: 37892128 PMCID: PMC10604144 DOI: 10.3390/biom13101446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/29/2023] Open
Abstract
The use of cannabinoids (substances contained specifically in hemp plants) for therapeutic purposes has received increased attention in recent years. Presently, attention is paid to two main cannabinoids: delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). With respect to the psychotropic effects and dependence potential of THC (though it is very mild), its use is associated with certain restrictions, and thus the therapeutic properties of CBD are frequently emphasized because there are no limitations associated with the risk of dependence. Therefore, this review covers the main pharmacodynamic and pharmacokinetic features of CBD (including characteristics of endocannabinoidome) with respect to its possible beneficial effects on selected diseases in clinical practice. A substantial part of the text deals with the main effects of CBD on aging, including Alzheimer's disease and related underlying mechanisms.
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Affiliation(s)
- Václav Trojan
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
| | - Leoš Landa
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
- Department of Pharmacology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Alexandra Šulcová
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
| | - Jiří Slíva
- Department of Pharmacology, Third Faculty of Medicine, Charles University, Ruská 87, 100 00 Prague, Czech Republic
| | - Radovan Hřib
- International Clinical Research Centre, Cannabis Facility, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
- Centre for Pain Management, Department of Anesthesiology and Intensive Care, St. Anne’s University Hospital, Pekařská 53, 602 00 Brno, Czech Republic
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Bulls HW, Althouse AD, Feldman R, Arnsten JH, Liebschutz JM, Nugent SM, Orris SR, Rohac R, Slawek DE, Starrels JL, Morasco BJ, Kansagara D, Merlin JS. Dispensary Staff Perceptions About the Benefits, Risks, and Safety of Cannabis for Medical Purposes. Subst Abus 2023; 44:226-234. [PMID: 37706479 DOI: 10.1177/08897077231186677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Therapeutic use of cannabis is common in the United States (up to 18.7% of Americans aged ≥12), and dispensaries in the US are proliferating rapidly. However, the efficacy profile of medical cannabis is unclear, and customers often rely on dispensary staff for purchasing decisions. The objective was to describe cannabis dispensary staff perceptions of medical cannabis benefits and risks, as well as its safety in high-risk populations. METHODS Online Survey study conducted using Qualtrics from February 13, 2020 to October 2, 2020 with a national sample of dispensary staff who reportedinteracting with customers in a cannabis dispensary selling tetrahydrocannabinol-containing products. Participants were queried about benefits ("helpfulness") and risks ("worry") about cannabis for a variety of medical conditions, and safety in older adults and pregnant women on a five-point Likert scale. These results were then collapsed into three categories including "neutral" (3/5). "I don't know" (uncertainty) was a response option for helpfulness and safety. RESULTS Participants (n = 434) were from 29 states and included patient-facing dispensary staff (40%); managers (32%); pharmacists (13%); and physicians, nurse practitioners, or physician assistants (5%). Over 80% of participants perceived cannabis as helpful for post-traumatic stress disorder (88.7%), epilepsy (85.3%) and cancer (83.4%). Generally, participants were not concerned about potential cannabis risks, including increased use of illicit drugs (76.3%), decreases in intelligence (74.4%), disrupted sleep (71.7%), and new/worsening health problems from medical cannabis use (70.7%). Cannabis was considered safe in older adults by 81.3% of participants, though there was much less consensus on safety in pregnancy. CONCLUSIONS Cannabis dispensary staff generally view medical cannabis as beneficial and low-risk. However, improvements in dispensary staff training, an increased role for certifying clinicians, and interventions to reduce dispensary staff concerns (e.g., cost, judgment) may improve evidence-based staff recommendations to patients seeking medical cannabis.
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Affiliation(s)
- Hailey W Bulls
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Andrew D Althouse
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert Feldman
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shannon M Nugent
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Steven R Orris
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rebecca Rohac
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Benjamin J Morasco
- Department of Psychiatry, Oregon Health and Science University, Portland, OR, USA
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Jessica S Merlin
- CHAllenges in Managing and Preventing Pain (CHAMPP) Clinical Research Center, University of Pittsburgh, Pittsburgh, PA, USA
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
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8
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Halamish N, Schleider LBL, McGuire S, Novack V. Can we predict the treatment doses of THC and CBD and does it matter? Eur J Intern Med 2023; 112:100-108. [PMID: 37003923 DOI: 10.1016/j.ejim.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/04/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Medical cannabis is an increasingly prevalent treatment for a wide variety of indications, yet there is still no uniformly accepted protocol for the titration of cannabinoid doses. We aimed to develop a model to predict the stable THC and CBD dosages after six months of treatment using available baseline patient characteristics. METHODS In this prospective study, we included all consecutive adult patients (age 18 and above) who exclusively used a single method of cannabis delivery. Telephone interviews were conducted six months post-treatment initiation to assess changes in symptoms and side effects. We prospectively analyzed THC and CBD dosages with respect to demographic variables and patient characteristics in two main groups divided according to cannabis administration method - inhalation or sublingual oil. RESULTS A total of 3,554 patients were included in the study (2,724 exclusively inhaled cannabis and 830 exclusively consumed cannabis as sublingual oil). The daily THC and CBD doses were significantly higher in the inhalation group than in the sublingual group (p<.001). None of the four models predicting THC and CBD doses in the two groups had satisfactory prediction ability (adjusted R-squared between 0.007 and 0.09). Male gender, unemployed status, tobacco smoking and a lack of concern about cannabis treatment were associated with a higher inhaled THC dose (p<.001). CONCLUSION Models based on patient characteristics failed to accurately predict the final titration doses of CBD and THC for both inhalation and sublingual administration. Clinical guidelines should maintain a highly individual approach for cannabinoid dosing.
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Affiliation(s)
- Nitzan Halamish
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Lihi Bar-Lev Schleider
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel; Research Department, Tikun Olam - Cannbit Pharmaceuticals, Tel Aviv, Israel
| | - Sydney McGuire
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel
| | - Victor Novack
- Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheva, Israel; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, United States.
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Ang SP, Sidharthan S, Lai W, Hussain N, Patel KV, Gulati A, Henry O, Kaye AD, Orhurhu V. Cannabinoids as a Potential Alternative to Opioids in the Management of Various Pain Subtypes: Benefits, Limitations, and Risks. Pain Ther 2023; 12:355-375. [PMID: 36639601 PMCID: PMC10036719 DOI: 10.1007/s40122-022-00465-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/22/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Pain is a global phenomenon encompassing many subtypes that include neuropathic, musculoskeletal, acute postoperative, cancer, and geriatric pain. Traditionally, opioids have been a mainstay pharmacological agent for managing many types of pain. However, opioids have been a subject of controversy with increased addiction, fatality rates, and cost burden on the US healthcare system. Cannabinoids have emerged as a potentially favorable alternative or adjunctive treatment for various types of acute and chronic pain. This narrative review seeks to describe the efficacy, risks, and benefits of cannabinoids as an adjunct or even potential replacement for opioids in the treatment of various subtypes of pain. METHODS In June of 2022, we performed a comprehensive search across multiple databases for English-language studies related to the use of cannabinoids in the treatment of various types pain: neuropathic pain, musculoskeletal pain, acute postoperative pain, cancer pain, and geriatric pain. Data from meta-analyses, systematic reviews, and randomized control trials (RCTs) were prioritized for reporting. We sought to focus our reported analysis on more recent literature as well as include older relevant studies with particularly notable findings. RESULTS There is conflicting evidence for the use of cannabinoids in the management of pain. While cannabinoids have shown efficacy in treating specific chronic pain subtypes such as neuropathic pain, fibromyalgia pain, and geriatric pain, they do not show as clear benefit in acute postoperative and the majority of musculoskeletal pain syndromes. Data trends towards cannabinoids having a positive effect in treating cancer pain, but results are not as conclusive. To date, there is a paucity of data comparing cannabinoids directly to opioids for pain relief. Overall, the side effects of cannabinoids appear to be relatively mild. However, there is still potential for addiction, altered brain development, psychiatric comorbidities, and drug-drug interactions. CONCLUSION Cannabinoids may be effective in specific subtypes of pain, but current evidence and guidelines do not yet support its use as the first-line treatment for any type of acute or chronic pain. Rather, it may be considered a good adjunct or alternative for patients who have failed more typical or conservative measures. Additional studies are needed with standardized forms of cannabinoids, route of delivery, and dosing for greater-powered analysis. Providers must weigh the individualized patient risks, benefits, and concurrent medication list in order to determine whether cannabinoids are appropriate for a patient's pain treatment plan.
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Affiliation(s)
- Samuel P Ang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Shawn Sidharthan
- Department of Neurology, Northwell Health-Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, USA
| | - Wilson Lai
- Department of Anesthesiology and Pain Medicine, Northwell Health-Donald and Barbara Zucker School of Medicine at Hofstra, Hempstead, NY, USA
| | - Nasir Hussain
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kiran V Patel
- Department of Anesthesiology, New York University Langone Medical Center, New York, NY, USA
- Department of Anesthesiology and Pain Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Hempstead, NY, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Onyeaka Henry
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan D Kaye
- Anesthesiology and Pharmacology, Toxicology, and Neurosciences, LSU School of Medicine, Shreveport, LA, USA
- Anesthesiology and Pharmacology, LSU School of Medicine, New Orleans, LA, USA
- Anesthesiology and Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Vwaire Orhurhu
- University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA.
- MVM Health, East Stroudsburg, PA, USA.
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Costa AC, Joaquim HPG, Pedrazzi JFC, Pain ADO, Duque G, Aprahamian I. Cannabinoids in Late Life Parkinson's Disease and Dementia: Biological Pathways and Clinical Challenges. Brain Sci 2022; 12:brainsci12121596. [PMID: 36552056 PMCID: PMC9775654 DOI: 10.3390/brainsci12121596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/16/2022] [Accepted: 11/18/2022] [Indexed: 11/25/2022] Open
Abstract
The use of cannabinoids as therapeutic drugs has increased among aging populations recently. Age-related changes in the endogenous cannabinoid system could influence the effects of therapies that target the cannabinoid system. At the preclinical level, cannabidiol (CBD) induces anti-amyloidogenic, antioxidative, anti-apoptotic, anti-inflammatory, and neuroprotective effects. These findings suggest a potential therapeutic role of cannabinoids to neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer. Emerging evidence suggests that CBD and tetrahydrocannabinol have neuroprotective therapeutic-like effects on dementias. In clinical practice, cannabinoids are being used off-label to relieve symptoms of PD and AD. In fact, patients are using cannabis compounds for the treatment of tremor, non-motor symptoms, anxiety, and sleep assistance in PD, and managing responsive behaviors of dementia such as agitation. However, strong evidence from clinical trials is scarce for most indications. Some clinicians consider cannabinoids an alternative for older adults bearing Parkinson's disease and Alzheimer's dementia with a poor response to first-line treatments. In our concept and experience, cannabinoids should never be considered a first-line treatment but could be regarded as an adjuvant therapy in specific situations commonly seen in clinical practice. To mitigate the risk of adverse events, the traditional dogma of geriatric medicine, starting with a low dose and proceeding with a slow titration regime, should also be employed with cannabinoids. In this review, we aimed to address preclinical evidence of cannabinoids in neurodegenerative disorders such as PD and AD and discuss potential off-label use of cannabinoids in clinical practice of these disorders.
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Affiliation(s)
- Alana C. Costa
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-903, Brazil
- Instituto Nacional de Biomarcadores em Neuropsiquiatria (INBioN), Conselho Nacional de Desenvolvimento Científico e Tecnológico, São Paulo 05403-010, Brazil
| | - Helena P. G. Joaquim
- Department of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-903, Brazil
| | - João F. C. Pedrazzi
- Department of Neurosciences and Behavioral Sciences, School of Medicine of Ribeirão Preto, University of São Paulo, São Paulo 05403-903, Brazil
| | - Andreia de O. Pain
- Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí 13202-550, Brazil
| | - Gustavo Duque
- Division of Geriatric Medicine, Research Institute of the McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Ivan Aprahamian
- Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Geriatrics Division, Department of Internal Medicine, Jundiaí Medical School, Jundiaí 13202-550, Brazil
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9712 Groningen, The Netherlands
- Correspondence:
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11
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Ilan Y. Digital Medical Cannabis as Market Differentiator: Second-Generation Artificial Intelligence Systems to Improve Response. Front Med (Lausanne) 2022; 8:788777. [PMID: 35141242 PMCID: PMC8818992 DOI: 10.3389/fmed.2021.788777] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/20/2021] [Indexed: 12/19/2022] Open
Abstract
Legalized use of cannabis products and the rising interest in their therapeutic benefits have opened up new opportunities for therapy and marketing. However, the marked variability in formulations, administration modes, therapeutic regimens, and inter- and intra-subject responses make the standardization of medical cannabis-based regimens difficult. Legalization has made the cannabis market highly competitive and lowered the revenue margins. This study reviews some of the challenges in medical cannabis use and difficulties in standardizing its therapeutic regimens that hinder maximizing its beneficial effects. The development of tolerance toward cannabis and low adherence to chronic administration further impair its long-term beneficial effects. Digital medical cannabis is a cannabis product controlled by a second-generation artificial intelligence (AI) system that improves patient responses by increasing adherence and dealing with tolerance. Second-generation AI systems focus on a single patient's outcome and deal with the inter- and intra-subject variability in responses. The use of digital medical cannabis is expected to improve product standardization, maximize therapeutic benefits, reduce health care costs, and increase the revenue of companies. Digital medical cannabis offers several market differentiators for cannabis companies. This study presents a model for promoting the use of digital medical cannabis and presents its advantages for patients, clinicians, health care authorities, insurance companies, and cannabis manufacturers. Ongoing trials and real-world data on the use of these systems further support the use of digital medical cannabis for improved global health.
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Affiliation(s)
- Yaron Ilan
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Department of Medicine, Hadassah Medical Center, Jerusalem, Israel
- *Correspondence: Yaron Ilan
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12
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MacCallum CA, Lo LA, Pistawka CA, Christiansen A, Boivin M, Snider-Adler M. A Clinical Framework for Assessing Cannabis-Related Impairment Risk. Front Psychiatry 2022; 13:883517. [PMID: 35832600 PMCID: PMC9272752 DOI: 10.3389/fpsyt.2022.883517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022] Open
Abstract
Clinicians play an important role in promoting safe and responsible medical cannabis use. One essential component to safe use is considering a patient's risk of neurocognitive impairment. However, there remains a lack of practical guidance on how clinicians can evaluate this risk for medical cannabis patients. Here, a practical framework is presented for clinicians to assess and stratify cannabis-associated impairment risk. The proposed framework is intended to practically guide healthcare providers in gaining a more comprehensive review of a patient's impairment-related factors. This framework can be used to assess impairment risk for patients currently using or considering medical cannabis and is recommended for all patients who perform safety-sensitive duties. Healthcare providers (HCP) managing patient's medical cannabis or those conducting assessments to determine risk of impairment for safety-sensitive workplaces can utilize this framework to stratify patients' risk of impairment. Such assessments can inform patient-specific needs for support, education, and guidance, to ensure cannabis is used safely and responsibly.
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Affiliation(s)
- Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay A Lo
- Department of Public Health Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Carly A Pistawka
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - April Christiansen
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | | | - Melissa Snider-Adler
- Department of Medicine, Faculty of Medicine, Queen's University School of Medicine, Kingston, ON, Canada
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13
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Pisani S, McGoohan K, Velayudhan L, Bhattacharyya S. Safety and Tolerability of Natural and Synthetic Cannabinoids in Older Adults: A Systematic Review and Meta-Analysis of Open-Label Trials and Observational Studies. Drugs Aging 2021; 38:887-910. [PMID: 34235645 DOI: 10.1007/s40266-021-00882-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVE Although cannabinoid-based medications are increasingly used by older adults, their safety and tolerability in this age group remain unclear. The purpose of this systematic review was to examine the safety and tolerability of cannabinoid-based medications by conducting a meta-analysis of open-label observational studies of cannabinoid-based medications for all indications in individuals with a mean age of ≥50 years. METHODS A systematic search was conducted on PubMed, PsycINFO, MEDLINE, EMBASE and CINHAL. Study quality was assessed using an adapted version of the Grading of Recommendations Assessment, Development and Evaluation criteria and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. We included studies that (a) were published from 1990 onwards; (b) included older adults (mean age ≥50 years); and (c) provided data on the safety and tolerability of medical cannabinoids. Data were pooled using a random-effects approach. Risk of adverse events, serious adverse events and withdrawals was computed as the incidence rate (IR). Separate analyses were conducted by the cannabinoid-based medication used, for delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD) and a combination of THC and CBD (THC:CBD). RESULTS Thirty-eight studies were identified (THC = 23; CBD = 6; THC:CBD = 9; N = 2341, mean age: 63.19 ± 8.08 years, men: 53.86%). THC had a very low incidence of all-cause and treatment-related adverse events (IR: 122.18, 95% confidence interval [CI] 38.23-253.56; IR: 84.76, 95% CI 0.13-326.01, respectively) and negligible serious adverse events (IR = 0). Similar IRs for CBD (all cause, IR: 111.91, 95% CI 1.24-495.93; treatment related, IR: 1.76, 95% CI 4.63-23.05) and no serious adverse events (IR = 0). CBD was not associated with a risk of treatment-related withdrawals. THC had a low risk of all-cause and treatment-related withdrawals (IR: 25.18, 95% CI 12.35-42.52; IR: 7.83, 95% CI 3.26-14.38, respectively). The THC:CBD treatment had a low risk of all-cause and treatment-related adverse events (IR: 100.72, 95% CI 0.25-383.00; IR: 55.38, 95% CI 8.61-142.80, respectively), but reported a risk of all-cause and treatment-related serious adverse events (IR: 21.32, 95% CI 0.18-93.26; IR: 3.71, 95% CI 0.21-11.56, respectively), and all-cause and treatment-related withdrawals (IR: 78.63, 95% CI 17.43-183.90; IR: 34.31, 95% CI 6.09-85.52, respectively). Significant heterogeneity (I2 >55%) was present in most analyses. CONCLUSIONS Although cannabinoid-based medications were generally safe and acceptable to adults aged over 50 years, these estimates are limited by the lack of a control condition and considerable heterogeneity. Nevertheless, they complement and are consistent with comparable evidence from randomised controlled trials.
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Affiliation(s)
- Sara Pisani
- Division of Academic Psychiatry, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK
| | - Katie McGoohan
- Division of Academic Psychiatry, Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK
| | - Latha Velayudhan
- Division of Academic Psychiatry, Department of Old Age Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK
| | - Sagnik Bhattacharyya
- Division of Academic Psychiatry, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 8AF, UK.
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14
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MacCallum CA, Lo LA, Boivin M. "Is medical cannabis safe for my patients?" A practical review of cannabis safety considerations. Eur J Intern Med 2021; 89:10-18. [PMID: 34083092 DOI: 10.1016/j.ejim.2021.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/23/2021] [Accepted: 05/01/2021] [Indexed: 02/07/2023]
Abstract
Medical cannabis use is increasing worldwide. Clinicians are commonly asked by patients to provide guidance on its safety and efficacy. Although there has been an increase in research on the role of medical cannabis for a number of different conditions, we found that there was a paucity of clear safety guidance on its use. We aim to address this issue by answering two pertinent clinician safety questions: 1 Can medical cannabis be safely used in this patient? 2. What strategies can be used to ensure that any harms from medical cannabis are mitigated? To address these questions, we reviewed available evidence and provided expert clinical opinion to summarize the fundamental components for evaluating medical cannabis safety and strategies to reduce risk from its use. Our review resulted in a safety-focused framework for medical cannabis initiation and utilization. We provide clear recommendations for patients being considered for cannabis (e.g. precautions, contraindications and drug interactions). Risk mitigation strategies such as appropriate chemovar (strain) selection, routes of administration, and dosing are reviewed. As with any other pharmacotherapy, we review the key components of monitoring and address potential issues that may arise while using medical cannabis. We propose a structured assessment and monitoring strategy that can be used by clinicians recommending cannabis (CRC) to guide patients through each step of their cannabis journey. This framework can be used to ensure that medical cannabis utilization is associated with the lowest possible risk to the patient.
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Affiliation(s)
- Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Faculty of Medicine, Division of Palliative Care, UBC, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, UBC, Vancouver, BC, Canada.
| | - Lindsay A Lo
- Department of Psychology, Queen's University, Kingston, ON, Canada
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15
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Subbaraman MS, Kerr WC. Cannabis use frequency, route of administration, and co-use with alcohol among older adults in Washington state. J Cannabis Res 2021; 3:17. [PMID: 34082833 PMCID: PMC8176731 DOI: 10.1186/s42238-021-00071-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 05/12/2021] [Indexed: 11/29/2022] Open
Abstract
Background The US national surveys and data from legal adult use cannabis states show increases in the prevalence of cannabis use among older adults, though little is known about their manner of cannabis consumption. Here, we examine cannabis use frequency, routes of cannabis administration, and co-use with alcohol, focusing on adults aged 50–64 and ≥65. Methods Data come from a general population survey conducted January 2014–October 2016 (N=5492) in Washington state. We first estimate prevalence and trends in cannabis frequency, routes of administration, and co-use with alcohol in gender by age groups (18–29, 30–49, 50–64, ≥ 65). To test associations between cannabis frequency, route of administration, and co-use with alcohol, we then use sample-weighted multinomial regression adjusted for gender, race/ethnicity, marital status, education, employment, and survey year. Sampling weights are used so results better represent the Washington state population. Regressions focus on the 50–64 and ≥65 age groups. Results Among men and women 50–64, the prevalence of no cannabis use in the past 12 months decreased significantly (84.2% in 2014 to 75.1% in 2016 for women, 76.8% in 2014 to 62.4% in 2016 for men). Among those who report past-year cannabis use, oral administration and vaping and other routes of administration increased by 70% and 94%, respectively each year. Almost one-third of women aged 50–64 and one-fifth of women aged ≥65 who use cannabis reported daily/near daily use, and more than one-third of men who use cannabis in all age groups reported daily/near daily use, including 41.9% of those ≥65. Among men, the prevalence of edibles, drinks, and other oral forms of cannabis administration went up significantly with age (6.6% among 18–29, 21.5% among ≥65). Vaping and other administration are more strongly related to regular and daily/near daily use than infrequent use among those ≥65. The pattern of associations between cannabis frequency and co-use with alcohol differed for women vs. men. Conclusions In a general population representative sample of adults living in a state with legal adult use cannabis, the prevalence of cannabis use increased among those aged 50–64 between 2014 and 2016, the prevalence of daily use is substantial, and oral administration and vaping are increasing.
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Affiliation(s)
- Meenakshi S Subbaraman
- Alcohol Research Group, Public Health Institute, 6001 Shellmound Ave, Suite 450, Emeryville, CA, 94608, USA.
| | - William C Kerr
- Alcohol Research Group, Public Health Institute, 6001 Shellmound Ave, Suite 450, Emeryville, CA, 94608, USA
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Abuhasira R, Haviv YS, Leiba M, Leiba A, Ryvo L, Novack V. Cannabis is associated with blood pressure reduction in older adults - A 24-hours ambulatory blood pressure monitoring study. Eur J Intern Med 2021; 86:79-85. [PMID: 33483174 DOI: 10.1016/j.ejim.2021.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Medical cannabis use is increasing rapidly in the past several years, with older adults being the fastest growing group. Nevertheless, the evidence for cardiovascular safety of cannabis use is scarce. The aim of this study was to assess the effect of cannabis on blood pressure, heart rate, and metabolic parameters in older adults with hypertension. METHODS We conducted a prospective study of patients aged 60 years or more with hypertension and a new prescription of cannabis. We have performed the following assessments: 24-hours ambulatory blood pressure monitoring, ECG, blood tests, and anthropometric measurements prior to the initiation of cannabis therapy and 3 months afterward. The primary outcome was change in mean 24-h blood pressure at 3 months. RESULTS Twenty-six patients with a mean age of 70.42 ± 5.37 years, 53.8% females completed the study. At 3 months follow-up, the mean 24-hours systolic and diastolic blood pressures were reduced by 5.0 mmHg and 4.5 mmHg, respectively (p<0.001 for both). The nadir for the blood pressure and heart rate was achieved at 3 hours post-administration. The proportion of normal dippers changed from 27.3% before treatment to 45.5% afterward. No significant changes were seen in the different metabolic parameters assessed by blood tests, anthropometric measurements, or ECG exam. CONCLUSION amongst older adults with hypertension, cannabis treatment for 3 months was associated with a reduction in 24-hours systolic and diastolic blood pressure values with a nadir at 3 hours after cannabis administration.
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Affiliation(s)
- Ran Abuhasira
- Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
| | - Yosef S Haviv
- Department of Nephrology, Soroka University Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
| | - Merav Leiba
- Division of Hematology, Assuta Ashdod Academic Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Adi Leiba
- Division of Nephrology and Hypertension, Assuta Ashdod Academic Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel; Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Larisa Ryvo
- Division of Oncology, Assuta Ashdod Academic Medical Center, and Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Victor Novack
- Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center, and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Velayudhan L, McGoohan K, Bhattacharyya S. Safety and tolerability of natural and synthetic cannabinoids in adults aged over 50 years: A systematic review and meta-analysis. PLoS Med 2021; 18:e1003524. [PMID: 33780450 PMCID: PMC8007034 DOI: 10.1371/journal.pmed.1003524] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Cannabinoid-based medicines (CBMs) are being used widely in the elderly. However, their safety and tolerability in older adults remains unclear. We aimed to conduct a systematic review and meta-analysis of safety and tolerability of CBMs in adults of age ≥50 years. METHODS AND FINDINGS A systematic search was performed using MEDLINE, PubMed, EMBASE, CINAHL PsychInfo, Cochrane Library, and ClinicalTrials.gov (1 January 1990 to 3 October 2020). Randomised clinical trials (RCTs) of CBMs in those with mean age of ≥50 years for all indications, evaluating the safety/tolerability of CBMs where adverse events have been quantified, were included. Study quality was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Two reviewers conducted all review stages independently. Where possible, data were pooled using random-effects meta-analysis. Effect sizes were calculated as incident rate ratio (IRR) for outcome data such as adverse events (AEs), serious AEs (SAEs), and death and risk ratio (RR) for withdrawal from study and reported separately for studies using tetrahydrocannabinol (THC), THC:cannabidiol (CBD) combination, and CBD. A total of 46 RCTs were identified as suitable for inclusion of which 31 (67%) were conducted in the United Kingdom and Europe. There were 6,216 patients (mean age 58.6 ± 7.5 years; 51% male) included in the analysis, with 3,469 receiving CBMs. Compared with controls, delta-9-tetrahydrocannabinol (THC)-containing CBMs significantly increased the incidence of all-cause and treatment-related AEs: THC alone (IRR: 1.42 [95% CI, 1.12 to 1.78]) and (IRR: 1.60 [95% CI, 1.26 to 2.04]); THC:CBD combination (IRR: 1.58 [95% CI,1.26 to 1.98]) and (IRR: 1.70 [95% CI,1.24 to 2.33]), respectively. IRRs of SAEs and deaths were not significantly greater under CBMs containing THC with or without CBD. THC:CBD combination (RR: 1.40 [95% CI, 1.08 to 1.80]) but not THC alone (RR: 1.18 [95% CI, 0.89 to 1.57]) significantly increased risk of AE-related withdrawals. CBD alone did not increase the incidence of all-cause AEs (IRR: 1.02 [95% CI, 0.90 to 1.16]) or other outcomes as per qualitative synthesis. AE-related withdrawals were significantly associated with THC dose in THC only [QM (df = 1) = 4.696, p = 0.03] and THC:CBD combination treatment ([QM (df = 1) = 4.554, p = 0.033]. THC-containing CBMs significantly increased incidence of dry mouth, dizziness/light-headedness, and somnolence/drowsiness. Study limitations include inability to fully exclude data from those <50 years of age in our primary analyses as well as limitations related to weaknesses in the included trials particularly incomplete reporting of outcomes and heterogeneity in included studies. CONCLUSIONS This pooled analysis, using data from RCTs with mean participant age ≥50 years, suggests that although THC-containing CBMs are associated with side effects, CBMs in general are safe and acceptable in older adults. However, THC:CBD combinations may be less acceptable in the dose ranges used and their tolerability may be different in adults over 65 or 75 years of age.
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Affiliation(s)
- Latha Velayudhan
- Department of Old age Psychiatry, Division of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Katie McGoohan
- Department of Old age Psychiatry, Division of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies, Division of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- * E-mail:
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Aftab A, Lam JA, Liu F, Ghosh A, Sajatovic M. Recent developments in geriatric psychopharmacology. Expert Rev Clin Pharmacol 2021; 14:341-355. [PMID: 33499693 DOI: 10.1080/17512433.2021.1882848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION There is a tremendous growing need to address the burden of geriatric psychiatric disorders. Recent developments relevant to geriatric psychiatry have focused on Alzheimer's disease (AD), severe/refractory depression, and cancer/end of life care. AREAS COVERED This is a non-systematic, narrative review (databases and websites for search: PubMed, Google Scholar, Medscape, ClinicalTrials.gov; focusing on the last 6 years), and covers developments in disease-modifying therapies for AD, diagnostic radiotracers for AD, medications for neuropsychiatric symptoms of dementia, ketamine/esketamine, psychedelics, and cannabinoids. EXPERT OPINION The focus of on-going trials of anti-amyloid agents has been on individuals with very early stage AD; several agents are under phase 3 investigation, and aducanumab is under FDA review. Amyloid and tau PET scans have been approved by the FDA to assist in the diagnoses of AD. Promising pharmaceuticals for neuropsychiatric symptoms of dementia include pimavanserin, brexpiprazole, escitalopram, dextromethorphan/quinidine, and lithium. Esketamine, although approved for treatment-resistant depression in general adults, failed to demonstrate efficacy in elderly patients in a phase 3 trial. There is preliminary evidence for benefit of psychedelic-assisted psychotherapy in end-of-life and cancer-related depression/anxiety. Evidence for the use of cannabinoids is currently lacking.
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Affiliation(s)
- Awais Aftab
- Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey A Lam
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Fred Liu
- Departments of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Anjan Ghosh
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Martha Sajatovic
- Departments of Psychiatry and Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Abuhasira R, Novack V. Increased risk of cardiac arrhythmias with cannabis use - More studies are needed. Eur J Intern Med 2020; 80:14-15. [PMID: 32773275 DOI: 10.1016/j.ejim.2020.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Ran Abuhasira
- Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Victor Novack
- Cannabis Clinical Research Institute and Clinical Research Center, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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