Clinical outcome data of anxiety patients treated with cannabis-based medicinal products in the United Kingdom: a cohort study from the UK Medical Cannabis Registry

NSW cannabis medicines advisory service retrospective enquiry analysis to inform clinical guidance resource development

BACKGROUND

An innovative New South Wales government funded statewide Cannabis Medicines Advisory Service (CMAS) operated between January 2018 and June 2022. The service provided comprehensive patient-specific and evidence-based information to support health professionals in prescribing and patient care decisions. This study aimed to describe real-world data collected by CMAS.

METHODS

A sub-set of de-identified, patient-specific enquiries collected between January 2021 and June 2022 (n = 123/567; 21.7%) were analyzed using R version 4.2.1. Diagnosis, indication, and comorbidities were coded using Medical Dictionary for Regulatory Activities (MedDRA) terminology.

RESULTS

Most patient-specific enquiries from medical practitioners were from general practitioners (n = 103/123; 83.7%). Female (n = 53/123; 43.1%) and male (n = 59/123; 48.0%) patients were similarly represented. Sex was not specified for 8.9% (n = 11/123) of patients. The mean age of patients was 52.1 years (range <10-90). The most common three diagnoses were osteoarthritis, anxiety, and chronic pain. Indications that were most frequently reported included chronic pain, anxiety, back pain, non-neuropathic pain, and insomnia. Comedications were most commonly non-opioid and opioid analgesics and antidepressants. Most practitioners were considering prescribing a cannabidiol (CBD) product for their patient. Cannabinoid composition selection guidance provided by CMAS was predominantly (delta-9-tetrahydrocannabinol) THC:CBD ~1:1, followed by CBD-only products. CMAS was contacted by health professionals regarding the management of potential adverse events for five patients.

CONCLUSION

The findings of this study shed light on the information medical practitioners were seeking to inform their clinical decision-making about medical cannabis and can inform the development of clinical guidance resources.

UK Medical Cannabis Registry: a cohort study of patients prescribed cannabis-based oils and dried flower for generalised anxiety disorder

BACKGROUND

Generalized anxiety disorder (GAD) is a common mental health condition. The endocannabinoid system has become a focus for new therapies, increasing interest in cannabis-based medicinal products (CBMPs). This study uses data from the UK Medical Cannabis Registry (UKMCR) to investigate real-world outcomes and safety of different CBMP formulations in GAD patients.

METHODS

This study analyzed patient-reported outcomes from 302 GAD patients prescribed CBMPs (oil-based, dried flower, or a combination). Anxiety (GAD-7), sleep quality (SQS), and quality of life (EQ-5D-5 L) were assessed at 1, 3, 6, and 12 months. Adverse events were recorded.

RESULTS

All CBMP formulations were associated with improvements in anxiety, sleep, and quality of life over 12 months (p < 0.050). At 12 months, there were no significant differences in outcomes between formulations (p > 0.050). The majority of reported adverse events (n = 707) were mild (n = 343) or moderate (n = 285) in severity, with no life-threatening events observed.

CONCLUSION

This study provides real-world evidence supporting the potential of CBMPs for improving GAD symptoms. Patients prescribed both oil-based and dried flower formulations have similar outcomes over 12 months. Further research is needed to determine the optimal CBMP formulation and long-term effects.

UK Medical Cannabis Registry: a case series analyzing clinical outcomes of medical cannabis therapy for generalized anxiety disorder patients

This study aims to analyze changes in health-related quality of life (HRQoL) and safety in patients with generalized anxiety disorder (GAD) prescribed a homogenous selection of cannabis-based medicinal products (CBMPs). Patients prescribed Adven CBMPs (Curaleaf International, UK) for GAD were identified from the UK Medical Cannabis Registry. Primary outcomes were changes in patient-reported outcome measures (PROMs) from baseline up to 12 months, including GAD-7, Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L. Adverse events were recorded using CTCAE version 4.0. A total of 120 patients were identified for inclusion, of which 38 (31.67%), 52 (43.33%), and 30 (25.00%) were prescribed oils, dried flower, and both formulations of CBMP. Associated improvements in GAD-7, SQS, and EQ-5D-5L at 1, 3, 6, and 12 months were observed compared to baseline ( P  < 0.010). There were 24 (20.00%) patients who reported 442 (368.33%) adverse events, most of which were mild (n = 184, 41.63%) and moderate (n = 197, 44.57%). This study reports an association between initiation of a homogeneous CBMP therapy and improvements in anxiety severity and HRQoL in individuals with GAD. Moreover, therapy was well-tolerated at 12 months follow-up. Further investigation through randomized controlled trials will ultimately be required to determine causation.

Pleasant Odor Decreases Mouse Anxiety-like Behaviors by Regulating Hippocampal Endocannabinoid Signaling

Anxiety disorder is one of the most common neuropsychiatric disorders, and affects many people's daily activities. Although the pathogenesis and treatments of anxiety disorder have been studied for several decades, the underlying mechanisms remain elusive. Here, we provide evidence that olfactory stimuli with inhaled linalool or 2-phenylethanol decreased mouse anxiety-like behaviors and increased the activities of hippocampal dentate granule cells (DGCs). RNA-sequencing analysis identified retrograde endocannabinoid signaling, which is a critical pathway for mood regulation and neuron activation, is altered in the hippocampus of both linalool- and 2-phenylethanol-exposed mice. Further studies found that selective inhibition of endocannabinoid signaling by injecting rimonabant abolished the activation of DGCs and the anxiolytic effect induced by linalool or 2-phenylethanol. Together, these results uncovered a novel mechanism by which linalool or 2-phenylethanol decreases mouse anxiety-like behaviors and increases DG activity likely through activating hippocampal retrograde endocannabinoid signaling.

Illicit Cannabis Use to Self-Treat Chronic Health Conditions in the United Kingdom: Cross-Sectional Study

Background

In 2019, it was estimated that approximately 1.4 million adults in the United Kingdom purchased illicit cannabis to self-treat chronic physical and mental health conditions. This analysis was conducted following the rescheduling of cannabis-based medicinal products (CBMPs) in the United Kingdom but before the first specialist clinics had started treating patients.

Objective

The aim of this study was to assess the prevalence of illicit cannabis consumption to treat a medically diagnosed condition following the introduction of specialist clinics that could prescribe legal CBMPs in the United Kingdom.

Methods

Adults older than 18 years in the United Kingdom were invited to participate in a cross-sectional survey through YouGov between September 22 and 29, 2022. A series of questions were asked about respondents' medical diagnoses, illicit cannabis use, the cost of purchasing illicit cannabis per month, and basic demographics. The responding sample was weighted to generate a sample representative of the adult population of the United Kingdom. Modeling of population size was conducted based on an adult (18 years or older) population of 53,369,083 according to 2021 national census data.

Results

There were 10,965 respondents to the questionnaire, to which weighting was applied. A total of 5700 (51.98%) respondents indicated that they were affected by a chronic health condition. The most reported condition was anxiety (n=1588, 14.48%). Of those enduring health conditions, 364 (6.38%) purchased illicit cannabis to self-treat health conditions. Based on survey responses, it was modeled that 1,770,627 (95% CI 1,073,791-2,467,001) individuals consume illicit cannabis for health conditions across the United Kingdom. In the multivariable logistic regression, the following were associated with an increased likelihood of reporting illicit cannabis use for health reasons-chronic pain, fibromyalgia, posttraumatic stress disorder, multiple sclerosis, other mental health disorders, male sex, younger age, living in London, being unemployed or not working for other reasons, and working part-time (P<.05).

Conclusions

This study highlights the scale of illicit cannabis use for health reasons in the United Kingdom and the potential barriers to accessing legally prescribed CBMPs. This is an important step in developing harm reduction policies to transition these individuals, where appropriate, to CBMPs. Such policies are particularly important considering the potential risks from harmful contaminants of illicit cannabis and self-treating a medical condition without clinical oversight. Moreover, it emphasizes the need for further funding of randomized controlled trials and the use of novel methodologies to determine the efficacy of CBMPs and their use in common chronic conditions.

Overview of global monitoring systems for the side effects and adverse events associated with medicinal cannabis use: a scoping review using a systematic approach

OBJECTIVES

The use of cannabis-based medicine (CBM) as a therapeutic has surged in Australia over the past 5 years. Historically, the United Nations Single Convention on Narcotic Drugs (1961) prohibited cannabis use in Europe, the USA, the UK and Australia, leading to legislative resistance and limited preclinical data on CBM. Existing safety monitoring systems for CBM are poorly structured and do not integrate well into the workflows of busy health professionals. As a result, postmarketing surveillance is inconsistent. This review aims to evaluate international systems for monitoring CBM side effects and adverse events.

DESIGN

To undertake a scoping review with a systematic approach, we used the Population, Intervention, Comparison, Outcome (PICO) framework to develop keyword elements, and two search queries to maximise search sensitivity and specificity.

DATA SOURCES

Search queries were entered into Embase and Scopus for peer-reviewed literature, and additional searches for grey literature were conducted on 23 June 2023.

ELIGIBILITY CRITERIA

We included 54 full-text articles in the review: 39 from peer-reviewed searches, 8 from grey literature and 7 from citations of relevant texts.

DATA EXTRACTION AND SYNTHESIS

Our search yielded two main forms of monitoring systems: databases and registries. Out of the 24 monitoring systems identified, there were 10 databases and 14 registries, with databases often created by regulatory authorities. Systems differed in methods of causality assessment, level of detail collected, terminology and affiliations.

RESULTS

Within the monitoring systems with enough published data for analysis, all except one remain active at the time of this review. VigiBase is the largest centralised monitoring system, receiving international case reports, however data heterogeneity persists.

CONCLUSIONS

Our study emphasises the need for a centralised, consistent and accessible system for the postmarketing surveillance of side effects and adverse events associated with medicinal cannabis use.

Assessment of clinical outcomes in patients with inflammatory arthritis: analysis from the UK Medical Cannabis Registry

The aim of this study was to assess changes in validated patient-reported outcome measures after initiation of cannabis-based medicinal products (CBMPs) and the safety of CBMPs in patients with inflammatory arthritis. A prospective case series from the UK Medical Cannabis Registry was analyzed. The primary outcomes changes were in Brief Pain Inventory, McGill Pain Questionnaire, EuroQol 5-dimension 5-level (EQ-5D-5L), Generalised Anxiety Disorder-7 questionnaire, and Single-Item Sleep Quality Scale at 1, 3, 6, and 12 months of follow-up compared with baseline. Adverse events were analyzed in accordance with Common Terminology Criteria for Adverse Events, v.4.0. Statistical significance was defined as a P-value less than 0.050. Eighty-two patients met the inclusion criteria. Initiation of CBMP treatment was associated with improvements in Brief Pain Inventory, McGill Pain Questionnaire, EQ-5D-5L, Generalised Anxiety Disorder-7 questionnaire, and Single-Item Sleep Quality Scale at 1, 3, 6, and 12 months compared with baseline (P < 0.050). There were 102 (44.35%) mild adverse events, 97 (42.17%) moderate adverse events, and 31 (13.48%) severe adverse events recorded by 21 (25.61%) participants. This study suggests that CBMP treatment is associated with pain improvement and increased health-related quality of life for inflammatory arthritis patients. While causality cannot be inferred in this observational study, the results support the development of randomized control trials for inflammatory arthritis pain management with CBMPs.

Prediction and Discovery of Cannabidiol Crystal Polymorph Form 2

The article puts into perspective the recent discovery of cannabidiol crystal polymorph Form 2.

Cannabis use in the UK: a quantitative comparison of individual differences in medical and recreational cannabis users

There is a paucity of research, especially in the UK, that investigates individual differences in both medical and recreational cannabis users. A cross-sectional survey study design was used to assess recreational cannabis users and medical cannabis users currently living in the UK. Recreational cannabis users were invited to take part via social media. Medical cannabis users were recruited from Sapphire Medical Clinics, London, UK, which provides treatment with prescribed cannabis-based medicinal products. Demographic data and cannabis use frequency, as well as post-traumatic stress disorder symptoms (PCL-5), depression symptoms (Centre for Epidemiological Studies Depression Scale), trait and state anxiety (State-Trait Anxiety Inventory), and cannabis use motives [Comprehensive Marijuana Motives Questionnaire (CMMQ)] were collected. The Chi-square and independent-sample t-tests were used for the comparison of categorical variables and normally distributed continuous variables. Data were analyzed using analyses of variance (ANOVAs) and t-tests. Statistical significance was considered where the value of p was <0.05. The survey was completed by 161 participants. Medical cannabis users were older, consumed cannabis more often, had a higher "Sleep" motive on the CMMQ, and had a higher prevalence in self-reporting current diagnoses of neurological problems, mood disorders, and anxiety disorders (p < 0.05). Recreational cannabis users had higher scores on several motives for use (e.g., "Enjoyment," "Coping," "Experimentation," "Boredom," and "Celebration") and higher state anxiety scores (p < 0.05). The most common motives for cannabis use in both groups were "Enjoyment," "Low Risk," and "Sleep." There were no differences between groups in gender, "Low-Risk" motive, post-traumatic stress disorder symptoms, depression scores, trait anxiety scores, self-reported prevalence of substance use-related disorders, and past consumption of alcohol, tobacco, or caffeine (p > 0.05). The current study not only demonstrates a difference in age and motivations for cannabis consumption between recreational and medical cannabis users but also shows areas of potential overlap, including mental health outcomes, past substance use, and gender. These UK-specific findings indicate that recreational cannabis users experience higher state anxiety, highlighting the need for further evaluation of potential anxiogenic/anxiolytic properties of cannabis. These findings demonstrate the importance of researching individual differences in cannabis users and hold significant implications for future research, clinical practice, and legislation.

The potential for medicinal cannabis to help manage challenging behaviour in people with intellectual disability: A perspective review

BACKGROUND

Around 2% of the population have intellectual disabilities. Over one-third people with intellectual disabilities (PwID) present with 'challenging behaviour', which nosologically and diagnostically is an abstract concept. Challenging behaviour is influenced by a range of bio-psycho-social factors in a population, which is unable to suitably comprehend and/or communicate concerns. This predisposes to poor health and social outcomes. There is no evidence-based treatments for managing challenging behaviour. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are being trialled for a range of disorders, which are over-represented in PwID and provoke challenging behaviours, such as severe epilepsy, spasticity, post-traumatic stress disorder, social phobia, pain, etc.

METHODS

This perspective review explores the different conditions, which benefit from medicinal CBD/THC preparations, by analysing recent literature from neurobiological, pre-clinical and clinical studies related to the topic. The evidence is synthesised to build an argument of the therapeutic benefits and challenges of medicinal cannabis to manage severe challenging behaviour in PwID.

RESULTS

There is developing evidence of medicinal CBD/THC improving psychiatric and behavioural presentations in general. In particular, there is emergent proof in certain key areas of influence of medicinal CBD/THC positively supporting challenging behaviour, for example in children with neurodevelopmental disorders. However, there are significant challenges in employing such treatments in vulnerable populations such as PwID.

CONCLUSION

Further clinical research for the considered use of medicinal CBD/THC for challenging behaviour management in PwID is needed. Strong co-production with experts with lived experience is needed for further testing to be done in this exciting new area.

An observational study of clinical outcome measures in patients treated with cannabis-based medicinal products on the UK Medical Cannabis Registry

INTRODUCTION

While there is increasing evidence of the effects of cannabis-based medicinal products (CBMPs) on health-related quality of life (HRQoL), a major limitation of the current literature is the heterogeneity of studied CBMPs. This study aims to analyze changes in HRQoL in patients prescribed a homogenous selection of CBMPs.

METHODS

Primary outcomes were changes in patient-reported outcomes (PROMs) at 1, 3, 6, and 12 months from baseline. The secondary outcome was an adverse events analysis. Statistical significance was defined as p < 0.050.

RESULTS

1378 patients prescribed Adven® CBMPs (Curaleaf International, Guernsey, UK) were included in the final analysis. 581 (42.16%) participants were current users of cannabis at baseline. 641 (46.51%), 235 (17.05%), and 502 (36.43%) patients were treated with oils, dried flowers, or a combination of the two, respectively. Improvements were found in all PROMs in each route of administration at 1, 3, 6, and 12 months from baseline (p < 0.010). Those prescribed dried flower only or both oils and dried flower experienced greater improvements in GAD-7, SQS, and EQ-5D-5L index values at 12 months (p < 0.050). There was no difference in outcomes between those prescribed dried flower only or dried flower with oils (p > 0.050). 3663 (265.82%) adverse events were reported by 297 (21.55%) patients.

CONCLUSION

There was an associated improvement in self-reported anxiety, sleep quality, and HRQoL in patients treated with the CBMPs. Those prescribed treatment formulations including dried flower were most likely to show a clinical improvement. However, these results must be interpreted with caution given the limitations of study design.

Anxiety Modulation by Cannabinoids-The Role of Stress Responses and Coping

Endocannabinoids were implicated in a variety of pathological conditions including anxiety and are considered promising new targets for anxiolytic drug development. The optimism concerning the potentials of this system for anxiolysis is probably justified. However, the complexity of the mechanisms affected by endocannabinoids, and discrepant findings obtained with various experimental approaches makes the interpretation of research results difficult. Here, we review the anxiety-related effects of the three main interventions used to study the endocannabinoid system: pharmacological agents active at endocannabinoid-binding sites present on both the cell membrane and in the cytoplasm, genetic manipulations targeting cannabinoid receptors, and function-enhancers represented by inhibitors of endocannabinoid degradation and transport. Binding-site ligands provide inconsistent findings probably because they activate a multitude of mechanisms concomitantly. More robust findings were obtained with genetic manipulations and particularly with function enhancers, which heighten ongoing endocannabinoid activation rather than affecting all mechanisms indiscriminately. The enhancement of ongoing activity appears to ameliorate stress-induced anxiety without consistent effects on anxiety in general. Limited evidence suggests that this effect is achieved by promoting active coping styles in critical situations. These findings suggest that the functional enhancement of endocannabinoid signaling is a promising drug development target for stress-related anxiety disorders.

Cannabinoids: Emerging sleep modulator

Sleep is an essential biological phase of our daily life cycle and is necessary for maintaining homeostasis, alertness, metabolism, cognition, and other key functions across the animal kingdom. Dysfunctional sleep leads to deleterious effects on health, mood, and cognition, including memory deficits and an increased risk of diabetes, stroke, and neurological disorders. Sleep is regulated by several brain neuronal circuits, neuromodulators, and neurotransmitters, where cannabinoids have been increasingly found to play a part in its modulation. Cannabinoids, a group of lipid metabolites, are regulatory molecules that bind mainly to cannabinoid receptors (CB1 and CB2). Much evidence supports the role of cannabinoid receptors in the modulation of sleep, where their alteration exhibits sleep-promoting effects, including an increase in non-rapid-eye movement sleep and a reduction in sleep latency. However, the pharmacological alteration of CB1 receptors is associated with adverse psychotropic effects, which are not exhibited in CB2 receptor alteration. Hence, selective alteration of CB2 receptors is also of clinical importance, where it could potentially be used in treating sleep disorders. Thus, it is crucial to understand the neurobiological basis of cannabinoids in sleep physiology. In this review article, the alteration of the endocannabinoid system by various cannabinoids and their respective effects on the sleep-wake cycle are discussed based on recent findings. The mechanisms of the cannabinoid receptors on sleep and wakefulness are also explored for their clinical implications and potential therapeutic use on sleep disorders.