Medicinal cannabis in Thailand: 1-year experience after legalization

Design Considerations for Medicinal Cannabis Clinical Trials in People Receiving Palliative Care

CONTEXT

Evaluating medicinal cannabis in clinical trials is important for informing its efficacy and safety in clinical care. Alongside the inherent practical challenges of conducting clinical trials in people receiving palliative care, operationalizing clinical trials with a medicinal cannabis product requires additional consideration of legal, regulatory, ethical, feasibility, pharmacological and product requirements.

OBJECTIVES

This manuscript aims to explore these considerations when operationalizing medicinal cannabis clinical trials in people receiving palliative care.

METHODS

Our Phase I/IIb trial examined pharmacokinetic, toxicity and secondary (efficacy) outcomes of a vaporized medicinal cannabis product for anorexia in people with advanced cancer (ACTRN12616000516482). Using action research methodology, notes from trial investigator meetings served as an audit trail for the planning and execution of the trial. These data were integrated and synthesized to reveal key design considerations for operationalizing medicinal cannabis trials evaluating symptom control in people receiving palliative care.

RESULTS

Six key considerations emerged including: 1) Operating within medicinal cannabis legislation; 2) Biological plausibility of cannabinoid type(s) and impact on target symptoms; 3) Standardising cannabinoid content, mode of administration, dosage and packaging; 4) Ethical and safety considerations; 5) Optimizing trial site operationalization; and 6) Pharmacy dispensing, storage and security of product. Learnings and recommendations for future trials are also discussed.

CONCLUSION

This study explores the learnings and challenges involved in designing and conducting medicinal cannabis trials for symptom management in people receiving palliative care. These insights gained from our experience can inform the optimal design and operationalization of future medicinal cannabis trials in cancer and other chronic conditions.

Dietary supplementation of Cannabis sativa residues in broiler chickens affects performance, carcass characteristics, intestinal morphology, blood biochemistry profile and oxidative stability

Public interest in the cannabis plant has increased after its legalization in many countries. Cannabis sativa residues (CR) are a part of the plant waste in the cannabis industry. The CR contain medicinal properties that could be used as a feed additive in poultry production. The trial was conducted to investigate the effects of CR on growth performance, carcass characteristics, intestinal morphology, and blood biochemistry profile of broiler chickens. In a completely randomized design, 256 one-day-old male Ross 308 broilers were randomly allocated to 4 treatments with 8 replicates and 8 birds per replicate. These 4 dietary treatments included a basal diet with 0, 0.5, 1 and 2% CR for 40 d. The results showed that 2% CR supplementation reduced feed intake (FI) in the starter phase (d 3-23, P < 0.05). The birds in the CR groups had lower FI in the finishing phase (d 24-40, P < 0.01) and the whole raising period (d 3-40, P < 0.01) than the control. However, the body weight and carcass yield were not different (P > 0.05). In addition, the CR diet had no adverse effects on the blood biochemistry profile, including total cholesterol, triglycerides, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total protein, globulin, albumin, and direct bilirubin (P > 0.05). In addition, total bilirubin and malondialdehyde were better in the plasma of CR-supplemented birds than in the control groups (P < 0.05). The observations on intestinal morphology showed that CR supplementation improved the ratio between villus height and crypt depth in the ileum (P < 0.05). In conclusion, CR supplementation can improve intestinal morphology and oxidative stability of broiler chickens. This suggests that CR could potentially be used as an alternative feed additive in broiler production.

Supporting gut health with medicinal cannabis in people with advanced cancer: potential benefits and challenges

The side effects of cancer therapy continue to cause significant health and cost burden to the patient, their friends and family, and governments. A major barrier in the way in which these side effects are managed is the highly siloed mentality that results in a fragmented approach to symptom control. Increasingly, it is appreciated that many symptoms are manifestations of common underlying pathobiology, with changes in the gastrointestinal environment a key driver for many symptom sequelae. Breakdown of the mucosal barrier (mucositis) is a common and early side effect of many anti-cancer agents, known to contribute (in part) to a range of highly burdensome symptoms such as diarrhoea, nausea, vomiting, infection, malnutrition, fatigue, depression, and insomnia. Here, we outline a rationale for how, based on its already documented effects on the gastrointestinal microenvironment, medicinal cannabis could be used to control mucositis and prevent the constellation of symptoms with which it is associated. We will provide a brief update on the current state of evidence on medicinal cannabis in cancer care and outline the potential benefits (and challenges) of using medicinal cannabis during active cancer therapy.

Thai veterinarians' perceptions of cannabidiol products for dogs with osteoarthritis: a qualitative interview study

Introduction

The global popularity of cannabidiol (CBD) led to its approval for human use in Thailand and potential use in animals. Many studies revealed CBD's efficacy in treating chronic osteoarthritis (OA) in dogs. To facilitate tailored CBD product development for canine OA and ensure market success, this study explores Thai veterinarians' perception of CBD for canine OA.

Methods

In-depth interviews were conducted with experienced veterinarians who treated OA in ≥25% of their canine patients. Interview questions covered treatment, CBD perception, and adoption. Interviews were held from January to March 2023.

Results

Eleven out of twenty invited veterinarians participated in the study. Though all favored non-steroidal anti-inflammatory drugs (NSAIDs) for OA in dogs, concerns about adverse reactions, including ulcers and renal failure, emerged. CBD was widely known and was perceived positively for pain, inflammation, cancer, and epilepsy. However, half distinguished CBD from marijuana and tetrahydrocannabinol (THC). Ten expressed willingness to prescribe CBD for OA upon robust clinical evidence. Worries centered on product consistency and impurities. Many suggested CBD should be under veterinarians' supervision at first, but this can be relaxing once safety and efficacy are established. CBD products should be chewable tablets, oils, or gelatin capsules with flavors like beef, liver, pork, fish, or seafood.

Conclusion

Though CBD benefits were recognized, knowledge gaps among the participants persisted, warranting robust CBD safety, efficacy, and quality evidence to ensure Thai market success. Comprehensive education, including continuing education for those in practice and incorporating CBD-related topics into the Schools of Veterinary's curriculum, is recommended.

'What price do you put on your health?': Medical cannabis, financial toxicity and patient perspectives on medication access in advanced cancer

INTRODUCTION

Following 2016 legislation permitting limited access to cannabis for research and medicinal purposes, the number of randomized clinical trials (RCTs) investigating the effectiveness of medicinal cannabis (MC) on symptom burden relief in cancer contexts has increased in Australia. This study aimed to understand the perceptions, hopes and concerns of people with advanced cancer regarding the future availability and regulation of MC in Australia.

METHODS

This qualitative study draws on semistructured interviews conducted between February 2019 and October 2020 in Brisbane, Australia, as part of an MC RCT substudy. Interviews were undertaken on 48 patients with advanced cancer in palliative care eligible to participate in an MC trial (n = 26 participated in an RCT; n = 2 participated in a pilot study; n = 20 declined). Interviews included a discussion of patients' decision-making regarding trial participation, concerns about MC and perceptions of future availability, including cost. Transcribed interviews were analysed inductively and abductively, informed by constructivist thematic analysis conventions.

RESULTS

Overall, participants supported making MC legally accessible as a prescription-only medication. Fear of financial toxicity, however, compromised this pathway. Steep posttrial costs of accessing MC prompted several people to decline trial participation, and others to predict-if found effective-that many would either access MC through alternative pathways or reduce their prescribed dosage to enable affordable access.

CONCLUSIONS

These findings suggest that-despite a relatively robust universal healthcare system-Australians are potentially vulnerable to and fearful of financial toxicity. Prevalent in the United States, financial toxicity occurs when disadvantaged cancer patients access necessary but expensive medications with lasting consequences: bankruptcy, ongoing anxiety and cancer worry. Interview transcripts indicate that financial fears-and the systems sustaining them-may pose a threat to RCT completion and to equitable access to legal MC. Such findings support calls for embedding qualitative substudies and community partnerships within RCTs, while also suggesting the importance of subsidisation to overcoming injustices.

PATIENT OR PUBLIC CONTRIBUTION

A patient advisory committee informed RCT design. This qualitative substudy foregrounds patients' decision-making, perceptions and experiences.

Growing ganja permission: a real gate-way for Thailand's promising industrial crop?

The current revision to Thailand’s Narcotics Act (B.E. 2563) permits Thai corporations to produce cannabis (ganja) for therapeutic purposes, as well as conduct beneficial research and development in science and agriculture. While ganja possession, distribution, and use are still illegal in Thailand, the law removes certain elements of Cannabis sativa (including hemp) from the narcotic lists as of December 2020 and Thailand's narcotics board plans to remove them totally from the lists before the last quarter of 2022. The Thai Food and Drug Administration (Thai FDA) board maintains the exclusive licensing authority to assess applications and provide authorization due to the complexity of the registration process. In this view, we analyzed the guidelines for obtaining cannabis production license, and it was apparent that the announced law was in-line with regulations set-out by many countries in terms of security and prevention of misuse. The other criteria however fall merely onto the government gains, rather than public interests. To avoid the claimed state monopoly, several types of licensing should be issued in the future, depending on the genuine purpose of the farmers. The complete regulation process and conditions for obtaining a ganja growing license in Thailand are highlighted and discussed in this review.

International Association for the Study of Pain Presidential Task Force on Cannabis and Cannabinoid Analgesia: research agenda on the use of cannabinoids, cannabis, and cannabis-based medicines for pain management

ABSTRACT

The President of the International Association for the Study of Pain established a task force on cannabis and cannabinoid analgesia to systematically examine the evidence on (1) analgesic pharmacology of cannabinoids and preclinical evidence on their efficacy in animal models of injury-related or pathological persistent pain; (2) the clinical efficacy of cannabis, cannabinoids, and cannabis-based medicines for pain; (3) harms related to long-term use of cannabinoids; as well as (4) societal issues and policy implications related to the use of these compounds for pain management. Here, we summarize key knowledge gaps identified in the task force outputs and propose a research agenda for generating high-quality evidence on the topic. The systematic assessment of preclinical and clinical literature identified gaps in rigor of study design and reporting across the translational spectrum. We provide recommendations to improve the quality, rigor, transparency, and reproducibility of preclinical and clinical research on cannabis and cannabinoids for pain, as well as for the conduct of systematic reviews on the topic. Gaps related to comprehensive understanding of the endocannabinoid system and cannabinoid pharmacology, including pharmacokinetics and drug formulation aspects, are discussed. We outline key areas where high-quality clinical trials with cannabinoids are needed. Remaining important questions about long-term and short-term safety of cannabis and cannabinoids are emphasized. Finally, regulatory, societal, and policy challenges associated with medicinal and nonmedicinal use of cannabis are highlighted, with recommendations for improving patient safety and reducing societal harms in the context of pain management.