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

Cannabis use in Crohn's disease: a systematic review and meta-analysis of randomized controlled trials (RCTs)

OBJECTIVE

This meta-analysis aims to systematically evaluate the efficacy and safety of cannabis in the management of Crohn's disease (CD) by synthesizing evidence from randomized controlled trials (RCTs). By adhering to the 2020 PRISMA guidelines and registering the study protocol with PROSPERO, this research intends to offer robust, evidence-based recommendations for healthcare practitioners on the therapeutic potential and clinical implications of cannabis use in CD management.

METHODS

A literature search encompassing PubMed, Google Scholar, and the Cochrane Library was conducted to identify relevant RCTs comparing cannabis to placebo or standard therapy in CD patients. Inclusion criteria focused on outcomes such as remission rates, C-reactive protein (CRP) levels, quality of life (QoL), and adverse events (AEs). Statistical analysis using RevMan 5.3 involved weighted mean differences (MD) and 95% confidence intervals to compare outcomes between the cannabis and control groups.

RESULTS

The meta-analysis revealed significant findings regarding the impact of cannabis on CD management. The cannabis group exhibited significantly higher clinical remission rates at 8 weeks compared to the control group, with low heterogeneity [MD = - 67.98; 95% CI: (- 100.68, - 35.29)]. However, a statistically significant improvement in QoL was observed in the placebo group compared to the cannabis-treated group [MD = 19.62; 95% CI (14.24 to 25.00)]. There was a non-significant lowering in serum CRP levels compared to the placebo group [MD: - 0.51; 95% CI: (- 1.05, 0.02)].

CONCLUSION

The study concludes that cannabis shows promise as a therapeutic option for CD, demonstrating higher remission rates and potential benefits for disease management. However, it also highlights the need for larger, standardized research studies to solidify conclusions regarding efficacy, safety, and biomarker responses in CD patients.

The comparative effectiveness of medicinal cannabis for chronic pain versus prescription medication treatment

ABSTRACT

Reviews of the effectiveness of medicinal cannabis for chronic pain vary in their conclusions. IASP has identified that a key missing evidence in this debate is data from observational cohort studies, analyzed with comparative effectiveness methods. In a medically supervised context to the use of marijuana for chronic pain, we identified 440 patients certified for medical marijuana by pain specialists in a single healthcare system. They were characterized by a battery of patient-reported outcomes stored electronically in the University of Pittsburgh Patient Outcomes Repository for Treatment (PORT). At 3 months, 38.6% were responders, based on clinically meaningful improvements in pain, function, or global impression of change, and maintained this response at 6 months. In the 157 patients who were coprescribed opioids, at 6 months there was a mean 39.3% decrease in morphine milligram equivalents (P < 0.05 for the difference vs baseline). In addition, 8114 patients treated in the same pain clinics with prescription pain medications instead (nonopioid or opioid) during the same timeframe were selected from PORT as a control group for comparison. They had a 34.9% rate of response at 3 months. Using the causal inference method of stratified modeling, logistic regression revealed an odds ratio of 2.6 in favor of medical marijuana vs medication treatment (P < 0.01). Potential harms data were not available in the PORT registry. Medical marijuana was comparatively more effective than prescription medications for the treatment of chronic pain at 3 months, although the populations compared were slightly different.

A pain research strategy for Europe: A European survey and position paper of the European Pain Federation EFIC

BACKGROUND

Pain is the leading cause of disability and reduced quality of life worldwide. Despite the increasing burden for patients and healthcare systems, pain research remains underfunded and under focused. Having stakeholders identify and prioritize areas that need urgent attention in the field will help focus funding topics, reduce 'research waste', improve the effectiveness of pain research and therapy and promote the uptake of research evidence. In this study, the European Pain Federation (EFIC) developed a Pain Research Strategy for Europe.

METHODS

The study used multiple methods, including literature searches, multidisciplinary expert debate, a survey and a final consensus meeting. The cross-sectional survey was conducted among 628 European pain researchers, clinicians, educators and industry professionals to obtain the rating and hierarchy of pain research priorities. The final consensus meeting involved a multidisciplinary expert panel including people with lived experience from 23 countries. The survey results guided discussions where top priorities were agreed.

RESULTS

Content analysis identified nine survey themes, of which five emerged as top priorities: (i) understand the pathophysiology of pain; (ii) understand and address comorbidities; (iii) critically assess current therapies; (iv) develop new treatments; and (v) explore the biopsychosocial impacts of pain. Physical, psychological and social approaches were prioritized at the same level as pharmacological treatments. The top priorities were endorsed by a multidisciplinary expert panel. The panel emphasized the importance of also clearly communicating the concepts of prediction, prevention self-management and personalized pain management in the final strategy.

CONCLUSIONS

The content of the final top research priorities' list reflects a holistic approach to pain management. The equal importance given to physical, psychological and social aspects alongside pharmacological treatments highlights the importance of a comprehensive biopsychosocial-orientated research strategy. The expert panel's endorsement of five top priorities, coupled with an emphasis on communicating the concepts of prediction, prevention, self-management and personalized pain management, provides a clear direction for future basic, translational and clinical research.

SIGNIFICANCE

EFIC has developed a Pain Research Strategy for Europe that identifies pain research areas deserving the most focus and financial support. Implementation and wide dissemination of this Strategy is vital to increase the conduct of urgent pain projects, pain research funding and the implementation of research findings into practice, to ultimately decrease the personal, societal and financial burden of pain.

Perceived Risk of Medical Cannabis and Prescribed Cannabinoids for Chronic Pain: A Cross-Sectional Study Among Quebec Clinicians

Objective

An increase in medical cannabis and prescribed cannabinoids use for chronic pain management has been observed in Canada in the past years. This study aimed to: 1) Describe clinicians' perceived risk associated with the use of medical cannabis and prescribed cannabinoids for the management of chronic pain; and 2) Identify sociodemographic and professional factors associated with perceived risk of adverse effects.

Method

A web-based cross-sectional study was conducted in Quebec, Canada in 2022. A convenience sample of 207 clinicians was recruited (physicians/pharmacists/nurse practitioners). They were asked to rate the risk of adverse effects associated with medical cannabis (e.g., smoke, or oil) and prescribed cannabinoids (e.g., nabilone) on a scale of 0 to 10 (0: no risk, 10: very high risk), respectively. Multiple linear regression was performed to identify factors associated with perceived risk.

Results

Average perceived risk associated with medical cannabis and prescribed cannabinoids were 5.93 ± 2.08 (median:6/10) and 5.76 ± 1.81 (median:6/10). Factors associated with higher medical cannabis perceived risk were working in primary care (β = 1.38, p = .0034) or in another care setting (β = 1.21, p = .0368) as compared to a hospital setting. As for prescribed cannabinoids, being a pharmacist (β = 1.14, p = .0452), working in a primary care setting (β = 0.83, p = .0408) and reporting more continuing education about chronic pain (β = 0.02, p = .0416) were associated with higher perceived risk. No sex differences were found in terms of perceived risk.

Conclusions

Considering the clinician's experience provide insights on cannabis risk as these professionals are at the forefront of patient care when they encounter adverse effects.

Evidence for therapeutic use of cannabidiol for nail-patella syndrome-induced pain in a real-world pilot study

Nail-patella syndrome (NPS) is a rare genetic disease characterized by dysplastic nails, patella abnormalities, skeletal malformation, and chronic pain. Although chronic pain in NPS is mainly due to bone and musculoskeletal symptoms, it can also result from neurological dysfunction. Conventional analgesics are often insufficient to relieve NPS-associated chronic pain. Cannabinoids, which act on the serotonergic and/or noradrenergic pain systems, may therefore represent valuable non-psychoactive alternatives for managing pain in these patients. The effectiveness and safety of synthetic cannabidiol (CBD) for the management of NPS-associated pain was assessed using real-world data from a pilot cohort of patients with NPS who received a 3-month treatment with oral CBD. The treatment (median dose of 900 mg/day) was associated with a significant reduction in pain intensity (mean score of 7.04 ± 0.24 at initiation versus 4.04 ± 0.38 at 3 months, N = 28, p < 0.0001), which correlated with changes in the peripheral concentration of noradrenaline (r = 0.705, 95% CI [0.44-0.86], p < 0.0001). Health-related quality of life and other NPS-associated symptoms also improved in most patients. CBD treatment was well tolerated and no elevations in liver enzyme levels were reported. Synthetic CBD therefore appears to be a safe and effective treatment option for managing NPS-associated chronic pain.

Physiological profiling of cannabidiol reveals profound inhibition of sensory neurons

ABSTRACT

Cannabidiol (CBD), the main nonpsychoactive cannabinoid of cannabis, holds promise for nonaddictive treatment of pain. Although preclinical studies have been encouraging, well-controlled human trials have been largely unsuccessful. To investigate this dichotomy and better understand the actions of CBD, we used high-content calcium imaging with automated liquid handling and observed broad inhibition of neuronal activation by a host of ionotropic and metabotropic receptors, including transient receptor potential (Trp) and purinergic receptors, as well as mediators of intracellular calcium cycling. To assess the effect of CBD on overall nociceptor electrical activity, we combined the light-activated ion channel channelrhodposin in TRPV1-positive nociceptors and a red-shifted calcium indicator and found that 1 µM CBD profoundly increased the optical threshold for calcium flux activation. Experiments using traditional whole-cell patch-clamp showed increase of nociceptor activation threshold at submicromolar concentrations, but with unusually slow kinetics, as well as block of voltage-activated currents. To address a more integrated capacity of CBD to influence nociceptor sensitization, a process implicated in multiple pain states, we found that submicromolar concentrations of CBD inhibited sensitization by the chemotherapeutic drug vincristine. Taken together, these results demonstrate that CBD can reduce neuronal activity evoked by a strikingly wide range of stimuli implicated in pain signaling. The extensive effects underscore the need for further studies at substantially lower drug concentrations, which are more likely to reflect physiologically relevant mechanisms. The slow kinetics and block raise biophysical questions regarding the lipophilic properties of CBD and its action on channels and receptors within membranes.

Self-Medication Paths: A Descriptive Study Unveiling the Interplay Between Medical and Nonmedical Cannabis in Chronic Pain Management

OBJECTIVES

Cannabis is used by one-third of people living with chronic pain to alleviate their symptoms despite warnings from several organizations regarding its efficacy and safety. We currently know little about self-medication practices (use of cannabis for therapeutic purposes without guidance), mainly since the legalization of recreational cannabis in countries such as Canada has expanded the scope of this phenomenon. This study aimed to describe legal cannabis self-medication for pain relief in people living with chronic pain and to explore perceptions of the effectiveness and safety of cannabis.

METHODS

A cross-sectional descriptive study was performed among 73 individuals living with chronic pain and using cannabis (Quebec, Canada). Data collection using telephone interviews occurred in early 2023.

RESULTS

Results indicated that 61.6% of participants reported using cannabis without the guidance of a health care professional (self-medication). Surprisingly, among those, 40.0% held a medical authorization. Overall, 20.6% of study participants were using both medical and legal nonmedical cannabis. Different pathways to self-medication were revealed. Proportion of women versus men participants self-medicating were 58.2% versus 70.6% ( P =0.284). In terms of perceptions, 90.4% of the sample perceived cannabis to be effective for pain management; 72.6% estimated that it posed no or minimal health risk.

DISCUSSION

Cannabis research is often organized around medical versus nonmedical cannabis but in the real-world, those 2 vessels are connected. Interested parties, including researchers, health care professionals, and funding agencies, need to consider this. Patients using cannabis feel confident in the safety of cannabis, and many of them self-medicate, which calls for action.

The endocannabinoid system as a therapeutic target in neuropathic pain: a review

INTRODUCTION

This review highlights the critical role of the endocannabinoid system (ECS) in regulating neuropathic pain and explores the therapeutic potential of cannabinoids. Understanding the mechanisms of the ECS, including its receptors, endogenous ligands, and enzymatic routes, can lead to innovative treatments for chronic pain, offering more effective therapies for neuropathic conditions. This review bridges the gap between preclinical studies and clinical applications by emphasizing ECS modulation for better pain management outcomes.

AREAS COVERED

A review mapped the existing literature on neuropathic pain and the effects of modulating the ECS using natural and synthetic cannabinoids. This analysis examined ECS components and their alterations in neuropathic pain, highlighting the peripheral, spinal, and supraspinal mechanisms. This review aimed to provide a thorough understanding of the therapeutic potential of cannabinoids in the management of neuropathic pain.

EXPERT OPINION

Advances in cannabinoid research have shown significant potential for the management of chronic neuropathic pain. The study emphasizes the need for high-quality clinical trials and collaborative efforts among researchers, clinicians, and regulatory bodies to ensure safe and effective integration of cannabinoids into pain management protocols. Understanding the mechanisms and optimizing cannabinoid formulations and delivery methods are crucial for enhancing therapeutic outcomes.

The State of Synthetic Cannabinoid Medications for the Treatment of Pain

Synthetic cannabinoids are compounds made in the laboratory to structurally and functionally mimic phytocannabinoids from the Cannabis sativa L. plant, including delta-9-tetrahydrocannabinol (THC). Synthetic cannabinoids (SCs) can signal via the classical endogenous cannabinoid system (ECS) and the greater endocannabidiome network, highlighting their signalling complexity and far-reaching effects. Dronabinol and nabilone, which mimic THC signalling, have been approved by the Food and Drug Administration (FDA) for treating nausea associated with cancer chemotherapy and/or acquired immunodeficiency syndrome (AIDS). However, there is ongoing interest in these two drugs as potential analgesics for a variety of other clinical conditions, including neuropathic pain, spasticity-related pain, and nociplastic pain syndromes including fibromyalgia, osteoarthritis, and postoperative pain, among others. In this review, we highlight the signalling mechanisms of FDA-approved synthetic cannabinoids, discuss key clinical trials that investigate their analgesic potential, and illustrate challenges faced when bringing synthetic cannabinoids to the clinic.

Targeting the endocannabinoid system for the management of low back pain

Low back pain (LBP) is a major unmet clinical need. The endocannabinoid system (ECS) has emerged as a promising therapeutic target for pain, including LBP. This review examines the evidence for the ECS as a therapeutic target for LBP. While preclinical studies demonstrate the potential of the ECS as a viable therapeutic target, clinical trials have presented conflicting findings. This review underscores the need for innovative LBP treatments and biomarkers and proposes the ECS as a promising avenue for their exploration. A deeper mechanistic understanding of the ECS in LBP could inform the development of new pain management strategies.

Parental knowledge and attitude of postoperative paediatric pain: stepwise linear regression analysis

Background

Despite the fact that mothers care for their children's pain in most cases, it has been noted that mothers have limited knowledge and attitude about paediatric pain. This study aims to assess parental knowledge and attitude of postoperative paediatric pain (POPP).

Method

This is institutional based cross sectional study conducted with 102 parents at Nigist Eleni Mohamed Memorial Comprehensive Specialized Hospital (NEMMCSH). A convenience sampling technique was used to select parents. This study has used a questionnaire (Parental Pain Expression Perception (PPEM), examine parents' attitudes and knowledge about how their children exhibit their pain and Medication Attitude Questioner (MAQs), focuses on how parents feel about giving their child analgesic medication to alleviate post-operative pain). Descriptive statistics were utilized to analyse the parent's response and presented with frequency and percentage. Factor analysis to analyze factor structure and stepwise linear regression analysis to examine the impact of socio-demographic factors in predicting parental knowledge and attitude about POPP were done. The statistical tests were performed at 95% confidence interval and 5% significance level.

Result

A total of 102 parents fulfilling the inclusion criteria were included. About 78% of parents agreed that children always express pain by crying or whining. The majority of parents (75.6%) believe children who are playing are not in pain. Regarding parental attitudes about pain medications, majority of parents (61%) believe that children should be given pain medication as little as possible because of its side effects. According to about 26.8% of parents, giving children pain medication for pain might teach them to use drugs for other issues. On the other hand, 63.4% of parents say that giving children pain medication as little as possible is the most effective way to manage their pain. Parents of younger children and parents from rural area are more likely to score higher in attention seeking sub-score of PPEP while parents from urban residence and those parents who are employed are more likely to perceive about the side effects of pain medications (Side effects factors).

Conclusion

The overall knowledge and attitude of parents about postoperative pain and pain medications were poor.

Therapeutic use of medical Cannabis in neurological diseases: a clinical update

The use of medical Cannabis has increased in recent years due to changing legal circumstances in many countries. Approval exists only for a few neurological conditions such as rare forms of epilepsy or spasticity in multiple sclerosis. Beyond that, however, medical Cannabis is used for a wide range of neurological conditions and symptoms. In Germany, in parallel with new legislation that has simplified the prescription of medical Cannabis, an accompanying survey has been implemented for which initial data are now available. In this context, our review provides an overview of the evidence for the therapeutic use of medical Cannabis in neurology, the potential benefits, and side effects.

The Medication Quantification Scale 4.0: An Updated Index Based on Prescribers' Perceptions of the Risk Associated With Chronic Pain Medications

To quantify risks associated with drug utilization in the real world for the treatment of chronic pain (CP), an index called the Medication Quantification Scale (MQS) was developed in 1992 in the United States and last updated in 2003. This study aimed to update, adapt to the contemporary Canadian context, and validate a revised version of the MQS (the MQS-4.0). Step 1: An expert committee adapted the MQS to the Canadian clinical practice context. Step 2: An update of risk weights given to medication subclasses was achieved using a prescriber survey (weights were derived from median 0-10 scores given to each subclass). Step 3: Construct validity of the MQS-4.0 was assessed after applying risk weights to the medication use profile of persons living with CP covered by public drug insurance plan. Thirty-six medication subclasses were included in the MQS-4.0. A total of 207 prescribers (physicians, pharmacists, and nurse practitioners) participated in the perception survey; 10.63% identified as pain specialists. When risk weights were applied to prescription claims (n = 9,122), the MQS-4.0 score was associated (P < .05) with the MQS-III score and variables associated with polypharmacy (eg, Charlson Comorbidity Index, number of prescribers or health care visits). This study provides an updated index intended for adult populations based on prescribers' perceptions of the risk associated with CP medications that can be useful for clinical practice and research among persons living with CP in Canada. It will, however, be relevant to verify whether similar risk weights are obtained in future pain specialist surveys. PERSPECTIVE: The MQS-4.0 is an update of the MQS used for quantifying the risk associated with the use of analgesics/coanalgesics. Adequate psychometrics properties were found.

Legal and Regulatory Aspects of Medical Cannabis in the United States

Federal and state laws in the United States governing the use of cannabis are rapidly evolving. Under federal law, marijuana and its derivatives remain schedule I, defined as substances having no currently accepted medical use and a high potential for abuse. Hemp and its derivatives, in contrast, have been removed from schedule I. At the state level, a majority of states have passed laws legalizing cannabis in some form, although these laws vary from state to state in terms of the extent to which use is permitted, approved medical uses, and the types of regulation placed on commercial activity and quality control. This inconsistency has contributed to uncertainty among medical providers and their patients. In this review, we provide a brief account of the evolution and current state of federal and state laws and regulatory agencies involved in overseeing medical cannabis use in the United States.

Impact of Δ9-Tetrahydrocannabinol and oxycodone co-administration on measures of antinociception, dependence, circadian activity, and reward in mice

Oxycodone is commonly prescribed for moderate to severe pain disorders. While efficacious, long-term use can result in tolerance, physical dependence, and the development of opioid use disorder. Cannabis and its derivatives such as Δ9-Tetrahydrocannabinol (Δ9-THC) have been reported to enhance oxycodone analgesia in animal models and in humans. However, it remains unclear if Δ9-THC may facilitate unwanted aspects of oxycodone intake, such as tolerance, dependence, and reward at analgesic doses. This study sought to evaluate the impact of co-administration of Δ9-THC and oxycodone across behavioral measures related to antinociception, dependence, circadian activity, and reward in both male and female mice. Oxycodone and Δ9-THC produced dose-dependent antinociceptive effects in the hotplate assay that were similar between sexes. Repeated treatment (twice daily for 5 days) resulted in antinociceptive tolerance. Combination treatment of oxycodone and Δ9-THC produced a greater antinociceptive effect than either administered alone, and delayed the development of antinociceptive tolerance. Repeated treatment with oxycodone produced physical dependence and alterations in circadian activity, neither of which were exacerbated by co-treatment with Δ9-THC. Combination treatment of oxycodone and Δ9-THC produced CPP when co-administered at doses that did not produce preference when administered alone. These data indicate that Δ9-THC may facilitate oxycodone-induced antinociception without augmenting certain unwanted features of opioid intake (e.g. dependence, circadian rhythm alterations). However, our findings also indicate that Δ9-THC may facilitate rewarding properties of oxycodone at therapeutically relevant doses which warrant consideration when evaluating this combination for its potential therapeutic utility.

Cannabinoid CB1 Receptor Expression and Localization in the Dorsal Horn of Male and Female Rat and Human Spinal Cord

Background

Preclinical and clinical evidence suggests that cannabis has potential analgesic properties. However, cannabinoid receptor expression and localization within spinal cord pain processing circuits remain to be characterized across sex and species.

Aims

We aimed to investigate the differential expression of the cannabinoid type 1 (CB1) receptor across dorsal horn laminae and cell populations in male and female adult rats and humans.

Methods

To investigate and quantify CB1 receptor expression in the spinal dorsal horn across species, we refined immunohistochemical procedures for successful rat and human fixed tissue staining and confocal imaging. Immunohistochemical results were complemented with analysis of CB1 gene (CNR1) expression within rodent and human dorsal horn using single-cell/nuclei RNA sequencing data sets.

Results

We found that CB1 was preferentially localized to the neuropil within the superficial dorsal horn of both rats and humans, with CB1 somatic staining across dorsal horn laminae. CB1 receptor immunoreactivity was significantly higher in the superficial dorsal horn compared to the deeper dorsal horn laminae for both rats and humans, which was conserved across sex. Interestingly, we found that CB1 immunoreactivity was not primarily localized to peptidergic afferents in rats and humans and that CNR1 (CB1) but not CNR2 (CB2) was robustly expressed in dorsal horn neuron subpopulations of both rodents and humans.

Conclusions

The conserved preferential expression of CB1 receptors in the superficial dorsal horn in male and female rodents and humans has significant implications for understanding the roles of this cannabinoid receptor in spinal mechanisms of nociception and analgesia.

Beyond the study of pain: the evolving role of the International Association for the Study of Pain in global advocacy

ABSTRACT

Although founded on the basis of the study of pain, the International Association for the Study of Pain (IASP) has actively advocated for improving pain relief and access to pain management in a variety of ways. The Global Year was launched in 2004 and has continued with a different theme each year, and "Pain Awareness Month" is held every September. The Declaration of Montreal (2010) emphasized that access to pain management is a fundamental human right as a result from the IASP-hosted International Pain Summit. The IASP has continued to publish timely statements related to pain and pain management. The work of IASP on the 11th version of the International Classification of Disease has ensured that chronic pain is recognized as a disease in its own right, and the establishment of the Global Alliance of Partners for Pain Advocacy Task Force recognizes the importance of engaging people with lived experience of pain in accomplishing IASP's mission. The Working Group on Global Advocacy now spearheads IASP's global efforts in capacity building to ensure that pain advocacy activities will continue to grow.

The value of the International Association for the Study of Pain to developing countries

ABSTRACT

Since it was founded, the International Association for the Study of Pain (IASP) has been at the forefront of improving pain research, education, and effective pain management in both developed and developing countries. As IASP activities progressed, major differences between the practice of pain management, education, and research in developed countries compared with developing countries were identified. This led to areas of focus by IASP that included pain education to address poor knowledge of pain assessment and treatment, prioritization of pain management by governments and official national legislation and programs, and availability of pain treatments (especially potent analgesics). A few pioneering IASP members from developing countries in the early years encouraged more multidisciplinary professionals to join IASP and attend conferences. Inauguration of national and regional chapters was also encouraged, and regular continuing medical education programs were held, especially on topics from IASP conferences and global pain events. Many IASP chapters in developing countries have established collaborations with groups from developed countries, whereas IASP also implemented other innovative approaches including the developing countries working group, educational grants, pain camps, and multidisciplinary pain hubs with toolkits to develop pain experts for regions in the developing world. Thus, the influence of IASP in many developing countries has had a multiplier effect on the progress made in effective pain management, education, and research. Nonetheless, challenges remain and include better integration of pain management, education, and research in national health systems and academic programs for health professionals.

Pain Medications Used by Persons Living With Fibromyalgia: A Comparison Between the Profile of a Quebec Sample and Clinical Practice Guidelines

Background

Pharmacological management of fibromyalgia is complex. Chronic pain management is characterized by off-label prescribing and use, multimorbidity, and polypharmacy.

Aims

This study aimed to describe pain medications use and perceived risk among people living with fibromyalgia and compare this use to evidence-based recommendations.

Methods

Directive telephone interviews were conducted with 63 individuals self-reporting a diagnosis of fibromyalgia (Quebec, Canada). The questionnaire addressed specific questions about their pain and pharmacological treatments currently used for pain management (prescribed and over-the-counter). Collected data were compared to the Canadian Fibromyalgia Clinical Practice Guidelines and to evidence reports published by recognized organizations.

Results

Despite a lack of robust scientific evidence to support opioids use to manage pain in fibromyalgia, 33% of our sample reported using them. Nonsteroidal anti-inflammatory drugs were used by 54.0% of participants, although this medication is not recommended due to lack of efficacy. Tramadol, which is recommended, was used by 23.8% of participants. Among the medications strongly recommended, anticonvulsants were used by 36.5%, serotonin norepinephrine reuptake inhibitor antidepressants by 55.6%, and tricyclic antidepressants by 22.2%. Cannabinoids (17.5%) and medical cannabis (34.9%) use were also reported. For all of these medication subclasses, no differences were found between participants not reporting (n = 35) or reporting (n = 28) more than one pain diagnosis (P < 0.05). Medication subclasses considered most at risk of adverse effects by participants were the least used.

Conclusions

Results reveal discordance between evidence-based recommendations and medications use, which highlights the complexity of pharmacological treatment of fibromyalgia.

An answered call for aid? Cannabinoid clinical framework for the opioid epidemic

BACKGROUND

The opioid crisis continues in full force, as physicians and caregivers are desperate for resources to help patients with opioid use and chronic pain disorders find safer and more accessible non-opioid tools.

MAIN BODY

The purpose of this article is to review the current state of the opioid epidemic; the shifting picture of cannabinoids; and the research, policy, and current events that make opioid risk reduction an urgent public health challenge. The provided table contains an evidence-based clinical framework for the utilization of cannabinoids to treat patients with chronic pain who are dependent on opioids, seeking alternatives to opioids, and tapering opioids.

CONCLUSION

Based on a comprehensive review of the literature and epidemiological evidence to date, cannabinoids stand to be one of the most interesting, safe, and accessible tools available to attenuate the devastation resulting from the misuse and abuse of opioid narcotics. Considering the urgency of the opioid epidemic and broadening of cannabinoid accessibility amidst absent prescribing guidelines, the authors recommend use of this clinical framework in the contexts of both clinical research continuity and patient care.

Development of cannabis use disorder in medical cannabis users: A 9-month follow-up of a randomized clinical trial testing effects of medical cannabis card ownership

Background

Evidence for long-term effectiveness of commercial cannabis products used to treat medical symptoms is inconsistent, despite increasingly widespread use.

Objective

To prospectively evaluate the effects of using cannabis on self-reported symptoms of pain, insomnia, anxiety, depression, and cannabis use disorder (CUD) after 12 months of use.

Methods

This observational cohort study describes outcomes over 9 months following a 12-week randomized, waitlist-controlled trial (RCT: NCT03224468) in which adults (N = 163) who wished to use cannabis to alleviate insomnia, pain, depression, or anxiety symptoms were randomly assigned to obtain a medical marijuana card immediately (immediate card acquisition group) or to delay obtaining a card for 12 weeks delay (delayed card acquisition group). During the 9-month post-randomization period, all participants could use cannabis as they wished and choose their cannabis products, doses, and frequency of use. Insomnia, pain, depression, anxiety, and CUD symptoms were assessed over the 9-month post-randomization period.

Results

After 12 months of using cannabis for medical symptoms, 11.7% of all participants (n = 19), and 17.1% of those using cannabis daily or near-daily (n = 6) developed CUD. Frequency of cannabis use was positively correlated with pain severity and number of CUD symptoms, but not significantly associated with severity of self-reported insomnia, depression, or anxiety symptoms. Depression scores improved throughout the 9 months in all participants, regardless of cannabis use frequency.

Conclusions

Frequency of cannabis use was not associated with improved pain, anxiety, or depression symptoms but was associated with new-onset cannabis use disorder in a significant minority of participants. Daily or near-daily cannabis use appears to have little benefit for these symptoms after 12 months of use.

UK Medical Cannabis Registry: A Patient Evaluation

The UK Medical Cannabis Registry is the largest real world data platform for medical cannabis outcomes in the UK, providing insight into clinical outcomes and monitoring safety of this novel therapy. This study aims to assess the functionality and accessibility of the online data collection platform and patient priorities for future research. Descriptive statistics were used to analyze quantitative data. For open-ended questions an inductive thematic analysis was performed. 600 responses were recorded. 554 (92.3%) patients had used the platform. 272 (90.4%) patients believed it was easy to input medications. 52 (8.67%) patients recorded an adverse event with 38 (73.1%) finding it easy to record. 535 (96.6%) patients had completed health questionnaires with 490 (91.6%) patients finding this easy to do. 553 (92.2%) patients agreed that contributing to the registry would impact the medical care of future patients. 'Assessing the impact of medical cannabis on quality of life generally' was the top research priority for 357 (59.3%) patients. This study demonstrates that most enrolled patients found the platform easy to use and believed they were positively impacting future medical cannabis patient care. Future patient research priorities included assessment of quality of life and condition-specific outcomes.

Cannabis use and sleep quality in daily life: An electronic daily diary study of adults starting cannabis for health concerns

BACKGROUND

Real world patterns of cannabis use for health concerns are highly variable and rarely overseen by a physician. Pragmatic effectiveness studies with electronic daily diaries that capture person-specific patterns of cannabis use and health symptoms may help clarify risks and benefits.

METHODS

As part of a larger, randomized trial (NCT03224468), adults (N = 181) seeking cannabis for insomnia, pain, or anxiety or depressive symptoms were randomized to obtain a medical cannabis card immediately (MCC) or a waitlist control (WLC) and completed 12-weeks of daily web-based surveys on cannabis use and sleep, pain, and depressive symptoms.

RESULTS

Completion rates of daily surveys were moderate to high (median completed: 72 out of 90 days). Daily reports of cannabis use were consistent with monthly interview assessments and urinalysis. The MCC group increased cannabis use frequency in the 12 weeks following randomization, while WLC did not. Among the MCC group, self-reported sleep quality was significantly higher on cannabis use days, compared to nonuse days. The MCC group displayed long-term sleep improvements, consistent with increasing cannabis frequency. No improvements were found for pain or depressive symptoms.

CONCLUSION

Cannabis use is associated with same day improvements in self-reported sleep quality, but not pain or depressive symptoms, although sleep improvements occurred in the context of increased frequency of cannabis use, raising the risk for cannabis use disorder. Daily web-based assessments of cannabis appear valid and feasible in adults seeking cannabis for health concerns, providing a flexible, complementary method for future real-world effectiveness studies with expanded and objective measures.

Optimal Treatment with Cannabis Extracts Formulations Is Gained via Knowledge of Their Terpene Content and via Enrichment with Specifically Selected Monoterpenes and Monoterpenoids

Differences between therapeutic effects of medical cannabis inflorescences and those of their extracts are generally attributed to the differences in administration form and in the resultant pharmacokinetics. We hypothesized that difference may further extend to the composition of the actually consumed drug. Cannabinoid and terpene contents were compared between commercial cannabis inflorescences (n = 19) and decarboxylated extracts (n = 12), and between inflorescences and decarboxylated extracts produced from them (n = 10). While cannabinoid content was preserved in the extracts, a significant loss of terpenes was evident, mainly in the more volatile monoterpenes and monoterpenoids (representing a loss of about 90%). This loss changes the total terpene content, the proportion of monoterpenes out of the total terpenes, and the monoterpene/cannabinoid ratio. Terpene deficiency might impair extracts’ pharmacological efficacy and might contribute to the patients’ preference to inflorescences-smoking. This argues against the validity of terms such as “whole plant” and “full spectrum” extracts and creates a misleading assumption that extracts represent the pharmacological profile of the sourced inflorescences. Furthermore, it reduces the diversity in extracts, such as loss of differences between sativa-type and indica-type. Enriching cannabis extracts with selected terpenes may provide a suitable solution, generating a safe, precise, and reproducible drug with tailored cannabinoid and terpene contents. Careful selection of terpenes to be added enables tailor-made extracts, adjusted for various medicinal aims and for different populations.

Cannabis-Based Medicines and Medical Cannabis for Chronic Neuropathic Pain

Neuropathic pain represents a broad category of pain syndromes that include a wide variety of peripheral and central disorders. The overall prevalence of neuropathic pain in the general population is reported to be between 7 and 10%. Management of neuropathic pain presents an unmet clinical need, with less than 50% of patients achieving substantial pain relief with medications currently recommended such as pregabalin, gabapentin, duloxetine and various tricyclic antidepressants. It has been suggested that cannabis-based medicines (CbMs) and medical cannabis (MC) may be a treatment option for those with chronic neuropathic pain. CbMs/MC are available in different forms: licensed medications or medical products (plant-derived and/or synthetic products such as tetrahydrocannabinol or cannabidiol); magistral preparations of cannabis plant derivatives with defined molecular content such as dronabinol (tetrahydrocannabinol); and herbal cannabis with a defined content of tetrahydrocannabinol and/or cannabidiol, together with other active ingredients (phytocannabinoids other than cannabidiol/tetrahydrocannabinol, terpenes and flavonoids). The availability of different types of CbMs/MC varies between countries worldwide. Systematic reviews of available randomised controlled trials have stated low-quality evidence for CbMs and MC for chronic neuropathic pain. Depending on the studies included in the various quantitative syntheses, authors have reached divergent conclusions on the efficacy of CbMs/MC for chronic neuropathic pain (from not effective to a clinically meaningful benefit). Clinically relevant side effects of CbMs/MC, especially for central nervous system and psychiatric disorders, have been reported by some systematic reviews. Recommendations for the use of CbMs/MC for chronic neuropathic pain by various medical associations also differ, from negative recommendations, no recommendation possible, recommended as third-line therapy, or recommended as an alternative in selected cases failing standard therapies within a multimodal concept. After reading this paper, readers are invited to formulate their own conclusions regarding the potential benefits and harms of CbMs/MC for the treatment of chronic neuropathic pain.

Cannabidiol treatment in hand osteoarthritis and psoriatic arthritis: a randomized, double-blind placebo-controlled trial

ABSTRACT

Cannabidiol (CBD) is increasingly used as analgesic medication even though the recent International Association for the Study of Pain presidential task force on cannabis and cannabinoid analgesia found a lack of trials examining CBD for pain management. The present trial examines CBD as add on analgesic therapy in patients with hand osteoarthritis or psoriatic arthritis experiencing moderate pain intensity despite therapy. Using a randomized double-blind, placebo-controlled design, patients received synthetic CBD 20-30mg or placebo daily for 12 weeks. Primary outcome was pain intensity during the last 24 hours (0-100mm); safety outcomes were percentage of patients experiencing adverse events and a characterization of serious adverse events. Explorative outcomes included change in Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), Pain Catastrophizing Scale (PCS) and Health Assessment Questionnaire (HAQ-DI).One hundred and thirty-six patients were randomized 129 were included in the primary analysis. Between group difference in pain intensity at 12 weeks was 0.23mm (95%CI -9.41 to 9.90; p = 0.96). 22% patients receiving CBD and 21% receiving placebo experienced a reduction in pain intensity of more than 30mm. We found neither clinically nor statistically significant effect of CBD for pain intensity in patients with hand osteoarthritis and psoriatic arthritis when compared to placebo. Additionally, no statistically significant effects were found on sleep quality, depression, anxiety, or pain catastrophizing scores.