Benefits and harms of medical cannabis: a scoping review of systematic reviews

Use of cannabinoids for acute postoperative pain

Doubts about the efficacy of medicinal cannabis in the treatment of acute postoperative pain are well justified, at least in light of the information gathered from Google Scholar, Clinical Trials, PubMed, and Cochrane databases.The conflation of cannabis and cannabinoids engenders not only normative but also medical implications. Despite cannabinoids having evinced their efficacy in the treatment of various pathologies, they have yet to demonstrate such in the context of acute postoperative pain. The burgeoning corpus of research on this subject does instill a modicum of hope in this regard; nevertheless, the manifold methodological approaches employed obfuscate the prospect of reaching unequivocal conclusions.Given the current status of this matter, this article abstains from making a definitive pronouncement either in favor of or against the role of pharmaceuticals incorporating cannabinoid compounds in the management of acute postoperative pain.

Clinical outcome analysis of patients with multiple sclerosis - Analysis from the UK Medical Cannabis Registry

INTRODUCTION

Whilst disease-modifying therapies are the cornerstone for treatment of multiple sclerosis (MS), there is a need to develop novel therapeutics for the symptomatic sequalae of the disease. Cannabis-based medicinal products (CBMPs) have been suggested as a potential therapy for the associated pain, spasticity, and mental health disorders. However, there is a paucity of clinical evidence on CBMPs in MS. The aim of this study is to assess changes in MS-specific and general health-related quality of life (HRQoL) outcomes alongside adverse event incidence in patients prescribed CBMPs for MS from the UK Medical Cannabis Registry (UKMCR).

METHOD

Patients prescribed CBMPs for MS symptoms for longer than one month were identified from the UKMCR. The primary outcomes were changes from baseline in MS Quality of Life-54 (MSQoL-54), Generalised Anxiety Disorder-7 (GAD-7), Single-Item Sleep Quality Scale (SQS), and EQ-5D-5L scales at one month, three months and six months. p < 0.050 was defined as statistically significant.

RESULTS

141 patients met the inclusion criteria for the study. There was an improvement in the following subscales of the MSQoL-54 at 6 months: change in health scale, cognitive function, mental health composition, physical health, role limitations due to physical limitation and due to emotional problems, as well as social and sexual function (p < 0.050). There were also improvements in the EQ-5D-5L index value, GAD-7 and SQS (p < 0.050). 146 (103.55 %) adverse events were reported in total. Most were considered mild (n = 47; 33.33 %) and moderate (n = 72; 51.06 %).

CONCLUSIONS

This preliminary analysis demonstrates a possible association with improved general health-related quality of life in those prescribed CBMPs for MS. Moreover, the results suggest that CBMPs are well-tolerated in the first 6 months of treatment. However, this must be interpreted with caution considering the limitations of the observational study design.

Cannabis use in liver transplant candidates and recipients

The increasing legality and acceptance of cannabis sale and consumption across the United States has led to a measurable increase in cannabis use nationwide, including in liver transplant (LT) candidates and recipients. With over 75% of liver transplant recipients transplanted in states with legalized use of medicinal and/or recreational cannabis, liver transplant clinicians must have expertise in the assessment of cannabis use given its potential impact on clinical care. In this review, the authors provide an understanding of nomenclature and tools to assess cannabis use, highlight essential components to guide clinical policy development and implementation, and discuss the potential impacts of cannabis use on patients' transplant course.

Potential Anti-Tumorigenic Properties of Diverse Medicinal Plants against the Majority of Common Types of Cancer

Globally, cancer is one of the primary causes of both morbidity and mortality. To prevent cancer from getting worse, more targeted and efficient treatment plans must be developed immediately. Recent research has demonstrated the benefits of natural products for several illnesses, and these products have played a significant role in the development of novel treatments whose bioactive components serve as both chemotherapeutic and chemo-preventive agents. Phytochemicals are naturally occurring molecules obtained from plants that have potential applications in both cancer therapy and the development of new medications. These phytochemicals function by regulating the molecular pathways connected to the onset and progression of cancer. Among the specific methods are immune system control, inducing cell cycle arrest and apoptosis, preventing proliferation, raising antioxidant status, and inactivating carcinogens. A thorough literature review was conducted using Google Scholar, PubMed, Scopus, Google Patent, Patent Scope, and US Patent to obtain the data. To provide an overview of the anticancer effects of several medicinal plants, including Annona muricata, Arctium lappa, Arum palaestinum, Cannabis sativa, Catharanthus roseus, Curcuma longa, Glycyrrhiza glabra, Hibiscus, Kalanchoe blossfeldiana, Moringa oleifera, Nerium oleander, Silybum marianum, Taraxacum officinale, Urtica dioica, Withania somnifera L., their availability, classification, active components, pharmacological activities, signaling mechanisms, and potential side effects against the most common cancer types were explored.

Public Knowledge, Perceptions, and Behavioral Intention Regarding Medical Cannabis in Belgium

Growing evidence on medical cannabis has moved its legislation forward in various countries, which has increased research on stakeholder reactions. While various studies looked at experts and users, research on public perceptions is scarce. This study aims to (1) examine the relationships between knowledge, perceptions, and behavioral intention toward medical cannabis, and (2) identify and profile key segments within the general public. An online survey was conducted among 656 respondents in Belgium. Findings showed that both subjective and objective knowledge are relatively poor, while risk/benefit perceptions and behavioral intention are much more positive. Subjective and objective knowledge as well as social trust have a positive influence on benefit perceptions and a negative influence on risk perceptions. In turn, risk and benefit perceptions are key determinants of behavioral intention, but in opposite directions. Furthermore, cluster analysis identified a cautious (23% of the sample), positive (50%), and enthusiastic cluster (27%). In terms of socio-demographic profile, older and highly educated people were significantly more represented in the latter two clusters. While our study demonstrated that cannabis is well accepted for medical purposes, research is needed to further validate the relationships between knowledge, perceptions, and (intended) behavior in different settings and policy contexts.

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.

Planting the seeds for success: A qualitative study exploring primary healthcare providers' perceptions about medical cannabis

BACKGROUND

In Canada, cannabis legalization altered the way that the public can access cannabis for medical purposes. However, Canadians still struggle with finding healthcare professionals (HCPs) who are involved in medical cannabis counselling and authorization. This raises questions about the barriers that are causing this breakdown in care. Our study explored the perceptions of primary care providers regarding cannabis in their practice.

METHODS

Semi-structured interviews were conducted by Zoom with HCPs in Newfoundland and Labrador (NL) to discuss their experiences with medical and non-medical cannabis in practice. Family physicians and nurse practitioners who were practicing in primary care in NL were included. The interview guide and coding template were developed using the Theoretical Domains Framework (TDF). A thematic analysis across the TDF was then conducted.

RESULTS

Twelve participants with diverse demographic backgrounds and experience levels were interviewed. Five main themes emerged including, knowledge acquisition, internal influences, patient influences, external HCP influences, and systemic influences. The TDF domain resulting in the greatest representation of codes was environmental context and resources.

INTERPRETATION

The findings suggested that HCPs have significant knowledge gaps in authorizing medical cannabis, which limited their practice competence and confidence in this area. Referring patients to cannabis clinics, while enforcing harm-reduction strategies, was an interim option for patients to access cannabis for medical purposes. However, developing practice guidelines and educational resources were suggested as prominent facilitators to promote medical cannabis authorization within the healthcare system.

Cannabis Use Disorder Trends and Health Care Utilization After Cervical and Lumbar Spine Fusions

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

To identify differences in complication rates after cervical and lumbar fusion over the first postoperative year between those with and without cannabis use disorder (CUD) and to assess how CUD affects opioid prescription patterns.

SUMMARY OF BACKGROUND DATA

Cannabis is legal for medical purposes in 36 states and for recreational use in 18 states. Cannabis has multisystem effects and may contribute to transient vasoconstrictive, prothrombotic, and inflammatory effects.

METHODS

The IBM MarketScan Database (2009-2019) was used to identify patients who underwent cervical or lumbar fusions, with or without CUD. Exact match hospitalization and postdischarge outcomes were analyzed at index, six, and 12 months.

RESULTS

Of 72,024 cervical fusion (2.0% with CUD) and 105,612 lumbar fusion patients (1.5% with CUD), individuals with CUD were more likely to be young males with higher Elixhauser index. The cervical CUD group had increased neurological complications (3% vs. 2%) and sepsis (1% vs. 0%) during the index hospitalization and neurological (7% vs. 5%) and wound complications (5% vs. 3%) at 12 months. The lumbar CUD group had increased wound (8% vs. 5%) and myocardial infarction (MI) (2% vs. 1%) complications at six months and at 12 months. For those with cervical myelopathy, increased risk of pulmonary complications was observed with CUD at index hospitalization and 12-month follow-up. For those with lumbar stenosis, cardiac complications and MI were associated with CUD at index hospitalization and 12 months. CUD was associated with opiate use disorder, decreasing postoperatively.

CONCLUSIONS

No differences in reoperation rates were observed for CUD groups undergoing cervical or lumbar fusion. CUD was associated with an increased risk of stroke for the cervical fusion cohort and cardiac (including MI) and pulmonary complications for lumbar fusion at index hospitalization and six and 12 months postoperatively. Opiate use disorder and decreased opiate dependence after surgery also correlated with CUD.

The role of stigma in cannabis use disclosure: an exploratory study

BACKGROUND

Although cannabis use incidence, societal acceptance, and legislation all trend positively, cannabis remains federally illegal in the USA. Prior studies have revealed that patients are reluctant to disclose their cannabis use history in the healthcare system, which can negatively impact patient care. This study reports the frequency of cannabis use disclosure with special considerations for stigmatization. To better understand the limitations, providers face in providing collaborative, comprehensive, and informed care, this study evaluated four domains of stigma: perceived, anticipated, enacted, and internalized.

METHODS

This study used a descriptive exploratory design. Data collection occurred using an anonymous, online national survey with a convenience sample in the USA. Recruitment relied on electronic media and occurred between July and December 2022. Participants were adults older than 21 years and self-identified as having used cannabis and accessed the healthcare system within the last five years. The survey measured demographic characteristics, cannabis use, and disclosure patterns. Stigma was measured using the Stigma Use Stigma Mechanism Scale (SU-SMS) and Substance Abuse Use Self-Stigma Scale (SASSS) with language modifications for cannabis. Ordinal logistic regression models were performed to evaluate associations between the frequency of cannabis use disclosure patterns and each stigma category. Associations were assessed using Chi-squared or Fisher's exact tests.

RESULTS

Data were available for 249 respondents. Most participants (57.1%) reported initiating a conversation about cannabis with their healthcare provider; 27.8% of the time, cannabis is never discussed, and healthcare providers initiate only 15.1% of related discussions. Anticipated stigma [95% CI 1.045-1.164] and total stigma [95% CI 1.001-1.039] had statistically significant associations with nondisclosure. Annual household income (p = .04), chronicity of cannabis use (p = .03), frequency of cannabis use (p = .02), and a known amount of CBD in products consumed (p = .01) had statistically significant associations with the frequency of cannabis use disclosure.

CONCLUSIONS

Patients who use cannabis experience stigmatization in the healthcare setting that may limit disclosure of cannabis use history. Future studies would be well served to explore anticipated stigma more deeply. Healthcare providers should be knowledgeable to lead such conversations relating to cannabis while maintaining an unbiased perspective.

Cannabis use disorder and adverse cardiovascular outcomes: A population-based retrospective cohort analysis of adults from Alberta, Canada

AIM

To measure the association between cannabis use disorder (CUD) and adverse cardiovascular disease (CVD) outcomes.

DESIGN AND SETTING

We conducted a matched, population-based retrospective cohort study involving five linked administrative health databases from Alberta, Canada.

PARTICIPANTS

We identified participants with CUD diagnosis codes and matched them to participants without CUD codes by gender, year of birth and time of presentation to the health system. We included 29 764 pairs (n = 59 528 individuals in total).

MEASUREMENTS

CVD events were defined by at least one incident diagnostic code within the study period (1 January 2012-31 December 2019). Covariates included comorbidity, socio-economic status, prescription medication use and health service use. Using mortality-censored Poisson regression models, we computed survival analyses for time to incident CVD stratified by CUD status. In addition, we calculated crude and stratified risk ratios (RRs) across various covariates using the Mantel-Haenszel technique.

FINDINGS

The overall prevalence of documented CUD was 0.8%. Approximately 2.4% and 1.5% of participants in the CUD and unexposed groups experienced an incident adverse CVD event (RR = 1.57; 95% confidence interval = 1.40-1.77). CUD was significantly associated with reduced time to incident CVD event. Individuals who appeared to have greater RRs for incident CVD were those without mental health comorbidity, who had not used health-care services in the previous 6 months, who were not on prescription medications and who did not have comorbid conditions.

CONCLUSIONS

Canadian adults with cannabis use disorder appear to have an approximately 60% higher risk of experiencing incident adverse cardiovascular disease events than those without cannabis use disorder.

Perceptions, Attitudes, and Knowledge of Cannabis and its Use: A Qualitative Study among Herbal Heart Study Young Adult Cannabis Consumers in South Florida

Growing cannabis use among young adults in the United States surpasses research and public understanding, raising health concerns despite potential benefits. Limited research focuses on their knowledge, attitudes, risks, and motivations, especially in states with limited legalization. This study explores cannabis knowledge and attitudes among healthy young adult cannabis consumers to understand their risk and benefit perceptions. Data include a subsample of participants in the Herbal Heart Study, a cohort to examine subclinical cardiovascular risk among healthy young adult (18-35 years old) cannabis consumers and non-consumers. A qualitative thematic analysis of the interviews was performed using a deductive approach driven by the theory of the Health Belief Model to generate categories and codes. Dedoose was used to organize transcripts and coding. A total of 22 young adult cannabis consumers (M age = 25.3, SD = 4.4) were interviewed between May 5, 2021- September 23, 2022. Participants were predominantly female (n = 13) and Hispanic (n = 9) or non-Hispanic Black (n = 7). Five themes were identified: perceived health benefits and risks associated with cannabis use, motivation for cannabis use, knowledge of cannabis, and perceived barriers to cannabis use. Participants discussed knowledge, positive/negative attitudes toward cannabis, and perceived risks/benefits based on personal experience and gathered information. Some showed knowledge deficits, and most wanted more health-related cannabis research. Given the current climate of rising cannabis legalization, availability of novel cannabis products, and societal acceptance, further research and evidence-based cannabis literacy for young adults are essential to keep pace with liberalization trends.

What is the hype on #MedicinalCannabis in the United States? A content analysis of medicinal cannabis tweets

INTRODUCTION

Medicinal cannabis is now legal in 44 US jurisdictions. Between 2020 and 2021 alone, four US jurisdictions legalised medicinal cannabis. The aim of this study is to identify themes in medicinal cannabis tweets from US jurisdictions with different legal statuses of cannabis from January to June 2021.

METHODS

A total of 25,099 historical tweets from 51 US jurisdictions were collected using Python. Content analysis was performed on a random sample of tweets accounting for the population size of each US jurisdictions (n = 750). Results were presented separately by tweets posted from jurisdictions where all cannabis use (non-medicinal and medicinal) is 'fully legalised', 'illegal' and legal for 'medical-only' use.

RESULTS

Four themes were identified: 'Policy', 'Therapeutic value', 'Sales and industry opportunities' and 'Adverse effects'. Most of the tweets were posted by the public. The most common theme was related to 'Policy' (32.5%-61.5% of the tweets). Tweets on 'Therapeutic value' were prevalent in all jurisdictions and accounted for 23.8%-32.1% of the tweets. Sales and promotional activities were prominent even in illegal jurisdictions (12.1%-26.5% of the tweets). Fewer than 10% of tweets were about intoxication and withdrawal symptoms.

DISCUSSION AND CONCLUSION

This study has explored if content themes of medicinal cannabis tweets differed by cannabis legal status. Most tweets were pro-cannabis and they were related to policy, therapeutic value, and sales and industry opportunities. Tweets on unsubstantiated health claims, adverse effects and crime warrants continued surveillance as these conversations could allow us to estimate cannabis-related harms to inform health surveillance.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Examining the Association between Medical Marijuana Legalization and Criminal Behaviors: Evidence from a U.S. Representative Sample

Background: Medical marijuana legalization (MML) has been widely implemented in the past decade. However, the debates regarding the consequences of MML persist, especially criminal behaviors. Objectives: We examined the association between MML and criminal behaviors among adults in the United States. The criminal behaviors measured three past-year offenses: whether the adult (1) have sold illegal drugs, (2) have stolen anything worth > $50 USD, or (3) have attacked someone. Methods: Using the 2015-2020 National Survey of Drug Use and Health, we included 214,505 adults in our primary analysis for 2015-2019 and 27,170 adults in 2020 for supplemental analysis (age > = 18). Weighted multivariable logistic regression models were used to examine the association between MML and three criminal behaviors. Results: In our primary analysis, we observed no statistically significant association between MML and the three outcomes of criminal behavior. Nevertheless, our supplemental analysis of the 2020 data showed MML was associated with increasing odds of the three criminal behaviors (have sold illegal drugs: AOR [adjusted odds ratio] = 1.7; have stolen anything worth > $50 USD: AOR = 1.9; have attacked someone: AOR = 1.8; all p < 0.05). Conclusion: Surveys from 2015 to 2019 did not suggest MML as a risk factor for higher incidence of criminal behaviors. However, 2020 data showed statistically significant association between MML and selected criminal behaviors. Issues related to the COVID-19 pandemic, such as the U.S. economic downturn, could potentially explain this discrepancy. Further research efforts may be warranted.

Legalization of marijuana or not? Opinions from over 38,000 residents in Taiwan

BACKGROUND

Marijuana is legal in many Western countries and Thailand. In Taiwan, Marijuana remains a category-2 narcotic; however, some legislative candidates recently advocated legalization of medical marijuana. This study surveyed a large sample of Taiwanese to gain a better understanding of the public's knowledge and attitudes towards legalizing marijuana.

METHODS

This cross-sectional mixed-methods study included demographic data and responses to a survey questionnaire, "Knowledge and Attitudes of Legalizing Marijuana" (KALM). The survey included 15 statements about four categories: public health, social impact, medical applications of THC (Δ9-tetrahydrocannabinol), and legal and tax consequences; and two yes/no questions about medical use and legalization of marijuana. Knowledge was scored as disagree = 0, no knowledge = 2, or agree = 4; attitude was scored from 0 = very unimportant to 4 = very important. Responses to an open-ended question asking for additional comments/concerns were analysed with content analysis. The survey was conducted from February 15 to March 1, 2023.

RESULTS

Data were analysed from 38,502 respondents, aged 15 to > 56 years. Most were female (67.1%) and parents (76.4%). Scores were higher for respondents who were parents, religious, ≥ 36 years of age, had a high-income status, no history of substance abuse, knowledge of medical marijuana, and did not support legalization of marijuana. Medical personnel had greater knowledge of marijuana, but their attitude indicated they viewed legalization as less important. In the open-ended question, many respondents requested more information about marijuana be provided to the public before considering legalization.

CONCLUSIONS

Taiwanese respondents considered legalization of marijuana a significant concern, especially as it relates to impacts on public health.

A Pragmatic, Person-Centered View of Cannabis in the United States: Pursuing Care That Transcends Beliefs

BACKGROUND

Rates of cannabis use are increasing in the United States, likely as a result of changes in societal attitudes and expanding legalization. Although many patients report wanting to discuss the risks and benefits of cannabis use with their clinical providers, many providers hold conflicting beliefs regarding cannabis use and often do not engage patients in discussion about cannabis. This dilemma is underscored by the limitations imposed on cannabis related research, and lack of empirically based best-practice guidelines for clinicians when addressing cannabis use with patients.

OBJECTIVES

We aimed to briefly summarize clinician and patient attitudes toward cannabis use and review current clinical guidelines and provide suggestions to assist health care providers and clinicians in increasing their comfort and skill in discussing cannabis use with patients.

METHODS

A narrative review on attitudes toward cannabis use and clinical guidelines was performed to summarize the literature and provide evidence-based recommendations.

RESULTS

Attitudes toward cannabis use have been shaped by personal and political factors and contribute to clinician hesitance in speaking with patients about the topic. Administrative barriers have hindered the development of clearer public health guidelines that might enable the dissemination of evidence-based information on the health effects of cannabis use and might ultimately lead to better health outcomes.

CONCLUSION

Not discussing cannabis use with patients may be a crucial missed opportunity for harm reduction. In the absence of empirically supported best-practice guidelines, a person-centered approach can facilitate conversations on the harms and benefits of cannabis use.

Perceptions of Safety of Daily Cannabis vs Tobacco Smoking and Secondhand Smoke Exposure, 2017-2021

Importance

While rates of cigarette use are declining, more US adults are using cannabis. Perceptions of safety are important drivers of substance use and public policy; however, little is known about the comparative views of US adults on tobacco and cannabis safety.

Objective

To compare public perceptions of safety of cannabis vs tobacco smoke and evaluate how perceptions may be changing over time.

Design, Setting, and Participants

This longitudinal survey study was conducted using a web-based survey administered in 2017, 2020, and 2021. US adults participating in Ipsos KnowledgePanel, a nationally representative, population-based survey panel, were included. Data were analyzed from March 2021 through June 2023.

Main Outcomes and Measures

Two questions directly compared the perception of safety of cannabis vs tobacco in terms of daily smoking and secondhand smoke exposure. Additional questions assessed perceptions of safety of secondhand tobacco smoke for adults, children, and pregnant women, with an analogous set of questions for secondhand cannabis smoke.

Results

A total of 5035 participants (mean [SD] age, 53.4 [16.2] years; 2551 males [50.7%]) completed all 3 surveys and provided responses for tobacco and cannabis risk questions. More than one-third of participants felt that daily smoking of cannabis was safer than tobacco, and their views increasingly favored safety of cannabis vs tobacco over time (1742 participants [36.7%] in 2017 vs 2107 participants [44.3%] in 2021; P < .001). The pattern was similar for secondhand cannabis smoke, with 1668 participants (35.1%) responding that cannabis was safer than tobacco in 2017 vs 1908 participants (40.2%) in 2021 (P < .001). Participants who were younger (adjusted odds ratio [aOR] for ages 18-29 years vs ≥60 years, 1.4 [95% CI, 1.1-1.8]; P = .01) or not married (aOR, 1.2 [95% CI, 1.0-1.4]; P = .01) were more likely to move toward safer views of cannabis use over time, while those who were retired (aOR vs working, 0.8 [95% CI, 0.7-0.9]; P = .01) were less likely to move toward a safer view of cannabis. Participants were also more likely to rate secondhand smoke exposure to cannabis vs tobacco as completely or somewhat safe in adults (629 participants [12.6%] vs. 119 participants [2.4%]; P < .001), children (238 participants [4.8%] vs. 90 participants [1.8%]; P < .001), and pregnant women (264 participants [5.3%] vs. 69 participants [1.4%]; P < .001).

Conclusions and Relevance

This study found that US adults increasingly perceived daily smoking and secondhand exposure to cannabis smoke as safer than tobacco smoke from 2017 to 2021. Given that these views do not reflect the existing science on cannabis and tobacco smoke, the findings may have important implications for public health and policy as the legalization and use of cannabis increase.

Challenges and considerations for treating PTSD with medicinal cannabis: the Australian clinician's perspective

INTRODUCTION

Preclinical and experimental research have provided promising evidence that medicinal cannabis may be efficacious in the treatment of posttraumatic stress disorder (PTSD). However, implementation of medicinal cannabis into routine clinical therapies may not be straightforward.

AREAS COVERED

In this review, we describe some of the clinical, practical, and safety challenges that must be addressed for cannabis-based treatment of PTSD to be feasible in a real-world setting. These issues are especially prevalent if medicinal cannabis is to be combined with trauma-focused psychotherapy.

EXPERT OPINION

Future consideration of the clinical and practical considerations of cannabis use in PTSD therapy will be essential to both the efficacy and safety of the treatment protocols that are being developed. These issues include dose timing and titration, potential for addiction, product formulation, windows of intervention, and route of administration. In particular, exposure therapy for PTSD involves recall of intense emotions, and the interaction between cannabis use and reliving of trauma memories must be explored in terms of patient safety and impact on therapeutic outcomes.

Cannabidiol-rich non-psychotropic Cannabis sativa L. oils attenuate peripheral neuropathy symptoms by regulation of CB2-mediated microglial neuroinflammation

Neuropathic pain (NP) is a chronic disease that affects the normal quality of life of patients. To date, the therapies available are only symptomatic and they are unable to reduce the progression of the disease. Many studies reported the efficacy of Cannabis sativa L. (C. sativa) on NP, but no Δ9 -tetrahydrocannabinol (Δ9 -THC)-free extracts have been investigated in detail for this activity so far. The principal aim of this work is to investigate the potential pain-relieving effect of innovative cannabidiol-rich non-psychotropic C. sativa oils, with a high content of terpenes (K2), compared to the same extract devoid of terpenes (K1). Oral administration of K2 (25 mg kg-1 ) induced a rapid and long-lasting relief of pain hypersensitivity in a mice model of peripheral neuropathy. In spinal cord samples, K2 reduced mitogen-activated protein kinase (MAPKs) levels and neuroinflammatory factors. These effects were reverted by the administration of a CB2 antagonist (AM630), but not by a CB1 antagonist (AM251). Conversely, K1 showed a lower efficacy in the absence of CB1/CB2-mediated mechanisms. In LPS-stimulated murine microglial cells (BV2), K2 reduced microglia pro-inflammatory phenotype through the downregulation of histone deacetylase 1 (HDAC-1) and nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor (IKBα) and increased interleukin-10 (IL-10) expression, an important antiinflammatory cytokine. In conclusion, these results suggested that K2 oral administration attenuated NP symptoms by reducing spinal neuroinflammation and underline the important role of the synergism between cannabinoids and terpenes.

Antitumor Effects of Cannabis sativa Bioactive Compounds on Colorectal Carcinogenesis

Cannabis sativa is a multipurpose plant that has been used in medicine for centuries. Recently, considerable research has focused on the bioactive compounds of this plant, particularly cannabinoids and terpenes. Among other properties, these compounds exhibit antitumor effects in several cancer types, including colorectal cancer (CRC). Cannabinoids show positive effects in the treatment of CRC by inducing apoptosis, proliferation, metastasis, inflammation, angiogenesis, oxidative stress, and autophagy. Terpenes, such as β-caryophyllene, limonene, and myrcene, have also been reported to have potential antitumor effects on CRC through the induction of apoptosis, the inhibition of cell proliferation, and angiogenesis. In addition, synergy effects between cannabinoids and terpenes are believed to be important factors in the treatment of CRC. This review focuses on the current knowledge about the potential of cannabinoids and terpenoids from C. sativa to serve as bioactive agents for the treatment of CRC while evidencing the need for further research to fully elucidate the mechanisms of action and the safety of these compounds.

The effect of prenatal cannabis exposure on offspring preterm birth: a cumulative meta-analysis

BACKGROUND AND AIMS

Mixed results have been reported on the association between prenatal cannabis exposure and preterm birth. This study aimed to examine the magnitude and consistency of associations reported between prenatal cannabis exposure and preterm birth.

METHODS

This review was guided by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. We performed a comprehensive search of the literature on the following electronic databases: PubMed, EMBASE, SCOPUS, Psych-INFO and Web of Science. The revised version of the Newcastle-Ottawa Scale (NOS) was used to appraise the methodological quality of the studies included in this review. Inverse variance weighted random-effects cumulative meta-analysis was undertaken to pool adjusted odds ratios (aOR) after sequential inclusion of each newly published study over time. The OR and 95% confidence interval (CI) limits required (stability threshold) for a new study to move the cumulative odds ratio to the null were also computed.

RESULTS

A total of 27 observational studies published between 1986 and 2022 were included in the final cumulative meta-analysis. The sample size of the studies ranged from 304 to 4.83 million births. Prenatal cannabis exposure was associated with an increased risk of preterm birth (pooled aOR = 1.35, 95% CI = 1.24-1.48). The stability threshold was 0.74 (95% CI limit = 0.81) by the end of 2022.

CONCLUSIONS

Offspring exposed to maternal prenatal cannabis use was associated with higher risk of preterm birth, which warrants public health messages to avoid such exposure, particularly during pregnancy.

Peroral Exposure to Cannabis Sativa Ethanol Extract Caused Neuronal Degeneration and Astrogliosis in Wistar Rats' Prefrontal Cortex

Background

Despite widespread concerns about its possible side effects, notably on the prefrontal cortex (PFC), which mediates cognitive processes, the use of Cannabis sativa as a medicinal and recreational drug is expanding exponentially. This study evaluated possible behavioral alterations, neurotransmitter levels, histological, and immunohistochemical changes in the PFC of Wistar rats exposed to Cannabis sativa.

Purpose

To evaluate the effect of graded doses of Cannabis sativa on the PFC using behavioural, histological, and immunohistochemical approaches.

Methods

Twenty-eight juvenile male Wistar rats weighing between 70 g and 100 g were procured and assigned into groups A-D (n = 7 each). Group A served as control which received distilled water only as a placebo; rats in groups B, C, and D which were the treatment groups were orally exposed to graded doses of Cannabis sativa (10 mg/kg, 50 mg/kg, and 100 mg/kg, respectively). Rats in all experimental groups were exposed to Cannabis sativa for 21 days, followed by behavioral tests using the open field test for locomotor, anxiety, and exploratory activities, while the Y-maze test was for spatial memory assessment. Rats for biochemical analysis were cervically dislocated and rats for tissue processing were intracardially perfused following neurobehavioral tests. Sequel to sacrifice, brain tissues were excised and prefrontal cortices were obtained for the neurotransmitter (glutamate, acetylcholine, and dopamine) and enzymatic assay (Cytochrome C oxidase (CcO) and Glucose 6- Phosphate Dehydrogenase-G-6-PDH). Brain tissues were fixed in 10% Neutral Buffered Formalin (NBF) for histological demonstration of the PFC cytoarchitecture using H&E and glial fibrillary acidic protein (GFAP) for astrocyte evaluation.

Results

Glutamate and dopamine levels were significantly increased (F = 24.44, P = .0132) in groups D, and B, C, and D, respectively, compared to control; likewise, the activities of CcO and G-6-PDH were also significantly elevated (F = 96.28, P = .0001) (F = 167.5, P = .0001) in groups C and D compared to the control. Cannabis sativa impaired locomotor activity and spatial memory in B and D and D, respectively. All Cannabis sativa exposed groups demonstrated evidence of neurodegeneration in the exposed groups; GFAP immunoexpression was evident in all groups with a marked increase in group D.

Conclusion

Cannabis sativa altered neurotransmitter levels, energy metabolism, locomotor, and exploratory activity, and spatial working memory, with neuronal degeneration as well as reactive astrogliosis in the PFC.

Disentangling Medicinal and Recreational cannabis Use Among People Living with HIV: An Ecological Momentary Assessment Study

This study examined the feasibility of using ecological momentary assessment (EMA) to disentangle medicinal cannabis use (MCU) from recreational cannabis use (RCU) among people living HIV (PLWH). Over a 14-day period, PLWH (N = 29) who engaged in both MCU and RCU completed a smartphone-based survey before and after every cannabis use event assessing general motivation for cannabis use (MCU-only, RCU-only, or mixed MCU/RCU), cannabis use behavior, and several antecedents and outcomes of cannabis use. A total of 739 pre-cannabis surveys were completed; 590 (80%) of the prompted post-cannabis surveys were completed. Motives for cannabis use were reported as MCU-only on 24%, RCU-only on 30%, and mixed MCU/RCU on 46% of pre-cannabis surveys. Mixed effects models examined within-person differences across MCU-only, RCU-only, and mixed MCU/RCU events. Results showed that relative to RCU-only events, MCU-only events were more likely to involve symptom management and drug substitution motives, physical and sleep-related symptoms, solitary cannabis use, and use of cannabis oils and sprays; MCU-only events were less likely to involve relaxation, happiness, and wellness motives, cannabis flower use, and positive cannabis consequences. Differences between mixed MCU/RCU and RCU-only events were similar, except that mixed MCU/RCU events were additionally associated with stress reduction motives and symptoms of anxiety and depression. Findings support the feasibility of partially disentangling MCU and RCU behavior among PLWH who engage in concurrent MCU and RCU. This study highlights the need for more EMA studies isolating MCU from RCU to inform ongoing changes to cannabis policies.

Patient Experiences With Prescription Cannabinoids in Germany: Protocol for a Mixed Methods, Exploratory, and Anonymous Web-Based Survey

BACKGROUND

Medical cannabinoids are controversial. Their use is comparatively rare, but it is rising. Since 2017, cannabinoids can be prescribed in Germany for a broader range of indications. Patient surveys on these drugs are hampered by the stigmatization of cannabinoids and their (still) low prevalence in medical contexts. Against this background, patients' willingness to provide information is limited. Moreover, it is logistically challenging to reach them with a survey. A thorough knowledge of currently ongoing therapies and their effects and side effects, however, is important for a more appropriate and effective use of cannabinoids in the future.

OBJECTIVE

This study is an exploratory data collection using a representative sample. The main goal is to provide a detailed picture of the current use of medical cannabinoids in Germany. It is intended to identify subgroups that may benefit particularly well or poorly.

METHODS

We are conducting a representative, anonymous, cross-sectional, one-time, web-based survey based on mixed methods in 3 German federal states. Health conditions under cannabinoid therapy and before are documented with validated, symptom-specific questionnaires. This allows an estimation of the effect sizes of these therapies. The selection of parameters and questionnaires was based on the results of independent qualitative interviews in advance. Representative samples of the hard-to-reach study population are obtained by cluster sampling via contracted physicians of the statutory health insurance companies.

RESULTS

Recruitment was ongoing until the end of June 2022, with 256 enrolled participants. Validated questionnaires on pain, spasticity, anorexia or wasting, multiple sclerosis, nausea or vomiting, depression, and attention deficit hyperactivity disorder (ADHD) were selected. Symptom scores are being assessed for both current conditions under cannabinoid therapy and conditions prior to this therapy (in retrospect). Validated questionnaires are also used for treatment satisfaction and general quality of life. These are supplemented by existing diagnoses, a detailed medication history, any previous experiences with cannabis or illegal substances, experiences with the prescription process, and sociodemographic data. Based on the results of the previous qualitative interviews, questions were added regarding prior experience with relaxation methods and psychotherapy, personal opinions about cannabinoids, pre-existing or symptom-related psychological trauma, and different experiences with different cannabis-based therapies.

CONCLUSIONS

The exploratory mixed methods approach of this project is expected to provide valid and relevant data as a basis for future clinical research. The study design may be representative for a large proportion of outpatients treated with cannabinoids in the German federal states studied. It may have less bias toward social desirability and may provide valuable information in addition to existing studies. Due to the observational and cross-sectional nature of this study, various limitations apply. Causal relations cannot be drawn.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00023344; https://drks.de/search/en/trial/DRKS00023344.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38814.

A Retrospective Medical Record Review of Adults with Non-Cancer Diagnoses Prescribed Medicinal Cannabis

Research describing patients using medicinal cannabis and its effectiveness is lacking. We aimed to describe adults with non-cancer diagnoses who are prescribed medicinal cannabis via a retrospective medical record review and assess its effectiveness and safety. From 157 Australian records, most were female (63.7%; mean age 63.0 years). Most patients had neurological (58.0%) or musculoskeletal (24.8%) conditions. Medicinal cannabis was perceived beneficial by 53.5% of patients. Mixed-effects modelling and post hoc multiple comparisons analysis showed significant changes overtime for pain, bowel problems, fatigue, difficulty sleeping, mood, quality of life (all p < 0.0001), breathing problems (p = 0.0035), and appetite (p = 0.0465) Symptom Assessment Scale scores. For the conditions, neuropathic pain/peripheral neuropathy had the highest rate of perceived benefit (66.6%), followed by Parkinson's disease (60.9%), multiple sclerosis (60.0%), migraine (43.8%), chronic pain syndrome (42.1%), and spondylosis (40.0%). For the indications, medicinal cannabis had the greatest perceived effect on sleep (80.0%), followed by pain (51.5%), and muscle spasm (50%). Oral oil preparations of balanced delta-9-tetrahydrocannabinol/cannabidiol (average post-titration dose of 16.9 mg and 34.8 mg per day, respectively) were mainly prescribed. Somnolence was the most frequently reported side effect (21%). This study supports medicinal cannabis' potential to safely treat non-cancer chronic conditions and indications.

Cannabis use, risk behaviours and harms in Brazil: A comprehensive review of available data indicators

ISSUES

Cannabis use and related health/social outcome indicator data for Brazil-where non-medical cannabis is generally illegal-are limited.

APPROACH

Towards a comprehensive overview of relevant indicators, we searched primary databases by combining MeSH-index terms related to cannabis, geographic location and subtopic terms (e.g., use, health, mortality) focusing on cannabis use and key outcome indicators in Brazil since 2010. In addition, relevant 'grey literature' (e.g., survey reports) was identified. Key indicator data were mainly narratively summarised.

KEY FINDINGS

Overall, cannabis use has increased somewhat since pre-2010, with (past-year) use rates measured at 2-3% for general population adults, yet 5% or higher among youth and/or (e.g., post-secondary) student populations. For key risk behaviours, the presence of tetrahydrocannabinol-positivity among motor-vehicle drivers has been measured at <2%. While the prevalence of cannabis use disorder appears to have decreased, the relative proportion of treatment provided for cannabis-related problems increased. National- and local-based studies indicated an association of cannabis use with mental health harms, including depression and suicidality. Although some non-representative and/or local studies contain information, other monitoring data, including cannabis-related risks and harms (e.g., cannabis-related driving, mortality, hospitalisations), are limited in availability.

IMPLICATIONS AND CONCLUSION

The prevalence of cannabis use in Brazil is comparably low (e.g., relative to elsewhere in the Americas). Data on numerous key cannabis-related indicators is absent, or limited in scope for Brazil. Considering ongoing evolutions in cannabis control and its status as the most common illicit drug, more comprehensive surveillance of cannabis use and related outcomes is advised.

Microglial Cannabinoid CB2 Receptors in Pain Modulation

Pain, especially chronic pain, can strongly affect patients' quality of life. Cannabinoids ponhave been reported to produce potent analgesic effects in different preclinical pain models, where they primarily function as agonists of G_i/o protein-coupled cannabinoid CB₁ and CB₂ receptors. The CB₁ receptors are abundantly expressed in both the peripheral and central nervous systems. The central activation of CB₁ receptors is strongly associated with psychotropic adverse effects, thus largely limiting its therapeutic potential. However, the CB₂ receptors are promising targets for pain treatment without psychotropic adverse effects, as they are primarily expressed in immune cells. Additionally, as the resident immune cells in the central nervous system, microglia are increasingly recognized as critical players in chronic pain. Accumulating evidence has demonstrated that the expression of CB₂ receptors is significantly increased in activated microglia in the spinal cord, which exerts protective consequences within the surrounding neural circuitry by regulating the activity and function of microglia. In this review, we focused on recent advances in understanding the role of microglial CB₂ receptors in spinal nociceptive circuitry, highlighting the mechanism of CB₂ receptors in modulating microglia function and its implications for CB₂ receptor- selective agonist-mediated analgesia.

Cultural and Social Factors in Care Delivery Among African American Caregivers of Persons With Dementia: A Scoping Review

Cultural and social factors significantly influence the care provided to persons with dementia. This scoping review aimed to map emerging evidence on the influence of cultural and social factors on care delivery among Africa American caregivers of persons with dementia, especially during the COVID-19 pandemic. Using a systematic scoping review approach, we identified 21 studies on cultural and social factors influencing care delivery. The search included EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, and Epistemonicos. A narrative synthesis of the data revealed that cultural and social factors greatly influence African American caregivers of persons with dementia and COVID-19 in care delivery, who perceive caregiving as a responsibility and not just a job. These caregivers are additionally guided by their racial identity and faith beliefs, integrating family values and culture into caregiving. African American caregivers showed compassion and resilient care selfperceptions. Supporting compassionate care delivery by African American caregivers requires an understanding of the social and cultural factors which drive their commitment to quality care for older adults with dementia in a pandemic environment.

Integrating Systematic Reviews into Supportive Care Trial Design: The Rethinking Clinical Trials (REaCT) Program

PURPOSE

To review the successes and challenges of integrating systematic reviews (SRs) into the Rethinking Clinical Trials (REaCT) Program.

METHODS

All REaCT program SRs were evaluated and descriptive summaries presented.

RESULTS

Twenty-two SRs have been performed evaluating standard of care interventions for the management of: breast cancer (n = 15), all tumour sites (n = 4), breast and prostate cancers (n = 2), and prostate cancer (n = 1). The majority of SRs were related to supportive care (n = 14) and survivorship (n = 5) interventions and most (19/22, 86%) confirmed the existence of uncertainty relating to the clinical question addressed in the SR. Most SRs (15/22, 68%) provided specific recommendations for future studies and results were incorporated into peer-reviewed grant applications (n = 6) and clinical trial design (n = 12). In 12/22 of the SRs, the first author was a trainee. All SRs followed PRISMA guidelines.

CONCLUSION

SRs are important for identifying and confirming clinical equipoise and designing trials. SRs provide an excellent opportunity for trainees to participate in research.

Cannabinoid Poisoning-Related Emergency Department Visits and Inpatient Hospitalizations in Kentucky, 2017 to 2019

Background and objectives: Cannabis is the most used federally illicit substance. Due to widespread medicinal use and state-level legalization, public perceptions of cannabis have shifted toward the assumption that cannabis is safe. However, cannabinoids can cause adverse medical complications that may lead people to seek treatment. This study characterized cannabinoid poisoning-related medical encounters, poisoning involving cannabinoids and other psychoactive substances, and cannabinoid poisoning-related cardiac complications. Methods: Administrative billing data for emergency department visits and inpatient hospitalizations in acute care facilities with a discharge date from January 1, 2017 to December 31, 2019 were used to characterize cannabinoid poisoning events in Kentucky, identified by ICD-10-CM diagnosis code T40.7X. Results: There were 1,490 encounters of cannabinoid poisoning; patients were primarily non-Hispanic White males, ages 15-44, who had Medicaid and lived in a metropolitan area. Of those, 31.21% involved poisoning with a second psychoactive substance, primarily stimulants and/or opioids, and 17.72% experienced a cardiac complication. Cannabinoid-polydrug poisoning was associated with inpatient treatment (χ2=199.18, p < 0.001) and cardiac complications (χ2=4.58, p < 0.001). Discussion and Conclusions: These results are consistent with other state-level data. Patients who were diagnosed with cannabis-polydrug poisoning, compared to cannabis alone poisoning, had greater odds of hospital admission and cardiac complications, and longer length of hospital stays. Scientific Significance: The health risks of cannabinoid use must be more broadly recognized, while timely and accurate data need to be shared to guide policies on cannabis access. Future research on cannabinoid poisoning should consider the involvement of other psychoactive drugs.

Online survey of medicinal cannabis users: Qualitative analysis of patient-level data

Aim: To characterize perceived benefits and challenges experienced by medicinal cannabis users.

Methods: An anonymous online survey collected demographics, health information, and open-ended responses from medicinal cannabis users regarding perceptions, motivations, and experience of treatment. Qualitative open-ended responses were thematically analyzed.

Results: Respondents (N = 808) were predominantly White (79%), female (63%), with a mean (SD) age of 38 (20). Two hundred eighty-four (35%) respondents provided data on a dependent family member (e.g., child; 22% of total sample). Most used cannabidiol (CBD)-dominant products (58%), primarily for neurological disorders (38%) or pain (25%). Primary motivations for medicinal cannabis use were based on beliefs that traditional treatments were ineffective and/or had intolerable side effects (51%), positive scientific or media portrayals of the safety/efficacy of cannabis as a therapeutic (29%), or preference for “natural” treatments over pharmaceuticals (21%). A majority of respondents (77%) attributed positive effects to the medicinal use of cannabis/cannabinoids. These included physical symptom improvements such as reduced pain (28%), improved sleep (18%), and seizure reduction (18%), and mental health improvements including reduced anxiety (22%) and improved mood (11%). Additionally, respondents reported reduced use of other medications (e.g., opioids) (12%), and improved quality of life (14%). Problems associated with use were cited by 41% of respondents, and included unwanted side effects (16%), lack of information or medical support (16%), prohibitive costs (12%), and legal concerns (10%).

Conclusion: Most participants reported benefits from cannabis use for a variety of conditions where traditional treatments were ineffective or unacceptable. Concerns regarding cannabis side effects, legality, lack of information, and cost were raised. Data indicate greater research and education on the safety and efficacy of medicinal cannabis/cannabinoid use is warranted.

Cannabinoid consumption among cancer patients receiving systemic anti-cancer treatment in the Netherlands

PURPOSE

Despite the inconclusiveness regarding health effects of cannabinoids among cancer patients, studies from non-European countries suggest that the medical-intended consumption of such products by this patient group is significant. The current study analyses cannabinoid usage among oncology patients receiving systemic treatment in the Netherlands.

METHODS

The current study included adult patients receiving intravenous systemic therapy at Maastricht Comprehensive Cancer Centre, for a solid malignancy. Participants were asked to complete an anonymous questionnaire including questions on demographic variables, clinical variables and cannabinoid consumption.

RESULTS

A total of 153 patients with solid cancer were included in this study. Almost 25% reported usage of cannabinoids for medical purposes, with 15% of the patients currently using the substance. Additionally, 18% of non-users considered future medical usage. In 48% of the cases, consumption was reported by the oncologist. The proposed anti-cancer effect was reported by 46% of the users as motivation for consumption. Current users were mainly palliative patients and 54% of the users were undergoing immunotherapy. Intention of treatment and type of therapy were predictive factors for consumption. Cannabinoid-oil was the most frequently used way of consumption.

CONCLUSION

This study underlines the high number of cannabinoid users among oncology patients in the Netherlands in presumed absence of clinical guidance. It highlights the essence of a pro-active role of the clinician, assessing cannabinoid usage and educating the patients on the most recent evidence regarding its potential benefits and risks. Further studies on clinical decision making and efficacy of cannabinoids are recommended, to improve clinical guidance.

Lifestyle, behaviour, and environmental modification for the management of patients with inflammatory bowel diseases: an International Organization for Study of Inflammatory Bowel Diseases consensus

Environmental and lifestyle factors play an important role in the natural history of Crohn's disease and ulcerative colitis. A group of international experts from the International Organization for the Study of Inflammatory Bowel Diseases voted on a series of consensus statements to inform the management of inflammatory bowel disease (IBD). The recommendations include avoiding traditional cigarette smoking in patients with Crohn's disease or ulcerative colitis, screening for symptoms of depression, anxiety, and psychosocial stressors at diagnosis and during flares (with referral to mental health professionals when appropriate), and encouraging regular physical activity as tolerated. Patients using dietary approaches for treatment of their IBD should be encouraged to adopt diets that are best supported by evidence and involve monitoring for the objective resolution of inflammation. We recommend formal assessment for obesity and nutritional deficiencies, and patients should be encouraged to maintain a normal body-mass index. A shared decision-making approach to contraception should include the consideration of IBD-related factors, and risk factors for venous thromboembolism. Long-term or frequent use of high-dose non-steroidal anti-inflammatory drugs should be avoided. For primary prevention of disease in the offspring of patients with IBD, we recommend avoiding passive exposure to tobacco, using antibiotics judiciously, and considering breastfeeding when able.

Management site and level of health care for cannabis- and synthetic cannabinoid-related poison control center cases involving older adults, 2016-2019

Increasing numbers of older adults use cannabis and cannabis-derived products that can have adverse effects. This study examined management site and level of healthcare services for older adult poison control center cases involving cannabis products. Using the American Association of Poison Control Centers' (PCC) National Poison Data System, 2016-2019, we extracted the 3109 cases aged 50+ for which cannabis was the only or primary substance. Multinomial logistic regression models were fit to examine associations between specific cannabis forms and management/care site (on site [mostly at home], at a healthcare facility [HCF], or no follow-up due to referral refusal or leaving against medical advice) and level of healthcare services for cases managed at a HCF. The results show that between 2016 and 2019, PCC cannabis cases involving older adults increased twofold, largely due to cases of cannabidiol, edibles, and concentrated extracts. Plant form and synthetic cannabinoid cases declined substantially. Compared to plant forms, synthetic cannabinoid cases had 4.22 (95% CI = 2.59-6.89) greater odds of being managed at, rather than outside, a HCF and 2.17 (1.42-3.31) greater odds of critical care unit admission. Although e-cigarette cases, compared to plant form cases, had lower odds of being managed at a HCF, HCF-managed e-cigarette cases had 3.43 greater odds (95% CI = 1.08-10.88) of critical care unit admission. Synthetic cannabinoid cases also had 1.86 (95% CI = 1.03-3.35) greater odds of no follow-up, and the presence of a secondary substance was also a significant factor. Stricter regulations for listing chemical ingredients and providing safety guidelines are needed for cannabis-derived products.

Use of cannabis in the treatment of animals: a systematic review of randomized clinical trials

Cannabis is used in the treatment of several human conditions; however, its use is still less explored in veterinary medicine. This systematic review aims to summarize the evidence of efficacy and safety of the use of cannabis for the treatment of animal disease. A literature search was performed for studies published until 16 March 2021 in five databases. Randomized clinical trials (RCTs) that reported the efficacy or safety of cannabis in the treatment of animal disease were included. The RoB 2 Tool was used to assess the risk of bias. A total of 2427 records were identified, of which six studies fully met the eligibility criteria. RCTs were conducted in dogs with osteoarthritis (n = 4), with epilepsy (n = 1), and with behavioral disorders (n = 1). All studies used cannabidiol (CBD) oil in monotherapy or in combination with other drugs. Studies used CBD at 2 or 2.5 mg kg^-1 twice daily (n = 4), orally (n = 5), during 4 or 6 weeks (n = 3), and compared CBD with placebo (n = 5). CBD significantly reduced pain and increased activity in dogs with osteoarthritis (n = 3). Moreover, CBD significantly reduced the frequency of seizures in dogs with epilepsy (n = 1) and the aggressive behavior of dogs (n = 1). Although promising results were identified, studies were heterogeneous and presented risks of bias that required caution in the interpretation of findings. Therefore, there was some evidence to support the use of CBD in dogs with osteoarthritis to reduce pain and increased activity, but limited evidence against epilepsy and behavioral problems. In addition, CBD was well tolerated with mild adverse effects. More RCTs with high quality of evidence are needed, including greater numbers of animal subjects, additional species, and clear readout measures to confirm these findings.

Cannabis and cannabinoids for symptomatic treatment for people with multiple sclerosis

BACKGROUND

Spasticity and chronic neuropathic pain are common and serious symptoms in people with multiple sclerosis (MS). These symptoms increase with disease progression and lead to worsening disability, impaired activities of daily living and quality of life. Anti-spasticity medications and analgesics are of limited benefit or poorly tolerated. Cannabinoids may reduce spasticity and pain in people with MS. Demand for symptomatic treatment with cannabinoids is high. A thorough understanding of the current body of evidence regarding benefits and harms of these drugs is required.

OBJECTIVES

To assess benefit and harms of cannabinoids, including synthetic, or herbal and plant-derived cannabinoids, for reducing symptoms for adults with MS.

SEARCH METHODS

We searched the following databases from inception to December 2021: MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), CINAHL (EBSCO host), LILACS, the Physiotherapy Evidence Database (PEDro), the World Health Organisation International Clinical Trials Registry Platform, the US National Institutes of Health clinical trial register, the European Union Clinical Trials Register, the International Association for Cannabinoid Medicines databank. We hand searched citation lists of included studies and relevant reviews.

SELECTION CRITERIA

We included randomised parallel or cross-over trials (RCTs) evaluating any cannabinoid (including herbal Cannabis, Cannabis flowers, plant-based cannabinoids, or synthetic cannabinoids) irrespective of dose, route, frequency, or duration of use for adults with MS.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane Risk of bias 2 tool for parallel RCTs and crossover trials. We rated the certainty of evidence using the GRADE approach for the following outcomes: reduction of 30% in the spasticity Numeric Rating Scale, pain relief of 50% or greater in the Numeric Rating Scale-Pain Intensity, much or very much improvement in the Patient Global Impression of Change (PGIC), Health-Related Quality of Life (HRQoL), withdrawals due to adverse events (AEs) (tolerability), serious adverse events (SAEs), nervous system disorders, psychiatric disorders, physical dependence.

MAIN RESULTS

We included 25 RCTs with 3763 participants of whom 2290 received cannabinoids. Age ranged from 18 to 60 years, and between 50% and 88% participants across the studies were female.  The included studies were 3 to 48 weeks long and compared nabiximols, an oromucosal spray with a plant derived equal (1:1) combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (13 studies), synthetic cannabinoids mimicking THC (7 studies), an oral THC extract of Cannabis sativa (2 studies), inhaled herbal Cannabis (1 study) against placebo. One study compared dronabinol, THC extract of Cannabis sativa and placebo, one compared inhaled herbal Cannabis, dronabinol and placebo. We identified eight ongoing studies. Critical outcomes • Spasticity: nabiximols probably increases the number of people who report an important reduction of perceived severity of spasticity compared with placebo (odds ratio (OR) 2.51, 95% confidence interval (CI) 1.56 to 4.04; 5 RCTs, 1143 participants; I² = 67%; moderate-certainty evidence). The absolute effect was 216 more people (95% CI 99 more to 332 more) per 1000 reporting benefit with cannabinoids than with placebo. • Chronic neuropathic pain: we found only one small trial that measured the number of participants reporting substantial pain relief with a synthetic cannabinoid compared with placebo (OR 4.23, 95% CI 1.11 to 16.17; 1 study, 48 participants; very low-certainty evidence). We are uncertain whether cannabinoids reduce chronic neuropathic pain intensity. • Treatment discontinuation due to AEs: cannabinoids may increase slightly the number of participants who discontinue treatment compared with placebo (OR 2.41, 95% CI 1.51 to 3.84; 21 studies, 3110 participants; I² = 17%; low-certainty evidence); the absolute effect is 39 more people (95% CI 15 more to 76 more) per 1000 people. Important outcomes • PGIC: cannabinoids probably increase the number of people who report 'very much' or 'much' improvement in health status compared with placebo (OR 1.80, 95% CI 1.37 to 2.36; 8 studies, 1215 participants; I² = 0%; moderate-certainty evidence). The absolute effect is 113 more people (95% CI 57 more to 175 more) per 1000 people reporting improvement. • HRQoL: cannabinoids may have little to no effect on HRQoL (SMD -0.08, 95% CI -0.17 to 0.02; 8 studies, 1942 participants; I² = 0%; low-certainty evidence); • SAEs: cannabinoids may result in little to no difference in the number of participants who have SAEs compared with placebo (OR 1.38, 95% CI 0.96 to 1.99; 20 studies, 3124 participants; I² = 0%; low-certainty evidence); • AEs of the nervous system: cannabinoids may increase nervous system disorders compared with placebo (OR 2.61, 95% CI 1.53 to 4.44; 7 studies, 1154 participants; I² = 63%; low-certainty evidence); • Psychiatric disorders: cannabinoids may increase psychiatric disorders compared with placebo (OR 1.94, 95% CI 1.31 to 2.88; 6 studies, 1122 participants; I² = 0%; low-certainty evidence); • Drug tolerance: the evidence is very uncertain about the effect of cannabinoids on drug tolerance (OR 3.07, 95% CI 0.12 to 75.95; 2 studies, 458 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Compared with placebo, nabiximols probably reduces the severity of spasticity in the short-term in people with MS. We are uncertain about the effect on chronic neurological pain and health-related quality of life. Cannabinoids may increase slightly treatment discontinuation due to AEs, nervous system and psychiatric disorders compared with placebo. We are uncertain about the effect on drug tolerance. The overall certainty of evidence is limited by short-term duration of the included studies.

Advances in the management of fibromyalgia: what is the state of the art?

INTRODUCTION

Fibromyalgia (FM) is a chronic pain syndrome associated with fatigue, insomnia, dyscognition, and emotional distress. Critical illness mechanisms include central sensitization to nociceptive and non-nociceptive stimuli often resulting in hypersensitivity to all sensory input.

AREAS COVERED

The clinical presentation of FM can vary widely and therefore requires therapies tailored to each patient's set of symptoms. This manuscript examines currently prescribed therapeutic approaches supported by empirical evidence as well as promising novel treatments. Although pharmacological therapy until now has been only moderately effective for FM symptoms, it represents a critical component of every treatment plan.

EXPERT OPINION

Currently approved pharmacological therapies for FM symptoms have limited but proven effectiveness. Novel therapies with cannabinoids and naltrexone appear promising. Recent functional imaging studies of FM have discovered multiple brain network abnormalities that may provide novel targets for mechanism-based therapies. Future treatment approaches, however, need to improve more than clinical pain but also other FM domains like fatigue, insomnia, and distress.

Cannabis for Rheumatic Disease Pain: a Review of Current Literature

PURPOSE OF REVIEW

Changing attitudes about marijuana have led to an increase in use of medicinal marijuana, especially for painful chronic conditions. Patients ask rheumatologists for guidance on this topic. This review provides up-to-date information on the safety and efficacy of medicinal cannabis for rheumatic disease pain.

RECENT FINDINGS

The number of publications related to rheumatic disease and cannabis has increased, but recent literature skews heavily toward reviews vs primary research. Data supporting a role for cannabinoids in rheumatic disease continue to grow. Observational and survey studies show increased use of medicinal cannabis, both by people with rheumatic disease and the general population, and suggest that patients find these treatments beneficial. Prospective studies, however, including randomized controlled clinical trials, are rare and sorely needed. As medicinal cannabis use for rheumatic diseases rises, despite lack of evidence, we review the sparse data available and provide tips for conversations about medicinal cannabis for rheumatologists.

Mental Health Symptoms during the COVID-19 Pandemic among Cancer Survivors Who Endorse Cannabis: Results from the COVID-19 Cannabis Health Study

Our objective was to examine the prevalence of mental health symptoms and the behavioral impact of the COVID-19 pandemic on cancer survivors who endorse cannabis. Participants included 158 adults (≥18 years) who self-reported medicinal cannabis use and responded to our internet-based questionnaire (21 March 2020−24 March 2021). Data included 79 cancer survivors and 79 age-matched adults without a history of cancer. Descriptive statistics were used to compare demographics, the prevalence of generalized anxiety (GAD-7), depression (CES-D-10), and changes in behavior during the COVID-19 pandemic by cancer survivorship status. Overall, 60.8% and 48.1% of cancer survivors self-reported the use of cannabis to manage their anxiety and depression, respectively. Probable clinical depression (CES-D-10 score ≥ 10) and anxiety (GAD-7 score ≥ 10) were identified in 50.7% and 38.9% of cancer survivors, respectively. Cancer survivors were more likely to report that their anxiety symptoms made it very or extremely difficult to work, take care of home, or get along with others than their counterparts. Cancer survivors with anxiety and/or depression were more likely to fear giving COVID-19 to someone else (47.5% vs. 23.1%, p = 0.023) and to fear being diagnosed with COVID-19 (77.5% vs. 38.5%, p < 0.001) compared to cancer survivors without anxiety and depression symptoms. Further research is recommended to evaluate the use of cannabis as palliative care to improve mental health among cancer survivors.

Primary care physicians' attitudes and knowledge regarding medical cannabis and willingness to prescribe it: the Israeli experience

BACKGROUND

Use of medical cannabis (MC) in Israel has increased since its regulatory approval in 2016. Currently, more than 1% of Israeli adults are treated with MC; this requires primary care physicians (PCPs) to be familiar with this treatment option.

OBJECTIVES

We assessed the attitudes and knowledge of Israeli PCPs toward MC and evaluated their willingness to prescribe it for different medical conditions.

METHODS

A cross-sectional survey which was distributed to PCPs in Israel. Physicians were asked about their opinions, knowledge, and willingness to prescribe MC.

RESULTS

Two hundred and one PCPs answered the questionnaire. Their average age was 47 years (±11.2), 71% were specialists. 51% of the respondents thought that MC is an effective treatment. 63% replied that they had little knowledge and 75% indicated that they would like to deepen it. 61% of the respondents were willing to initiate an MC treatment for a dying patient, while less than 50% were willing to initiate MC treatment for various other conditions. Most respondents indicated that they were willing to renew a prescription for any approved medical condition. Willingness to prescribe MC increased for physicians who agreed that MC was effective (odds ratio [OR] 21.9, 95% confidence interval [CI] 2.40-200.85), for physicians who strongly agreed with the statement that they had sufficient knowledge (OR 5.0, 95% CI 1.58-15.83) and for residents compared with specialists (OR 4.0, 95% CI 1.52-10.73).

CONCLUSIONS

Our survey revealed PCPs' differing opinions and insufficient knowledge regarding treatment with MC. These findings suggest that continuing medical education regarding MC is needed.

Lower-Risk Cannabis Use Guidelines (LRCUG) for reducing health harms from non-medical cannabis use: A comprehensive evidence and recommendations update

BACKGROUND

Cannabis use is common, especially among young people, and is associated with risks for various health harms. Some jurisdictions have recently moved to legalization/regulation pursuing public health goals. Evidence-based 'Lower Risk Cannabis Use Guidelines' (LRCUG) and recommendations were previously developed to reduce modifiable risk factors of cannabis-related adverse health outcomes; related evidence has evolved substantially since. We aimed to review new scientific evidence and to develop comprehensively up-to-date LRCUG, including their recommendations, on this evidence basis.

METHODS

Targeted searches for literature (since 2016) on main risk factors for cannabis-related adverse health outcomes modifiable by the user-individual were conducted. Topical areas were informed by previous LRCUG content and expanded upon current evidence. Searches preferentially focused on systematic reviews, supplemented by key individual studies. The review results were evidence-graded, topically organized and narratively summarized; recommendations were developed through an iterative scientific expert consensus development process.

RESULTS

A substantial body of modifiable risk factors for cannabis use-related health harms were identified with varying evidence quality. Twelve substantive recommendation clusters and three precautionary statements were developed. In general, current evidence suggests that individuals can substantially reduce their risk for adverse health outcomes if they delay the onset of cannabis use until after adolescence, avoid the use of high-potency (THC) cannabis products and high-frequency/-intensity of use, and refrain from smoking-routes for administration. While young people are particularly vulnerable to cannabis-related harms, other sub-groups (e.g., pregnant women, drivers, older adults, those with co-morbidities) are advised to exercise particular caution with use-related risks. Legal/regulated cannabis products should be used where possible.

CONCLUSIONS

Cannabis use can result in adverse health outcomes, mostly among sub-groups with higher-risk use. Reducing the risk factors identified can help to reduce health harms from use. The LRCUG offer one targeted intervention component within a comprehensive public health approach for cannabis use. They require effective audience-tailoring and dissemination, regular updating as new evidence become available, and should be evaluated for their impact.

Children as voices and images for medicinal cannabis law reform

This article situates the movement for the legalisation of medicinal cannabis within the bigger picture of the impetus toward recreational cannabis legalisation. It describes the role played by children with epileptic syndromes in the medicinal cannabis law reform campaigns in the United Kingdom, and Queensland, New South Wales and Victoria in Australia. Noting the 'rule of rescue' and the prominence in media campaigns of children in Australian and English cases of parental disputation with clinicians about treatment for their children, it reviews whether paediatric epilepsy is a suitable test case for the legalisation of medicinal cannabis. Taking into account the vested commercial interests of Big Cannabis, the current medico-scientific knowledge of the efficacy of medicinal cannabis in controlling paediatric epileptic seizures, and issues of dignity, health privacy, and the enduring digital footprints of media coverage, the article commences discussion about the ethics of the media, parents, politicians and entrepreneurial doctors utilising parents' testimonials about the effects of medicinal cannabis as part of the cannabis law reform movement.

Facilitators and barriers to the regulation of medical cannabis: a scoping review of the peer-reviewed literature

Background

In recent decades, several political, legislative, judicial, consumer, and commercial processes around the world have advanced legalization efforts for the use of medical cannabis (MC). As the use of MC evolves through legislative reform, with an increase in public acceptance and therapeutic potential, a need exists to further investigate the facilitators and barriers to MC regulation.

Methods

A scoping review was conducted to identify the facilitators and barriers associated with the implementation of MC regulations. MEDLINE, EMBASE, AMED and PsycINFO databases were systematically searched; no restrictions were placed on geographic location/jurisdiction. Eligible articles included those that evaluated the MC regulatory framework of one or more countries.

Results

Twenty-two articles were deemed eligible and included in this review. Themes identified include: (1) effects of conflicts, mindset, and ideology of state population, (2) the use of comparisons to analyze MC regulation, and (3) the need for more knowledge, advice, and empirical/clinical evidence to inform future MC policies.

Conclusion

Policymakers should be aware of facilitators to the MC regulation implementation process, such as the influence of state and federal congruence, increased transparency, and the incorporation of stakeholder concerns, in order to effectively respond to a growing societal acceptance of MC and its use among patients. Given a comprehensive understanding of these influential factors, policymakers may be better equipped to meet the consumer and commercial demands of a rapidly evolving MC regulatory environment.

The Green Sheep: Exploring the Perceived Risks and Benefits of Cannabis Among Young Military Members and Veterans

Medical and recreational cannabis are becoming more accessible and socially accepted across the United States. Emerging adults (EAs; 18 to 29) are the largest group of cannabis users. Studies have found that veterans are more likely to report cannabis use compared to nonveterans. While research exists on the use levels of cannabis, limited knowledge is available on the perceived risks and benefits of using cannabis among EA military and veteran populations. Helping professionals encounter veterans who use cannabis and must consider military cultural factors and attitudes towards cannabis that may influence or exacerbate cannabis use. We conducted a qualitative study with 23 EA veteran and military members with high-risk substance use and asked about their thoughts on the acceptability, risks, and perceived benefits associated with cannabis. Two qualitative coders used NVivo to find themes following the six steps of thematic analysis. Results provide in-depth understanding of EA military members and veterans' perceptions of cannabis. Overall, we found participants were receptive to using cannabis for pain ailments, mental health issues, and as an alternative to benzodiazepines, opioids, and alcohol. However, they acknowledged restrictions are needed to moderate cannabis use and mitigate negative outcomes. Lastly, participants recognized the incongruence of cannabis use with military job responsibilities and expectations. These findings shed light on potential risk and protective factors related to using cannabis for recreational or medical reasons and should be considered when consulting EA military members and veterans.

The Effect of Medical Cannabis on Pain Level and Quality of Sleep among Rheumatology Clinic Outpatients

Introduction

Medical cannabis (MC) is becoming increasingly popular for the treatment of chronic pain conditions. In this study, we evaluated the effect of MC treatment on pain level and quality of sleep of patients with different medical conditions at the rheumatology clinic.

Methods

Patients licensed for the use of MC at the rheumatology clinics at different settings were located and contacted. Their demographic and clinical parameters were documented, including type of medical cannabis consumed, way of consumption, and current monthly consumed amount. These patients were contacted by phone and asked about the effect on pain level and quality of sleep.

Results

A total of 351 patients were located, and 319 completed the questionnaire. Mean age was 46 ± 12 years, 76% were female, 82% had fibromyalgia, ∼9% had mechanical problems, ∼4% had inflammatory problems, ∼4% had neurological problems, and ∼1% had other problems. The average monthly consumed dose of MC was 31, 35, 36, and 32 g, with mean pain level reduction of 77%, 82%, 83%, and 57%, and mean sleep quality improvement of 78%, 71%, 87%, and 76% among patients with fibromyalgia, mechanical, neuropathic, and inflammatory problems, respectively. Mean THC and CBD contents were 18.38% ± 4.96 and 2.62% ± 4.87, respectively. The THC concentration, duration of MC consumption, and MC consumption dose had independent significant correlations with pain reduction while only the duration of MC consumption had an independent significant correlation with sleep quality improvement.

Conclusions

MC had a favorable effect on pain level and quality of sleep among all spectrums of problems at the rheumatology clinic.

Medical cannabis and cannabis-based medicine show both potential efficacy and potential harms: Cross-sectional comparison with controls on self-rated and interviewer-rated outcomes within the Danish pilot program on medical cannabis

BACKGROUND AND PURPOSE

Denmark launched a pilot program of medical cannabis in January 2018. The aim was to establish whether medical cannabis and cannabis-based medicine (MC/CBM) were superior and safe compared to conventional treatment, regardless of the indications for which people received such medication.

MATERIALS AND METHODS

People (cases) were identified who had redeemed at least one prescription of MC/CBM according to the nationwide, unselected Danish registers. These were propensity-score matched to controls with the same indications who had not used MC/CBM. Potential participants were contacted electronically, and if willing to participate filled in various survey instruments online. Participants were also interviewed in person in order to investigate symptoms of depression, anxiety, and to assess cognitive levels. Different sets of analyses were conducted, handling potential confounders in different ways.

RESULTS

In the primary analyses, cases were more satisfied with their treatment than were controls (mean (SD) 29.2 (4.8) versus 26.5 (4.5) on the CSQ, p = 0.006), and scored lower on depression (3.3 (3.0) versus 4.6 (2.9), p = 0.03). Cases reported higher levels of pain than controls when measured on the SF-36 bodily-pain subdomain (36.3 (23.0) versus 48.7 (30.1), p = 0.01). There were indications of worse symptoms of multiple sclerosis in cases compared to controls. Reported side-effects were generally mild.

CONCLUSION

Both potential effects and harms of MC/CBM were observed. Randomized trials are required to establish if these are true effects and harms, or due to confounding by indication.