Category Archives: Chronic Pain

Prolonged Medical Cannabis Treatment is Associated With Quality of Life Improvement and Reduction of Analgesic Medication Consumption in Chronic Pain Patients

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Frontiers in Pharmacology (@FrontPharmacol) | Twitter“Introduction: Chronic non-cancer pain (CNCP) is one of the most prevalent indications for medical cannabis (MC) treatment globally. In this study, we investigated CNCP parameters in patients during prolonged MC treatment, and assessed the interrelation between CNCP parameters and the chemical composition of MC chemovar used. 

Methods: A cross-sectional questionnaire-based study was performed in one-month intervals for the duration of six months. Subjects were adult patients licensed for MC treatment who also reported a diagnosis of CNCP by a physician. Data included self-reported questionnaires. MC treatment features included administration route, cultivator, cultivar name and monthly dose. Comparison statistics were used to evaluate differences between the abovementioned parameters and the monthly MC chemovar doses at each time point. 

Results: 429, 150, 98, 71, 77 and 82 patients reported fully on their MC treatment regimens at six one-month intervals, respectively. Although pain intensities did not change during the study period, analgesic medication consumption rates decreased from 46 to 28% (p < 0.005) and good Quality of Life (QoL) rates increased from 49 to 62% (p < 0.05). These changes overlapped with increase in rates of (-)-Δ9–trans-tetrahydrocannabinol (THC) and α-pinene high dose consumption. 

Conclusion: Even though we observed that pain intensities did not improve during the study, QoL did improve and the rate of analgesic medication consumption decreased alongside with increasing rates of high dose THC and α-pinene consumption. Understanding MC treatment composition may shed light on its long-term effects.”

https://pubmed.ncbi.nlm.nih.gov/34093173/

“In this study, although pain intensities did not change under long-term MC treatment, analgesic medication consumption rates decreased and ‘better’ QoL rates increased. These changes coincided with the increased rates of patients’ consumption of high dose THC and α pinene. These results may shed light on the long-term beneficial effects of MC on CNCP.”

https://www.frontiersin.org/articles/10.3389/fphar.2021.613805/full

A Large-Scale Naturalistic Examination of the Acute Effects of Cannabis on Pain

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View details for Cannabis and Cannabinoid Research cover image“Cannabis use for pain relief is commonly reported, yet laboratory studies and clinical trials suggest that cannabinoids are weak analgesics, and it is unclear whether perceived reductions in pain from before to after cannabis use relate to factors such as dose, method of administration, phytocannabinoid content, or the age or gender of the user. We determined whether inhalation of cannabis decreased self-reported pain ratings as well as whether user gender, age, time, method of administration, tetrahydrocannabinol (THC)/cannabidiol (CBD) content, or dose of cannabis contribute to changes in these ratings. We also examined whether tolerance may develop to the analgesic effects of cannabis over time.

Results: For all three pain symptoms, severity ratings decreased significantly after cannabis use. Women reported higher baseline and postcannabis pain severity than did men, and men reported larger decreases in pain than did women. Neither THC nor CBD content nor their interaction predicted reductions in pain ratings. However, vaping was associated with larger reductions in joint pain ratings than was smoking, and lower doses were associated with larger reductions in nerve pain ratings. Additionally, for all three pain symptoms, the dose of cannabis used to manage pain increased significantly over time.

Conclusions: Inhaled cannabis reduces self-reported pain severity by ∼42–49%. However, these reductions appear to diminish across time, and patients use larger doses across time, suggesting that analgesic tolerance develops with continued use.”

https://www.liebertpub.com/doi/abs/10.1089/can.2020.0068?journalCode=can

“Inhaled Cannabis Associated with Significant Reductions in Self-Reported Pain Severity”

A Survey on the Effect That Medical Cannabis Has on Prescription Opioid Medication Usage for the Treatment of Chronic Pain at Three Medical Cannabis Practice Sites

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Cureus | LinkedIn“Objective: The opioid epidemic continues to claim thousands of lives every year without an effective strategy useful in mitigating mortality. The use of medical cannabis has been proposed as a potential strategy to decrease opioid usage. The objective of this study was to determine how the use of medical cannabis affects prescribed opioid usage in chronic pain patients.

Methods: We conducted an online convenience sample survey of patients from three medical cannabis practice sites who had reported using opioids. A total of 1181 patients responded, 656 were excluded for not using medical cannabis in combination with opioid use or not meeting the definition of chronic pain, leaving 525 patients who had used prescription opioid medications continuously for at least three months to treat chronic pain and were using medical cannabis in combination with their prescribed opioid use.

Results: Overall, 40.4% (n=204) reported that they stopped all opioids, 45.2% (n=228) reported some decrease in their opioid usage, 13.3% (n=67) reported no change in opioid usage, and 1.1% (n=6) reported an increase in opioid usage. The majority (65.3%, n=299) reported that they sustained the opioid change for over a year. Almost half (48.2%, n=241) reported a 40-100% decrease in pain while 8.6% (n=43) had no change in pain and 2.6% (n=13) had worsening pain. The majority reported improved ability to function (80.0%, n=420) and improved quality of life (87.0%, n=457) with medical cannabis. The majority (62.8%, n=323) did not want to take opioids in the future. While the change in pain level was not affected by age and gender, the younger age group had improved ability to function compared with the middle and older age groups.

Conclusions: Patients in this study reported that cannabis was a useful adjunct and substitute for prescription opioids in treating their chronic pain and had the added benefit of improving the ability to function and quality of life.”

https://pubmed.ncbi.nlm.nih.gov/33409086/

“Our results show a remarkable percentage of patients both reporting complete cessation of opioids and decreasing opioid usage by the addition of medical cannabis, with results lasting for over a year for the majority. Additional benefits of medical cannabis included improved ability to function and improved quality of life, especially for the younger age group. We believe our results lend further support that medical cannabis provided in a standardized protocol can lead to decreased pain and opioid usage, improved function, and quality of life measures, and even complete cessation of opioids in patients with chronic pain treated by opioids.”

https://www.cureus.com/articles/41928-a-survey-on-the-effect-that-medical-cannabis-has-on-prescription-opioid-medication-usage-for-the-treatment-of-chronic-pain-at-three-medical-cannabis-practice-sites

Cannabis use is associated with reduced risk of exposure to fentanyl among people on opioid agonist therapy during a community-wide overdose crisis

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Drug and Alcohol Dependence “Background: The ongoing opioid overdose crisis is driven largely by exposure to illicitly-manufactured fentanyl. Preliminary observational and experimental research suggests that cannabis could potentially play a role in reducing use of prescription opioids among individuals with chronic pain. However, there is limited data on the effects of cannabis on illicit opioid consumption, particularly fentanyl, especially among individuals on opioid agonist therapy (OAT). We sought to assess the longitudinal association between cannabis use and exposure to fentanyl among people on OAT.

Results: Among the 819 participants on OAT who contributed 1989 observations over the study period, fentanyl exposure was common. At the baseline interview, fentanyl was detected in a majority of participants (431, 53 %), with lower prevalence among individuals with urine drug tests positive for tetrahydrocannabinol (47 vs. 56 %, p = 0.028). Over all study interviews, cannabis use was independently associated with reduced likelihood of being recently exposed to fentanyl (Adjusted Prevalence Ratio = 0.91, 95 % Confidence Interval: 0.83 – 0.99).

Conclusions: Participants on OAT using cannabis had significantly lower risk of being exposed to fentanyl. Our findings reinforce the need for experimental trials to investigate the potential benefits and risks of controlled cannabinoid administration for people on OAT.”

https://pubmed.ncbi.nlm.nih.gov/33342591/

“Opioid agonist therapies (OAT) are the primary treatments for opioid use disorder. Exposure to fentanyl is driving mortality risk in the overdose crisis. Among 819 participants on OAT, cannabis was negatively associated with fentanyl. Experimental trials are needed to evaluate cannabis use during OAT.”

https://www.sciencedirect.com/science/article/abs/pii/S0376871620305858?via%3Dihub

“Cannabis could reduce fentanyl use, reduce overdose risk: study” https://www.bccsu.ca/blog/news-release/cannabis-could-reduce-fentanyl-use-reduce-overdose-risk-study/

“Cannabis could reduce fentanyl use, reduce overdose risk” https://www.med.ubc.ca/news/cannabis-could-reduce-fentanyl-use-reduce-overdose-risk/

Cannabis Significantly Reduces the Use of Prescription Opioids and Improves Quality of Life in Authorized Patients: Results of a Large Prospective Study

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Pain Medicine“Objectives: This article presents findings from a large prospective examination of Canadian medical cannabis patients, with a focus on the impacts of cannabis on prescription opioid use and quality of life over a 6-month period.

Results: Participants were 57.6% female, with a median age of 52 years. Baseline opioid use was reported by 28% of participants, dropping to 11% at 6 months. Daily opioid use went from 152 mg morphine milligram equivalent (MME) at baseline to 32.2 mg MME at 6 months, a 78% reduction in mean opioid dosage. Similar reductions were also seen in the other four primary prescription drug classes identified by participants, and statistically significant improvements were reported in all four domains of the WHOQOL-BREF.

Conclusions: This study provides an individual-level perspective of cannabis substitution for opioids and other prescription drugs, as well as associated improvement in quality of life over 6 months. The high rate of cannabis use for chronic pain and the subsequent reductions in opioid use suggest that cannabis may play a harm reduction role in the opioid overdose crisis, potentially improving the quality of life of patients and overall public health.”

https://pubmed.ncbi.nlm.nih.gov/33367882/

https://academic.oup.com/painmedicine/advance-article-abstract/doi/10.1093/pm/pnaa396/6053211?redirectedFrom=fulltext

Use of Cannabis for Self-Management of Chronic Pelvic Pain

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 View details for Journal of Women's Health cover image“Chronic pelvic pain (CPP) affects up to 15% of women in the United States. The endocannabinoid system is a potential pharmacological target for pelvic pain as cannabinoid receptors are highly expressed in the uterus and other nonreproductive tissues.

We hypothesize that cannabis use is common for self-management of CPP, and our primary objective was to determine the prevalence of cannabis use in this population.

Results: A total of 240 patients were approached, with 113 responses (47.1% response rate). There were 26 patients who used cannabis (23%). The majority used at least once per week (n = 18, 72%). Most users (n = 24, 96%) reported improvement in symptoms, including pain, cramping, muscle spasms, anxiety, depression, sleep disturbances, libido, and irritability. Over one-third (35%) stated that cannabis use decreased the number of phone calls or messages sent to their provider, and 39% reported decreased number of clinical visits. Side effects, including dry mouth, sleepiness, and feeling “high,” were reported by 84% (n = 21).

Conclusions: Almost one-quarter of patients with CPP report regular use of cannabis as an adjunct to their prescribed therapy. Although side effects are common, most users report improvement in symptoms. Our study highlights the potential of cannabis as a therapeutic option for patients with CPP.”

https://pubmed.ncbi.nlm.nih.gov/33252316/

https://www.liebertpub.com/doi/10.1089/jwh.2020.8737

Consensus-Based Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control

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International Journal of Clinical Practice“Opioid misuse and overuse has contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids, and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids.

Results: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain, and/or the cannabis dose has been optimized. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥ 30% reduction in pain intensity, a ≥ 25% reduction in opioid dose, a reduction in opioid dose to < 90 mg MED, and/or reduction in opioid-related adverse events.

Conclusions: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.”

https://pubmed.ncbi.nlm.nih.gov/33249713/

https://onlinelibrary.wiley.com/doi/10.1111/ijcp.13871

Antinociception mechanisms of action of cannabinoid-based medicine: an overview for anesthesiologists and pain physicians

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 Pain Rounds“Cannabinoid-based medications possess unique multimodal analgesic mechanisms of action, modulating diverse pain targets.

Cannabinoids are classified based on their origin into three categories: endocannabinoids (present endogenously in human tissues), phytocannabinoids (plant derived) and synthetic cannabinoids (pharmaceutical). Cannabinoids exert an analgesic effect, peculiarly in hyperalgesia, neuropathic pain and inflammatory states.

Endocannabinoids are released on demand from postsynaptic terminals and travels retrograde to stimulate cannabinoids receptors on presynaptic terminals, inhibiting the release of excitatory neurotransmitters. Cannabinoids (endogenous and phytocannabinoids) produce analgesia by interacting with cannabinoids receptors type 1 and 2 (CB1 and CB2), as well as putative non-CB1/CB2 receptors; G protein-coupled receptor 55, and transient receptor potential vanilloid type-1. Moreover, they modulate multiple peripheral, spinal and supraspinal nociception pathways.

Cannabinoids-opioids cross-modulation and synergy contribute significantly to tolerance and antinociceptive effects of cannabinoids. This narrative review evaluates cannabinoids’ diverse mechanisms of action as it pertains to nociception modulation relevant to the practice of anesthesiologists and pain medicine physicians.”

https://pubmed.ncbi.nlm.nih.gov/33239391/

https://rapm.bmj.com/content/early/2020/11/24/rapm-2020-102114

Calling for Openness to the Study of Cannabis Use in Chronic Pelvic Pain

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JOGC (@JOGC_Social) | Twitter“Chronic pelvic pain affects women across all demographics. Its management is complex and requires a multimodal approach.

Cannabis has been legal for medical purposes for many years; however, its pharmacokinetics are just beginning to be understood, as are its analgesic effects and other benefits, such as improved sleep quality and reduced nausea and vomiting.

Given the recent Canada-wide legalization of cannabis for non-medical use, patients may be more willing to disclose cannabis use and use it for pain management. Given the complexity of chronic pain management, physicians must be open to cannabis as an analgesic option.

Cannabis use may decrease the need for opioids, a phenomenon that could reduce opioid dependency. Now is the ideal time to study patients’ use of and perspectives on cannabis for pain relief in order to establish its effectiveness and safety.

Cannabis shows potential to be a key player in a multimodal approach to chronic pelvic pain.”

https://pubmed.ncbi.nlm.nih.gov/33132057/

https://www.jogc.com/article/S1701-2163(20)30791-X/fulltext

Medical Cannabis Treatment for Chronic Pain: Outcomes and Prediction of Response

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“Although studied in a few randomized controlled trials (RCTs), the efficacy of medical cannabis (MC) for chronic pain remains controversial. Using an alternative approach, this multicenter, questionnaire-based prospective cohort was aimed to assess the long-term effects of MC on chronic pain of various etiologies and to identify predictors for MC treatment success.

Results: 1045 patients completed the baseline questionnaires and initiated MC treatment, and 551 completed the 12 month follow-up. At one year, average pain intensity declined from baseline by 20% [-1.97 points (95%CI= -2.13 to -1.81; p<0.001)]. All other parameters improved by 10-30% (p<0.001). A significant decrease of 42% [reduction of 27mg; (95%CI= -34.89 to -18.56, p<0.001)] from baseline in morphine equivalent daily dosage of opioids was also observed. Reported adverse effects were common but mostly non-serious. Presence of normal to long sleep duration, lower body mass index (BMI) and lower depression score predicted relatively higher treatment success, whereas presence of neuropathic pain predicted the opposite.

Conclusions: This prospective study provides further evidence for the effects of MC on chronic pain and related symptoms, demonstrating an overall mild to modest long-term improvement of the tested measures and identifying possible predictors for treatment success.

Significance: This “real world” paper shows that MC mildly to modestly attenuates chronic pain and related symptoms. MC treatment can also cause frequent, but mostly non-serious adverse effects, although central nervous system (CNS)-related AEs that can impair the ability to drive vehicles are not uncommon. This study is novel in identifying possible predictors for treatment success, including normal to long sleep duration, lower BMI and lower depression scores. In contrast to current beliefs the diagnosis of neuropathic pain predicts a less favorable outcome. These findings provide physicians with new data to support decision making on recommendations for MC treatment.”

https://pubmed.ncbi.nlm.nih.gov/33065768/

https://onlinelibrary.wiley.com/doi/10.1002/ejp.1675