References
Boehnke KF, et al. “Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain.” J Pain 2016; 17(6):739–744. doi:10.1016/j.jpain.2016.03.002.
Bonn-Miller MO, et al. Labeling accuracy of Cannabidiol extracts sold online. JAMA. 2017 Nov 7;318(17):1708-1709. doi: 10.1001/jama.2017.11909.
Borrell-Carrio F, Suchman AL, Epstein RM. The Biopsychosocial Model 25 years later: Principles, practice, and scientific inquiry. Ann Fam Med 2004; 2(6):576–582. doi: 10.1370/afm.245
Brown JD, Winterstein AG. Potential adverse drug events and drug-drug interactions with medical and consumer cannabidiol (CBD) use. J Clin Med 8(7). Pii: E989. doi: 3390/jcm8070989.
Center for Disease Control and Prevention (CDC). Morbidity and Mortality Weekly Report. Opioids for Chronic Pain. March 15, 2016
Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977; 196:129–136.
Golan DE, Armstrong EJ, Armstrong AW. Principles of Pharmacology. The Pathophysiologic Basis of Drug Therapy. Wolters Kluwer, 4th ed. Diagram: LWW, Principles of Pharmacology, /2e (Golan)
Herring AA, et al. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med 2019; 73(5):481–487. doi:10.1016/j.annemergmed.2018.11.032.
Jamtvedt G, Kristin TD, Christie A, et al. Physical therapy interventions for patients with osteoarthritis of the knee : An overview of systematic reviews. PTJ, 2008; 88(1), 123-136.
Kapoor M, Matel-Pelletier J, Lajeunesse D, et al. Cytokines in the pathophysiology of osteoarthritis. Nature Reviews Rheumatology 2011; 7:33-42
Koppel BS, et al. “Systematic Review: Efficacy and Safety of Medical Marijuana in Selected Neurologic Disorders: Report of the Guideline Development Subcommittee of the American Academy of Neurology.” Neurology, 2014; 82, (17):1556–1563, doi:10.1212/wnl.0000000000000363.
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Ling SM, Bathon JM, Johns Hopkins Arthritis Center. Osteoarthritis: Pathophysiology.
Lucas CJ, et al. The pharmacokinetics and the pharmacodynamics of cannabinoids. Br J Clin Pharmacol 2018; 84(11):2477-2482. doi: 10.111/bcp.13710 Epub 2018
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Mücke, Martin, et al. “Cannabis-based medicines for chronic neuropathic pain in adults.”
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Nielsen S, et al. “Opioid-sparing effect of cannabinoids: A systematic review and meta-analysis.” Neuropsychopharmacology, 2017; 42(9):1752–1765., doi:10.1038/npp.2017.51.
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Resources
American Pain Society/American Academy of Pain Medicine
https://painmed.org/american-pain-society/
American Society of Addiction Medicine (ASAM)
American Society of Addiction Medicine. Buprenorphine Waiver Management.
American Physical Therapy Association (APTA). Move Forward.
APTA. Choose PT: Popular resources.
Canadian Pharmacists Association: How to use naloxone nasal spray in a few simple steps.
CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 - March 15, 2016
Clinical Opiate Withdrawal Scale
College of Psychiatric & Neurologic Pharmacists: Substance Use Disorders.
Collaborative Family Healthcare Association
COWS Score for opiate withdrawal
DIRE: Diagnosis, Intractability, Psychological Risk, Chemical
FDA U.S. Food and Drug Administration. Risk evaluation and mitigation strategies: REMS
International Association for the Study of Pain https://www.iasp-pain.org/
Mayo Clinic. Drug addition (substance use disorder).
Mayo Clinic. Patient Care and Health Information. Osteoarthritis.
Oxford University Medical School. Orthopaedics Knee Examination
ORT: Opioid Risk Tool
Perspectives Clinic: Clinical & Health Psychology
PPM: Practical Pain Management
PrescribetoPrevent.org: Prescribe naloxone, save a life.
School of Medicine and Public Health, University of Wisconsin https://anesthesia.wisc.edu/clinical-commitments/chronic-pain-anesthesia/
Patient Resources
Arthritis Foundation https://www.arthritis.org/
American Cancer Society https://www.cancer.org/
American Chronic Pain Association https://www.theacpa.org/
National Hospice and Palliative Care Organization https://www.nhpco.org/
National Headache Foundation https://headaches.org/
Cannabidiol (CBD) in Pain Management
“Cannabis-Based Medicines for Chronic Neuropathic Pain in Adults” (Review)
- 2017 Cochrane Review
- High quality systematic review of available published literature
- 16 Randomized Controlled Trials (RCTs) with a total of 1750 patients included
- Included studies with mix of THC & CBD, plant material only, and synthetic cannabinoid medications VERSUS placebo or other pain medication
Conclusions
- No high quality evidence is available
- Low quality of evidence that some patients might achieve a 50% pain reduction over placebo
- 20 patients need to be treated for 1 to see this potential benefit
- Moderate quality of evidence that some patients might achieve a 30% pain reduction over placebo
- 11 patients need to be treated for 1 to see this potential benefit
- Many patients experienced undesirable sleepiness, dizziness and confusion
- 3 patients need to be treated for 1 to see this potential harm
- 10% of patients withdrew from studies due to adverse effects
- This is a high number for this type of literature
- “The potential benefits of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD oromucosal spray) in chronic neuropathic pain might be outweighed by their potential harms”
Reference
Mücke, Martin, et al. “Cannabis-based medicines for chronic neuropathic pain in adults.”
Cochrane Database of Systematic Reviews, 2018, doi:10.1002/14651858.cd012182.pub2.
“Cannabinoids in Pain Management and Palliative Medicine: An Overview of Systematic Reviews and Prospective Observational Studies"
- 11 reviews containing data from randomized controlled trials (RCTs) included
- Some weak evidence to support 30% short term (<2 weeks) reduction in neuropathic pain
- Effect may be lost if looking at studies greater than 2 weeks duration
- “…we found inadequate evidence to support the “established” indications claimed by proponents of medical marijuana therapy, such as chronic cancer pain or loss of appetite, nausea and vomiting in advanced disease stages. Likewise, there was no evidence to support the claimed positive effects in patients with internal disorders (arthritis, ulcerative colitis)”
Reference
Häuser W, Fitzcharles MA, Radbruch L, Petzke F: Cannabinoids in pain management and palliative. Dtsch Arztebl Int 2017; 114(38): 627–34. DOI: 10.3238/arztebl.2017.0627
“Systematic Review: Efficacy and Safety of Medical Marijuana in Selected Neurologic Disorders”
- Systematic review of 34 studies of various preparations of medicinal cannabis or cannabinoids
- Conclusions
- For Multiple Sclerosis related spasticity and central pain some cannabis and cannabinoid preparations are probably effective
- For Multiple Sclerosis related urinary dysfunction and tremor cannabis and cannabinoid preparations are probably not effective
- Negative or insufficient data to suggest benefit in Parkinson’s, Huntington’s, Tourette’s, Cervical Dystonia, Epilepsy
Reference
- Koppel BS, et al. “Systematic Review: Efficacy and Safety of Medical Marijuana in Selected Neurologic Disorders: Report of the Guideline Development Subcommittee of the American Academy of Neurology.” Neurology, 2014; 82, (17):1556–1563, doi:10.1212/wnl.0000000000000363.
“Opioid-Sparing Effect of Cannabinoids: A Systematic Review and Meta-Analysis”
- Systematic review of pre-clinical (animal study) and clinical data
- Meta-analysis of data from 6 pre-clinical studies
- Conclusions
- In animal models there is robust and significant opioid sparing effect when opioids are co-administered with THC
- 9 clinical studies were reviewed including 750 patients
- Only one study demonstrated an opioid sparing effect with a very low quality of evidence (a single case series)
Reference
Nielsen S, et al. “Opioid-sparing effect of cannabinoids: A systematic review and meta-analysis.” Neuropsychopharmacology, 2017; 42(9):1752–1765., doi:10.1038/npp.2017.51.
“Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain”
- A widely cited paper
- The results of 185 responses to a 46 question survey
- Medical cannabis patients patronizing a cannabis dispensary filled out an online survey
- The average patient-generated estimate on opioid medication use was a 64% reduction
- Lowest quality of evidence with many limitations
- Heterogeneous/unknown chronic pain syndromes
- Subjective data with recall bias
- Lack of control for other variables
- Physician prescribing practices when patients are certified for medical cannabis
Reference
Boehnke KF, et al. “Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain.” J Pain 2016; 17(6):739–744. doi:10.1016/j.jpain.2016.03.002.
