Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Busse, Jason W.; Vankrunkelsven, Patrik; Zeng, Linan; Heen, Anja Fog; Merglen, Arnaud; Campbell, Fiona; Granan, Lars-Petter; Aertgeerts, Bert; Buchbinder, Rachelle; Coen, Matteo; Juurlink, David N.; Samer, Caroline Flora; Siemieniuk, Reed A C; Kumar, Nimisha; Cooper, Lynn; Brown, John R.; Lytvyn, Lyubov; Zeraatkar, Dena; Wang, Li; Guyatt, Gordon; Vandvik, Per Olav; Agoritsas, Thomas

doi:10.1136/bmj.n2040

Cited by 80 publications

(92 citation statements)

References 87 publications

(28 reference statements)

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“…Regarding cannabis AEs, there is mixed evidence depending on the cannabinoids used (eg THC vs CBD or a combination of both), however the majority tends to demonstrate that THC use presents more AEs than CBD. [98][99][100][101] Similarly to our findings, somnolence, drowsiness, dizziness and dry mouth are the most common AEs reported for cannabis, no matter the compound used. 99,102 Nevertheless, according to Parihar et al 99 , CBD generally caused somnolence and gastrointestinal disturbances, whereas THC induced psychoactive effects, motor and cognitive impairments.…”

Section: Dovepresssupporting

confidence: 73%

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

Grzelak¹,

Bérubé²,

Gagnon³

et al. 2022

JPR

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To examine 1) pain management strategies within the care trajectory of orthopaedic trauma patients and patients' perception of their effectiveness, 2) adverse effects (AEs) associated with pharmacological treatments, particularly opioids and cannabis, and 3) patients' perceptions of strategies that should be applied after an orthopaedic trauma and support that they should obtain from health professionals for their use. Patients and Methods: This study was conducted with orthopaedic trauma patients in a level 1 trauma center. A convergent mixedmethods design was used. Data on pain experience, pain management strategies used and AEs were collected with self-administered questionnaires at hospital discharge (T1) and at 3 months after injury (T2). Patients' preferences about the pain management strategies used, the required support and AEs were further examined through semi-structured individual interviews at the same time measures. Descriptive statistics and thematic analyses were performed.Results: Seventy-one patients were recruited and 30 individual interviews were undertaken. Pharmacological pain management strategies used at T1 and T2 were mainly opioids (95.8%; 20.8%) and acetaminophen (91.5%; 37.5%). The most frequently applied non-pharmacological strategies were sleep (95.6%) and physical positioning (89.7%) at T1 and massage (46.3%) and relaxation (32.5%) at T2. Findings from quantitative and qualitative analyses highlighted that non-pharmacological strategies, such as comfort, massage, distraction, and physical therapy, were perceived as the most effective by participants. Most common AEs related to opioids were dry mouth (78.8%) and fatigue (66.1%) at T1 and insomnia (30.0%) and fatigue (20.0%) at T2. Dry mouth (28.6%) and drowsiness (14.3%) were the most reported AEs by patients using recreational cannabis. An important need for information at hospital discharge and for a personalized follow-up was identified by participants during interviews. Conclusion: Despite its AEs, we found that opioids are still the leading pain management strategy after an orthopaedic trauma and that more efforts are needed to implement non-pharmacological strategies. Cannabis was taken for recreational purposes but patients also used it for pain relief. Support from health professionals is needed to promote the adequate use of these strategies.

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Section: Dovepresssupporting

confidence: 73%

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

Grzelak¹,

Bérubé²,

Gagnon³

et al. 2022

JPR

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“…This systematic review is part of the BMJ Rapid Recommendations project, a collaborative effort from the MAGIC Evidence Ecosystem Foundation (https://magicevidence.org) and The BMJ. This systematic review informed a parallel guideline published on bmj.com 26 and MAGICapp (box 1).…”

Section: Introductionmentioning

confidence: 90%

Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials

Wang

Hong

May

et al. 2021

BMJ

Self Cite

156

108

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Objective To determine the benefits and harms of medical cannabis and cannabinoids for chronic pain. Design Systematic review and meta-analysis. Data sources MEDLINE, EMBASE, AMED, PsycInfo, CENTRAL, CINAHL, PubMed, Web of Science, Cannabis-Med, Epistemonikos, and trial registries up to January 2021. Study selection Randomised clinical trials of medical cannabis or cannabinoids versus any non-cannabis control for chronic pain at ≥1 month follow-up. Data extraction and synthesis Paired reviewers independently assessed risk of bias and extracted data. We performed random-effects models meta-analyses and used GRADE to assess the certainty of evidence. Results A total of 32 trials with 5174 adult patients were included, 29 of which compared medical cannabis or cannabinoids with placebo. Medical cannabis was administered orally (n=30) or topically (n=2). Clinical populations included chronic non-cancer pain (n=28) and cancer related pain (n=4). Length of follow-up ranged from 1 to 5.5 months. Compared with placebo, non-inhaled medical cannabis probably results in a small increase in the proportion of patients experiencing at least the minimally important difference (MID) of 1 cm (on a 10 cm visual analogue scale (VAS)) in pain relief (modelled risk difference (RD) of 10% (95% confidence interval 5% to 15%), based on a weighted mean difference (WMD) of −0.50 cm (95% CI −0.75 to −0.25 cm, moderate certainty)). Medical cannabis taken orally results in a very small improvement in physical functioning (4% modelled RD (0.1% to 8%) for achieving at least the MID of 10 points on the 100-point SF-36 physical functioning scale, WMD of 1.67 points (0.03 to 3.31, high certainty)), and a small improvement in sleep quality (6% modelled RD (2% to 9%) for achieving at least the MID of 1 cm on a 10 cm VAS, WMD of −0.35 cm (−0.55 to −0.14 cm, high certainty)). Medical cannabis taken orally does not improve emotional, role, or social functioning (high certainty). Moderate certainty evidence shows that medical cannabis taken orally probably results in a small increased risk of transient cognitive impairment (RD 2% (0.1% to 6%)), vomiting (RD 3% (0.4% to 6%)), drowsiness (RD 5% (2% to 8%)), impaired attention (RD 3% (1% to 8%)), and nausea (RD 5% (2% to 8%)), but not diarrhoea; while high certainty evidence shows greater increased risk of dizziness (RD 9% (5% to 14%)) for trials with <3 months follow-up versus RD 28% (18% to 43%) for trials with ≥3 months follow-up; interaction test P=0.003; moderate credibility of subgroup effect). Conclusions Moderate to high certainty evidence shows that non-inhaled medical cannabis or cannabinoids results in a small to very small improvement in pain relief, physical functioning, and sleep quality among patients with chronic pain, along with several transient adverse side effects, compared with placebo. The accompanying BMJ Rapid Recommendation provides contextualised guidance based on this body of evidence. Systematic review registration https://osf.io/3pwn2

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“…A series of four systematic reviews and meta-analyses formed a 2021 BMJ Clinical Practice Summary for the use of medical cannabis and cannabinoids in chronic pain [39 ▪▪ ]. The reviews included randomized trials assessing benefits and harms [40], studies exploring patient values and preferences [41] and the impact of its addition to treatment with opioids [42].…”

Section: Future Developments: Cannabinoidsmentioning

confidence: 99%

New analgesics in cancer pain

Farrer

Dickman

2022

Current Opinion in Supportive &Amp; Palliative Care

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Purpose of reviewCancer pain continues to be a significant problem despite the range of analgesic and adjuvant medications available. The purpose of this review is to explore the most recent developments in the management of cancer pain.Recent findingsTapentadol, launched in the United Kingdom in May 2011, represents the last new analgesic entity with a novel mode of action to enter clinical practice for moderate-to-severe pain. Recent evidence describes the benefit of duloxetine for cancer-related neuropathic pain, and parecoxib by continuous subcutaneous infusion for refractory cancer pain. There is interest in the role of cannabinoids in cancer pain management but much of the evidence to date is in chronic noncancer pain. Conflicting evidence complicates the role that biased opioid agonism may offer in terms of alternative analgesics in the future.SummaryThere is development of new drugs with clinical utility on the horizon but a need for high-quality, randomized controlled trials specifically assessing efficacy and tolerability in cancer pain.

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Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Cited by 80 publications

References 87 publications

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

Pain Management Strategies After Orthopaedic Trauma: A Mixed-Methods Study with a View to Optimizing Practices

Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials

New analgesics in cancer pain

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