Medical Cannabis in the Treatment of Chronic Pain ______________________________________________________________________ Elon Eisenberg Institute of Pain Medicine, Rambam Health Care Campus, The Technion – Israel Institute of Technology, Haifa, Israel
44
Embed
Medical Cannabis in the Treatment of Chronic Pain...For all other chronic pain conditions (cancer, non-neuropathic noncancer pain), the use of cannabis-based medicines should be regarded
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Medical Cannabis in the Treatment of Chronic Pain______________________________________________________________________
Elon Eisenberg
Institute of Pain Medicine, Rambam Health Care Campus,
The Technion – Israel Institute of Technology, Haifa, Israel
History of Cannabis___________________________________________________________________________________________________________________________
Chinese emperor Shen Nung
3500 or 2800 BCE
Ramses II’ tomb,
dating back to 1224 BCE.
Beit Shemesh 4th century AD
Zias et al. Nature 1993
Sir John R. Reynolds (1828-1896)_____________________________________________________________________________________________________________________________
• The house physician to Queen
Victoria
• President of the Royal College of
Physicians in London
Medicinal use of Cannabis___________________________________________________________________________________________________________________________
“The prohibition”________________________________________________________________________________________________________________
▪ Harry J. Anslinger (1892-1975) played a
pivotal role in cannabis prohibition.
▪ 1937: Marijuana Tax Act
▪ Cannabis is still considered schedule I drug
in the USA, similar to heroin and cocaine
▪ Federal law prohibit use or research
First Commissioner of the U.S. Treasury Department’s
Cannabinoids and pain________________________________________________________________________________________________________________________________
▪ Cannabinoid receptors are localized in areas known as
the “pain matrix” in the CNS and in sites associated
with nociception outside of the CNS.
▪ Cannabinoids interact with non-cannabinoids receptors,
which are associated with pain processing (i.e. TRPV,
serotonin and more).
Spinal Cord
Brain Stem
Thalamus
Sensory Cortex
Limbic Cortex
Ascending pathwaysDescending pathway
CB1R
CB2R
DRG
Nociceptor
Preclinical studies with cannabis________________________________________________________________________________________________________________________________
Ways of consuming herbal cannabis________________________________________________________________________________________________________________________________
FlowersOil drop extracts
Smoking
InhalingInhaling -Bung
Eating Edibles
Sublingual/swallowing
TopicalSwallowing
Cannabis based medications ________________________________________________________________________________________________________________________________
• Oral tablets/capsules of synthetic THC
– Nabilone
– Dronabinole
• Oral mucosal spray of 1:1 THC:CBD cannabis extract
– Nabiximols (Sativex®).
• More recently oil based cannabis extracts with various
THC:CBD concentration ratios
Medical cannabis and pain_____________________________________________________________________________________________________________________________
Headache
Bone pain
Muscle /widespread
pain
Neuropathic
pain
Visceral pain
Joint pain
Inhaled cannabinoids for NP - RCTs (1)________________________________________________________________________________________________________________________________
Main outcomeDurationIntake/
preparation
NIndicationStudy
Smoked or inhaled cannabis
*Cannabis > placebo5 daysSmoked34HIV painAbrams
*Cannabis > placebo5 days X 2Smoked55HIV painWilsey
Cannabinoids for neuropathic pain________________________________________________________________________________________________________________________________
▪ The most extensively studied type of pain
▪ Six low-quality RCTs on smoked cannabis point to efficacy
▪ Seven higher-quality RCTs on cannabinoid based oral/S.L.
medications & eight high-quality RCTs on oral-mucosal
Medical cannabis and pain_____________________________________________________________________________________________________________________________
Bone pain
Muscle /widespread
pain
Neuropathic
pain
Visceral pain
Joint pain
Headache
Cannabinoids for headaches________________________________________________________________________________________________________________________________
Lochte et al. Cannabis & Cannabinoids Research 2017
Cannabinoids for headaches________________________________________________________________________________________________________________________________
Lochte et al. Cannabis & Cannabinoids Research 2017
▪ Currently, there is not enough evidence from well-
designed clinical trials to support the use of cannabis for
headache.
▪ There are anecdotal and preliminary results, as well as
plausible neurobiological mechanisms, to warrant properly
designed clinical trials.
Medical cannabis and pain_____________________________________________________________________________________________________________________________
Bone pain
Muscle /widespread
pain
Neuropathic
pain
Visceral pain
Joint pain
Headache
➢ A single-center, double-blind, placebo-controlled, 4-way crossover
Hoggart B et al. J Neurol 2015 Ware M et al. J Pain 2015
Haroutounian S et al. Clin J Pain 2016 Abuhasira R, et al., Eur J Intern Med 2018
• A prospective, multicenter, longitudinal questionnaire-based
cohort study
• Data collection before and at 1, 3, 6, 9 and 12 months
following HC treatment initiation.
• In total, 843 patients completed at least one follow-up
questionnaire, providing a total of 2,965 observations
following treatment initiation.
The Israeli prospective cohort study (registry)____________________________________________________________________________________________________________________
Percent of change from baseline in weekly pain intensity________________________________________________________________________________________________________________
Percent of change from baseline in related symptoms________________________________________________________________________________________________________________
Reduction in opioid consumption________________________________________________________________________________________________________________
Prediction of response (Alluvial plot)____________________________________________________________________________________________________________________
“Treatment success” was defined as > points reduction in pain
Prediction of response____________________________________________________________________________________________________________________
▪ Significant predictors for “treatment success” were:
▪ Severe baseline pain intensity
▪ Age under 65
▪ Normative anxiety and sleep
▪ Mild disability
▪ Preserved quality of life
▪ The total proportion of variance explained by the mixed
effect model was 61% (random= 39% & fixed= 22%).
▪ Notably, pain diagnosis, pain duration & route of
cannabis consumption did not predict response.
Attitudes towards medical use of cannabis for chronic pain