{"id":6693,"date":"2022-04-18T15:27:42","date_gmt":"2022-04-18T19:27:42","guid":{"rendered":"https:\/\/www.santecannabis.ca\/?p=6693"},"modified":"2023-01-23T13:26:03","modified_gmt":"2023-01-23T17:26:03","slug":"chronic-pain-as-seen-by-a-clinic-dedicated-to-medical-cannabis-part-2","status":"publish","type":"post","link":"https:\/\/www.santecannabis.ca\/en\/chronic-pain-as-seen-by-a-clinic-dedicated-to-medical-cannabis-part-2\/","title":{"rendered":"Chronic Pain as Seen by a Clinic Dedicated to Medical Cannabis – Part 2"},"content":{"rendered":"

Part 1<\/a> of this blog post showed some real-world data from the Sant\u00e9 Cannabis observational study and quickly went over chronic pain classification; next came a summary of chronic pain management and the importance of a global treatment, ending with a section on the stigma of chronic pain and pain expression.<\/span>\u00a0<\/span><\/p>\n

This sequel focuses on medical cannabis, from its role regarding opioid substitution to the evidence supporting cannabinoids and features of a cannabis treatment.<\/span>\u00a0<\/span><\/p>\n

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OPIOID SUBSTITUTION IN CHRONIC PAIN<\/span><\/span><\/b>\u00a0<\/span><\/h2>\n

Chronic pain treatment generally consists of pharmacologic and non-pharmacologic approaches. In certain cases, pain and other symptoms are not successfully controlled, which can be difficult to manage, and it\u2019s challenging to return to a pain-free state. Several non-opioid analgesics are available, but many have low efficacy, poor tolerability and significant adverse effects. <\/span>[1]<\/span> Opioids are widely prescribed to relieve chronic non-cancer pain, <\/span>[2]<\/span> but their prolonged use is problematic due to their addictive potential, the development of tolerance, the hyperalgesia they can induce and their adverse effects. <\/span>[1]<\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

Safety is the keyword in the case for cannabinoid-based medicines substitution for opioids: the predominant cannabinoid in cannabis, delta-9-tetrahydrocannabinol (THC), has a very low toxicity (\u201cabsence of mortality\u201d\u2014World Health Organization). <\/span>[3]<\/span> Cannabidiol (CBD), which is gaining in use, has a favourable safety profile as well. <\/span>[4, 5]<\/span>\u00a0<\/span><\/p>\n

A recent Canadian initiative produced a consensus-based algorithm on the safe introduction of cannabinoid-based medicines and opioids taper in chronic pain patients. According to this algorithm, cannabinoid-based medicines can be considered in patients with chronic pain taking opioids and not reaching treatment goals, having opioid-related adverse effects and\/or at risk of opioid-related harm. <\/span>[6]<\/span>\u00a0<\/span><\/p>\n

But what about the evidence supporting the use of cannabinoid-based medicines for chronic pain? Contrary to what some politicians and uninformed healthcare professionals may say, <\/span>there is evidence<\/span><\/i><\/b>. The subject of debate should rather be: <\/span>is there sufficient evidence<\/span><\/i><\/b>?\u00a0<\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

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\"Person<\/span><\/p>\n

EVIDENCE FOR CANNABINOIDS USE IN PAIN MANAGEMENT<\/span><\/span><\/b>\u00a0<\/span><\/h2>\n

Cannabinoid-based medicines still carry an important stigma in the research and medical fields.\u00a0<\/span>\u00a0<\/span><\/p>\n

Interpretation of clinical trial results can vary between authors, but the variation is especially high when judging the evidence for cannabinoids\u2019 efficacy. Indeed, depending on reviews, low to substantial evidence support cannabinoid-based treatments use to manage chronic non-cancer pain. <\/span>[7-19]<\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

However, the fact remains that for some conditions like multiple sclerosis-related neuropathic pain, \u201cthe current literature has provided more reliable data for cannabinoids than for any other drugs\u201d. <\/span>[20]<\/span>\u00a0<\/span><\/p>\n

The following subsections cover the evidence in chronic neuropathic pain, fibromyalgia, and chronic pain with an inflammatory component \u2013 since those are common pain types seen at our clinic.<\/span>\u00a0<\/span><\/p>\n

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CHRONIC NEUROPATHIC PAIN<\/span>\u00a0<\/span><\/span><\/h2>\n

Chronic neuropathic pain is the best studied type of pain in clinical trials assessing cannabinoids and medical cannabis<\/span><\/i><\/b>, <\/span>[10, 19]<\/span> with at least 23 published randomized controlled trials (RCTs). <\/span>[21-46]<\/span>\u00a0<\/span><\/p>\n

The level and quality of the evidence is highly impacted by the quality of trials (questionable blinding to the treatment, small sample size, short trial duration, etc.). Despite the contribution of numerous trials, the evidence that cannabinoids and medical cannabis are effective in chronic neuropathic pain is limited or modest, depending on authors. <\/span>[9-11, 15, 17, 47]<\/span>\u00a0<\/span>\u00a0<\/span><\/p>\n

The following table summarizes study results and shows the supporting evidence for pain reduction with cannabinoid-based medicines (in chronic neuropathic pain), with a modest effect size.\u00a0<\/span>\u00a0<\/span><\/p>\n

\"Chronic<\/p>\n

A group of pain specialists and psychiatrists, researchers, and patient representatives compared 12 pharmacological treatments (including THC-rich, CBD-rich and THC:CBD 1:1 treatments) for the management of chronic neuropathic pain. In agreement with several reviews, cannabinoids (especially CBD) scored modestly in pain relief rates as compared to other medications (such as duloxetine, gabapentin, pregabalin, amitriptyline). <\/span>[48]<\/span> However, cannabinoids scored higher than all other medications when combining benefits and safety scores, with the benefits on quality-of-life contributing heavily to the cannabinoids scores. <\/span>[48]<\/span>\u00a0<\/span><\/p>\n

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FIBROMYALGIA<\/span>\u00a0<\/span><\/span><\/h2>\n

Fibromyalgia is being more and more investigated in recent years and patients frequently turn to medical cannabis in the hope of getting some relief from their symptoms. <\/span>[49, 50]<\/span> Four published RCTs can be found, <\/span>[51-54]<\/span> as well as several observational and retrospective studies. <\/span>[49, 50, 55-63]<\/span>\u00a0<\/span><\/p>\n

This is understandable since chronic non-cancer pain is an umbrella term that combines various pain conditions that have not been studied to the same extent (see Part 1<\/a> for pain classification). Also, reviews may obtain different results based on article design, such as inclusion vs. exclusion of non-randomized controlled trials, analysis per condition vs. \u201cchronic pain\u201d as a single condition, analysis per cannabinoid vs. pooled cannabinoids, etc.\u00a0<\/span>\u00a0<\/span><\/p>\n

The ongoing opioid epidemic<\/a> (and human deaths) is linked to habitual partiality in opioid prescriptions for chronic pain, <\/span>[1]<\/span> and has prompted a search for other analgesic options. Fuelled by public interest, medical cannabis makes a distinguished mark as a new yet centuries old option.\u00a0<\/span>\u00a0<\/span><\/p>\n