When I worked inpatient oncology in the early 1980s, pain was one of the major symptoms we were attempting to manage with limited to moderate success.
Today, pain is one of the most common symptoms in cancer patients occurring in 20-50% of patients with Quality of Life (QoL) being a major concern.
Cancer pain and QoL is a significant concern with risks of developing depression with increased duration and severity of pain. Untreated pain can lead to increased requests for physician assisted suicide, increased hospitalizations and ER visits. Adding to QoL issues, 20-50% of cancer patients are unable to work.
Primary tumors are the source for pain in 65% of cancer patients. Pain can also occur from surgery and radiation and chemotherapy as well as post operative pain.
Also, infusion related pain treatment related mucositis (a complication of some cancer therapies in which the lining of the digestive system becomes inflamed. Often seen as sores in the mouth.) Bone pain and chemo related musculoskeletal pain are also reported.
The National Academy of Sciences has stated that there is conclusive evidence that cannabis or cannabinoids are effective for treatment of chronic pain in adults.
Cannabis has been shown to be effective at reducing inflammation, modulating pain, boosting opioid analgesic effects, resulting in opioid sparing and shifting the dysphoria associated with pain.
On March 2023, The New Guidelines for Cannabis in Chronic Pain Management were released in the journal Cannabis and Cannabinoid Research.
The guidelines offer evidence with a clear framework for tapering patients off opioids using cannabinoids, especially those who are on higher doses of opioid medicine, which places them at a greater risk for fatal overdose.
Strong evidence found that cannabinoids can be effective monotherapy, replacement therapy and or adjunct therapy in:
· Neuropathic pain
· Muscular and neuropathic pain in people living with HIV
· Multiple sclerosis
· Arthritic Conditions
· Fibromyalgia
· Chronic Pain not well controlled with opioids
Eloise Theisen, a board-certified adult geriatric nurse practitioner, presented at the April 2023 Portland, Oregon Cannabis Science Conference. She reviewed her work the last eight years in specialized cannabis therapy working out of Stanford Medicine Health Care Palliative Medicine Clinic in San Jose CA.
She has treated over 8500 patients with an average age of 76:
· 90% have never used cannabis
· 85% are female
· 40% want cannabis for pain
· 45% want to use it for sleep
· Most new patients don’t want psycho activity
Delta 9 THC was identified as the most effective cannabinoid with opioid sparing effects and best used in combination with CBD which mitigates some of the side effects of THC and provides its own pain relief by reducing anxiety and through its anti-inflammatory action.
In addition to products with THC products with CBN or CBG are also helpful.
Meta-analysis of observational studies found 39% reported opioid cessation and 85% reported reduction of opioid use.
Sativex (an oral mucosal spray with 2.7 mg delta 9 THC and 2.5 mg CBD) reported 30% reduction of peripheral neuropathic pain compared to placebo group.
Per Christopher Gilligan, MD, MBA, associate chief medical officer and a pain medicine physician at Brigham & Women's Hospital in Boston, Massachusetts, points to the risks:
"When we have an opportunity to use cannabinoids in place of opioids for our patients, I think that that's a positive thing…and a wise choice in terms of risk benefit."
References
New Guidelines for Cannabis in Chronic Pain Management Released
Pharmacotherapy for diabetic peripheral neuropathy pain and quality of life
Safety of Medical Cannabis in Neuropathic Chronic Pain Management
https://www.mdpi.com/1420-3049/26/20/6257
Cannabinoids and Pain: New Insights from Old Molecules
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277878/
Notes from 2023 Portland CSC presentation Eloise Theisen, board-certified adult geriatric nurse practitioner, Stanford Medicine Health Care Palliative Medicine Clinic in San Jose CA.
https://stanfordhealthcare.org/doctors/t/eloise-theisen.html
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