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Medical cannabis provides only small improvement in chronic pain

21st September 2021

A systematic review found that use of non-inhaled medical cannabis in patients with chronic pain leads to only a small improvement compared with placebo.

In a 2006 European survey of over 46,000 respondents in 15 countries, 19% reported experiencing pain which lasted for at least 6 months. Moreover, a more recent 2019 study in developing countries found a similar incidence (18%) among the general population. However, the impact of chronic pain, i.e., which persists past the normal healing time and lasts or recurs for more than 3 to 6 months, has a much wider impact upon affected individuals, reducing physical functioning, daily activities and mental health. Although opioid drugs have been used for the management of chronic pain, evidence suggests that compared with placebo, there are only small beneficial effects. Consequently, there has been increased interest in the use of alternative pain management strategies, one of which is the use of medical cannabis. In fact, its use as a therapeutic alternative has been recommended in some guidance for chronic pain, especially in cases where other treatments have been ineffective. However, the overall effectiveness of medical cannabis in chronic pain remains unclear with some organisations such as NICE in the UK, advising against the use of cannabis-based medicinal products to manage chronic pain in adults unless as part of a clinical trial.

With uncertainty over the effectiveness of medical cannabis in chronic pain, Canadian researchers led by a team from the Department of Anesthesia, McMaster University, Ontario, Canada, performed a systematic review and meta-analysis to determine the benefits and harms of medical cannabis in patients with chronic pain, including cancer pain. They included randomised controlled trials that enrolled at least 20 patients with chronic pain (defined as lasting longer than 3 months) and who were assigned to any form of medical cannabis and which was compared to placebo with a follow-up period of at least one month. As well as the impact on pain, the team also captured data on physical, emotional and social functioning and sleep quality. They assessment the benefits in terms of change scores from baseline as opposed to end of study results and determined whether use of cannabis achieved the minimally important difference (MID). This represents the smallest amount of improvement in a treatment outcome that patients recognise as important. For example, using a 10 cm visual analogue scale for pain, the MID is approximately 1 cm. The researchers modelled the risk difference (RD) of achieving at least the MID.

Findings
A total of 32 trials with 5174 adults in which 29 compared medical cannabis with placebo were included in the analysis. In terms of pain relief, there was moderate certainty evidence from 27 trials that medical cannabis compared to placebo, resulted in a small increase in the proportion of patients experiencing pain relief at or above the MID. This difference was modelled as 10 % (95% CI 5% to 15%). Data from 10 trials suggested a 7% increase in the proportion of patient experiencing at least a 30% reduction in pain with medical cannabis compared to placebo. Similarly, there was a 4% modelled difference in physical functioning and a 6% modelled risk difference for an improvement in sleep quality. However, there was no apparent improvement in emotional or social functioning. With respect to adverse effects, it appeared that medical cannabis gave rise to a 2% risk of transient cognitive impairment, impaired attention (3%) and nausea (5%).

The authors concluded that there was moderate to high certainty evidence of a small to very small increase in the proportion if people with chronic pain who experience an important improvement in their pain. Their results have been summarised in an accompanying rapid recommendation.

Citation
Wang L et al. Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials. BMJ 2021

Medicinal cannabis does not impair driving performance

4th December 2020

Epidemiological studies have shown that cannabis is associated with an increased risk of car crashes.

Whether or not, cannabidiol, the derivative widely used as medicinal cannabis, also impairs driving performance is largely unknown.

Cannabis is available in three different varieties (or technically, chemovars) which are cannabidiol (CBD) dominant, tetrahydrocannabinol (THC) dominant and a CBD-THC equivalent mixture. Individuals inhale the THC dominant form because of its intoxicating effects. Whether the CBD dominant form, used medicinally, has sedating properties is currently equivocal.

As a result, researchers from the Lambert Initiative for Cannabinoid Research, University of Sidney, Australia, conducted a randomised trial to examine the extent and duration to which each of the different cannabis chemovars impaired driving performance. They recruited 26 individuals with a history of occasional cannabis use and employed a cross-over design study that involved four on-road driving periods, one week apart. For the study, the participants inhaled one of vapourised cannabis containing 13.75mg CBD, THC, CBD-THC equal mixture or placebo. The driving tests twice; 40 to 100 minutes and 240 to 300 minutes post-vaporisation. The primary outcome was the mean standard deviation of lateral position (SDLP), which measures the extent of lane weaving, swerving and overcorrecting.

Findings
The mean age of the 26 individuals was 23.2 years (including 16 women), all of whom completed the 8 driving tests. At 40 to 100 minutes and following inhalation of cannabis, the mean SDLP after CBD was 84.07cm, 86.94cm after THC, 84.07cm after the CBD-THC mixture and 84.41cm after placebo and these values remained similar between 240 and 300 minutes. Pairwise comparisons revealed that both SDLP values for THC and the THC-CBD were higher than placebo at 40 to 100 minutes, but not between 240 and 300 minutes. In other words, both THC and the combination but not, CBD, impaired driving performance in the short-term, but that this effect was abolished in the longer term.

Although a limitation in the study, recognised by the authors, was that the dosages used might not reflect common usage, their data implied that CBD did not affect driving ability.

Citation
Arkell TR et al. Effect of cannabidiol and delta-nine tetrahydrocannabiniol on driving performance. A randomised clinical trial. JAMA Net Open 2020 doi:10.1001/jama.2020.21218