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Cannabis and pain management

Since 1974, there have been at least 119 clinical studies examining the effects of cannabis and cannabinoids on pain.

Results are particularly encouraging for those who suffer from chronic and neuropathic pain. For example, the paper “Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical Review” by Kevin P. Hill MD appeared in the June 23/30, 2015 edition of the prestigious Journal of the American Medical Association (JAMA). Hill concludes:

“Use of marijuana for chronic pain, neuropathic pain and spasticity due to multiple sclerosis is supported by high-quality evidence [emphasis DFCR]. Six trials that included 325 patients examined chronic pain, 6 trials that included 396 patients investigated neuropathic pain, and 12 trials that included 1600 patients focused on multiple sclerosis. Several of these trials had positive results, suggesting that marijuana or cannabinoids may be efficacious for these indications.”

Published in that same edition of JAMA, Whiting et al. presented a different meta-analysis from that of Hill, but interestingly reached similar conclusions:

“A total of 79 trials (6462 participants) were included; 4 were judged at low risk of bias. Most trials showed improvement in symptoms associated with cannabinoids but these associations did not reach statistical significance in all trials. Compared with placebo, cannabinoids were associated with a greater average number of patients showing a complete nausea and vomiting response (47% vs 20%; odds ratio [OR], 3.82 [95% CI, 1.55 – 9/42]; 3 trials), reduction in pain [emphasis DFCR] (37% vs 31%; OR, 1.41 [95% CI, 0.99 – 2.00]; 8 trials), a greater average reduction in numerical rating scale pain assessment [emphasis DFCR] (on a 0 – 10 – point scale; weighted mean difference [WMD], -0.46 [95% CI, -0.24 to 0.01]; 5 trials).”

Whiting P, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, Keurentjes C, Lang S, Misso K, Ryder S, Schmidlkofer S, Westwood M, Kleijnen J. Cannabinoids for medical use: a systematic reviewand meta-analysis. JAMA 313:2456-2473 (2015).

In a 2013 review that appeared on the cover of The Clinical Journal of Pain, DFCR’s Sunil Aggarwal, MD found that of “38 published randomized controlled trials of cannabis and cannabinoids for pain, 71% (27) concluded that cannabinoids had empirically demonstrable and statistically significant pain-relieving effects, whereas 29% (11) did not”.

Aggarwal SK. Cannabinergic pain medicine: a concise clinical primer and survey of randomized-controlled trial resultsClin J Pain. 2013;29(2):162-71.

Cannabis as neuroprotectant in brain injury

A positive THC screen is associated with decreased mortality in adult patients sustaining traumatic brain injury (TBI). Effect of marijuana use on outcomes in traumatic brain injuryAm Surg. 2014 Oct;80(10):979-83.

Dr Julius Axelrod, who shared the Nobel Prize in Physiology or Medicine in 1970 for his work on catecholamine neurotransmitters, researched the use of cannabinoids as antioxidants and neuroprotectants while at the NIH and co-filed a use patent on this application owned by the Department of Health and Human Services of the United States Government since 2003.

Hampson, Aidan J., Julius Axlerod, and Maurizio Grimaldi. Cannabinoids as Antioxidants and Neuroprotectants. The United States of America as Represented by the Department of Health and Human Services, assignee. Patent 6630507. 7 Oct. 2003. 

In a 2014 review in the journal Neurotherapeutics, a team of Spanish researchers cited 169 articles in the scientific literature, and summed up the potential therapeutic mechanisms of cannabinoids in this area as follows: “The studies reviewed here are all concordant with the view that cannabinoid-based medicines may serve as a novel therapy able to delay/arrest neurodegeneration in acute and chronic neurodegenerative conditions, owing to their capability of normalizing glutamate homeostasis, reducing oxidative injury, and/or attenuating local inflammatory events, and possibly also by their capability of activating cellular responses (e.g., induction of autophagy) in controlling the toxicity of protein aggregates.”

Fernández-ruiz J, Moro MA, Martínez-orgado J. Cannabinoids in Neurodegenerative Disorders and Stroke/Brain Trauma: From Preclinical Models to Clinical Applications. Neurotherapeutics. 2015;12(4):793-806.

Cannabis vs. Opioids

Former players who misused opioids during their NFL career were most likely to misuse compared to others. Current misuse was associated with more pain, undiagnosed concussions and heavy drinking. 

Injury, pain, and prescription opioid use among former National Football League (NFL) playersDrug Alcohol Depend. 2011 Jul 1;116(1-3):188-94.

This study found that 52% of retired NFL players had used prescription opioid pain medications during their active years. Of those, 71% reported misusing these drugs, with approximately one in seven players reporting ongoing dependence. That makes NFL players four times more likely than the general population to become addicted to painkillers.

About 40 people die daily from prescription opioid overdoses, according to the US Centers for Disease Control.

Medical cannabis laws are associated with a stunning 25% lower rate of state-level prescription opioid overdose mortalities. 

Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010JAMA Intern Med. 2014;174(10):1668-1673.

Two recent clinical studies showed significant decrease in use of opioids in patients with chronic pain with legal access to medicinal cannabis. A University of Michigan retrospective survey of 244 chronic pain patients published in The Journal of Pain showed a 64% decrease in opioid use, and a Hebrew University open-label prospective study of medicinal cannabis for 176 chronic, intractable pain patients showed a 44% decrease in opioid use after 6 months.

Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain. 2016;17(6):739-44.
Haroutounian S, Ratz Y, Ginosar Y, et al. The Effect of Medicinal Cannabis on Pain and Quality of Life Outcomes in Chronic Pain: A Prospective Open-label Study. Clin J Pain. 2016 Feb 17.

We conclude that, at a minimum, cannabis is a potentially valuable adjunct to conventional pain-killers, and that NFL players should be permitted to avail themselves of this potentially less harmful substitute.

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