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While the authors call for rigorous future studies, they acknowledge that cannabis being a Schedule 1 drug makes it difficult to conduct clinical trials.
Many people use cannabis products (CPs) and cannabis-based medicines (CBMs) to manage chronic pain, but clinicians often lack the information needed to help guide their patients on appropriate cannabis use.
“Products and dosing regimens in existing trials are not generalizable to the current cannabis market, making it difficult to compare and reconcile these two bodies of literature…Clinicians cannot wait years for definitive clinical trials before engaging with patients about these products,” Kevin F. Boehnke, PhD, and coauthors write in Anesthesia & Analgesia. “In this complex environment, pain specialists require straightforward, actionable information to effectively work with patients.”
The researchers summarize the latest scientific literature and provide practical advice on cannabis use to help clinicians develop a therapeutic alliance with their patients, reduce harm, and use pragmatic clinical judgment.
They define terms; give an overview of the effects when cannabis is smoked, taken orally, sublingually, or topically; discuss preclinical studies of the effects of cannabinoids, including cannabidiol (CBD) and tetrahydrocannabinol (THC), on pain; and talk about systematic reviews and observational studies of cannabis. They also cover sleep and anxiety, adverse effects, harms, and medication interactions.
While the authors call for rigorous future studies, they acknowledge that cannabis being a Schedule 1 drug makes it difficult to conduct clinical trials. They recommend that, until results of definitive trials are available, clinicians refer to complementary studies that use real-world data, including longitudinal studies, retrospective chart reviews or case series studies, and pragmatic trials.
Physician’s Weekly (PW) talked with Dr. Boehnke about some of the current issues around integrating cannabis products into chronic pain treatment.
PW: What advice do you have for clinicians about medicinal cannabis?
Dr. Boehnke: The big clinician takeaways are that clinicians need to engage with their patients by compassionately and thoughtfully trying to understand why they’re using cannabis, how they’re using it, and treating it like any other medication. Clinicians can help people learn how to optimize cannabis use to improve symptoms or discontinue it if it’s not helpful.
Why is it important to share this information now?
I’ve been a researcher in this space for over a decade, and this article synthesizes information I’ve collected over time. My coauthors and I hope it spurs clinical conversations that help people figure out when, how, and if they should use cannabis.
Cannabis has been used medicinally for thousands of years. Many people use cannabis for chronic pain, and cannabis use is becoming destigmatized and widely acceptable culturally and legally. We can collect better data when people are not afraid of legal, medical, or other consequences.
It’s important to understand the connection between how criminalization directly harms people and how that direct harm influences the prevalence of chronic pain, trauma, and other medical conditions that people are, coincidentally, going to treat with cannabis. We need to shift our thinking about healing and how we practice medicine at individual and societal levels.
How may your article affect patient care?
This article lays out a template for clinicians to think about the various domains of cannabis use. I’m hoping this will give clinicians who are on the fence permission to engage their patients around cannabis use. These clinical conversations often do not happen, although they should.
What issues about cannabis for pain are especially worth noting?
Unfortunately, we don’t have clinical trials for several reasons, including criminalization and the structure of the existing market. Clinicians want to see clinical trials to understand appropriate products and dosages. But the marketplace has many products, and they’re changing much faster than the science. That makes it challenging to inform clinical care and offers an enormous opportunity to provide people with choices.
The FDA has approved a handful of cannabinoid-based medications, and people can get products in various forms. Depending on the state they’re in, they may be able to purchase non-FDA-approved products from a dispensary that are far less expensive and easier to titrate than FDA-approved products. Clinicians should become familiar with their own state and institutional policies around cannabis.
What additional research are you planning?
I’m working on a clinical trial that involves people who have chronic pain and receive one-on-one coaching to determine whether that affects their cannabis use patterns and improves their chronic pain symptoms.
