Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Clinical question: What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes? Current practice: Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries. Recommendation: The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain. How this guideline was created: An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective. The evidence: This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain. Understanding the recommendation: The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.

Cannabis and Migraine: It's Complicated.

PURPOSE OF REVIEW: The use of cannabis for the treatment of migraine has become an area of interest with the legalization of medical cannabis in the USA. Understanding the mechanisms of cannabinoids, available studies, and best clinical recommendations is crucial for headache providers to best serve patients. RECENT FINDINGS: Patients utilizing medical cannabis for migraine have reported improvement in migraine profile and common comorbidities. Reduction in prescription medication is also common, especially opioids. Side effects exist, with the majority being mild. Not enough data is available for specific dose recommendations, but THC and CBD appear to mediate these observed effects. The purpose of this article is twofold: review the limited research surrounding cannabis for migraine disease and reflect on clinical management experiences to provide recommendations that best capture the potential use of cannabis for migraine.

A regulatory take on cannabis and cannabinoids for medicinal use in the European Union.

The discovery of the endocannabinoid system has raised public interest in the medicinal use of cannabis, phytocannabinoids, and synthetic cannabinoids, which has always been closely regulated due to their psychotropic effects and potential abuse. The review takes a quick look at the current legal framework in the European Union, which regulates cannabis use and cultivation for medicinal purposes in line with the United Nations Conventions on the production, trade, and use of cannabis, phytocannabinoids, and synthetic cannabinoids. And while the EU legislation precisely defines requirements and marketing authorisation procedures for medicinal products for all EU member states, there is no common regulatory framework for magistral and officinal preparations containing cannabinoids, as they are exempt from marketing authorisation. Instead, their regulation is left to each member state, and it is quite uneven at this point, mainly due to cultural and historical differences between the countries, leading to different access to non-authorised medicinal products. Therefore, to meet great public interest, harmonised approaches on cannabinoid-containing products without marketing authorisation would be welcome to level the playing field in the EU.

Surveys of pharmacy students and pharmacy educators regarding medical marijuana.

INTRODUCTION: In this study, a cohort of Ohio pharmacy students were surveyed about knowledge and attitudes regarding medical marijuana (MMJ). Pharmacy educators in legalized states were asked how MMJ education was incorporated into pharmacy curricula. METHODS: Pharmacy students from six colleges were emailed surveys. Pharmacy educators from 79 colleges in states with legal MMJ programs were emailed regarding curricular content covering MMJ. RESULTS: A total of 319 student respondents received scores between 50 and 60% on knowledge-based questions. Students favored legalization of medical, but not recreational marijuana; they are not confident in ability to counsel; they believe little education on MMJ is provided in pharmacy school; and feel that more education is needed on MMJ. Students supporting MMJ were more likely to support recreational use of marijuana (p < 0.001), and education about MMJ (p < 0.001). Students in advanced years were less willing to dispense medical marijuana (p < 0.01), and less likely to support pharmacist availability for counseling (p < 0.05). Sixty-two percent of colleges who responded to the survey in legalized states provided education on MMJ to pharmacy students. Sixty-four percent of colleges responding who provided MMJ education offered a required course; 84.6% educated on indications and misuse/abuse; 92.3% on side effects, and adverse drug reactions; 53.8% on drug interactions. CONCLUSION: Ohio pharmacy student knowledge regarding medical marijuana is low. Students believe pharmacists should be available for counseling on MMJ; they feel unprepared to dispense MMJ, and would like more education on MMJ. Some colleges of pharmacy in the US report providing MMJ education; extent is unknown.

[Cannabis for medicinal use: development of pharmacopoeia monographs as a quality standard]. / Cannabis für medizinische Zwecke: Entwicklung von Arzneibuchmonographien als Qualitätsstandard.

Herbal drugs and extracts, like all pharmaceutical starting materials used in the manufacture of medicinal products, must have an appropriate pharmaceutical quality. Corresponding quality standards are described in the individual monographs of the pharmacopoeia according to § 55 of the German Drug Law. This includes information on ingredients and active substance content, among other things. This article describes the development of the Cannabis Flower Monograph for the German Pharmacopoeia (DAB) and the quality requirements and storage conditions contained therein. The state of development of monographs for the European Pharmacopoeia is also presented.After it was announced that there would be new legal regulations for the medical use of cannabis flowers and cannabis extracts, the first work on the cannabis flower monograph for the DAB began as early as 2015. First, a monograph on cannabis flowers was published in May 2016 in the German Drug Codex (DAC). The monograph was replaced in May 2017 by the publication of the DAB monograph. A revised version of the DAB monograph has been in force since April 2018 as a national quality standard.A harmonised cannabis flower monograph for the European Pharmacopoeia is currently being prepared to replace national quality standards. In addition, the German Pharmacopoeia and subsequently the European Pharmacopoeia develops monographs for preparations from cannabis flowers. In future, harmonised monographs in the European Pharmacopoeia will make it possible to avoid multiple testing according to the respective national standards and to facilitate analyses in laboratories and pharmacies.

Barriers to Achieving Optimal Success with Medical Cannabis: Opportunities for Quality Improvement.

This commentary describes the clinician experience of certifying patients for medical cannabis (MC) in a north suburban Chicago integrative family medicine practice. The physician and research assistant performed a comprehensive chart review of the first 166 MC patients certified in the practice. Based on this review, barriers and opportunities were elucidated to improve delivery of MC therapy in Illinois within the existing framework of regulation, licensing, certification, and distribution. The following factors have posed challenges for the Illinois Medical Cannabis Pilot Program. These factors are interrelated and include: (1) inadequate scientific knowledge regarding effectiveness, dosage, delivery mechanism, indications, and drug interactions in humans; (2) lack of educational standards for dispensary and medical staff training; (3) lack of communication and coordination of patient care; (4) complexity and inconsistent availability of dosing options; and (5) barriers to access for patients seeking this therapy.

The Role of Cannabis in the Management of Inflammatory Bowel Disease: A Review of Clinical, Scientific, and Regulatory Information.

There is significant interest among patients and providers in using cannabis (marijuana) and its derivatives to treat a number of chronic illnesses, including inflammatory bowel disease. Despite the Schedule I classification of cannabis by the federal government, state governments have sought ways to make cannabis available for specific medical conditions, and some states have legalized cannabis outright. This white paper summarizes the preclinical data, clinical data, safety data, and the regulatory landscape as they apply to medical cannabis use in inflammatory bowel disease. Animal models of cannabinoid chemistry and physiology give evidence of anti-inflammatory, antidiarrheal, and nociceptive-limiting properties. Human studies have found benefit in controlling symptoms and improving quality of life, but no studies have established true disease modification given the absent improvement in biomarker profiles or endoscopic healing. Finally, this review describes the legal, regulatory, and practical hurdles to studying the risks and benefits of medical cannabis in the United States. 10.1093/ibd/izy319_video1 izy319.video1 5852852028001.

Comprehensive quality evaluation of medical Cannabis sativa L. inflorescence and macerated oils based on HS-SPME coupled to GC-MS and LC-HRMS (q-exactive orbitrap®) approach.

There are at least 554 identified compounds in C. sativa L., among them 113 phytocannabinoids and 120 terpenes. Phytocomplex composition differences between the pharmaceutical properties of different medical cannabis chemotype have been attributed to strict interactions, defined as 'entourage effect', between cannabinoids and terpenes as a result of synergic action. The chemical complexity of its bioactive constituents highlight the need for standardised and well-defined analytical approaches able to characterise the plant chemotype, the herbal drug quality as well as to monitor the quality of pharmaceutical cannabis extracts and preparations. Hence, in the first part of this study an analytical procedures involving the combination of headspace-solid-phase microextraction (HS-SPME) coupled to GC-MS and High Resolution Mass-Spectrometry LC-HRMS (Orbitrap®) were set up, validated and applied for the in-depth profiling and fingerprinting of cannabinoids and terpenes in two authorised medical grade varieties of Cannabis sativa L. inflorescences (Bedrocan® and Bediol®) and in obtained macerated oils. To better understand the trend of all volatile compounds and cannabinoids during oil storage a new procedure for cannabis macerated oil preparation without any thermal step was tested and compared with the existing conventional methods to assess the potentially detrimental effect of heating on overall product quality.

Propuestas de regulación del uso terapéutico de los productos derivados del cannabis / Proposals for the regulation of the therapeutic use of products derived from cannabis

En las últimas décadas en España se ha producido un movimiento de la sociedad civil reivindicando la regulación del consumo, cultivo y distribución del cannabis. Al mismo tiempo, se ha reclamado reiteradamente, tanto por pacientes, asociaciones de pacientes y distintos profesionales, la regulación del uso terapéutico del cannabis y de los productos derivados, que en nuestro país carece de una regulación específica. El presente estudio tiene como finalidad ofrecer con carácter general las propuestas que en la legislación española existen acerca del uso terapéutico del cannabis y productos derivados. La exigua legislación que se aplica a dicho uso deriva de la Convención Única de 1961 de Estupefacientes y su protocolo; en esta legislación se permite que el THC se pueda dispensar en oficinas de farmacia con receta médica y que pueda ser objeto de investigación médica o científica, con la preceptiva autorización. Por lo que parece que en nuestro país se encuentra permitido el uso terapéutico del cannabis, aunque sometido a requisitos muy estrictos. Sin embargo, esta normativa resulta insuficiente para regular todos los aspectos que se pueden derivar del uso terapéutico del cannabis, por cuanto se ha puesto de relieve que hay unas limitaciones importantes en cuanto al uso que se realiza del mismo y en cuanto al acceso, lo que determina que existan vacíos legales que requieren de una regulación más concreta. Esto ha motivado la presentación, tanto en el ámbito autonómico como en el estatal, de diversas propuestas de creación de comisiones y comités que estudien en profundidad dicho uso, y de regulación del uso terapéutico del cannabis, que todavía no se han materializado en una normativa concreta

In recent decades in Spain there has been a movement of civil society demanding the regulation of consumption, cultivation and distribution of cannabis. At the same time, regulation of the therapeutic use of cannabis and derived products has been repeatedly demanded by patients, patient associations and different professionals, which in our country lacks specific regulation. The present study has as a general purpose to offer the proposals that in Spanish legislation exist on the therapeutic use of cannabis and derived products. The meager legislation that applies to such use derives from the 1961 Single Convention on Narcotic Drugs and its protocol; This legislation allows THC to be dispensed in pharmacies with a medical prescription and that can be the subject of medical or scientific research, with the required authorization. It seems that in our country is allowed the therapeutic use of cannabis, although subject to very strict requirements. However, this legislation is insufficient to regulate all aspects that can be derived from the therapeutic use of cannabis, since it has been emphasized that there are important limitations in the use that is made of it and in terms of access, Which determines that there are legal loopholes that require more concrete regulation. This has motivated the presentation, both in the autonomous and in the state, of various proposals for the creation of commissions and committees that study in depth such use, and regulation of the therapeutic use of cannabis, which have not yet materialized in legislation concrete

Medical marijuana: A treatment worth trying?

With medical marijuana available in more and more states, family physicians need to know what the evidence says about its use. This review includes a step-by-step guide and a list of red flags to watch for.

Cannabinoids: Medical implications.

Herbal cannabis has been used for thousands of years for medical purposes. With elucidation of the chemical structures of tetrahydrocannabinol (THC) and cannabidiol (CBD) and with discovery of the human endocannabinoid system, the medical usefulness of cannabinoids has been more intensively explored. While more randomized clinical trials are needed for some medical conditions, other medical disorders, like chronic cancer and neuropathic pain and certain symptoms of multiple sclerosis, have substantial evidence supporting cannabinoid efficacy. While herbal cannabis has not met rigorous FDA standards for medical approval, specific well-characterized cannabinoids have met those standards. Where medical cannabis is legal, patients typically see a physician who "certifies" that a benefit may result. Physicians must consider important patient selection criteria such as failure of standard medical treatment for a debilitating medical disorder. Medical cannabis patients must be informed about potential adverse effects, such as acute impairment of memory, coordination and judgment, and possible chronic effects, such as cannabis use disorder, cognitive impairment, and chronic bronchitis. In addition, social dysfunction may result at work/school, and there is increased possibility of motor vehicle accidents. Novel ways to manipulate the endocannbinoid system are being explored to maximize benefits of cannabinoid therapy and lessen possible harmful effects.