Medicinal Cannabis (MedCan 3): a randomised, multicentre, double-blind, placebo-controlled trial to assess THC/CBD (1:20) to relieve symptom burden in patients with cancer-a study protocol for a randomised controlled trial.

BACKGROUND: Distressing symptoms are common in advanced cancer. Medicinal cannabinoids are commonly prescribed for a variety of symptoms. There is little evidence to support their use for most indications in palliative care. This study aims to assess a 1:20 delta-9-tetrahydrocannabinol/cannabidiol (THC/CBD) cannabinoid preparation in the management of symptom distress in patients with advanced cancer undergoing palliative care. METHODS AND DESIGN: One hundred and fifty participants will be recruited across multiple sites in Queensland, Australia. A teletrial model will facilitate the recruitment of patients outside of major metropolitan areas. The study is a pragmatic, multicenter, randomised, placebo-controlled, two-arm trial of escalating doses of an oral 1:20 THC/CBD medicinal cannabinoid preparation (10 mg THC:200 mg CBD/mL). It will compare the efficacy and safety outcomes of a titrated dose range of 2.5 mg THC/50mgCBD to 30 mg THC/600 mg CBD per day against a placebo. There is a 2-week patient-determined titration phase, to reach a dose that achieves symptom relief or intolerable side effects, with a further 2 weeks of assessment on the final dose. The primary objective is to assess the effect of escalating doses of a 1:20 THC/CBD medicinal cannabinoid preparation against placebo on change in total symptom distress score, with secondary objectives including establishing a patient-determined effective dose, the effect on sleep quality and overall quality of life. Some patients will be enrolled in a sub-study which will more rigorously evaluate the effect on sleep. DISCUSSION: MedCan-3 is a high-quality, adequately powered, placebo-controlled trial which will help demonstrate the utility of a THC:CBD 1:20 oral medicinal cannabis product in reducing total symptom distress in this population. Secondary outcomes may lead to new hypotheses regarding medicinal cannabis' role in particular symptoms or in particular cancers. The sleep sub-study will test the feasibility of using actigraphy and the Insomnia Severity Index (ISI) in this cohort. This will be the first large-scale palliative care randomised clinical trial to utilise the teletrial model in Australia. If successful, this will have significant implications for trial access for rural and remote patients in Australia and internationally. TRIAL REGISTRATION: ANZCTR ACTRN12622000083796 . Protocol number 001/20. Registered on 21 January 2022. Recruitment started on 8 August 2022.

Cannabis medicine for chronic pain.

In the last decade, patients with chronic pain have expressed increasing interest in cannabis-derived products for adjuvant therapy when treatment is deemed refractory to conventional analgesics. At present, clinical evidence to support this treatment approach appears to be sparse. Not because clinical studies as such are lacking, but rather as a result of methodological bias in relation to study design, patient populations, and treatment protocols. In this review, research in cannabis medicine for relief of chronic pain is reviewed, mainly with reference to published meta-analytic studies.

State-level policies and receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users.

OBJECTIVES: To evaluate the association of state-level policies on receipt of opioid regimens informed by Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day recommendations. DESIGN: A retrospective cohort study of new chronic opioid users (NCOUs). SETTING: Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new chronic use between January 2014 and March 2015. PARTICIPANTS: NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid prescription. INTERVENTIONS: State-level policies including Prescription Drug Monitoring Program (PDMP) robustness and cannabis policies involving the presence of medical dispensaries and state-wide decriminalization. MAIN OUTCOME MEASURES: NCOUs were placed in three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). Multinomial logistic regression was used to estimate the association of state-level policies with the thresholds while adjusting for relevant patient-specific factors. RESULTS: NCOUs in states with medium or high PDMP robustness had lower odds of receiving medium (adjusted odds ratio [AOR] 0.74; 95 percent confidence interval [CI]: 0.62-0.69) and high (AOR 0.74; 95 percent CI: 0.59-0.92) thresholds. With respect to cannabis policies, NCOUs in states with medical cannabis dispensaries had lower odds of receiving high (AOR 0.75; 95 percent CI: 0.60-0.93) thresholds, while cannabis decriminalization had higher odds of receiving high (AOR 1.24; 95 percent CI: 1.04-1.49) thresholds. CONCLUSION: States with highly robust PDMPs and medical cannabis dispensaries had lower odds of receiving higher opioid thresholds, while cannabis decriminalization correlated with higher odds of receiving high opioid thresholds.

Perceptions and engagement of patients with chronic conditions on the use of medical cannabis: a scoping review.

CONTEXT: Studies generally focus on one type of chronic condition and the effect of medical cannabis (MC) on symptoms; little is known about the perceptions and engagement of patients living with chronic conditions regarding the use of MC. OBJECTIVES: This scoping review aims to explore: (1) what are the dimensions addressed in studies on MC that deal with patients' perceptions of MC? and (2) how have patients been engaged in developing these studies and their methodologies? Through these objectives, we have identified areas for improving future research. METHODS: We searched five databases and applied exclusion criteria to select relevant articles. A thematic analysis approach was used to identify the main themes: (1) reasons to use, to stop using or not to use MC, (2) effects of MC on patients themselves and empowerment, (3) perspective and knowledge about MC, and (4) discussion with relatives and healthcare professionals. RESULTS: Of 53 articles, the main interest when assessing the perceptions of MC is to identify the reasons to use MC (n = 39), while few articles focused on the reasons leading to stop using MC (n = 13). The majority (85%) appraise the effects of MC as perceived by patients. Less than one third assessed patients' sense of empowerment. Articles determining the beliefs surrounding and knowledge of MC (n = 41) generally addressed the concerns about or the comfort level with respect to using MC. Only six articles assessed patients' stereotypes regarding cannabis. Concerns about stigma constituted the main topic while assessing relationships with relatives. Some articles included patients in the research, but none of them had co-created the data collection tool with patients. CONCLUSIONS: Our review outlined that few studies considered chronic diseases as a whole and that few patients are involved in the co-construction of data collection tools as well. There is an evidence gap concerning the results in terms of methodological quality when engaging patients in their design. Future research should evaluate why cannabis' effectiveness varies between patients, and how access affects the decision to use or not to use MC, particularly regarding the relationship between patients and healthcare providers. Future research should consider age and gender while assessing perceptions and should take into consideration the legislation status of cannabis as these factors could in fact shape perception. To reduce stigma and stereotypes about MC users, better quality and accessible information on MC should be disseminated.

Cannabis Nursing.

Care for those seeking guidance in the therapeutic use of cannabis.

Trends in U.S. Medical Cannabis Registrations, Authorizing Clinicians, and Reasons for Use From 2020 to 2022.

BACKGROUND: As medical cannabis availability increases, up-to-date trends in medical cannabis licensure can inform clinical policy and care. OBJECTIVE: To describe current trends in medical cannabis licensure in the United States. DESIGN: Ecological study with repeated measures. SETTING: Publicly available state registry data from 2020 to 2022. PARTICIPANTS: People with medical cannabis licenses and clinicians authorizing cannabis licenses in the United States. MEASUREMENTS: Total patient volume and prevalence per 10 000 persons in the total population, symptoms or conditions qualifying patients for licensure (that is, patient-reported qualifying conditions), and number of authorizing clinicians. RESULTS: In 2022, of 39 jurisdictions allowing medical cannabis use, 34 reported patient numbers, 19 reported patient-reported qualifying conditions, and 29 reported authorizing clinician numbers. Enrolled patients increased 33.3% from 2020 (3 099 096) to 2022 (4 132 098), with a corresponding 23.0% increase in the population prevalence of patients (175.0 per 10 000 in 2020 to 215.2 per 10 000 in 2022). However, 13 of 15 jurisdictions with nonmedical adult-use laws had decreased enrollment from 2020 to 2022. The proportion of patient-reported qualifying conditions with substantial or conclusive evidence of therapeutic value decreased from 70.4% (2020) to 53.8% (2022). Chronic pain was the most common patient-reported qualifying condition in 2022 (48.4%), followed by anxiety (14.2%) and posttraumatic stress disorder (13.0%). In 2022, the United States had 29 500 authorizing clinicians (7.7 per 1000 patients), 53.5% of whom were physicians. The most common specialties reported were internal or family medicine (63.4%), physical medicine and rehabilitation (9.1%), and anesthesia or pain (7.9%). LIMITATION: Missing data (for example, from California), descriptive analysis, lack of information on individual use patterns, and changing evidence base. CONCLUSION: Enrollment in medical cannabis programs increased overall but generally decreased in jurisdictions with nonmedical adult-use laws. Use for conditions or symptoms without a strong evidence basis continues to increase. Given these trends, more research is needed to better understand the risks and benefits of medical cannabis. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse of the National Institutes of Health.

Assessing the preparedness and future-readiness of Malaysian community pharmacists in Klang Valley regarding the use of medical marijuana.

BACKGROUND: This study investigated community pharmacists' level of knowledge and attitude towards medical marijuana and its association with sociodemographic characteristics. METHODS: A cross-sectional study was conducted from 21 February 2022 to 15 November 2022. Community pharmacists working in Klang Valley were given a self-administered questionnaire. This survey instrument facilitated the collection of information about their sociodemographic attributes, training background, and knowledge and attitude concerning medical marijuana. Through rigorous analysis of the accumulated data, discernible factors correlating with the levels of knowledge and attitudes surrounding medical marijuana were identified. RESULTS: The majority (n=149, 53.8%) of participants had low knowledge of medical marijuana. Participants with lower knowledge of medical marijuana tend to have a negative attitude toward medical marijuana. Besides that, male participants showed higher knowledge of medical marijuana than female participants. Furthermore, it was found that atheists had the most negative attitude among other religions toward medical marijuana. CONCLUSION: Most community pharmacists in Malaysia lack sufficient knowledge about medical marijuana. This indicates that Malaysian pharmacists are not future-ready and need to equip themselves with adequate knowledge of the indications and adverse effects of medical marijuana if it is to be legalised one day. Thus, there is a need for improved training and education of pharmacists around cannabis-based medicines.

[Topical Use of Cannabis in Inflammatory Diseases in patients of the IPS Salud Social in Barranquilla, Colombia]. / Uso tópico de Cannabis para enfermedades inflamatorias, en pacientes de la IPS Salud Social de Barranquilla.

OBJECTIVE: To relate the topical use of cannabis as an analgesic therapeutic alternative in patients with some inflammatory diseases in Salud Social I.P.S during May to July 2023. METHODS: An analytical, retrospective study was carried out. The population from which the sample was obtained corresponds to patients diagnosed with Arthrosis, Unspecified, Non-Toxic Multinodular Goiter, Epilepsy, Unspecified Type Venous Insufficiency (Chronic) (Peripheral), Unspecified Lumbago, Secondary Gonarthrosis, Rotator Cuff Syndrome, Carpal Tunnel Syndrome, in Salud Social I.P.S of Barranquilla, Atlántico. A sample of 23 patients diagnosed with these pathologies was obtained by non-probabilistic convenience sampling. RESULTS: All patients showed pain relief after two months of follow-up, two experienced adverse effects. Some studies suggest that cannabinoids present in cannabis, such as CBD and THC, may have analgesic and anti-inflammatory properties that could alleviate pain and inflammation associated with these conditions. This is consistent with the present study. CONCLUSION: Topical cannabis is presented as a therapeutic alternative in inflammatory diseases, however, it is important to highlight that research on the use of cannabis in these diseases is limited and more studies are needed to fully understand its effects and potential benefits.

OBJETIVO: Relacionar el uso tópico de cannabis como alternativa terapéutica analgésica en pacientes con algunas enfermedades inflamatorias, de la IPS Salud Social, entre mayo y julio de 2023. MÉTODOS: Se realizó un estudio analítico, retrospectivo. La población de donde se obtuvo la muestra, corresponde a pacientes diagnosticados con Artrosis no especificada, bocio multinodular no tóxico, Epilepsia tipo no especificado, insuficiencia venosa crónica y periférica, Lumbago no especificado, gonartrosis secundaria, síndrome de manguito rotador, síndrome del túnel carpiano, de la IPS Salud Social de Barranquilla, Atlántico. Se obtuvo una muestra de 23 pacientes diagnosticados con estas patologías mediante muestreo no probabilístico por conveniencia. RESULTADOS: Todos los pacientes mostraron alivio del dolor, después de dos meses de seguimiento; dos experimentaron efectos adversos. Algunos estudios sugieren que los cannabinoides presentes en el cannabis, como el CBD y el THC, podrían tener propiedades analgésicas y antiinflamatorias que podrían aliviar el dolor y la inflamación asociados con estas afecciones, lo que es coherente con el presente estudio. CONCLUSIÓN: El cannabis tópico se presenta como una alternativa terapéutica para enfermedades inflamatorias, sin embargo, es importante destacar que la investigación sobre el uso del cannabis en estas enfermedades es limitada y se necesitan más estudios para comprender completamente sus efectos y beneficios potenciales.

Health Literacy and Demand for Medical Cannabis use among Colorectal Cancer Patients in Northern Thailand: A Cross-Sectional Study.

OBJECTIVE: This study aimed to explore health literacy and factors associated with demand for medical cannabis (MC) use among colorectal cancer (CRC) patients in Northern Thailand as a target group. METHODS: This cross-sectional analytical study administered multistage random sampling to recruit 439 CRC patients in northern Thailand. Ethical approval and signed written informed consents were obtained from the patients, prior to the study. A standardized, self-administered structured questionnaire was used to obtain the sociodemographic characteristics, clinical characteristics, social support, attitudes toward MC, knowledge about MC, health literacy about MC, and questions on demand for MC use. The scores from all questionnaires were converted to percentages before analysis. RESULTS: A total of 146 (33.26%) of patients with CRC reported demand to use MC. The multivariable analysis revealed that factors associated with demand for MC among CRC patients included: had high levels of health literacy about MC (adj.OR = 7.71; 95% CI: 4.28 to 13.87), aged less than 45 years (adj.OR =5.09; 95% CI: 2.78 to 9.34), positive attitudes toward MC use (adj.OR = 4.66; 95% CI: 2.68 to 8.10), and higher levels of social support (adj.OR =4.14; 95% CI: 2.39 to 7.17) when controlling effect of other covariates. CONCLUSIONS: Health literacy is an important factor affecting the demand for MC use of CRC patients. Therefore, improving health literacy, social support, and attitudes about MC especially among younger CRC patients, could help increase demand for MC as a complementary and alternative medicine alongside cancer treatment.

The prevalence of cannabis use disorders in people who use medicinal cannabis: A systematic review and meta-analysis.

BACKGROUND: The prevalence of cannabis use disorders (CUDs) in people who use cannabis recreationally has been estimated at 22%, yet there is a dearth of literature exploring CUDs among people who use medicinal cannabis. We aimed to systematically review the prevalence of CUDs in people who use medicinal cannabis. METHODS: In our systematic review and meta-analysis, we followed PRISMA guidelines and searched three databases (PsychInfo, Embase and PubMed) to identify studies examining the prevalence of CUDs in people who use medicinal cannabis. Meta-analyses were calculated on the prevalence of CUDs. Prevalence estimates were pooled across different prevalence periods using the DSM-IV and DSM-5. RESULTS: We conducted a systematic review of 14 eligible publications, assessing the prevalence of CUDs, providing data for 3681 participants from five different countries. The systematic review demonstrated that demographic factors, mental health disorders and the management of chronic pain with medicinal cannabis were associated with an elevated risk of CUDs. Meta-analyses were conducted on the prevalence of CUDs. For individuals using medicinal cannabis in the past 6-12 months, the prevalence of CUDs was 29% (95% CI: 21-38%) as per DSM-5 criteria. Similar prevalence was observed using DSM-IV (24%, CI: 14-38%) for the same period. When including all prevalence periods and using the DSM-5, the prevalence of CUDs in people who use medicinal cannabis was estimated at 25% (CI: 18-33%). CONCLUSIONS: The prevalence of CUDs in people who use medicinal cannabis is substantial and comparable to people who use cannabis for recreational reasons, emphasizing the need for ongoing research to monitor the prevalence of CUDs in people who use medicinal cannabis.

Assessment of education in a community hospital on healthcare providers' knowledge of and attitudes toward medical marijuana.

INTRODUCTION: Although medical marijuana usage continues to become more socially acceptable and is increasingly regarded as a legitimate treatment alternative for certain medical conditions such as cancer and epilepsy, stigma remains. METHODS: This study examined whether offering an educational session addressing several key aspects of medical marijuana (e.g., pharmacology, legality) to healthcare providers in a community hospital setting improved knowledge about and/or altered attitudes toward marijuana use. This information was collected through administration of pre- and post-education session surveys. Multiple choice questions were utilized to assess knowledge of marijuana pharmacotherapy, pharmacodynamic interactions, and regulations, whereas descriptive analyses via Likert-scale questions determined attitudes toward medical marijuana. A secondary outcome entailed analysis of drug interactions with marijuana users via retrospective chart review. RESULTS: A total of 43 healthcare providers participated in the study. There were statistically significant increases in healthcare provider knowledge post-education session across multiple occupations (physician, P < .01; nurse, P < .001; pharmacist, P < .01; and nurse technician, P < .05). A total of 72 patients (83%) who self-reported marijuana use for medical or recreational purposes had a potential drug-drug interaction with marijuana. CONCLUSIONS: As both medical and recreational marijuana continue to become legalized across the United States, formal education surrounding marijuana use and laws becomes increasingly important for healthcare providers and can be highly effective in preventing misinformation.

Stigma, risks, and benefits of medicinal cannabis use among Australians with cancer.

PURPOSE: People with cancer who use medicinal cannabis do so despite risks associated with limited clinical evidence, legalities, and stigma. This study investigated how Australians with cancer rationalise their medicinal cannabis use despite its risks. METHODS: Ten adults (5 males and 5 females; mean age of 53.3) who used cannabis medicinally for their cancer were interviewed in 2021-2022 about how they used and accessed the substance, attitudes and beliefs underpinning their use, and conversations with others about medicinal cannabis. RESULTS: Participants had cancer of the bowel, skin, oesophagus, stomach, thyroid, breast, and Hodgkin lymphoma for which they were receiving treatment (n = 5) or under surveillance (n = 5), with most (n = 6) encountering metastatic disease. Cannabis was used to treat a variety of cancer-related symptoms such as pain, poor sleep, and low mood. Cannabis was perceived as natural and thus less risky than pharmaceuticals. Participants legitimised their medicinal cannabis use by emphasising its natural qualities and distancing themselves from problematic users or riskier substances. Cost barriers and a lack of healthcare professional communication impeded prescription access. Similarly, participants navigated medicinal cannabis use independently due to a lack of guidance from healthcare professionals. CONCLUSION: Findings highlight the need for robust data regarding the harms and efficacy of medicinal cannabis and dissemination of such information among healthcare professionals and to patients who choose to use the substance. Ensuring healthcare professionals are equipped to provide non-judgmental and evidence-based guidance may mitigate potential safety and legal risks.

Cannabis and Cannabinoids in Adults With Cancer: ASCO Guideline.

PURPOSE: To guide clinicians, adults with cancer, caregivers, researchers, and oncology institutions on the medical use of cannabis and cannabinoids, including synthetic cannabinoids and herbal cannabis derivatives; single, purified cannabinoids; combinations of cannabis ingredients; and full-spectrum cannabis. METHODS: A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and cohort studies on the efficacy and safety of cannabis and cannabinoids when used by adults with cancer. Outcomes of interest included antineoplastic effects, cancer treatment toxicity, symptoms, and quality of life. PubMed and the Cochrane Library were searched from database inception to January 27, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations. RESULTS: The evidence base consisted of 13 systematic reviews and five additional primary studies (four RCTs and one cohort study). The certainty of evidence for most outcomes was low or very low. RECOMMENDATIONS: Cannabis and/or cannabinoid access and use by adults with cancer has outpaced the science supporting their clinical use. This guideline provides strategies for open, nonjudgmental communication between clinicians and adults with cancer about the use of cannabis and/or cannabinoids. Clinicians should recommend against using cannabis or cannabinoids as a cancer-directed treatment unless within the context of a clinical trial. Cannabis and/or cannabinoids may improve refractory, chemotherapy-induced nausea and vomiting when added to guideline-concordant antiemetic regimens. Whether cannabis and/or cannabinoids can improve other supportive care outcomes remains uncertain. This guideline also highlights the critical need for more cannabis and/or cannabinoid research.Additional information is available at www.asco.org/supportive-care-guidelines.

Medicinal Use of Different Cannabis Strains: Results from a Large Prospective Survey in Germany.

BACKGROUND: Up to now, it is unclear whether different medicinal cannabis (MC) strains are differently efficacious across different medical conditions. In this study, the effectiveness of different MC strains was compared depending on the disease to be treated. METHODS: This was an online survey conducted in Germany between June 2020 and August 2020. Patients were allowed to participate only if they received a cannabis-based treatment from pharmacies in the form of cannabis flowers prescribed by a physician. RESULTS: The survey was completed by n=1,028 participants. Most participants (58%) have used MC for more than 1 year, on average, 5.9 different strains. Bedrocan (pure tetrahydrocannabinol to pure cannabidiol [THC:CBD]=22:<1) was the most frequently prescribed strain, followed by Bakerstreet (THC:CBD=19:<1) and Pedanios 22/1 (THC:CBD=22:1). The most frequent conditions MC was prescribed for were different pain disorders, psychiatric and neurological diseases, and gastrointestinal symptoms. Overall, the mean patient-reported effectiveness was 80.1% (range, 0-100%). A regression model revealed no association between the patient-reported effectiveness and the variety. Furthermore, no influence of the disease on the choice of the MC strain was detected. On average, 2.1 side effects were reported (most commonly dry mouth (19.5%), increased appetite (17.1%), and tiredness (13.0%)). However, 29% of participants did not report any side effects. Only 398 participants (38.7%) indicated that costs for MC were covered by their health insurance. CONCLUSIONS: Patients self-reported very good efficacy and tolerability of MC. There was no evidence suggesting that specific MC strains are superior depending on the disease to be treated.

Perceptions, Experiences, and Patterns of Cannabis Use in Individuals with Mood and Anxiety Disorders in the Context of Cannabis Legalization and Medical Cannabis Program in Canada - A Qualitative Study.

INTRODUCTION: Perceptions of cannabis as a potential medical treatment for mood and anxiety disorders have been increasing in the context of legalizations, availability, and medical cannabis programs, though current evidence predominately indicates risks and negative effects of cannabis use (CU) on mental health outcomes. This study aims to understand motivations, perceptions, effects, and patterns of CU in individuals with mood and anxiety disorders. METHODS: Thirty-six adult patients diagnosed with mood or anxiety disorders, obsessive-compulsive disorder, or posttraumatic stress disorder who were currently using cannabis completed an in-depth qualitative interview on individual motivations, perceptions, experiences, effects, and patterns of their CU. The thematic analysis focused on phases of CU and sources of cannabis products and information. RESULTS: Reported motivations for initiation of CU included curiosity, peer pressure, and dissatisfaction with conventional treatments. Factors such as psychotropic effects and coping with mental health symptoms and insomnia contributed to the continuation of CU. More negative effects, including cognitive dysfunction, worsening of mood, and anxiety symptoms, were acknowledged with ongoing CU. Concerning findings included common initiation of CU before age 18, combined medical and recreational CU, rare consultation of medical professionals on CU, and potential effects and harms. DISCUSSION: Findings indicate individual complexity of motivations, perceptions, and patterns of CU in the study population. The reported potential beneficial effects of specific cannabis products should be further investigated. Findings emphasize patient-provider dialogue on both CU and conventional treatments. Information from this study can contribute to and inform the development of education, prevention, and intervention strategies.