Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2024.844513
Brazilian Journal of Anesthesiology
Narrative Review

Cannabinoid products for pain management: recommendations from the São Paulo State Society of Anesthesiology

Produtos canabinoides para tratamento da dor: recomendações da Sociedade de Anestesiologia do Estado de São Paulo

Guilherme Antonio Moreira de Barros, Alexandre Mio Pos, Ângela Maria Sousa, Carla Leal Pereira, Cecília Daniele de Azevedo Nobre, Cláudia Carneiro de Araújo Palmeira, Cristina Aparecida Arrivabene Caruy, Derli Conceição Munhoz, Durval Campos Kraychete, Esthael Cristina Querido Avelar, Fernanda Bono Fukushima, João Batista Santos Garcia, João Nathanael Lima Torres, Karenthan de Abreu Rodrigues, Mariana Palladini, Olympio de Hollanda Chacon Neto, Maria José Carvalho Carmona

Downloads: 2
Views: 550

Abstract

There is growing interest in using cannabinoids across various clinical scenarios, including pain medicine, leading to the disregard of regulatory protocols in some countries. Legislation has been implemented in Brazil, specifically in the state of São Paulo, permitting the distribution of cannabinoid products by health authorities for clinical purposes, free of charge for patients, upon professional prescription. Thus, it is imperative to assess the existing evidence regarding the efficacy and safety of these products in pain management. In light of this, the São Paulo State Society of Anesthesiology (SAESP) established a task force to conduct a narrative review on the topic using the Delphi method, requiring a minimum agreement of 60% among panelists. The study concluded that cannabinoid products could potentially serve as adjuncts in pain management but stressed the importance of judicious prescription. Nevertheless, this review advises against their use for acute pain and cancer-related pain. In other clinical scenarios, established treatments should take precedence, particularly when clinical protocols are available, such as in neuropathic pain. Only patients exhibiting poor therapeutic responses to established protocols or demonstrating intolerance to recommended management may be considered as potential candidates for cannabinoids, which should be prescribed by physicians experienced in handling these substances. Special attention should be given to individual patient characteristics and the likelihood of drug interactions.

Keywords

Cannabinoids Pain Treatment outcome Review

Resumo

Há um interesse crescente na utilização de canabinoides em vários cenários clínicos, incluindo medicamentos para a dor, levando ao desrespeito dos protocolos regulamentares em alguns países. A legislação foi implementada no Brasil, especificamente no estado de São Paulo, permitindo a distribuição de produtos canabinoides pelas autoridades de saúde para fins clínicos, gratuitamente para os pacientes, mediante prescrição profissional. Assim, é imperativo avaliar as evidências existentes sobre a eficácia e segurança destes produtos no tratamento da dor. Diante disso, a Sociedade Paulista de Anestesiologia (SAESP) criou uma força-tarefa para realizar uma revisão narrativa sobre o tema utilizando o método Delphi, exigindo concordância mínima de 60% entre os painelistas. O estudo concluiu que os produtos canabinoides poderiam servir potencialmente como adjuvantes no tratamento da dor, mas sublinhou a importância da prescrição criteriosa. No entanto, esta revisão desaconselha o seu uso para dor aguda e dor relacionada ao câncer. Em outros cenários clínicos, os tratamentos estabelecidos devem ter precedência, especialmente quando protocolos clínicos estão disponíveis, como na dor neuropática. Apenas os pacientes que apresentem respostas terapêuticas deficientes aos protocolos estabelecidos ou demonstrem intolerância ao manejo recomendado podem ser considerados como potenciais candidatos aos canabinoides, que devem ser prescritos por médicos com experiência no manuseio dessas substâncias. Deve ser dada especial atenção às características individuais do paciente e à probabilidade de interações medicamentosas.

Palavras-chave

Canabinoides; Dor; Resultado do tratamento; Análise

References

1. United Nations publication. UN commission reclassifies cannabis, yet still considered harmful [Internet]. UN News. [cited 2023 Sep 11]. Available from: https://news.un.org/en/story/ 2020/12/1079132.

2. Hauser W, Finn DP, Kalso E, et al. European Pain Federation € (EFIC) position paper on appropriate use of cannabis-based medicines and medical cannabis for chronic pain management. Eur J Pain. 2018;22:1547−64.

3. Franca C, Malunguinho E, Gama P, et al. Política estadual de for- ¸ necimento gratuito de medicamentos formulados de derivado vegetal a base de canabidiol, em associa c¸ ao com outras sub- ~ stancias canabinoides, incluindo o tetrahidrocanabidiol [Inter- ^ net]. Brazil: Assembleia Legislativa do Estado de S ao Paulo; ~ 2023. Available from: https://www.al.sp.gov.br/repositorio/ legislacao/lei/2023/lei-17618-31.01.2023.html.

4. Eisenberg E, Ogintz M, Almog S. The pharmacokinetics, efficacy, safety, and ease of use of a novel portable metered-dose cannabis inhaler in patients with chronic neuropathic pain: A phase 1a study. J Pain Palliat Care Pharmacother. 2014;28:216−25.

5. Aviram J, Samuelly-Leichtag G. Efficacy of cannabis-based medicines for pain management: a systematic review and meta-analysis of randomized controlled trials. Pain Physician. 2017;20:E755−96.

6. Gazendam A, Nucci N, Gouveia K, Abdel Khalik H, Rubinger L, Johal H. Cannabinoids in the Management of Acute Pain: A Systematic Review and Meta-analysis. Cannabis Cannabinoid Res. 2020;5:290−7.

7. Kopustinskiene DM, Masteikova R, Lazauskas R, Bernatoniene J. Cannabis sativa L. Bioactive Compounds and Their Protective Role in Oxidative Stress and Inflammation. Antioxidants. 2022;11:660.

8. ANVISA - Agencia Nacional de Vigil ^ ancia Sanit ^ aria. Produtos can- abinoides registrados na Agencia Nacional de Vigil ^ ancia Sanit ^ a- ria - Anvisa [Internet]. Produtos de Cannabis. [cited 2023 Sep 11]. Available from: https://consultas.anvisa.gov.br/#/cannabis/q/?situacaoRegistro=V.

9. Finn DP, Haroutounian S, Hohmann AG, Krane E, Soliman N, Rice AS. Cannabinoids, the endocannabinoid system, and pain: a review of preclinical studies. Pain. 2021;162(Suppl 1):S5−S25.

10. MacCallum CA, Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med. 2018;49:12−9.

11. Wilson FR, Pan W, Schumsky DA. Recalculation of the Critical Values for Lawshe’s Content Validity Ratio. Meas Eval Couns Dev. 2012;45:197−210.

12. Meng H, Johnston B, Englesakis M, Moulin DE, Bhatia A. Selective Cannabinoids for Chronic Neuropathic Pain. Anesth Analg. 2017;125:1638−52.

13. Hauser W, Welsch P, Klose P, Radbruch L, Fitzcharles MA. Ef € ficacy, tolerability and safety of cannabis-based medicines for cancer pain. Der Schmerz. 2019;33:424−36.

14. Dykukha I, Malessa R, Essner U, Uberall MA. Nabiximols in € Chronic Neuropathic Pain: A Meta-Analysis of Randomized Placebo-Controlled Trials. Pain Med. 2021;22:861−74.

15. Bilbao A, Spanagel R. Medical cannabinoids: A pharmacologybased systematic review and meta-analysis for all relevant medical indications. BMC Medicine. 2022;20(1):259.

16. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol. 2021;11:116−29.

17. Maguire DR, France CP. Impact of Efficacy at the m-Opioid Receptor on Antinociceptive Effects of Combinations of m-Opioid Receptor Agonists and Cannabinoid Receptor Agonists. J Pharmacol Exp Ther. 2014;351:383−9.

18. Noyes R, Brunk SF, Avery DH, Canter A. The analgesic properties of delta-9-tetrahydrocannabinol and codeine. Clin Pharmacol Ther. 1975;18:84−9.

19. Johnson JR, Burnell-Nugent M, Lossignol D, Ganae-Motan ED, Potts R, Fallon MT. Multicenter, Double-Blind, Randomized, Placebo-Controlled, Parallel-Group Study of the Efficacy, Safety, and Tolerability of THC:CBD Extract and THC Extract in Patients with Intractable Cancer-Related Pain. J Pain Symptom Manage. 2010;39:167−79.

20. Lynch ME, Cesar-Rittenberg P, Hohmann AG. A Double-Blind, Placebo-Controlled, Crossover Pilot Trial with Extension Using an Oral Mucosal Cannabinoid Extract for Treatment of Chemotherapy-Induced Neuropathic Pain. J Pain Symptom Manage. 2014;47:166−73.

21. Blake A, Wan BA, Malek L, et al. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017;6 (S2):S215−22.

22. To J, Davis M, Sbrana A, et al. MASCC guideline: cannabis for cancer-related pain and risk of harms and adverse events. Support Care Cancer. 2023;31:202.

23. Wallace MS, Marcotte TD, Atkinson JH, Padovano HT, BonnMiller M. A Secondary Analysis from a Randomized Trial on the Effect of Plasma Tetrahydrocannabinol Levels on Pain Reduction in Painful Diabetic Peripheral Neuropathy. J Pain. 2020;21:1175 −86.

24. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and metaanalysis. Lancet Neurol. 2015;14:162−73.

25. Moulin D, Boulanger A, Clark A, et al. Pharmacological Management of Chronic Neuropathic Pain: Revised Consensus Statement from the Canadian Pain Society. Pain Res Manag. 2014;19: 328−35.

26. Furrer D, Kroger E, Marcotte M, et al. Cannabis against chronic € musculoskeletal pain: a scoping review on users and their perceptions. J Cannabis Res. 2021;3:41.

27. Huggins JP, Smart TS, Langman S, Taylor L, Young T. An efficient randomised, placebo-controlled clinical trial with the irreversible fatty acid amide hydrolase-1 inhibitor PF-04457845, which modulates endocannabinoids but fails to induce effective analgesia in patients with pain due to osteoarthritis of th. Pain. 2012;153:1837−46.

28. Boehnke KF, Hauser W, Fitzcharles MA. Cannabidiol (CBD) in € Rheumatic Diseases (Musculoskeletal Pain). Curr Rheumatol Rep. 2022;24:238−46.

29. Khurshid H, Qureshi IA, Jahan N, et al. A Systematic Review of Fibromyalgia and Recent Advancements in Treatment: Is Medicinal Cannabis a New Hope? Cureus. 2021;13:e17332.

30. Walitt B, Klose P, Fitzcharles MA, Phillips T, Hauser W. Cannabi- € noids for fibromyalgia. Cochrane Database Syst Rev. 2016;7: CD011694.

31. van de Donk T, Niesters M, Kowal MA, Olofsen E, Dahan A, van Velzen M. An experimental randomized study on the analgesic effects of pharmaceutical-grade cannabis in chronic pain patients with fibromyalgia. Pain. 2019;160:860−9.

32. Chaves C, Bittencourt PCT, Pelegrini A. Ingestion of a THC-Rich Cannabis Oil in People with Fibromyalgia: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Pain Med. 2020;21:2212−8.

33. Fitzcharles MA, Rampakakis E, Sampalis JS, et al. Use of medical cannabis by patients with fibromyalgia in Canada after cannabis legalisation: a cross-sectional study. Clin Exp Rheumatol. 2021;39:115−9.

34. Bourke SL, Schlag AK, O’Sullivan SE, Nutt DJ, Finn DP. Cannabinoids and the endocannabinoid system in fibromyalgia: A review of preclinical and clinical research. Pharmacol Ther. 2022;240: 108216.

35. Sagy I, Bar-Lev Schleider L, Abu-Shakra M, Novack V. Safety and Efficacy of Medical Cannabis in Fibromyalgia. J Clin Med. 2019;8:807.

36. Abalo R, Martín-Fontelles MI. Cannabis, Cannabinoids, and Visceral Pain. Handbook of Cannabis and Related Pathologies. Elsevier; 2017. p. 439−49https://linkinghub.elsevier.com/ retrieve/pii/B978012800756300051X.

37. Picardo S, Kaplan GG, Sharkey KA, Seow CH. Insights into the role of cannabis in the management of inflammatory bowel disease. Therap Adv Gastroenterol. 2019;12:175628481987097.

38. Bogale K, Raup-Konsavage W, Dalessio S, Vrana K, Coates MD. Cannabis and Cannabis Derivatives for Abdominal Pain Management in Inflammatory Bowel Disease. Med Cannabis Cannabinoids. 2021;4:97−106.

39. Goyal H, Singla U, Gupta U, May E. Role of cannabis in digestive disorders. Eur J Gastroenterol Hepatol. 2017;29:135−43.

40. Nickel JC. Medical marijuana for urologic chronic pelvic pain. Can Urol Assoc J. 2018;12(6S3):S181−3.

41. Carrubba AR, Ebbert JO, Spaulding AC, DeStephano D, DeStephano CC. Use of Cannabis for Self-Management of Chronic Pelvic Pain. J Women’s Heal. 2021;30:1344−51.

42. Tripp DA, Nickel JC, Katz L, Krsmanovic A, Ware MA, Santor D. A survey of cannabis (marijuana) use and self-reported benefit in men with chronic prostatitis/chronic pelvic pain syndrome. Can Urol Assoc J. 2014;8:901.

43. Sharkey KA, Wiley JW. The Role of the Endocannabinoid System in the Brain−Gut Axis. Gastroenterology. 2016;151:252−66.

44. Okusanya BO, Lott BE, Ehiri J, McClelland J, Rosales C. Medical Cannabis for the Treatment of Migraine in Adults: A Review of the Evidence. Front Neurol. 2022;13:871187.

45. Grossman S, Tan H, Gadiwalla Y. Cannabis and orofacial pain: a systematic review. Br J Oral Maxillofac Surg. 2022;60:e677−90.

46. Votrubec C, Tran P, Lei A, et al. Cannabinoid therapeutics in orofacial pain management: a systematic review. Aust Dent J. 2022;67:314−27.

47. Abdallah FW, Hussain N, Weaver T, Brull R. Analgesic efficacy of cannabinoids for acute pain management after surgery: a systematic review and meta-analysis. Reg Anesth Pain Med. 2020;45:509−19.

48. Maione S, Costa B, Di Marzo V. Endocannabinoids: A unique opportunity to develop multitarget analgesics. Pain. 2013;154 (Supplement 1):S87−93.

49. Russo EB, Marcu J. Cannabis Pharmacology: The Usual Suspects and a Few Promising Leads. In 2017. p. 67-134. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1054358917300273.

50. Caspi A, Moffitt TE, Cannon M, et al. Moderation of the Effect of Adolescent-Onset Cannabis Use on Adult Psychosis by a Functional Polymorphism in the Catechol-O-Methyltransferase Gene: Longitudinal Evidence of a Gene X Environment Interaction. Biol Psychiatry. 2005;57:1117−27.

51. Abramovici H. Information for Health Care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids - Health Canada. Ethics [Internet]. 2013;9:152.. Available from: https://www.canada.ca/en/health-canada/services/drugsmedication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids.html.

52. Dryburgh LM, Bolan NS, Grof CPL, et al. Cannabis contaminants: sources, distribution, human toxicity and pharmacologic effects. Br J Clin Pharmacol. 2018;84:2468−76.

53. Schlag AK, Baldwin DS, Barnes M, et al. Medical cannabis in the UK: From principle to practice. J Psychopharmacol. 2020;34:931−7.

54. Jouanjus E, Raymond V, Lapeyre-Mestre M, Wolff V. What is the Current Knowledge About the Cardiovascular Risk for Users of Cannabis-Based Products? A Systematic Review. Curr Atheroscler Rep. 2017;19:26.

55. Cot^ e M, Trudel M, Wang C, Fortin A. Improving Quality of Life With Nabilone During Radiotherapy Treatments for Head and Neck Cancers. Ann Otol Rhinol Laryngol. 2016;125:317−24.

56. Shah S, Schwenk ES, Sondekoppam RV, et al. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. 2023;48:97−117.

57. Hutchings DE, Martin BR, Gamagaris Z, Miller N, Fico T. Plasma concentrations of delta-9-tetrahydrocannabinol in dams and fetuses following acute or multiple prenatal dosing in rats. Life Sci. 1989;44:697−701.

58. Bertrand KA, Hanan NJ, Honerkamp-Smith G, Best BM, Chambers CD. Marijuana Use by Breastfeeding Mothers and Cannabinoid Concentrations in Breast Milk. Pediatrics. 2018;142: e20181076.

59. Chesney E, Oliver D, Green A, et al. Adverse effects of cannabidiol: a systematic review and meta-analysis of randomized clinical trials. Neuropsychopharmacology. 2020;45:1799−806.

60. United Nations. World Drug Report 2019. Booklet 5: CANNABIS AND HALLUCINOGENS [Internet]. Vienna, Austria; 2019. Available from: https://wdr.unodc.org/wdr2019/prelaunch/WDR19_ Booklet_5_CANNABIS_HALLUCINOGENS.pdf.

61. Taha T, Meiri D, Talhamy S, Wollner M, Peer A, Bar-Sela G. Cannabis Impacts Tumor Response Rate to Nivolumab in Patients with Advanced Malignancies. Oncologist. 2019;24:549−54.

62. Zongo A, Lee C, Dyck JRB, et al. Medical cannabis authorization and the risk of cardiovascular events: a longitudinal cohort study. BMC Cardiovasc Disord. 2021;21:426.

63. Fisar Z. Inhibition of monoamine oxidase activity by cannabinoids. Naunyn Schmiedebergs Arch Pharmacol. 2010;381:563−72.

64. Wilens TE, Biederman J, Spencer TJ. Case Study: Adverse Effects of Smoking Marijuana While Receiving Tricyclic Antidepressants. J Am Acad Child Adolesc Psychiatry. 1997;36:45−8.

65. Bhaskar A, Bell A, Boivin M, et al. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. J Cannabis Res. 2021;3:22.


Submitted date:
07/21/2023

Accepted date:
04/24/2024

66563aa0a953956ea6517a55 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections