Chronic Non-Cancer Pain Management

A TREATMENT ROLE FOR MEDICINAL CANNABIS – ADJUVANT ANALGESIA

Overview

Chronic pain – ongoing treatment challenges

Managing chronic non-cancer pain (CNCP) is acknowledged as one of the greatest challenges in modern medicine. Chronic pain is thought to affect 1.6 million Australians, with GP encounters for treatment increasing by 67% over the past 10 years. The high burden of pain and impact on productivity and quality of life mean patients frequently experience mental health comorbidities including depression, anxiety, sleep disturbance and fatigue.1

The challenge of CNCP treatment is complicated by the complex nature and multiple causes of pain, the difficulty in tackling heightened and disrupted pain sensory signals, and the need to manage psychological consequences that are unique to each patient.

Patients may be recommended pain specialist referral, psychological support and physiotherapy as appropriate to the individual’s needs. Opioids are effective agents for moderate to severe acute and chronic pain, but tolerance reduces their efficacy, leading to potential abuse, overdose and addiction, polypharmacy and unwanted side effects.

The effect of medicinal cannabis on chronic pain

Cannabinoid receptor agonists have shown value in suppressing inflammatory and neuropathic pain often refractory to treatment, with cannabinoid receptors and endocannabinoids present in the pain circuits of both the central and peripheral nervous systems. Therapeutic Goods Administration (TGA) guidance drawing on recent research reports that CNCP patients achieve a 30% to 50% reduction in pain on medicinal cannabis treatment, with a 50% reduction in neuropathic pain.2

By acting on multiple pain targets, cannabinoids can also interfere with inflammatory hyperalgesia and regulate neuroimmune interactions.3,4 This can assist in the management of central sensitisation and symptoms of allodynia and hyperalgesia, common to fibromyalgia and other CNCP conditions.

Studies also show CBD-dominant cannabinoid treatment for pain can lead to improved secondary outcome measures, with improved sleep and mood.4 Further high-quality controlled trials will provide further insights into these early findings.

What are the therapeutic benefits? 5

The benefits of cannabidiol therapy for the chronic pain patient may include:

Is it right for my patient?

The TGA provides guidance on the use of medicinal cannabis products in Australia for the treatment of chronic non-cancer pain.

If patients have been investigated for reversible cause, harm minimising strategies are crucial in the treatment of patients with chronic pain. Prescribed CBD shows good outcomes for patients with escalating self-medicating behaviours, particularly in the use of opioids.3

Suitable patients include:

Dosage and administration

CBD can be used as an oil to activate endocannabinoid receptors in the brain, which makes it helpful not only to treat pain, but in reducing symptoms of stress and anxiety. Cannabidiol will not lead to any alterations in cognitive state or ‘high’, as it does not contain tetrahydrocannabinol (THC).

A suggested starting dose for oil formulations is 0.25–0.5 mL per day, titrating gradually to effect every 4-7 days.

“Start low, and go slow”

Many patients can be transitioned to capsules once the dose is stable. Treatment response, effectiveness and adverse effects can be reviewed after one month.2 Opiates may be weaned very slowly as the medicinal cannabis dose increases, with PRN dosage as needed.

Possible adverse effects

Studies into cannabidiol specifically have found few negative side effects. Potential side effects include dry mouth, nausea and light-headedness. There is no withdrawal period, so stopping CBD at any time is safe to do if side effects are not tolerated.

For further information on prescribing or dosage, visit the health professional portal at https://cannapacific.com.au

References

  • Hill, Palastro et al. Cannabis and Pain: A Clinical Review. Cannabis Cannabinoid Res. 2017; 2(1): 96-104
  • Vučković S, Srebro D, Vujović KS, et al. Cannabinoids and Pain: New Insights From Old Molecules. Front Pharmacol. 2018; 9: 1259. 
  • Argueta DA, Ventura CM, Kiven S, et al. A Balanced Approach for Cannabidiol Use in Chronic Pain. Front Pharmacol. 2020; 11: 561. 

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