Expert panel gives “weak” recommendation for the use of medical cannabis for chronic pain

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An international panel of experts has issued a “weak” recommendation that people with chronic pain should be offered a study with non-inhaled medical cannabis or cannabinoids if standard care is insufficient.

The BMJ quick recommendation published on September 9, 2021 applies to adults and children with moderate to severe chronic pain, regardless of the pain mechanism, including chronic cancer-related pain. It aims to clear the confusion surrounding the role of medicinal cannabis in treating chronic pain.

The recommendation comprises a linked series of four systematic reviews that summarize the current evidence and patient values ​​and preferences for medicinal cannabis or cannabinoid for chronic pain.

In its review, the guideline panel said it was “confident” that uninhaled medical cannabis or cannabinoids resulted in a “small” increase in the proportion of people with chronic pain who experienced “major” improvements in pain and sleep quality; and a “very small” increase in the proportion who experience improvement in physical function.

They said the treatment did not improve emotional functioning and could lead to “a small to very small increase” in the proportion of people with cognitive impairment, vomiting, drowsiness, and a “modest increase” in the proportion of dizziness.

The panel also said it was “less confident” whether the use of medicinal cannabis or cannabinoids will result in decreased opioid use or an increased risk of cannabis dependence.

They added that the recommendation was “weak” because of the close balance between the benefits and harms of medical cannabis in chronic pain.

“It reflects a high level of importance attached to small to very small improvements in self-reported pain intensity, physical function and sleep quality, as well as the willingness to accept a small to modest risk of mostly self-limiting and temporary damage,” said the guideline panel : He added that shared decision-making is needed to ensure that patients make decisions that reflect their values ​​and personal context.

“Further investigation is warranted and may change this recommendation,” they continued.

Andrew Yates, pharmacy manager at the Medical Cannabis Center, said the “important recommendation” was “warmly welcomed” by the organization.

“It represents a number of important innovations: It is the first recommendation regarding CBMPs [cannabis-based medicinal products] Treating chronic pain as a disease regardless of the cause is the first recommendation to have so far taken into account patient values ​​and preferences that are so often forgotten, and it is the first recommendation that can be easily translated into existing UK guidance on the use of non-inhaled formulations , and only after other therapies have been deemed unsuitable for the use of CBMPs.

“We hope that this new recommendation will be quickly reviewed by NICE [National Institute for Health and Care Excellence] who currently do not recommend the use of CBMPs as currently only patients who can pay for their medication privately will benefit from this recommendation, which will result in a two tier system of access to cannabis medicines here in the UK. ”

The NICE clinical guideline on cannabis-based medicinal products does not currently recommend their use in chronic pain.

A spokesperson for NICE said the quick recommendation “recognizes the need for more research to build the evidence base for the use of these drugs and supports the NHS England’s request to collect evidence from both randomized controlled trials and observational studies” .

The quick recommendation is that therapeutic trials should begin with low-dose, non-inhaled cannabidiol products, gradually increasing the dose and delta-9 tetrahydrocannabinol (THC) levels based on clinical response and tolerability.

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