The Efficacy of Medical Marijuana in the Treatment of Cancer-Related Pain
Publication: Journal of Palliative Medicine
Volume 23, Issue Number 6
Abstract
Background: The opioid epidemic has spurred investigations for nonopioid options, yet limited research persists on medical marijuana's (MMJ) efficacy in managing cancer-related symptoms.
Objective: We sought to characterize MMJ's role on symptomatic relief and opioid consumption in the oncologic population.
Design: Retrospective chart review of MMJ-certified oncology patients was performed. Divided patients into MMJ use [MMJ(+)] versus no use [MMJ(−)], and Edmonton Symptom Assessment System (ESAS)-reported pain cohorts: “mild-moderate” versus “severe.”
Measurements: Medical records were reviewed for ESAS, to measure physical and emotional symptoms, and opiate consumption, converted into morphine milligram equivalents (MME). Minimal clinically important differences were determined. Wilcoxon signed-rank tests determined statistical significance between MMJ-certification and most recent palliative care visit.
Results: Identified 232 patients [95/232 MMJ(−); 137/232 MMJ(+)]. Pain, physical and total ESAS significantly improved for total MMJ(−) and MMJ(+); however, only MMJ(+) significantly improved emotional ESAS. MMJ(−) opioid consumption increased by 23% (97.5–120 mg/day MME, p = 0.004), while it remained constant (45–45 mg/day MME, p = 0.522) in MMJ(+). Physical and total ESAS improved in mild-moderate-MMJ(−) and MMJ(+). Pain and emotional symptoms worsened in MMJ(−); while MMJ(+)'s pain remained unchanged and emotional symptoms improved. MMJ(−) opioid consumption increased by 29% (90–126 mg/day MME, p = 0.012); while MMJ(+)'s decreased by 33% (45–30 mg/day MME, p = 0.935). Pain, physical, emotional, and total ESAS scores improved in severe-MMJ(−) and MMJ(+); opioid consumption reduced by 22% in MMJ(−) (135–106 mg/day MME, p = 0.124) and 33% in MMJ(+) (90–60 mg/day MME, p = 0.421).
Conclusions: MMJ(+) improved oncology patients' ESAS scores despite opioid dose reductions and should be considered a viable adjuvant therapy for palliative management.
Get full access to this article
View all available purchase options and get full access to this article.
References
1. van den Beuken-van Everdingen MHJ, Hochstenbach LMJ, Joosten EAJ, et al.: Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manage 2016;51:1070–1090.e9.
2. Mercadante S, Ferrera P, Villari P, Casuccio A: Opioid escalation in patients with cancer pain: The effect of age. J Pain Symptom Manage 2006;32:413–419.
3. Hastie BA, Gilson AM, Maurer MA, Cleary JF: An examination of global and regional opioid consumption trends 1980–2011. J Pain Palliat Care Pharmacother 2014;28:259–275.
4. Cohen MZ, Easley MK, Ellis C, et al.: Cancer pain management and the JCAHO's pain standards: An institutional challenge. J Pain Symptom Manage 2003;25:519–527.
5. Burgess H, Siddiqui A, Burgess F: Long-term opioid therapy for chronic pain and the risk of opioid addiction. R I Med J 2014;1:25–28.
6. Wachholtz A, Gonzalez G: Co-morbid pain and opioid addiction: Long term effect of opioid maintenance on acute pain. Drug Alcohol Depend 2014;145:143–149.
7. Carmona-Bayonas A, Jimenez-Fonseca P, Castanon E, et al.: Chronic opioid therapy in long-term cancer survivors. Clin Trans Oncol 19:236–250.
8. Maida V, Ennis M, Irani S, et al.: Adjunctive nabilone in cancer pain and symptom management: A prospective observational study using propensity scoring. J Support Oncol 2008;6:119–124.
9. Karst M, Salim K, Burstein S, et al.: Analgesic effect of the synthetic cannabinoid CT-3 on chronic neuropathic pain: A randomized controlled trial. JAMA 2003;290:1757–1762.
10. Abrams DI, Guzman M: Cannabis in cancer care. Clin Pharmacol Ther 2015;97:575–586.
11. U.S. Food and Drug Administration. MARINOL (dronabinol) capsules, for oral use. Updated August 2017. www.accessdata.fda.gov/drugsatfda_docs/label/2017/018651s029lbl.pdf
12. Bedard G, Zeng L, Zhang L, et al.: Minimal clinically important differences in the Edmonton Symptom Assessment System in patients with advanced cancer. J Pain Symptom Manage 2013;46:192–200.
13. Hui D, Titus A, Curtis T, et al.: Implementation of the Edmonton Symptom Assessment System for symptom distress screening at a community cancer center: A pilot program. Oncologist 2017;22:995–1001.
14. Hui D, Bruera E: The Edmonton Symptom Assessment System 25 years later: Past, present and future developments. J Pain Symptom Manage 2017;53:630–643.
15. Calculating Total Daily Dose of Opioids for Safer Dosage. www.cdc.gov/drugoverdose/prescribing/guideline.html
16. Silver N, Dourado J, Hitchcock K, et al.: Chronic opioid use in patients undergoing treatment for oropharyngeal cancer. Laryngoscope 2019;129:2087–2093.
17. Sutradhar R, Lokku A, Barbera L: Cancer survivorship and opioid prescribing rates: A population-based matched cohort study among individuals with and without a history of cancer. Cancer 2017;123:4286–4293.
18. Linares OA, Fudin J, Schiesser WE, et al.: Oxycodone recycling: A novel hypothesis of opioid tolerance development in humans. Med Hypotheses 2014;83326–83331.
19. Kawashima H, Ariizumi T, Yamagishi T, et al.: Symptom burden and end-of-life palliative treatments during the last two weeks of life in patients with advanced musculoskeletal sarcoma. J Palliat Med 2019;22:908–914.
20. Madden K, van der Hoek N, Chona S, et al.: Cannabinoids in the management of musculoskeletal pain: A critical review of the evidence. JBJS Rev 2018;6:e7.
21. Schleider LBL, Mechoulam R, Lederman V, et al.: Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med 2018;49:37–43.
22. Boehnke KF, Litinas E, Clauw DJ. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. J Pain 2016;17:739–744.
23. Haroutounian S, Ratz Y, Ginosar Y, et al.: The effect of medicinal cannabis on pain and quality-of-life outcomes in chronic pain. Clin J Pain 2016;32:1036–1043.
24. Corli, O, Santucci C, Corsi N, et al.: The burden of opioid adverse events and the influence on cancer patients' symptomatology. J Pain Symptom Manage 2019;57:899–908.e6.
25. Corli O, Roberto A, Corsi N, et al.: Opioid switching and variability in response in pain cancer patients. Support Care Cancer 2019;27:2321–2327.
26. Erstad BL: Attempts to limit opioid prescribing in critically ill patients: Not So easy, not so fast. Ann Pharmacother 2019;53:716–725.
27. Schüchen RH, Mücke M, Marinova M, et al.: Systematic review and meta-analysis on non-opioid analgesics in palliative medicine. J Cachexia Sarcopenia Muscle 2018;9:1235–1254.
28. Birdsall SM, Birdsall TC, Tims LA. The use of medical marijuana in cancer. Curr Oncol Rep 2016;18:40.
29. Nielsen S, Sabioni P, Trigo JM, et al.: Opioid-sparing effect of cannabinoids: A systematic review and meta-analysis. Neuropsychopharmacology 2017;42:1752.
30. Noyes R, Brunk SF, Baram DA, Canter A: Analgesic effect of delta-9-tetrahydrocannabinol. J Clin Pharmacol 1975;15:139–143.
31. Wiese B, Wilson-Poe AR: Emerging evidence for cannabis' role in opioid use disorder. Cannabis Cannabinoid Res 2018;3:179–189.
32. Whiting PF, Wolff RF, Deshpande S, et al.: Cannabinoids for medical use: A systematic review and meta-analysis. JAMA 2015;313:2456–2473.
33. Cichewicz DL, McCarthy EA: Antinociceptive synergy between Δ9-tetrahydrocannabinol and opioids after oral administration. J Pharmacol Exp Ther 2003;304:1010–1015.
34. Portenoy RK, Ganae-Motan ED, Allende S, et al.: Nabiximols for opioid-treated cancer patients with poorly-controlled chronic pain: A randomized, placebo-controlled, graded-dose trial. J Pain 2012;13:438–449.
35. Johnson JR, Burnell-Nugent M, Lossignol D, et al.: 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;39:167–179.
36. Poli P, Crestani F, Salvadori C, et al.: Medical cannabis in patients with chronic pain: Effect on pain relief, pain disability, and psychological aspects. A prospective non randomized single arm clinical trial. Clin Ter 2018;169:e102–e107.
37. Herndon CM, Jackson KC, Hallin PA: Management of opioid-induced gastrointestinal effects in patients receiving palliative care. Pharmacotherapy 2002;22:240–250.
38. Wilkie G, Sakr B, Rizack T: Medical marijuana use in oncology: A review. JAMA Oncol 2016;2:670–675.
39. Dzierżanowski T. Prospects for the use of cannabinoids in oncology and palliative care practice: A review of the evidence. Cancers 2019;11:129.
40. Tramèr MR, Carroll D, Campbell FA, et al.: Cannabinoids for control of chemotherapy induced nausea and vomiting: Quantitative systematic review. BMJ 2001;323:16.
41. CDC Centers for Disease Control Opioid Overdose. Updated December 19, 2018. www.cdc.gov/drugoverdose/epidemic/index.html
42. Bohnert AS, Valenstein M, Bair MJ, et al.: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305:1315–1321.
43. Brown LF, Kroenke K, Theobald DE, et al.: The association of depression and anxiety with health-related quality of life in cancer patients with depression and/or pain. Psychooncol 2010;19:734–741.
44. William F: Pirl, evidence report on the occurrence, assessment, and treatment of depression in cancer patients. J Natl Cancer Inst Monogr 2004;2004:32–39.
45. Kim SY, Kim SW, Shin IS, et al. Changes in depression status during the year after breast cancer surgery and impact on quality of life and functioning. Gen Hosp Psychiatr 2018;50:33–37.
46. Faller H, Strahl A, Richard M, et al.: Symptoms of depression and anxiety as predictors of physical functioning in breast cancer patients. A prospective study using path analysis. Acta Oncol 2017;56:1677–1681.
47. Scherrer JF, Salas J, Lustman PJ, et al.: Change in opioid dose and change in depression in a longitudinal primary care patient cohort. Pain 2015;156:348.
48. Scherrer JF, Salas J, Copeland LA, et al.: Prescription opioid duration, dose, and increased risk of depression in 3 large patient populations. Ann Fam Med 2016;14:54–62.
49. van den Beuken-van MH, Hochstenbach LM, Joosten EA, et al.: Update on prevalence of pain in patients with cancer: Systematic review and meta-analysis. J Pain Symptom Manage 2016;51:1070–1090.
50. Hughes MT, Smith TJ: The growth of palliative care in the United States. Ann Rev Public Health 2014;35:459–475.
51. Ramchandran K, Tribett E, Dietrich B, Von Roenn J: Integrating palliative care into oncology: A way forward. Cancer Control 2015;22:386–395.
52. Chang VT, Hwang SS, Feuerman M: Validation of the Edmonton Symptom Assessment Scale. Cancer 2000;88:2164–2171.
53. Watanabe S, Nekolaichuk C, Beaumont C, Mawani A: The Edmonton symptom assessment system—What do patients think? Support Care Cancer 2009;17:675–683.
54. Watanabe SM, Nekolaichuk C, Beaumont C, et al.: A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. J Pain Symptom Manage 2011;41:456–468.
55. Braun IM, Wright A, Peteet J, et al.: Medical oncologists' beliefs, practices, and knowledge regarding marijuana used therapeutically: A nationally representative survey study. J Clin Oncol 2018;36:1957–1962.
56. Vigil JM, Stith SS, Adams IM, Reeve AP: Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLoS One 2017;12.
57. Scavone JL, Sterling RC, Van Bockstaele EJ: Cannabinoid and opioid interactions: Implications for opiate dependence and withdrawal. Neuroscience 2013;248:637–654.
58. Lucas P: Rationale for cannabis-based interventions in the opioid overdose crisis. Harm Reduct J 2017;14:58.
