Accurate Education – Marijuana (Cannabis): Chronic Pain Overview

Marijuana (Cannabis)

The medical information on this site is provided as a resource for information only, and is not to be used or relied upon for any diagnostic or treatment purposes and is not intended to create any patient-physician relationship.  Readers are advised to seek professional guidance regarding the diagnosis and treatment of their medical concerns.

 

Marijuana (Cannabis): Chronic Pain Overview

The use of marijuana (cannabis) for chronic pain remains highly controversial and lacks good quality evidence regarding the specifics of clinical effectiveness and the details of treatment including dosing frequency, amount and duration. The following information is provided as an introduction to uses of cannabis and cannabis-based products for chronic pain based on current research.

 

See:

Marijuana – Legislative Update for Louisiana

Marijuana – Medical Use Overview

“Medical Marijuana” – Getting Started

  

Cannabinoid-Based Medications:

Over-the-Counter Cannabinoid Medications:

 

Palmitoylethanolamide (PEA)

Palmitoylethanolamide (PEA)

 

Cannabidiol (CBD)

Cannabidiol (CBD) – Introduction

Cannabidiol (CBD) – Clinical Use

Cannabidiol (CBD) – Drug Actions & Interactions

 

Prescription Cannabis-Based Medications:

FDA-Approved Prescription Cannabis-Based Medications

Louisiana-Rx Cannabis-Based Products – “Medical Marijuana”

 

Clinical Applications of Cannabis:

Cannabis – Anxiety (coming soon)

Cannabis – Fibromyalgia

Cannabis – Headaches (coming soon)

Cannabis – Inflammatory Bowel Disease (coming soon)

Cannabis – Neuroinflammation (coming soon)

Cannabis – Pain (coming soon)

Cannabis – Sleep (coming soon)

 

The Medical Science of Cannabis:

The Endocannabinoid System

Marijuana – Pharmacokinetics

Marijuana – Cannabinoids and Opioids

 

Understanding Marijuana Products

Marijuana – Botanical

Marijuana – Ingestible (Orals & Edibles) coming soon

Marijuana – Inhaled (Smoked and Vaporized)

Marijuana – Topicals coming soon

 

Cannabinoids:

Cannabidiol (CBD)

Cannabigerol (CBG) (coming soon)

Cannabinol (CBN) (coming soon)

Tetrahydrocannabinol (THC) (coming soon)

Tetrahydrocannabivarin (THCV) (coming soon)

 

 Terpenes:

Terpenes – An Overview

   

See also:

Marijuana – Discontinuing Use

Marijuana Addiction – Cannabis Use Disorder (CUD)

  

 

Key to Links:

Grey text – handout

Red text – another page on this website

Blue text – Journal publication

Marijuana (Cannabis): Chronic Pain

Pain is the most common reason individuals seek health care and the most common reason people turn to marijuana (cannabis) and cannabis-based products for therapeutic beneifits. It has an estimated incidence in the United States higher than that of diabetes, cancer, and heart disease combined. Chronic pain can be complex and can result from different mechanisms. While there are different categories of pain, the two dominant categories are nociceptive and neuropathic pain. Nociceptive pain is the nervous system’s response to injury, often perceived as a localized dull, aching or throbbing pain. Neuropathic pain involves  the nerves and can result from changes in the nervous system exposed to chronic pain, independent of real tissue damage. Neuropathic pain is often experienced as sharp, burning or electric in nature, sometimes starting in one location and referred to another adjacent or distant location.

 

Cannabis and cannabis-based products interact with cannabinoid receptors in the endocannabinoid system to play a role in pain modulation and reduction of inflammation. Cannabinoid receptors are widely distributed throughout the central and peripheral nervous system. The hypothesis is that cannabinoids can reduce sensitization of pain sensory pathways and induce alterations in cognitive and autonomic processing in chronic pain states.

See: The Endocannabinoid System

 

There is  a great deal of interest in the potential therapeutic benefits of cannabis and there is substantial evidence that it is an effective treatment for chronic pain in adults, especially neuropathic pain. That being said, when evaluating evidence to guide a clinician’s approach to the use of cannabis and/or its constituents, one is confronted with a complex array of studies that ultimately fail to provide a very specific pathway for treatment recommendations. In an effort to base therapeutic recommendations on meaningful evidence it should be noted that evidence-based medicine (EBM) has three components: (1) clincial research evidence, (2) the physician’s experience, and (3) the patient’s experience. In order to reach a clinical decision in the management of an individual case, all three components are relevant. That being said, anecdotal medical experience and personal advocacy should not supercede evidence based on high-quality research when it is available.

 

 

Clincial research including systematic reviews and meta-analyses of such research, although part of the  evidence, is not the entirety of EBM. However, being that we are in the early history of the clinical application of cannabis and/or its constituents and we are still lacking in adequate documentation of both clinician and patient-based experience, it is necessary to rely on the current research available to guide recommendations for therapeutic uses of cannabis and/or its constituents.

 

Before embarking on a review of the current research regarding the use of  “medical marijuana” for chronic pain, it is important to remember that pain is defined as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” As such, the management of pain includes attention to chronic stress and emotional states, including anxiety and depression. Cannabinoids, the most abundant compounds found in cannabis, are known to facilitate reductions not only in pain but also in chronic stress reactions and emotional learning—important components in chronic pain.

 

To understand the application of cannabis and cannabis-based products in the management of chronic pain, it is necessary to understand that cannabis, the plant, contains many potentially pharmacologically active constituents, likely 100 or more, that might contribute to the analgesic benefits of cannabis. The two primary compounds found in cannabis, the cannabinoids delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD), appear likely to be responsible for the majority of cannabis’s pharmacologic effects, especially the analgesic effects. However, while other constituents may also contribute to the analgesic  effects of cannabis, their roles are not well defined or understood. These other constituents include other cannabinoids and terpenes such as caryophyllene as well as other compounds. Furthermore, different plants contain different amounts and ratios of these pharmacologically active constituents and therefore each plant offers different analgesic benefits. Most studies of “medical marijuana” are based on the use of different strains of cannabis, either smoked, vaped or ingested, in which little or nothing is known about the amounts or ratios of the constituents in the cannabis/cannabis products studied.

 

This fact is very important when, as in the case of Louisiana, “medical marijuana” products legally available are expected to be limited to gel caps or tinctures with specific amounts and ratios of THC & CBD but otherwise unknown amounts and ratios of any other constituents. Additionally, trying to apply conclusions based on studies of plants, either smoked or vaped, or other cannabis-based products that are different from those available in LA is extremely problematic, making it impossible to accurately predict specific analgesic or other clinical benefits likely to be obtained with the use of these legally available cannabis-based products. Out of necessity it is a trial and error process in the use of these products for pain or other conditions.

 

The two main variables in the use of cannabis-based products are the total amounts and the relative ratios of the THC and CBD in the products. The ratio of the two is important because THC and CBD interact with one another in ways that determine the clinical effects, although the exact mechanisms of this interaction remains unknown.

 

THC contributes to the analgesic, anti-spasmodic, anti-tremor, anti-inflammatory, appetite stimulant and anti-nausea properties of cannabis.  Importantly, THC and its active metabolite, 11-Hydroxy-THC. also produce the “high” or euphoria associated with use of cannabis as well as other side effects such as anxiety.

 

CBD, however, reduces pain and anxiety and enhance sleep but does not produce any mind-altering “high” or euphoric effects. CBD also has anti-inflammatory benefits as well as anti-convulsant, anti-psychotic, antioxidant, neuroprotective and immunomodulatory effects. CBD modulates some of the effects of THC, including reducing THC-induced anxiety.

For more detailed information about THC and CBD, please see:

THC, CBD and the Endocannabinoid System.

 

The following sections provide a review on what is currently known or believed regarding the use of cannabis and cannabis-derived constituents in the management of chronic pain. The sections are broken down by which cannabis or cannabis-based products have been studied. To begin, the first section offers a review of what has been published as systematic reviews of both cannabis and cannabis-based products related to chronic pain.

.

Cannabis & Pain: Systematic Reviews

A “systematic review” is a review of pertinent scientific literature using systematic methods to collect research data, critically appraise the quality of the research studies, and synthesize conclusions about the specific outcomes being measured.  They are designed to provide a complete, exhaustive summary of current evidence relevant to a research question. Review authors pool numerical data about the effects of treatments through a process called meta-analyses which assess the evidence for any benefits or harms from the treatments. In this way, systematic reviews summarise the existing clinical research on a topic.

 

In the case of systematic reviews evaluating cannabis and cannabis-based products and their effectiveness for chronic pain, the conclusions available are complicated by an extensive mix of  cannabis-based products studied. Many studies evaluate smoked camnabis plants with no definitive measure of the constituents in the plants and no definitive means of measuring actual dosing of these constituents. Other studies evaluate specific cannabis-based prescription drugs including Casemet (nabilone), a synthetic cannabinoid similar to but different from THC, Marinol (dronabinol), a synthetic THC and Sativex (nabiximols), a cannabis plant-based extract containing THC, CBD and other cannabinoids. While these studies are helpful, they do not provide definiitive evidence to guide conclusions regarding effectiveness or dosing of other different cannabis-based products such as those to be made available in Louisiana.

 

These systematic reviews do, however, provide evidence that at least 0n some level, cannabis-based products have the potential for analgesic benefit. A number of systematic reviews have been published in the last few years, especially since 2017.

 

In “Cannabinoids for medical use – a systematic review and meta-analysis. – 2015,” published in 2015 in the Journal of the American Medical Association, it was concluded that “there is moderate-quality evidence to support the use of cannabinoids for the treatment of chronic pain.”

 

In an article published in 2017, “Cannabis and Pain – A Clinical Review – 2017,” the authors also concluded that there is modest evidence supporting the use of cannabinoids for pain. Furthermore, they noted that there is initial evidence for the use of  “medical cannabis” to allow for a possible reduction in the use of opioids for pain.”

 

A systematic review of systematic reviews of randomized controlled trials (RCT) and prospective long-term observational studies of the use of cannabinoids in pain management and palliative medicine was published in 2017: Cannabinoids in Pain Management and Palliative Medicine. An RCT is defined as “a study design that randomly assigns participants into an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in an RCT is the outcome variable being studied.” In this case, the outcome variable is the cannabis product being studied. Randomized controlled trials are considered the only reliable method for establishing evidence for effective therapy and are the highest standard of research.

 

This 2017 study reviewed pertinent publications from 2009 to 2017 including 750 publications identified but only 11 SRs met their inclusion criteria; 3 of them were of high and 8 of moderate methodological quality. 2 prospective long-term observational studies with medical cannabis and 1 with tetrahydro- cannabinol/cannabidiol spray (THC/CBD spray) were also analyzed. According to evidence-based medicine criteria, the reviewers concluded that there is limited evidence for a benefit of THC/CBD spray in the treatment of neuropathic pain to support the use of THC/CBD spray in carefully selected neuropathic pain patients who have shown insufficient response to standard pharmacotherapy.

 

They further concluded that the use of all cannabinoids for any indication in pain management should be regarded as an individual therapeutic trial due to inadequate evidence for any benefit of cannabinoids (dronabinol, nabilone, medical cannabis, or THC/CBD spray) to treat cancer pain or pain of rheumatic or gastrointestinal origin. It was also noted that treatment with cannabis-based medicines is associated with central nervous and psychiatric side effects.

 

A subsequent systematic review was published in 2018 that evaluated only randomized controlled trials (RCTs), “Cannabinoids for the Treatment of Chronic Pain – A Critical Review of Randomized Controlled Trials – 2018.” This review evaluated 21 trials involving a total of 1614 adult participants with chronic pain including the following conditions: chronic back pain, chronic headaches, temporomandibular disorder, fibromyalgia, myofascial pain, neuropathic pain, HIV neuropathy, rheumatoid arthritis, and osteoarthritis. The duration of the selected trials were rather short, ranging from 5 days to 6 weeks. The types of cannabinoids studied included smoked cannabis, THC, cannabidiol (CBD), Sativex (nabiximol) and synthetic cannabinoids (e.g., dronabinol, nabilone) at different doses and routes of use.

 

All but one of the 21 trials concluded that cannabinoids are effective in managing chronic pain, especially, neuropathic pain. However, while various pain intensity scales were used to assess the effectiveness for pain, other relevant outcomes were often ignored. While 13 studies did evaluate other outcomes such as sleep, mood, anxiety, and depression, physical function and quality of life, the results for these outcomes were not clearly reported or absent. Only 7 trials reported improvements in sleep and only 5 trials reported improvements in quality of life. While 3 trials reported improvements in all measured outcomes. the variability in outcome measures in the studies made it very diffcult to evaluate and to conclude the overall effectiveness of cannabinoids for chronic pain. Unfortunately, the authors concluded that while there remains an inadequate number of of high-quality trials to allow for consistent guidelines or recommendations for clinical practice, cannabinoids can be a potential treatment for chronic pain.

 

 “Systematic review of systematic reviews for medical cannabinoids” is another study published in 2018 that evaluated 1085 articles and identified  23 for pain. Their meta-analysis of 15 RCTs found that 39% of patients taking cannabinoids attained at least a 30% pain reduction, with most studies evaluating nerve pain.  However, sensitivity analysis found study size and duration affected findings, with larger and longer RCTs finding no benefit. The systematic reviews focusing on pain reduction in rheumatologic pain and fibromyalgia generally found equivocal results or insufficient evidence for benefit, respectively. (For additional systematic reviews, see References below).

 

A recent systematic review published in 2018 evaluated cannabis and cannabis-based products specifically looking at their benefit in neuropathic (nerve) pain: Cannabis-based medicines for chronic neuropathic pain in adults (Review). This Cochrane review evaluated 16 studies with 1750 participants. The studies were 2 to 26 weeks long and compared an oromucosal spray with a plant-derived combination of THC and CBD (10 studies), a synthetic cannabinoid mimicking THC (nabilone) (two studies), inhaled herbal cannabis (two studies) and plant-derived THC (dronabinol) (two studies) against placebo (15 studies) and an analgesic (dihydrocodeine) (one study). As with the others, the authors concluded there is a lack of good evidence that any cannabis-derived product is effective for any chronic neuropathic pain. Existing evidence remains weak.

 

Cannabis and Cannabinoids for the Treatment of People With Chronic Noncancer Pain Conditions, a systematic review and meta-analysis of controlled and observational studies, published 2018 also concluded that the evidence on the effectiveness of cannabinoids for chronic noncancer pain conditions (CNCP) is limited, largely based on the quality of the research published. Several reasons were cited for the limitations. First, sample sizes are mostly small and risk of bias are significant so caution should be taken when interpreting their outcomes and applying their findings to the population at whole.

 

Second, since most studies are of limited duration (median of 8 weeks) the appropriateness of applying their findings to long-term use of cannabinoids in CNCP is questionable. Studies suggested that reductions in pain intensity were largest for the short term studies, and smaller or nonsignificant in studies of 13-week duration or longer,  suggesting that cannabinoids may lose their effectiveness over time. Of additional importance, cannabinoid dose was often poorly recorded in the studies.

 

Finally, the overall conclusion is that benefit from cannabinoids for pain are relatively small and side effects are significant, although studies indicate most side effects are not serious. Additionally, most of the higher-quality evidence was for neuropathic pain and multiple sclerosis-related pain, with little, low-quality evidence for fibromyalgia or visceral pain, and very few studies evaluating the most common CNCP conditions, such as back and neck problems, migraines, and arthritis.

 

Of special note: the greatest amount of high-quality evidence was for nabiximols (Sativex). This is important for Louisiana patients since this product most closely matches one of the cannabis-based products available in this state, the balanced THC:CBD tincture with a 1:1 ratio of 5 mg THC and 5 mg CBD/ml.

See: Sativex, FDA-Approved Cannabis-Based Prescription Medications

 

Conclusions Based on Systematic Reviews

While the evidence for benefit of cannabis and cannabis-based products for chronic pain remains limited and weak, based on few well-designed studies, there is still expectation of effectiveness for cannabis-based products. The future holds promise and new studies are pending. In LA it will be necessary to proceed with products for which there is very limited experience beyond their contents. With appropriate cautions and careful attention to dosing, it is likely benefits will be more clearly identified as well as a greater understanding of dosing amounts and ratios.

 

 

 

Resources:

National Academy of Sciences

The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research

 

These lay-person websites appear to be good resources for exploring medical marijuana. However, as is the case generally regarding medical applications of marijuana and its constitnuents, there is a huge amount of information that is not based in good science and relies on anecdotal (word-of-mouth) evidences. Reader, beware:

 

  1. www.CannabisBusinessTimes.com
  2. www.CBDschool.com
  3. www.gfarma.news
  4. www.GreenCamp.com
  5. www.Healer.com
  6. www.Marijuana.com
  7. www.MedicalJane.com
  8. www.profofpot.com
  9. www.ProjectCBD.org
  10. www.Weedmaps.com

 

References:

  1.  

Medical Marijuana – Chronic Pain

  1. A preliminary evaluation of the relationship of cannabinoid blood concentrations with the analgesic response to vaporized cannabis – 2016
  2. A tale of two cannabinoids – The therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. 2005
  3. Cannabinoids for medical use – a systematic review and meta-analysis. – 2015
  4. Cannabinoids for the Treatment of Chronic Pain – A Critical Review of Randomized Controlled Trials – 2018
  5. Cannabinoids for treatment of chronic non-cancer pain – 2011
  6. Cannabinoids for Treatment of Chronic Non-Cancer Pain – a Systematic Review of Randomized Trials*
  7. Cannabinoids in Pain Management and Palliative Medicine – 2017
  8. Cannabis and intractable chronic pain – an explorative retrospective analysis of Italian cohort of 614 patients – 2017
  9. Cannabis and Pain – A Clinical Review – 2017
  10. Cannabis-based medicines for chronic neuropathic pain in adults (Review) – 2018
  11. Cannabis-based medicines for chronic neuropathic pain in adults. 2018 – PubMed – NCBI
  12. Cannabis—A Valuable Drug That Deserves Better Treatment – 2012
  13. Efficacy, tolerability and safety of cannabinoids in chronicpain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis) – 2016
  14. Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management – An overview of systematic reviews.2018 – PubMed – NCBI
  15. Efficacy, Tolerability, and Safety of Cannabinoid Treatments in the Rheumatic Diseases – A Systematic Review of Randomized Controlled Trials – 2016
  16. Journal of Pain.Cannabis in Pain Treatment-Clinical and Research Considerations
  17. Medical Cannabis and Pain – IASP 2014
  18. Medical Cannabis for Non-Cancer Pain – A Systematic Review
  19. Medical cannabis associated with decreased opiate medication use in retrospective cross-sectional survey of chronic pain patients. 2016 – PubMed – NCBI
  20. Pharmacologic management of chronic neuropathic pain Review of the CanadianPain Society consensus statement- 2017
  21. Plant-Based Cannabinoids for the Treatment of Chronic Neuropathic Pain – 2018
  22. Preliminary evaluation of the efficacy, safety, and costs associated with the treatment of chronic pain with medical cannabis – 2018
  23. Selective Cannabinoids for Chronic Neuropathic Pain: A Systematic Review and Meta-analysis. – PubMed – NCBI
  24. Systematic review of systematic reviews for medical cannabinoids – 2018
  25. The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms – A Systematic Review – 2017
  26. The Endocannabinoid System, Cannabinoids, and Pain – 2013
  27. Overcoming the Bell‐Shaped Dose‐Response of Cannabidiol by Using Cannabis Extract Enriched in Cannabidiol – 2015
  28. Multicenter Study of the Efficacy, Safety, and Tolerability of THC:CBD Extract and THC Extract in Patients with Intractable Cancer-Related Pain – 2010
  29. Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study – 2017

 

Cannabis and Pain – Systematic Reviews

  1. Cannabis and Pain – A Clinical Review – 2017
  2. Cannabis-based medicines for chronic neuropathic pain in adults (Review) – 2018
  3. Cannabinoids for the Treatment of Chronic Pain – A Critical Review of Randomized Controlled Trials – 2018
  4. Cannabinoids for Treatment of Chronic Non-Cancer Pain – a Systematic Review of Randomized Trials*
  5. Cannabinoids in Pain Management and Palliative Medicine – 2017
  6. Systematic reviews on therapeutic efficacy and safety of Cannabis (including extracts and tinctures) – 2016
  7. Cannabinoids for treatment of chronic non-cancer pain – 2011
  8. Cannabinoids for medical use – a systematic review and meta-analysis. – 2015
  9. Medical Cannabis for Non-Cancer Pain – A Systematic Review
  10. The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review. – PubMed – NCBI – 2017

 

Medical Marijuana, Chronic Pain – Cannabinoids & Agmatine

  1. Agmatine co-treatment attenuates allodynia and structural abnormalities in cisplatin-induced neuropathy in rats. – PubMed – NCBI
  2. Cannabinoids and agmatine as potential therapeutic alternatives for cisplatin-induced peripheral neuropathy. – 2018
  3. Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study – 2017

 

Medical Marijuana, Chronic Pain – Cannabinoids & Palmitoylethanolamide

  1. Therapeutic utility of palmitoylethanolamide in the treatment of neuropathic pain associated with various pathological conditions – a case series – 2012
  2. Palmitoylethanolamide, a naturally occurring lipid, is an orally effective intestinal anti-inflammatory agent – 2013
  3. Cannabinoid-based drugs targeting CB1 and TRPV1, the sympathetic nervous system, and arthritis – 2015
  4. Fatty acid amide hydrolase: biochemistry, pharmacology, and therapeutic possibilities for an enzyme hydrolyzing anandamide, 2-arachidonoylglycerol,… – PubMed – NCBI 2001
  5. Endocannabinoid-related compounds in gastrointestinal diseases – 2018
  6. ‘Entourage’ effects of N-palmitoylethanolamide and N-oleoylethanolamide on vasorelaxation to anandamide occur through TRPV1 receptors – 2008
  7. Medical Cannabis and Cannabinoids- An Option for the Treatment of Inflammatory Bowel Disease and Cancer of the Colon? – 2018
  8. Effects of homologues and analogues of palmitoylethanolamide upon the inactivation of the endocannabinoid anandamide – 2001
  9. Phytocannabinoids beyond the Cannabis plant – do they exist? – 2010
  10. Palmitoylethanolamide, endocannabinoids and related cannabimimetic compounds in protection against tissue inflammation and pain: potential use in c… – PubMed – NCBI
  11. Cannabinoids as pharmacotherapies for neuropathic pain – from the bench to the bedside. – 2009
  12. Correction – Effect of a new formulation of micronized and ultramicronized N-palmitoylethanolamine in a tibia fracture mouse model of complex regional pain syndrome – 2018
  13. Palmitoylethanolamide induces microglia changes associated with increased migration and phagocytic activity – involvement of the CB2 receptor – 2017
  14. Mast cells, glia and neuroinflammation – partners in crime? – 2013
  15. A Pharmacological Rationale to Reduce the Incidence of Opioid Induced Tolerance and Hyperalgesia – A Review – 2018

 

   

Medical Marijuana – Opioids

  1. Use-of-Prescription-Pain-Medications-Among-Medical-Cannabis-Patients
  2. It is premature to expand access to medicinal cannabis in hopes of solving the US opioid crisis – 2018
  3. Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort – 2018
  4. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. – PubMed – NCBI
  5. Associations between medical cannabis and prescription opioid use in chronic pain patients – A preliminary cohort study – 2017
  6. The prevalence and significance of cannabis use in patients prescribed chronic opioid therapy: a review of the extant literature. – PubMed – NCBI
  7. The use of cannabis in response to the opioid crisis: A review of the literature. – PubMed – NCBI
  8. Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999–2010 – 2014
  9. Rationale for cannabis-based interventions in the opioid overdose crisis – 2017
  10. Cannabis and the Opioid Crisis – 2018
  11. Impact of co-administration of oxycodone and smoked cannabis on analgesia and abuse liability. – PubMed – NCBI
  12. Cannabinoid–Opioid Interaction in Chronic Pain
  13. Synergistic interactions between cannabinoid and opioid analgesics. – PubMed – NCBI
  14. FDA approves CBD drug – Epidiolex – The Washington Post
  15. Effect of cannabis use in people with chronic non-cancer pain prescribed opioids – findings from a 4-year prospective cohort study – 2018

 

Medical Marijuana – THC, Oral

  1. Tetrahydrocannabinol Does Not Reduce Pain in Patients With Chronic Abdominal Pain in a Phase 2 Placebo-controlled Study – 2017

 

 

Medical Marijuana – Pain

  1. Use-of-Prescription-Pain-Medications-Among-Medical-Cannabis-Patients
  2. It is premature to expand access to medicinal cannabis in hopes of solving the US opioid crisis – 2018
  3. Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort – 2018
  4. Patterns and correlates of medical cannabis use for pain among patients prescribed long-term opioid therapy. – PubMed – NCBI
  5. Associations between medical cannabis and prescription opioid use in chronic pain patients – A preliminary cohort study – 2017
  6. Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems – A Clinical Review – 2015
  7. Cannabis for the Management of Pain – Assessment of Safety Study (COMPASS) – 2015

 

Medical Marijuana – Product Evaluation

  1. The Cannabinoid Content of Legal Cannabis in Washington State Varies Systematically Across Testing Facilities and Popular Consumer Products – 2018
  2. Recommended methods for the identification and analysis of cannabis and cannabis products – 2009
  3. Quality Control of Traditional Cannabis Tinctures – Pattern, Markers, and Stability – 2016

 

Medical Marijuana –Misc

  1. A tale of two cannabinoids: the therapeutic rationale for combining tetrahydrocannabinol and cannabidiol. – PubMed – NCBI
  2. Cannabis and cannabis extracts – greater than the sum of their parts? – 2001
  3. Medical cannabis and mental health: A guided systematic review. 2016 – PubMed – NCBI
  4. Epidemiological characteristics, safety and efficacy of medical cannabis in the elderly. – PubMed – NCBI
  5. Cannabis-conclusions – 2017 National Academy of Sciences
  6. Cannabis-chapter-highlights – 2017 National Academy of Sciences
  7. Cannabis-report-highlights – 2017 National Academy of Sciences
  8. Clinical Endocannabinoid Deficiency (CECD): Can this Concept Explain Therapeutic Bene ts of Cannabis in Migraine, Fibromyalgia, Irritable Bowel Syndrome and other Treatment-Resistant Conditions?-2004
  9. Marijuana use and the risk of lung and upper aerodigestive tract cancers: results of a population-based case-control study. – PubMed – NCBI
  10. Cannabis use and cognitive function: 8-year trajectory in a young adult cohort. – PubMed – NCBI
  11. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. – PubMed – NCBI
  12. Cannabinoids and Cytochrome P450 Interactions. – PubMed – NCBI Pharmacogenetics of Cannabinoids – 2018
  13. Systematic review of systematic reviews for medical cannabinoids – 2018
  14. Adverse effects of medical cannabinoids – a systematic review – 2008
  15. Cannabimimetic effects modulated by cholinergic compounds. – PubMed – NCBI
  16. Antagonism of marihuana effects by indomethacin in humans. – PubMed – NCBI
  17. Pharmacokinetics and pharmacodynamics of cannabinoids. – PubMed – NCBI
  18. Clinical Pharmacodynamics of Cannabinoids – 2004
  19. Affinity and Efficacy Studies of Tetrahydrocannabinolic Acid A at Cannabinoid Receptor Types One and Two. – 2017
  20. Quality Control of Traditional Cannabis Tinctures – Pattern, Markers, and Stability – 2016
  21. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: a systematic review. – PubMed – NCBI
  22. Pharmacology of Cannabinoids
  23. Current-status-and-future-of-cannabis-research-Clin-Researcher-2015
  24. Taming THC – potential cannabis synergy and phytocannabinoid-terpenoid entourage effects – 2011
  25. The Cannabis sativa Versus Cannabis indica Debate – An Interview with Ethan Russo, MD – 2016
  26. Review of the neurological benefits of phytocannabinoids – 2018

Emphasis on Education

 

Accurate Clinic promotes patient education as the foundation of it’s medical care. In Dr. Ehlenberger’s integrative approach to patient care, including conventional and complementary and alternative medical (CAM) treatments, he may encourage or provide advice about the use of supplements. However, the specifics of choice of supplement, dosing and duration of treatment should be individualized through discussion with Dr. Ehlenberger. The following information and reference articles are presented to provide the reader with some of the latest research to facilitate evidence-based, informed decisions regarding the use of conventional as well as CAM treatments.

 

For medical-legal reasons, access to these links is limited to patients enrolled in an Accurate Clinic medical program.

 

Should you wish more information regarding any of the subjects listed – or not listed –  here, please contact Dr. Ehlenberger. He has literally thousands of published articles to share on hundreds of topics associated with pain management, weight loss, nutrition, addiction recovery and emergency medicine. It would take years for you to read them, as it did him.

 

For more information, please contact Accurate Clinic.

 

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