Using Cannabis to Treat Cancer-Related Pain

https://doi.org/10.1016/j.soncn.2019.04.012 Get rights and content

ABSTRACT

Objective

To describe which cannabinoids and terpenes are effective for treating pain.

Data Sources

Peer-reviewed articles, book chapters.

Conclusion

Cannabis and cannabinoid medicines, as modulators of the endocannabinoid system, offer novel therapeutic options for the treatment of cancer-related pain, not only for patients who do not respond to conventional therapies, but also for patients who prefer to try cannabis as a first treatment option.

Implications for Nursing Practice

Understanding the endocannabinoid system, cannabinoids, terpenes, routes of administration, potential drug interactions, clinical implications, and potential side effects ensures nurses can better assist patients who use cannabis for the treatment of cancer pain.

Section snippets

Cannabinoids and Pain

In 2016, The American Society of Clinical Oncology published guidelines to help cancer survivors manage chronic pain. These recommendations included the use of cannabis and cannabinoid-based medicines.7 The National Academy of Sciences, in their 2017 report titled The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research, stated that “There is conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment

Cannabinoids and Terpenes as Analgesic Agents

A cannabinoid is a chemical compound that influences cannabinoid receptors in cells to affect neurotransmitter release. The term cannabinoid can refer to any of the following categories—phytocannabinoids, endocannabinoids, and synthetic cannabinoids10., 11.:

  • Endocannabinoids are cannabinoids produced by and found in the nervous systems and in the immune systems of humans and animals. The two most well understood of these molecules are called anandamide (AEA) and 2-arachidonoylglycerol (2-AG).

Cannabinoids and Opioid Requirements

Cannabis can be a helpful analgesic adjuvant in patients with cancer. Patients with chronic pain have realized relief from cannabinoids in both inflammatory42 and neuropathic pain,43 among other pain categories. In three case studies presented by the Queen Elizabeth II Health Sciences Center in Nova Scotia, Canada, patients who supplemented with cannabis either reduced or eliminated their opioid requirements.44 Also, in a randomized, placebo-controlled, double-blinded crossover study, when THC

Using Cannabinoids to Treat Nociceptive Pain

Data suggest that cannabis can be effective at treating nociceptive pain when the pain has a maintaining cause. For example, a randomized, double-blind, placebo-controlled crossover trial using a 1:1 oromucosal spray in a group of 17 patients suffering from multiple sclerosis-based nociceptive pain found that cannabinoids provided relief to these patients.49 In another study, researchers found that CB1 receptors, CB2 receptors, and anandamide were abundant in the affected tissue of 45 patients

Using Cannabinoids to Treat Neuropathic Pain

Neuropathic pain is one of the most challenging pain syndromes to treat in patients with cancer. The pain can be centrally mediated (for example, brachial plexopathy resulting from a Pancoast tumor) or peripherally mediated (for example, chemotherapy-induced peripheral neuropathy [CIPN]). Nearly 40% of cancer pain is a result of peripheral neuropathy (PN) and studies have suggested that PN pain is more difficult to control with conventional therapies. CIPN is a predictor of PN and patients

Using Cannabinoids to Treat Nociplastic Pain

Data suggest the ECS, which is pivotal in mammalian nociception, is activated under stressful conditions,82 and can be an important signaling pathway for immune modulation.83 There is growing evidence84 that the ECS might be involved in modulating nociplastic pain as well. Nociplastic pain is a general category for all types of pain that do not fit into the nociceptive or neuropathic pain categories.85 Fibromyalgia, non-specific low back pain, and irritable bowel syndrome are all examples of

Assessment

Patient assessment in cannabis therapeutics leverages many of the same evaluation techniques from traditional modalities designed to reveal dysfunction and disease. Cannabis health care professionals should review the following patient information before the appointment:

  • Medical records related to the illness or condition;

  • Results of all related tests or examinations;

  • A list of medications and supplements, including indications, dates, type, dosage, and quantity prescribed;

  • A list of all allergies

Administration for Cancer Pain

There are a number of different delivery methods that patients with cancer can use to consume cannabis. Absorption, efficacy, and side effects are influenced by each method of administration. Typically, patients can benefit by using multiple different routes of administration when managing pain.

Dosing

Dosing remains one the biggest challenges to cannabis administration. There exist no standard cannabis dosing guidelines, no established safety standards, and a patient's response will vary. Cannabis dosing poses unique complexities because of unregulated markets, where there remain poorly labeled products and products with little quality assurance. Patients in most medical states lack opportunities to discuss cannabis products with a pharmacist, and therefore might not be informed about issues

Cancer Patient Case Study: Peripheral Neuropathy

A.Y. is a 53-year-old woman diagnosed with stage IIIB stomach cancer. Her chemotherapy regimen included FLOT (docetaxel, oxaliplatin, fluorouracil/leucovorin, oxaliplatin, and docetaxel) every 3 weeks for eight cycles. Midway through her chemotherapy regimen she developed CIPN grade 3, as defined by the National Cancer Institute Common Toxicity Criteria.96 A.Y. reported that she could not feel her feet. Her balance was unstable (though she suffered from no falls). The tingling sensations in her

Product Safety Considerations

Health care professionals should assist patients in making an informed decision for purchasing safe cannabis products. First, health care professionals should advise patients to purchase products only through state-regulated and county-licensed dispensaries and to avoid non-licensed dispensaries or delivery services. Patients can check their state, county, and department Web sites to locate a licensed dispensary or delivery service. Second, patients should call or visit dispensaries and ask if

Conclusion

Cannabis and cannabinoid medicines, as modulators of the ECS, can offer novel therapeutic options for the treatment of cancer-related pain, not only for patients who do not respond to conventional therapies, but also for patients who prefer to try cannabis (because of its safety profile, the relatively mild side effects, and high tolerability) as a first treatment option. While evidence for the use of cannabis is building, more research is needed in patients with cancer. Randomized controlled

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