Experience of adjunctive cannabis use for chronic non-cancer pain: Findings from the Pain and Opioids IN Treatment (POINT) study
Introduction
Chronic non-cancer pain (CNCP) is a common disorder that makes a major contribution to disease burden. The recent Global Burden of Disease 2010 study estimated that in 2010, low back pain, neck pain and migraines were the 1st, 4th and 8th largest contributors respectively to global non-fatal health burden (years lived with disability; Vos et al., 2012). CNCP also affects other domains, and can have a major adverse impact on social and financial well-being, as well as health care costs (Beubler et al., 2006). With the ageing of the population in many high income countries, the burden of chronic pain is likely to increase in the future.
Management of CNCP has been considered best through effective physical and psychological programmes, aided by non-opioid pharmacotherapy (Savage, 1999). Even when a combination of interventions is used, many people continue to experience pain that impairs daily functioning. Short-term controlled trials have evaluated pharmaceutical opioids in the treatment of a range of CNCP conditions and have demonstrated modest attenuation of pain (Bloodworth, 2005); one systematic review concluded that there is only weak evidence of long-term analgesic benefit (as defined by improved physical function and quality of life) (Noble et al., 2010).
There has been considerable debate about the role and efficacy of cannabinoids for medicinal use in a range of CNCP conditions (Bostwick, 2014, Farrell et al., 2014, Robson, 2014). A recent review concluded that there is poor quality evidence of cannabinoid analgesic efficacy from controlled trials of neuropathic pain associated with multiple sclerosis, spinal cord injury or HIV neuropathy (Farrell et al., 2014). Despite the limited data, there is strong advocacy by users for the symptomatic benefit of adjunctive cannabis, and increasing general interest in its use. Although in most jurisdictions, doctors cannot prescribe cannabis despite requests from patients to do so, in countries where cannabis use may be legally obtained via either prescription or authorised by a medical practitioner, chronic pain is the most common indication for use [e.g., the Netherlands (Hazekamp and Heerdink, 2013) and Canada (Ware et al., 2003)]. Although increasing numbers of US States are allowing the medical use of cannabis, most recently including New York, in many places cannabis remains illegal for any purpose. Many CNCP patients have resorted to obtaining cannabis from the illicit market, risking the consequences of arrest and legal penalties (Lucas, 2009), and exposure to contaminants potentially worsening the medical condition.
To date there have been few reports of patterns of use of cannabis for symptom control in chronic pain, whether initiated for this purpose or adapted for this use by recreational users (Ogborne et al., 2000, Ware et al., 2003). There is also little information about the role of cannabis use as an adjunct to the use of opioids for pain control. Clearly, there is a need for studies of efficacy of cannabis in the management of CNCP, both in its own right and as an adjunct to opioid use. In this paper, we use data from a national, community-based sample of people who have been prescribed opioids for their pain (Campbell et al., 2014b), to examine the extent to which cannabis is in fact used by this group. In Australia, as in many countries, there is no regulatory framework for medicinal cannabis or cannabinoid use, and cannabis possession and use are not legal. We specifically examined:
- 1.
The prevalence of non-medicinal use of cannabis and of cannabis use disorder;
- 2.
The prevalence and correlates of use of cannabis for pain;
- 3.
The association between cannabis use for pain, opioid dose and degree of interference from pain.
Section snippets
Methods
The Pain and Opioids IN Treatment (POINT) study includes 1514 people in Australia who have been prescribed opioids for chronic non-cancer pain; full details of the cohort and study design have been reported elsewhere (Campbell et al., 2014a, Campbell et al., 2014b). The study was approved by the Human Research Ethics Committee of the University of New South Wales (HREC reference: #HC12149). The study also received A1 Australian National Pharmacy Guild Approval to approach pharmacists to assist
Results
One in six of the cohort (16%) had used cannabis for pain relief, and 6% had done so in the previous month. A quarter (24%) reported that they would use it for pain relief if they had access to it (Table 1).
Among those using cannabis for pain, the average pain relief they reported they obtained from using cannabis was 70% (where 100% meant complete pain relief). In contrast, the average reported pain relief they reported receiving from their medications was 50%. Of those who had used cannabis
Discussion
There is increasing debate about the use of cannabinoids for medicinal purposes, with jurisdictions in many countries increasingly choosing to decriminalise or legalise cannabis use, or to schedule synthetic cannabinoids for this purpose. In many countries, however, no cannabinoids are legally available for the treatment of any condition, including chronic non-cancer pain.
Despite this, we found a high prevalence of cannabis use in a cohort of community-based people living with CNCP across
Role of funding source
This study received funding from the Australian National Health and Medical Research Council (NHMRC, #1022522). LD and WH are supported by NHMRC research fellowships (#1041472, #569738). The National Drug and Alcohol Research Centre at UNSW Australia is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. Cerissa Papanastasiou was supported by funding provided by the Victorian Drug Law Enforcement Fund. The funder had no
Contributors
LD, MF and WH conceived of the study. LD led the writing of the paper, with NL making a contribution to writing of sections of the first draft. GC undertook the analyses. All authors contributed to the analytic plan, contributed to writing and review of the manuscript. LD is guarantor.
Conflict of interest
LD and NL have received untied educational grants from Reckitt Benckiser for post-marketing surveillance of new OST medications in Australia. LD, NL, RB and MF have received untied educational grants from Mundipharma for post-marketing surveillance of a new oxycodone formulation in Australia. MC has received payments from Mundipharma Pty Limited for preparation and presentation of educational material. Neither had any knowledge of this manuscript.
Acknowledgements
Many thanks to the POINT participants, who were willing to share their experiences with us.Thanks to the POINT investigators who contributed to the broader design of the cohort: Suzanne Nielsen, Briony Larance, Richard P. Mattick and Fiona Shand.
Thanks to Jessica Belcher, Sarah Freckleton, Bianca Hoban, Anika Martin, Ranira Moodley, Kimberley Smith and Rachel Urquhart-Secord, NDARC, for their contribution to data collection. Thanks to Dr Suzanne Nielsen, NDARC, for her comments on a late draft
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2022, Journal of PainCitation Excerpt :This may be why we observed greater analgesic effects using the retrospective daily diary measure, but not from the moment-level measure. We believe that these findings may help contextualize prior conflicting results in the literature, whereby laboratory-based studies found limited evidence of analgesia following co-use of opioids and cannabis,22 whereas retrospective data from an epidemiological study suggested that patients experienced perceived pain relief from adjunctive cannabis use compared to opioid use alone.11 Contrary to the meta-analysis of pre-clinical studies demonstrating the robust opioid-sparing effects of cannabis,19 the present study found no significant differences in daily use of long- and short-acting MMEs on days when only opioids were used versus days when participants reported co-using opioids and cannabis.