Cannabis Oil Effective for UK Chronic Pain Patients

By Pat Anson, PNN Editor

Medical cannabis has been legal in the United Kingdom since 2018, but we’re only now getting the first evidence on the effectiveness of cannabis oil for UK chronic pain patients.

One hundred ten patients enrolled in the UK Medical Cannabis Registry reported significant improvements in their pain, discomfort and sleep quality after one, three and six months of treatment with cannabis oil. There was also statistically significant improvement in their health-related quality of life.

Due to strict rules, it is difficult to get a prescription for medical cannabis from the UK’s National Health Service. Patients can only be prescribed cannabis when conventional therapy has not provided adequate relief for conditions such as pain, anxiety and multiple sclerosis.

Most of the patients (65%) in the study had never used cannabis before. Their most common primary diagnosis was chronic non-cancer pain (48%), followed by neuropathic pain (24%) and fibromyalgia (16%).

“With the increasing number of prescriptions for medical cannabis in the UK, capturing patient outcomes and real-world evidence is essential for wider understanding and appropriate access for eligible patients,” Dr. Simon Erridge, head of research at Sapphire Medical Clinics, said in a statement.

“This research is the first of its kind in Europe and we continue to review condition and product-specific outcomes via the UK Medical Cannabis Registry. Though this is still observational data it will inform critical future research including randomised controlled trials.”

Sapphire Medical Clinics created the registry and surveyed patients to help fill some of the gaps in knowledge about medical cannabis. The findings were recently published in the Journal of Clinical Pharmacology.

“Despite promising preclinical data, there is a paucity of high-quality evidence to support the use of CBMPs (cannabis-based medicinal products). The evidence base, while broad, is inconclusive, variable across chronic pain types, and thus insufficient to inform guidelines, funders, and licensing agencies,” researchers said.

The cannabis oil used in the study is made by Adven, a subsidiary of Curaleaf International, Europe’s largest independent cannabis company. The median CBD dose was 20 mg per day, while the median THC dose was 1 mg per day, giving the oil a CBD/THC ratio of 20 to 1. Adverse events such as nausea, dizziness and constipation were reported by nearly a third of patients, with most symptoms being mild or moderate.

Sapphire Medical Clinics is planning further studies of cannabis products as more participants enroll in its cannabis registry.

‘Mother of All Cannabinoids’

Another study conducted in the U.S. found that people who use cannabis products that are rich in cannabigerol (CBG) reported significant improvement in their pain, anxiety, depression and insomnia.

CBG is known as the “mother of all cannabinoids” because it rapidly converts into THC and CBD. Only trace amounts of CBG are found in most cannabis plants, but in recent years cultivated strains rich in CBG have been grown in the Pacific Northwest.

Researchers at Washington State University and the University of California Los Angeles surveyed 127 people who self-identified as consumers of CBG-dominant cannabis. Most reported their pain and other symptoms were “very much improved” or “much improved” by CBG.

About 75% said CBG-predominant cannabis was superior to conventional medications for chronic pain, depression, insomnia and anxiety. A little over half reported minor side effects such as dry mouth, sleepiness, increased appetite, and dry eyes. Most reported no withdrawal symptoms.

“This is the first patient survey of CBG-predominant cannabis use to date, and the first to document self-reported efficacy of CBG-predominant products, particularly for anxiety, chronic pain, depression, and insomnia. Most respondents reported greater efficacy of CBG-predominant cannabis over conventional pharmacotherapy, with a benign adverse event profile and negligible withdrawal symptoms,” researchers reported in the journal Cannabis and Cannabinoid Research. 

“This study demonstrates that CBG-predominant cannabis and related products are available and being used by cannabis consumers and demonstrates the urgent need for randomized controlled trials of CBG-predominant cannabis-based medicines to be studied rigorously to assess safety and efficacy.”

Preliminary research suggests CBG has antibacterial properties and might be useful in treating inflammatory bowel disease (IBD), glaucoma, Huntington’s disease and some forms of cancer.  

UK Guideline Warns Against Using Opioids and Most Other Drugs for Chronic Pain

By Pat Anson, PNN Editor

The United Kingdom may be on the verge of adopting even more stringent opioid guidelines than the United States and Canada.  

The UK’s National Institute for Health and Care Excellence (NICE) has released a sweeping guideline drafted by an expert committee that recommends opioid medication not be prescribed for chronic primary pain at any dose due to lack of evidence and risk of addiction.

“Based on their experience, the committee agreed that even short-term use of opioids could be harmful for a chronic condition. The lack of evidence for effectiveness of opioids, along with evidence of long-term harm, persuaded the committee to recommend against opioid use for people with chronic primary pain,” the guideline states.

The NICE guideline doesn’t stop there. It recommends against the use of virtually every other medication commonly used to treat chronic pain, including gabapentinoids, benzodiazepines, acetaminophen (paracetamol), non-steroidal anti-inflammatory drugs (NSAIDS), ketamine, corticosteroids, and antipsychotics. According to NICE, these non-opioid pain relievers may be addictive, have risky side effects and do more harm than good.

“The committee agreed that not commenting on these medicines could result in their continued use in practice, which would be inappropriate given the lack of evidence and possible harms, so they recommended against the use of these treatments,” the guideline says.

The guideline is the first by NICE to address “chronic primary pain” — a vague term used to describe pain conditions that last longer than 3 months, and cause significant emotional distress and disability, such as fibromyalgia, Complex Regional Pain Syndrome, chronic musculoskeletal pain and symptoms that “can’t be accounted for by another diagnosis.”

NICE said the new guideline “should be used alongside” existing recommendations it has already issued for headache, low back pain and sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis and irritable bowel syndrome.

The draft guideline recommends that people with chronic primary pain get physical therapy, acupuncture, psychological therapy and regular exercise. Several other alternative therapies, including transcutaneous electrical nerve stimulation (TENS) and manual therapies such as chiropractic care, are not recommended due to lack of evidence.

Surprisingly, the only class of medication that was recommended for chronic primary pain is anti-depressants such as duloxetine (Cymbalta) and fluoxetine (Prozac), even though their use would be off-label.

Most Treatments Don’t Work

In short, the NICE guideline states that few treatments work for chronic primary pain and most should be avoided.

“There is no medical intervention, pharmacological or non-pharmacological, that is helpful for more than a minority of people with chronic pain, and benefits of treatments are modest in terms of effect size and duration. Additional morbidity resulting from treatment for chronic pain is not unusual, so it is important to evaluate the treatments we offer for chronic pain, to focus resources appropriately and to minimise harm,” the guideline warns.

The draft guidance is open for public comment until September 14.

The head of a large association of UK primary care physicians said the NICE recommendations are welcome, as long as the alternative therapies are made widely available.

“Most patients in pain do not want to take medication long-term, and GPs do not want this either, but sometimes medication has been the only thing that brings relief. As such these new guidelines, which focus on alternative therapies, have the potential to be beneficial for patients - but they will need to be guaranteed appropriate access to them,” Professor Martin Marshall, Chair of the Royal College of General Practitioners said in a statement.

“We should also be mindful not to disregard some medications completely as a lack of evidence may be due to a lack of high-quality research, particularly for older drugs, such as paracetamol.”

NICE estimates that chronic pain may affect between one-third and one-half of the UK population. Almost half of people with chronic pain have a diagnosis of depression and two-thirds are unable to work because of it.

The guideline emphasizes that physicians communicate and work collaboratively with patients to understand the symptoms and causes of their pain.  

“Understandably, people with chronic pain expect a clear diagnosis and effective treatment. But its complexity and the fact GPs and specialists alike find chronic pain very challenging to manage, means this is often not possible. This mismatch between patient expectations and treatment outcomes can affect the relationship between healthcare professionals and patients, a possible consequence of which is the prescribing of ineffective but harmful drugs,” Nick Kosky, a psychiatrist and chair of the NICE guideline committee said in a statement.

“This guideline, by fostering a clearer understanding of the evidence for the effectiveness of chronic pain treatments, will help to improve the confidence of healthcare professionals in their conversations with patients. In doing so it will help them better manage both their own and their patient’s expectations.” 

UK and Canada Legalizing Cannabis

By Pat Anson, PNN Editor

There’s a lot of hype this week about Canada becoming the second and largest country to legalize recreational marijuana. The first was Uruguay.

But the bigger news for the pain community may be in the United Kingdom, which has some of the strictest marijuana laws in Europe. Home Secretary Sajid Javid made a surprise announcement last week that medical cannabis products would be rescheduled on November 1 and become available by prescription to treat chronic pain, epilepsy and chemotherapy-induced nausea.

Javid agreed to review the scheduling of medical cannabis in June, after a public outcry over the seizure of CBD oil flown into Heathrow Airport for a 12-year old boy who has epilepsy. Although the oil primarily contained cannabidiol – the non-psychoactive ingredient in marijuana – it was still technically illegal under UK drug laws.

“I stressed the importance of acting swiftly to ensure that where medically appropriate, these products could be available to be prescribed to patients,” Javid said in a statement.

“I have been clear that this should be achieved at the earliest opportunity whilst ensuring that the appropriate safeguards were in place to minimise the risks of misuse and diversion.”

Javid was also clear he has no intention of supporting the legalization of recreational marijuana in the UK. Smoking cannabis in any form will also remain illegal. Even so, it was a big step forward for marijuana supporters..  

“This is a major victory for our campaign and will mean a lot of people will have a much better quality of life,” Clark French, a multiple sclerosis patient and cannabis activist, told Leafly.

“It does look that this could be the most open, accessible medical cannabis policy in Europe, if they get it right and we keep guiding them in the right directions,” said Jon Liebling of United Patients Alliance, a medical marijuana advocacy group.    

The rollout of CBD-based medicines in the UK will go slowly. It could take up to a year before the National Health Service comes up with guidelines to govern the distribution of CBD-based products. Initially, only medical specialists will be allowed to prescribe cannabis, although the guidelines are expected to eventually include general practitioners.

Activists are urging the Home Office to allow medical cannabis for all patients, not just those with pain, epilepsy or nausea.

“We do believe that everybody should have access,” said Liebling. "When you're talking about cannabis as a medicine, you really do have to compare the risks associated with cannabis that we're aware of versus the risks of those drugs that patients are already taking.” 

Legalization Worries Canadian Medical Association

Medical cannabis has been legal in Canada since 2001 and about 330,000 Canadians are registered and already have access to it.  But some health officials are less than enthused about the October 17 legalization of recreational cannabis.

"Given the known and unknown health hazards of cannabis, any increase in use of recreational cannabis after legalization, whether by adults or youth, should be viewed as a failure of this legislation," wrote Dr. Diane Kelsall, interim Editor-in-Chief, in an editorial in the Canadian Medical Association Journal.

Kelsall points to the stampede of Canadian and American companies looking to get into the cannabis industry and predicts many will brazenly advertise their products to young people.

“Cannabis companies may initially focus on attracting current consumers from black-market sources, but eventually, to maintain or increase profits, new markets will be developed as is consistent with the usual behaviour of a for-profit company. Marketing efforts may include encouraging current users to increase their use or enticing a younger demographic. The track record for tobacco producers has not been encouraging in this regard, and it is unlikely that cannabis producers will behave differently,” Kelsall warned.

Kelsall said the Canadian government needs to carefully track cannabis use and should have the courage to amend the law if problems arise.

Chronic Pain a ‘Silent Epidemic’ in UK

By Pat Anson, Editor

Nearly half of adults in the UK – nearly 28 million people – suffer from chronic pain, according to a new study in the British Medical Journal  that estimates about one in seven Britons have pain so severe it is disabling.

“Pain is really under-represented in terms of the public awareness of it,” lead author Alan Fayaz of Imperial College London said in The Guardian. “Nobody ever talks about chronic pain, it is like a silent epidemic.”

Fayaz and his colleagues conducted a meta-analysis of 19 studies involving nearly 140,000 people in the UK. Data from the studies was combined to arrive at the estimate that 43% of adults suffer from chronic pain – defined as pain that lasts for three months or more.

That estimate is over three times higher than a previous telephone survey study that found 7.8 million Britons have moderate to severe chronic pain.

About 8% of UK adults experience chronic neuropathic pain and 5.5% have fibromyalgia. Women are more likely to experience chronic pain than men.

Chronic pain was found to be a common experience among all age groups, including young adults, but increases steadily with age. Nearly two-thirds of adults over age 75 have chronic pain, according to one of the studies reviewed.

 “Bearing in mind that we are, in general an ageing population, that’s of concern because what you would then expect would be if you repeated this study in about 10 years time, the prevalence of chronic pain would be higher,” said Fayaz.

 “What I would really like is for us to have better tools in order for us to identify those people who are most severely affected and how we can help them, what their care needs are.”

The prevalence of chronic pain in the UK is similar to that in the United States, where the Institute of Medicine estimated that 40% of American adults – about 100 million people – have chronic pain.