A discussion held during the General Medicine Grand Rounds conference on October 2, 2020 at the Beth Israel Deaconess Medical Center in Boston focused on unique topics addressed to patients who “fall through the cracks” frequently. When asked whether or not cannabinoids should be recommended for a patient with painful neuropathy, 2 medical specialists with opposing views discussed the risks and benefits of using cannabinoids to treat neuropathic and chronic pain. This discussion was published in the Annals of Internal Medicine.
In recent years, the use of cannabinoids for medicinal purposes has increased and is now available in some form in all 50 states.
Few solid scientific studies have been published on the use of cannabinoids to treat chronic pain. However, in a meta-analysis, modest pain relief of around 30% was reported in 39% of patients, and those who used placebo had a similar result (30%).
In addition to the potential for pain relief, significant adverse effects have often been reported from the use of cannabinoids. These side effects included cognitive impairment, disorientation, impaired driving skills, and the risk of developing a cannabis use disorder.
The authors of this article, which went beyond the guidelines, asked if they would recommend cannabinoid use to a 79-year-old woman with type 2 diabetes who has had burning pain and numbness in her feet for 15 years. This patient had no relief from using topical cannabidiol (CBD) ointment. To relieve her pain, she uses topical lidocaine patches and takes 300 mg of pregabalin daily and 100 mg of tramadol up to three times a day.
Dr. Kevin Hill, director of the Department of Addiction Psychiatry at Beth Israel Deaconess Medical Center and Associate Professor of Psychiatry at Harvard Medical School, is an addiction psychiatrist based in Boston, Massachusetts, and he claimed that a subset of patients might actually benefit from using CBD .
In the meantime, Dr. Jeanette Tetrault Assistant Director of Education for the Addiction Medicine Program and Professor of Medicine at the Yale School of Medicine in New Haven, Connecticut. Dr. Tetrault, a general internist who focuses on addiction medicine, did not advise the general use of cannabinoids to treat chronic pain.
The case against cannabinoid use was supported by the fact that current research has found only modest pain relief with a high risk of multiple side effects. Aside from the prospect of cognitive impairment, the development of a cannabis use disorder remains a significant possibility, and withdrawal syndrome has often been reported at the time of cessation or reduction in cannabis use.
Many aspects of the case against the use of cannabinoids have been recognized from the opposing point of view. However, the results of a meta-analysis showed that some patients with chronic pain experienced relief from the use of cannabinoids. When prescribing these products to patients, there should be an in-depth risk-benefit discussion.
Doctors may consider CBD because it has a lower risk of cognitive side effects. Cannabinoids should be administered in appropriate doses under the supervision of the doctor during a trial period to test their effectiveness and to monitor patient responses.
Regardless of the doctor’s recommendations, the greater availability of cannabinoids means that they continue to be used to treat pain. Doctors should prepare to provide their patients with up-to-date information on possible benefits, side effects, and the risk of cannabis use disorder.
Smetana GW, Tetrault JM, Hill KP, Burns RB. Should you recommend cannabinoids to this patient with painful neuropathy? Large panel discussions from the Beth Israel Deaconess Medical Center. Ann Intern Med. 2021; 174 (2): 237- 246. doi: 10.7326 / M20-7945
This article originally appeared on Clinical Pain Advisor