A discussion held during the General Medicine Grand Rounds conference held at Beth Israel Deaconess Medical Center in Boston on October 2, 2020, focused on unique topics that address patients who often “fall through the cracks.” When asked whether or not cannabinoids should be recommended for a patient with painful neuropathy, 2 expert physicians with opposing viewpoints debated the risks and benefits of using cannabinoids for treating 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 robust scientific studies on the use of cannabinoids for the treatment of chronic pain have been published, but a modest relief of pain of about 30% in 39% of patients has been reported in a meta-analysis, and those using placebo had a similar result (30%).
In addition to the potential to relieve pain, significant adverse effects of the use of cannabinoids have been commonly reported. These side effects have included cognitive impairment, disorientation, impaired driving skills, and the risk of developing cannabis use disorder.
The authors of this beyond-the-guidelines article were posed with a question about whether they would recommend the use of cannabinoids for a 79-year-old woman with type 2 diabetes who has been experiencing 15 years of burning pain and numbness in her feet. This patient did not have relief from topical cannabidiol (CBD) ointment application. To ameliorate her pain, she uses topical lidocaine patches and has been taking 300 mg of pregabalin daily and 100 mg tramadol up to 3 times daily.
Dr Kevin Hill, Director of the Division of Addiction Psychiatry at Beth Israel Deaconess Medical Center and Associate Professor of Psychiatry at Harvard Medical School, is an addiction psychiatrist in Boston, Massachusetts, and he asserted that a subset of patients may indeed benefit from the use of CBD.
Meanwhile, Dr Jeanette Tetrault is the Associate Director of Training and Education for the Program in Addiction Medicine and a Professor of Medicine at Yale School of Medicine, New Haven, Connecticut. A general internist who is focused on addiction medicine, Dr Tetrault did not advise for the general use of cannabinoids for the treatment of chronic pain.
The case against the use of cannabinoids was supported by the fact that current research has identified only a modest relief of pain with high risk for multiple adverse effects. Beyond the prospect of cognitive impairment, development of cannabis use disorder remains a significant possibility, and withdrawal syndrome has been commonly reported at the time of cessation or reduction of cannabis use.
Many aspects of the case against the use of cannabinoids were acknowledged by the opposing viewpoint. However, results from a meta-analysis indicated that some patients with chronic pain did experience relief with the use of cannabinoids. When prescribing these products to patients, an in-depth risk-benefit discussion should occur.
Physicians may consider CBD because it has a reduced risk for cognitive side effects. Cannabinoids should be given in proper doses under the physician’s supervision for a trial period to test their effectiveness and monitor patients’ reactions.
Regardless of physician recommendations, the greater availability of cannabinoids will result in their continued use to treat pain. Clinicians should prepare themselves so that they may counsel their patients with up-to-date information about possible benefits, adverse effects, and the risk of developing cannabis use disorder.
Smetana GW, Tetrault JM, Hill KP, Burns RB. Should you recommend cannabinoids for this patient with painful neuropathy? Grand rounds discussion from Beth Israel Deaconess Medical Center. Ann Intern Med. 2021;174(2):237-246. doi:10.7326/M20-7945