Update following publication of the International Association for the Study of Pain (IASP) Position Statement (16 March 2021)
This statement is focused on the issues relating to cannabis derived medicinal products in relation to Pain Medicine. It does not comment on other areas of medical practice or recreational use, which lie outside our remit.
The issue of cannabis, its extracts, formulations and synthetics has very much been on the radar of Pain Medicine for many years.
The Faculty supports the guidance and conclusions of the NICE guidance NG144.1 In respect of Pain Medicine, the Faculty is in agreement that whilst these substances have potential for therapeutic use, their safety and efficacy have not yet been established and a strong evidence base is needed as for any properly licenced medicine. We strongly support and look forward to its development. The development of evidence must be robust and honest, allowing for full recognition of downsides and risks as well as positive outcomes.
The Cochrane review2 in March 2018 concluded, “There is a lack of good evidence that any cannabis derived product works for any chronic neuropathic pain.” The authors also concluded that “The potential benefits of cannabis-based medicine in chronic neuropathic pain might be outweighed by their potential harms.” The latest review in Pain3 determined that “It appears unlikely that cannabinoids are highly effective medicines for Chronic non-cancer pain.” It is important to note that both papers commented on the poor quality of the existing trials.
A comprehensive review by the IASP in March 2021 has concluded similarly that “Reviews of preclinical research and clinical safety and efficacy of cannabis and cannabinoids for pain relief have identified important research gaps. Due to the lack of high-quality clinical evidence, the International Association for the Study of Pain (IASP) does not currently endorse general use of cannabis and cannabinoids for pain relief.”7 National reports from the USA4, Australia5 and Ireland6 all comment on the lack of good quality evidence regarding short and long term outcome for both benefit and harm.
The widespread use of high dose opioids in the absence of good long-term evidence over the last 20 years is already the cause of considerable concern, and it is not difficult to see potential parallels.
With this in mind, the Faculty considers that the issue of cannabinoids needs to be carefully considered and researched in a comprehensive fashion, as would be the case for any new medicinal product reaching the therapeutic market, and that anecdotal positive reporting is not a mechanism to protect public safety. We therefore feel that further high quality research is mandated in view of potential benefit, when considering the numbers of patients with chronic pain and the limited pharmaceutical armoury. If there are specific patient populations that will benefit they should not be denied access when the evidence is available.
The use of unrefined dried plants containing a variety of cannabinoids and other pharmaco-active chemicals of varying quantity and quality cannot be supported and is clearly contrary to the direction of medical science. The potential for exposure to significantly harmful chemicals, in the short or long term, by such an unscientific ‘herbal’ approach is of considerable concern, as is diversion to non-medical use. Therefore, only products produced to pharmaceutical standards should be considered.
Patients living with chronic pain often have complex comorbidities and a multidisciplinary approach to management that includes physical and psychological therapy rather than reliance on medicines alone is more likely to be effective.
- The Faculty supports the setting up of robust trials to look at potential benefits for cannabinoids in pain management.
- The Faculty would, with qualifications, support the setting up of a database for the analysis of data from all areas. Such a database would need to be independent, compulsory, fully funded and under the auspices of a suitable organisation (e.g. NICE) to assess the value of treatments of relative rarity.
- Any use of cannabinoids for pain management should only occur after conventional interventions have failed and then only within the confines of a limited number of secondary care multidisciplinary specialist pain services, with all cases being nationally audited.
- The Faculty would wish to be directly involved in the establishment of guidance and data collection which impacts on the management of pain.
In order to ensure neutrality, the Faculty has no financial links to the cannabis industry.
- Cannabis-based medicinal products - NICE guideline [NG144] Published date 11 November 2019: https://www.nice.org.uk/guidance/ng144
- Mücke M, Phillips T, Radbruch L, Petzke F, Häuser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD012182. DOI: 10.1002/14651858.CD012182.pub2
- Stockings E, Campbell G, Hall WD, Nielsen S, Zagic D, Rahman R, et al. Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. PAIN. 2018;159(10):1932-54.
- National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. doi: 10.17226/24625.
- Guidance for the use of medicinal cannabis in Australia. Overview. Version 1 December 2017. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-canna…
- Cannabis for Medical Use - A Scientific Review. Health Products Regulatory Authority. January 2017. https://www.hpra.ie/docs/default-source/publications-forms/newsletters/…
- IASP Position Statement on the use of of Cannabinoids to Treat Pain. 16 March 2018. doi: 10.1097/j.pain.0000000000002265