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Original Article

Cannabinoids

Their Role in Pain and Palliation

(Founder and Director)
Pages 19-28 | Accepted 28 Feb 2007, Published online: 17 Aug 2009
 

Abstract

Controversy is associated with the issue of cannabis and cannabinoids in clinical care in the United States. Recent research has demonstrated the underlying mechanisms of cannabinoid analgesia via endocannabinoids, an endogenous system of retrograde neuromodulatory messengers that work in tandem with endogenous opioids. Additional receptor and non-receptor mechanisms of cannabinoid drugs have pertinent activity, including anti-carcinogenesis and neuroprotection, that may be of key importance in aging and terminal patient populations. The results of clinical trials with synthetic and plant-based cannabinoids suggest that the role of formulation and delivery system is critical in optimizing the risk-benefit profile of cannabinoid products. Synergy between opioids and cannabinoids may produce opioidsparing effects, as well as extend the duration of analgesia and reduce opioid tolerance and dependence. This article reviews the mechanism of action of cannabinoids, examines marketed agents and those in clinical trials, and addresses their role in treatment of chronic pain, cancer, neurodegenerative diseases, and HIV/ AIDS. The ability of cannabinoid medicines to treat pain, associated sleep disorders, appetite loss, muscle spasm and a wide variety of other symptoms suggests that such agents may in the future play an important role in palliative care.

Additional information

Notes on contributors

Bill H. McCarberg

Cherokee Layson-Wolf, PharmD, is Assistant Professor at the University of Maryland School of Pharmacy. At the time that this review was conducted, she was a Community Care Pharmacy Practice Resident at Virginia Commonwealth University.

Perry G. Fine, MD, is Professor of Anesthesiology, School of Medicine and Associate Medical Director, Pain Management Center at the University of Utah Health Sciences Center, Salt Lake City; and National Medical Director, VistaCare, based in Scottsdale, AZ. This commentary is based on an article in Dr. Fine's VistaCare Palliative Medicine Monitor.

Jonathan R. Gavrin, MD, is the Internet editor for the Journal. He is Associate Professor of Anesthesiology and Adjunct Associate Professor of Medicine at the University of Washington School of Medicine; Associate Member, Fred Hutchinson Cancer Research Center; and Associate Director for Clinical Anesthesia Services, Harborview Medical Center.

Perry G. Fine, MD, is Professor of Anesthesiology, School of Medicine and Associate Medical Director, Pain Management Center at the University of Utah Health Sciences Center, Salt Lake City; and National Medical Director, VistaCare, based in Scottsdale, AZ. This commentary is based on an article in Dr. Fine's VistaCare Palliative Medicine Monitor.

Philip J. Wiffen, is the Regional Pharmaceutical and Prescribing Adviser, Anglia & Oxford Region of the National Health Service Executive, a member of the Oxford Regional Pain Relief Unit and Coordinating Editor of the Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group.

Perry G. Fine, MD, is Professor of Anesthesiology, School of Medicine; Associate Medical Director, Pain Management Center at the University of Utah Health Sciences Center, Salt Lake City; and National Medical Director, VistaCare, based in Scottsdale, AZ. This commentary is based on an article in Dr. Fine's VistaCare Palliative Medicine Monitor.

Philip J. Wiffen, BPharm, MRPharmS, MFPHM (Hon) is Regional Pharmaceutical and Prescribing Adviser, Anglia & Oxford Region of the National Health Service Executive, a member of the Pain Relief Unit, Churchill Hospital, and Coordinating Editor, Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group.

Howard A. Heit, practices pain medicine and addiction medicine in Fairfax, Virginia, and is Assistant Clinical Professor of Medicine at Georgetown University, Washington, DC. Dr. Heit was a member of the Liaison Committee on Pain and Addiction.

Perry G. Fine, is Professor of Anesthesiology, School of Medicine and Associate Medical Director, Pain Management Center at the University of Utah Health Sciences Center, Salt Lake City; and National Medical Director, VistaCare, based in Scottsdale, AZ. This commentary is based on an article in Dr. Fine's VistaCare Palliative Medicine Monitor.

Philip J. Wiffen, is Regional Pharmaceutical and Prescribing Adviser, Anglia & Oxford Region of the National Health Service, a member of the Pain Relief Unit at Churchill Hospital and Coordinating Editor of the Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group.

Last Acts is a Robert Wood Johnson Foundation funded campaign to improve end-of-life care by a coalition of professional and consumer organizations. This coalition works to improve palliative care, focused on managing pain and making life better for individuals and families facing death. Last Acts envisions a world in which dying people and their loved ones receive excellent care and are honored and supported by their community.

S. R. Ghooi, MBBS, is a Medical Consultant in New Delhi.

Gustavo G. De Simone is Medical Oncologist (with Diploma in Palliative Medicine) and Pallium Latinoamérica Association Medical Director and Chief, Section on Palliative Care, Hospital Bonorino Udaondo, Bonpland 2287 (1425) Ciudad de Buenos Aires, Argentina ( [email protected].

The Reverend John S. Lunn, RN, MDiv, is Palliative Care and Hospice Consultant, Global Ministries for the Disciples of Christ and United Church of Christ, and former President, Board of Directors, Kauai Hospice, Hawaii.

Philip J. Wiffen, BPharm, MRPharmS, MFPHM (Hon), is Regional Pharmaceutical and Prescribing Adviser, Anglia & Oxford Region, National Health Service, a member of the Pain Relief Unit, Churchill Hospital and Coordinating Editor, Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group.

Jan Stjernswärd, MD, PhD, FRCP (Edin), is Former Chief, Cancer and Palliative Care, World Health Organization, Geneva, Switzerland, and International Director of the Oxford University International Centre for Palliative Care and World Health Organization Collaborating Centre for Palliative Care, Churchill Hospital, Oxford, UK. He also serves on the Steering Committee of the Diana Palliative Care Initiative, Diana Princess of Wales Memorial Fund in the UK, as a Consultant to the Open Society Institute in New York, and continues to serve as a World Health Organization advisor.

Barbara L. Kass-Bartelmes, MPH, CHES, and Ronda Hughes, PhD, wrote this report for the Agency for Health Care Research and Quality (AHRQ) of the U.S. Public Health Service.

Barbara L. Kass-Bartelmes, MPH, CHES, and Ronda Hughes, PhD, wrote this report for the Agency for Health Care Research and Quality (AHRQ) of the U.S. Public Health Service.

Robert J. Adams, PharmD, was at the time of this study Primary Care Resident, Pharmacy Service, Carl T. Hayden Veterans Affairs Medical Center, Phoenix, AZ.

Stephen P. Lordon, MD, was at the time of this study, Attending Physician in the Pain Management Center, University Hospitals and Clinics, and Clinical Assistant Professor of Anesthesiology, School of Medicine;

Arthur G. Lipman, PharmD, is Professor of Pharmacotherapy, College of Pharmacy, Adjunct Professor of Anesthesiology, School of Medicine and Director of Clinical Pharmacology, Pain Management Center, University Hospitals and Clinics; University of Utah Health Sciences Center.

Christopher Stock, PharmD, is Clinical Pharmacist, Substance Abuse Treatment Programs Pharmacist at the George E. Wahlen Veterans Affairs Salt Lake City Health Care System, and Clinical Associate Professor, College of Pharmacy, University of Utah

Perry G. Fine, MD, is Professor of Anesthesiology, School of Medicine, and Attending Physician at the Pain Management Center, University of Utah Health Sciences Center, Salt Lake City, UT; and Senior Medical Advisor, VistaCare, based in Scottsdale, AZ.

Phillip J. Wiffen, BPharm, MRPharmS, MFPHM(Hon), is Director of Training for the U.K. Cochrane Center, a member of the Oxford Regional Pain Relief Unit at Churchill Hospital, and Coordinating Editor of the Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group.

William J. Rusho, MS, RPh, is Professor (Clinical) of Pharmacotherapy, University of Utah College of Pharmacy and a former member of the FDA Advisory Committee on Pharmacy Compounding. He was clinical coordinator of sterile product compounding at the University of Utah Hospitals and Clinics for 32 years.

Jonathan R. Garvin, MD, is Director of Symptom Management and Palliative Care, Hospital of the University of Pennsylvania; Clinical Associate Professor of Anesthesia and Adjunct Associate Professor of Medicine, School of Medicine, University of Pennsylvania, Philadelphia.

Philip J. Wiffen, BPharm, MSc, MRPharmS, MFPHM (Hon), is a member of the Oxford Regional Pain Relief Unit, Churchill Hospital, Coordinating Editor, Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group, and Director of Training, U.K. Cochrane Center.

Dr. Fishman has developed this feature based on columns he has developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health. Dr. Fishman retains copyright for this material and has granted permission to the Journal of Pain & Palliative Care Pharmacotherapy to publish it.

Dr. Fishman has developed this feature based on columns he has developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health. Dr. Fishman retains copyright for this material and has granted permission to the Journal of Pain & Palliative Care Pharmacotherapy to publish it.

Mark R. Collen is a self-taught artist and the creator of PAIN Exhibit and the on-line pain art exhibit PainExhibit.com. As a result of an injury and failed back surgery in 1995, Mr. Collen was left with neuropathic pain. He started the PAIN Exhibit in 2001 as a response to years of undertreatment that he endured.

Mr. Collen has created art pieces about his pain and concluded that art is far more effective at communicating the pain experience than are words. His desire to help end undertreatment of pain, coupled with his understanding of the power of art to educate were the seminal factors in the birth of the PAIN Exhibit and PainExhibit.com.

William M. Lamers, Jr., MD, is Medical Consultant to the Hospice Foundation of America. He has over thirty years of experience as a hospice medical director and consultant.

Dr. Fishman has developed this feature based on columns he developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health. Dr. Fishman retains copyright for this material and has granted the Journal of Pain & Palliative Care Pharmacotherapy permission to publish it to facilitate patient education.

Philip J. Wiffen, BPharm, MSc, MRPharmS, MFPHM (Hon), is a member of the Oxford Regional Pain Relief Unit at Churchill Hospital, Coordinating Editor of the Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group, and Director of Training for the U.K. Cochrane Center.

Dr. Fishman, a member of the Journal Editorial Board, has developed this feature based on columns he developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health and he has granted the Journal of Pain & Palliative Care Pharmacotherapy permission to publish it to facilitate patient education.

Paul M. Gahlinger, MD, PhD, MPH, FACOEM, is a practicing physician and author. He is Adjunct Professor in the Department of Family and Preventive Medicine, School of Medicine, University of Utah.

Medical Consultant to the Hospice Foundation of America. He has over thirty years of experience as a hospice medical director and consultant.

Angela Huskey, PharmD, was with the Interdisciplinary Pain and Palliative Care and Integrative Medicine Program at H. Lee Moffitt Cancer Center, Tampa, FL at the time she wrote the cannabinoid review. She is currently Clinical Pharmacist, Pain Management and Palliative Care, and Clinical Assistant Professor, Department of Pharmacy, University of Florida, Gainesville.

Dr. Fishman, a member of the Journal Editorial Board, has developed this feature based on columns he developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health and he has granted the Journal of Pain & Palliative Care Pharmacotherapy permission to publish it to facilitate patient education.

William M. Lamers, Jr., MD, is Medical Consultant to the Hospice Foundation of America. He has over thirty years of experience as a hospice medical director and consultant.

Philip J. Wiffen, BPharm, MSc, MRPharmS, MFPHM (Hon), is a member of the Oxford Regional Pain Relief Unit at Churchill Hospital, Coordinating Editor of the Cochrane Collaboration Pain Palliative and Supportive Care Collaborative Review Group, and Director of Training for the U.K. Cochrane Center.

This feature is adapted from PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care) which was published electronically by the American Academy of Hospice and Palliative Medicine and was edited by Amy Abernethy, Assistant Professor of Medicine and Nursing, Director of the Palliative Care Clinical Research Initiative, Duke University, Durham, NC.

William M. Lamers, Jr., MD, is Medical Consultant to the Hospice Foundation of America. He has over thirty years of experience as a hospice medical director and consultant.

Dr. Fishman, a member of the Journal Editorial Board, has developed this feature based on columns he developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health and he has granted the Journal of Pain & Palliative Care Pharmacotherapy permission to publish it to facilitate patient education.

Mark Collen is a person with chronic pain and a member of the Journal Editorial Board. He also is the founder and coordinator of http://PainExhibit.com See: Collen M. Life of pain, life of pleasure: Pain form the patients' perspective-The evolution of the PAIN exhibit. J Pain Palliât Care Pharmacother 2004;19(4):45-52

Scott M. Fishman, MD, is Chief, Division of Pain Medicine and Professor, Department of Anesthesiology and Pain Medicine, University of California at Davis.

Dr. Fishman, a member of the Journal Editorial Board, has developed this feature based on columns he developed in collaboration with the American Pain Foundation Pain Monitor and Discovery Health and he has granted the Journal of Pain & Palliative Care Pharmacotherapy permission to publish it to facilitate patient education.

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