Cannabis-based medicines and medical cannabis for adults with cancer pain

• Published in: Cochrane database of systematic reviews 2023-06, Vol.6 (6), p.CD014915
• Main Authors: Häuser, Winfried, Welsch, Patrick, Radbruch, Lukas, Fisher, Emma, Bell, Rae Frances, Moore, R Andrew
• Format: Article
• Language: English
• Subjects: Adult; Analgesics, Opioid - adverse effects; Cancer Pain - drug therapy; Cannabis; Carcinoma, Non-Small-Cell Lung - drug therapy; Codeine; Humans; Lung Neoplasms - drug therapy; Medical Marijuana - adverse effects; Medicine General & Introductory Medical Sciences; Morphine; Randomized Controlled Trials as Topic
• ISSN: 1469-493X; 1469-493X
• DOI: 10.1002/14651858.CD014915.pub2

Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate-to-severe pain. This can have a major negative impact on their quality of life. Opioid (morphine-like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids. To evaluate the benefits and harms of cannabis-based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain. We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023. We selected double-blind randomised, controlled trials (RCT) of medical cannabis, plant-derived and synthetic cannabis-based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm. We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome. We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double-blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta-analysi