Cannabis-Based Medicine for MS Pain
Cannabis-Based Medicine for MS Pain
Abstract & Commentary
By Brian R. Apatoff, MD, PhD, Director, Multiple Sclerosis Clinical Care and Research Center, Department of Neurology and Neuroscience, NewYork-Presbyterian Hospital, Cornell Campus. Dr. Apatoff is on the speaker's bureau for Biogen and Teva.
Synopsis: A long term placebo controlled study is now needed to establish whether cannabinoids may have a role beyond symptom amelioration in MS.
Sources: Rog DJ, et al. Randomized, Controlled Trial of Cannabis-Based Medicine in Central Pain in Multiple Sclerosis. Neurology. 2005;65:812-819; Zajicek JP, et al. Cannabinoids in Multiple Sclerosis (CAMS) Study: Safety and Efficacy Data for 12 Months Follow Up. J Neurol Neurosurg Psychiatry. 2005;76:1664-1669.
This controlled study by rog and colleagues of 66 multiple sclerosis (MS) patients with advanced disability (mean EDSS, 5.9 ± 1.3) and chronic, stable neuropathic pain of at least 3 months duration (59 dysesthetic, 7 painful spasms), was conducted in a 5-week treatment period (1-week run-in, 4-week treatment) with a whole-plant cannabis-based medicine (CBM) containing delta-9-tetrahydrocannabinol:cannabidiol (THC:CBD), delivered via an oromucosal spray. The CBM was used as an adjunctive analgesic treatment, with each spray delivering 2.7 mg of THC and 2.5 mg of CBD, and patients could self-titrate up to a maximum of 48 sprays in a 24-hour period. In week 4, the mean number of daily sprays taken of CBM was 9.6 (range, 2-25, SD = 6.0), vs 19.1 daily sprays of placebo (range, 1-47, SD = 12.9). Pain and sleep disturbance were recorded daily on an 11-point rating scale.
CBM had a greater effect than placebo for reduction of pain intensity (CBM mean change-2.7, placebo-1.4, P = 0.005) and sleep disturbance (CBM-2.7, placebo-1.7, P = 0.003). CBM was generally well tolerated, with side-effects of dizziness, dry mouth, sedation, and memory complaints.
A longer term follow-up of the Cannabinoids in Multiple Sclerosis study (CAMS) was previously reported in Neurology Alert. Vol 22; No. 5; p. 37. and Zajicek J, et al. Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): Multicenter, randomized, placebo-controlled trial. Lancet. 2003;363:1517-1526. This large trial of 630 MS patients, followed for up to 12 months, showed a small treatment effect on muscle spasticity, as measured by an improvement in the Ashworth score. There was suggestive evidence of subtle benefits for other aspects of disability including ambulation, pain, spasms, and sleep.
Commentary
Although the use of cannabis products for medical indications remains a politicized issue in the United States, these controlled studies from the United Kingdom support a benefit of cannabinoids for severe chronic pain that often complicates the course of MS patients with advanced disease. Despite a randomized assignment to treatment arms in the CBM study, there appeared to be a disproportionate number of CBM patients on certain concomitant analgesic medications than placebo patients (eg, tricyclic antidepressants, 13 patients in the CBM group, 5 patients in the placebo group; strong opioids, 3 in the CBM group, 0 in the placebo group). Nonetheless, the significance of the overall results from both trials indicates a role for cannabinoids in the management of refractory pain syndromes and other complex neuropathic symptomatology in MS patients with advanced disability.
A long term placebo controlled study is now needed to establish whether cannabinoids may have a role beyond symptom amelioration in MS.Subscribe Now for Access
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