New Guideline Cautions Against Use of Medical Cannabis for Chronic Pain

By Pat Anson

One of the nation’s largest medical organizations has released a cautious new guideline that recommends against the use of medical cannabis for most patients with chronic noncancer pain. The American College of Physicians (ACP) represents over 160,000 internal medicine doctors and medical students in the United States.

The ACP’s “Best Practice Advice,” recently published in the Annals of Internal Medicine, is based on a review of medical cannabis in over three dozen randomized controlled trials and observational studies.

It urges physicians to warn patients that the harms of cannabis and cannabinoid use outweigh their potential benefits. Medical cannabis may produce small improvements in pain, function and disability, but potential harms include addiction and cognitive issues, as well as cardiovascular, gastrointestinal and pulmonary problems.

“This Best Practice Advice is important for practicing physicians when counseling our patients on the potential use of cannabis and cannabinoids to treat their chronic noncancer pain,” said Isaac Opole, MD, President of the ACP.

“As the use of cannabis for medicinal purposes grows it’s critical to open that dialogue and review the emerging evidence related to benefits and harms. We need to raise awareness and get the word out to ensure that patients have the information they need to make informed decisions.” 

The use of cannabis has steadily grown in recent years, with polls showing that nearly one in four U.S. adults have used medical or recreational cannabis at least once in the past year. Although chronic pain is the most common reason patients use medical cannabis, most have never discussed it with their physicians. Many get their information about cannabis from dispensary workers, who typically do not have any medical training.

The ACP recommends against the use of cannabis for chronic pain by young adults and adolescents, patients with substance use disorders, patients with a serious mental illness, patients who are pregnant or breastfeeding, and frail patients at risk of falling. Inhaled cannabis is not recommended for any patients.

There is some evidence that patients with painful neuropathy may benefit from using cannabis products that contain equal amounts of CBD and THC. 

“Evidence shows that in patients primarily with chronic noncancer neuropathic pain, a cannabis formulation with comparable THC–CBD ratio probably results in small improvements in pain severity (about 0.5 to 1.0 points on a zero to 10 pain scale) and function or disability (about 0.4-point improvement on the pain scale),” the ACP said.

“However, the evidence is insufficient to show benefit for other types of chronic noncancer pain. High THC–CBD ratio synthetic or purified products may result in small improvements in pain severity (about 0.5- to 1.0-point on the pain scale) but no change in overall function or disability.”

Currently, 24 states in the District of Columbia have legalized cannabis for adult recreational and medical use. It is legal for medical use only in an another 14 states. 

Research into the pain-relieving benefits of cannabis has been slow in the U.S., largely due to marijuana’s status as a Schedule 1 controlled substance, the same category as LSD and heroin. The DEA dragged its feet on implementing a request from the Biden Administration to reclassify marijuana as a Schedule 3 controlled substance that could be used for medical purposes. Rescheduling marijuana does not appear to be a priority for the Trump Administration.

There are only three cannabis-based medicines approved for use by the FDA: dronabinol and nabilone, which are used to treat nausea and loss of appetite, and a concentrated form of CBD used to control seizures from childhood epilepsy.

A German biotech company is in preliminary talks with the FDA about approving an experimental cannabis extract for chronic low back pain. A recent study in Australia found patients with chronic pain and other health conditions showed significant improvement in their quality of life, fatigue and sleep after taking cannabis oil over a one-year period. There were also small improvements in pain, anxiety and depression.

Guideline Recommends Topical Pain Relievers for Muscle Aches and Joint Sprains

By Pat Anson, PNN Editor

A new guideline for primary care physicians recommends against the use of opioid medication in treating short-term, acute pain caused by muscle aches, joint sprains and other musculoskeletal injuries that don’t involve the lower back.

The joint guideline by the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) – which collectively represent nearly 300,000 doctors in the U.S. – recommends using topical pain creams and gels containing non-steroidal anti-inflammatory drugs (NSAIDs) as first line therapy. Other recommended treatments include oral NSAIDs, acetaminophen, specific acupressure, or transcutaneous nerve stimulation (TENS).

Musculoskeletal injuries, such as ankle, neck and knee injuries, are usually treated in outpatient settings. In 2010, they accounted for over 65 million healthcare visits in the U.S., with the annual cost of treating them estimated at over $176 billion.

"As a physician, these types of injuries and associated pain are common, and we need to address them with the best treatments available for the patient. The evidence shows that there are quality treatments available for pain caused by acute musculoskeletal injuries that do not include the use of opioids," said Jacqueline Fincher, MD, president of ACP.

Opioids, including tramadol, are only recommended in cases of severe injury or intolerance to first-line therapies. While effective in treating pain, the guideline warns that a “substantial proportion” of patients given opioids for acute pain wind up taking them long-term.   

The new guideline, published in the Annals of Internal Medicine, recommends topical NSAIDs, with or without menthol, as the first-line therapy for acute pain from non-low back, musculoskeletal injuries. Topical NSAIDs were rated the most effective for pain reduction, physical function, treatment satisfaction and symptom relief.

Treatments found to be ineffective for acute musculoskeletal pain include ultrasound therapy, non-specific acupressure, exercise and laser therapy.

"This guideline is not intended to provide a one-size-fits-all approach to managing non-low back pain," said Gary LeRoy, MD, president of AAFP. "Our main objective was to provide a sound and transparent framework to guide family physicians in shared decision making with patients."

Guideline Based on Canadian Research

Interestingly, the guideline for American doctors is based on reviews of over 200 clinical studies by Canadian researchers at McMaster University in Ontario, who developed Canada’s opioid prescribing guideline. The Canadian guideline, which recommends against the use of opioids as a first-line treatment, is modeled after the CDC’s controversial 2016 opioid guideline.  

After reviewing data from over 13 million U.S. insurance claims, McMaster researchers estimated the risk of prolonged opioid use after a prescription for acute pain was 27% for “high risk” patients and 6% for the general population.

"Opioids are frequently prescribed for acute musculoskeletal injuries and may result in long-term use and consequent harms," said John Riva, a doctor of chiropractic and assistant clinical professor in the Department of Family Medicine at McMaster. "Potentially important targets to reduce rates of persistent opioid use are avoiding prescribing opioids for these types of injuries to patients with past or current substance use disorder and, when prescribed, restricting duration to seven days or less and to lower doses."

Riva and his colleagues said patients are also at higher risk of long-term use if they have a history of sleep disorders, suicide attempts or self-injury, lower socioeconomic status, higher household income, rural residency, lower education level, disability, being injured in a motor vehicle accident, and being a Medicaid recipient.

A history of alcohol abuse, psychosis, episodic mood disorders, obesity, and not working full-time “were consistently not associated with prolonged opioid use.”

The McMaster research, also published in the Annals of Internal Medicine, was funded by the National Safety Council (NSC), a non-profit advocacy group in the U.S. supported by major corporations and insurers. The NSC has long argued against the use of opioid pain relievers, saying they “do not kill pain, they kill people.”

Antibiotics Overprescribed More Than Opioids

By Pat Anson, Editor

Many pain patients report having trouble getting opioid pain medication prescribed by their physicians. So they may be surprised to hear about a new survey that found many doctors believe the overprescribing of antibiotics is a far bigger problem than opioids.

The random survey of over 1,100 members by the American College of Physicians (ACP) – most of them doctors who specialize in internal medicine -- asked them to identify two treatments frequently used by internists that are unlikely to provide “high value care” to patients.

The number one problem – identified by over 27% of the doctors -- was antibiotic prescribing, mostly for treating upper respiratory infections.

The second biggest problem was aggressive life support treatment for terminally ill patients (8.6%), followed by opioid medication for chronic pain management.

Only 7.3% of the doctors felt opioids do not provide high value care.

Dietary supplements (4.9%); statins (4.8%); proton-pump inhibitors (4.5%); cardiac procedures such as angioplasty, stents and catheters (3.5%); and antidepressants and sleep aids (3.4%) were also identified as treatments that often do not provide value.

"While many current clinical guidelines recommend appropriate care, the results of this survey may reflect intrinsic motivations to err on the side of treatment rather than 'doing nothing,'" said lead author Amir Qaseem, MD, Vice President of Clinical Policy at ACP. "However, as health care shifts to a value driven system, this study shows that doctors are willing to critically assess their own clinical practice."

Interestingly, non-pharmacological pain management -- mostly related to back pain -- was mentioned by 1.8% of the doctors as a treatment that provides little value. The Centers for Disease Control and Prevention recommends non-pharmacological treatment, such as physical therapy and cognitive behavioral therapy, as an alternative to opioids.

The study findings are being published in the Annals of Internal Medicine.

The ACP maintains a list of "high value care" recommendations to help doctors and patients better understand the benefits, harms, and costs of healthcare. Some expensive tests and treatments have high value, according to the ACP, because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit and might even be harmful.

The ACP is the largest medical specialty organization in the United States. ACP members include 148,000 internal medicine physicians (internists), related subspecialists and medical students.