Medical Marijuana vs. Standard Pain Management in Oncology

Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals Individual Evidence Summary Tool Appendix G EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality Piper, B. J., Beals, M. L., Abess, A. T., Nichols, S. D., Martin, M. W., Cobb, C. M., & DeKeuster, R. M. (2017) Chronic Pain Patients’ Perspectives of Medical Cannabis Quantitative analysis Participants in the study (N = 984) were legitimate clients of MC dispensaries in Maine (57.9%), Vermont (30.6%), and Rhode Island (11.5%), among other northeastern states. The study investigated how patients were using medical marijuana to treat their chronic pain. An online survey was given to the participants to complete, which asked them questions about their demographics, According to the study, two- thirds of the participants had a diagnosis of chronic pain. The most common type of chronic pain, according to those who experienced it, was back/neck pain, which was then followed by neuropathic pain, post- surgical pain, abdominal pain, chronic pain from trauma or injury, cancer pain, and menstrual pain. On a scale from 0 to 100, the participants gave medical cannabis an average rating of 74.7% for treating The study used an online survey that included multiple-choice questions about participants' demographic and medical information as well as open- ended inquiries to get their opinions. Descriptive statistics were used to analyse the quantitative Self-reported data, which is vulnerable to social desirability and recall bias, were used in the study. A convenience sample of patients from medical cannabis dispensaries was also used in the study, which means it may Evidence 1 and A quality © 2021 Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 1

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality medical histories, pain conditions, preferred administration methods, the efficiency of medical cannabis in treating their symptoms, and how much money they had spent on it. their symptoms or conditions. The health benefits of medical cannabis, such as pain relief and improved sleep, were the most frequently mentioned themes in the responses from the participants when asked what they liked best about it. data, and grounded theory was applied to the qualitative analysis to identify themes and subthemes. not be an accurate representation of all cancer patients who experience pain. Furthermore, no direct comparison between the use of medical marijuana and conventional pain management techniques was made in the study. Johal, H., Devji, T., Chang, Y., Simone, J., Vannabouathong, C., & Bhandari, M. (2020). Cannabinoids in Systematic Review and Meta-Analysis. Thirty-six trials which included 4006 participants Analysis of the data supporting the advantages and disadvantages of using There were 36 trials totaling 4006 participants, looking at oral cannabinoids (18 trials), oromucosal marijuana sprays (14 trials), and smoked cannabis (4 trials). Patient-reported pain and adverse events (AEs) The review suggested that older people with an elevated risk of arthritis, a condition that Evidence level V and A quality © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 2

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality Chronic Non- Cancer Pain: A Systematic Review and Meta-Analysis. medical marijuana to treat persistent, non-cancer pain. Cannabinoids significantly reduced pain when compared to placebo, with the greatest reduction occurring over treatment durations of 2 to 8 weeks (a weighted average difference on a 0–10 pain apparent analogue scale: 0.68; 95% CI: 0.96–0.40; I2 = 8%; P . 00001; n = 16 trials). Oral cannabinoids had a greater pain-relieving effect than oromucosal and smoked formulations, but the difference was not statistically significant (P[interaction] >.05 in all three treatment durations); cannabinoids had a smaller pain-relieving effect than placebo for multiple sclerosis pain compared to other neuropathic pain (P[interaction] =.05) within causes chronic non-cancer pain (CNCP), may experience more severe and severe neuropsychiatri c adverse events (AEs) related to cannabinoid uptake, such as dizziness and cognitive dysfunction. It would be helpful if they had enough data to assess if the frequency of neuropsychiatri c adverse events (AEs) among adults is, in fact, greater than that of younger © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 3

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Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality two weeks and the three treatment durations. people. Unfortunately, no information compared to the research included in our study was accessible for such a study. Allan, G. M., Finley, C. R., Ton, J., Perry, D., Ramji, J., Crawford, K., Lindblad, A. J., Korownyk, C., & Kolber, M. R. (2018). Systematic review of systematic reviews for medical cannabinoids Systematic reviews with 2 or more randomized controlled trials The review included systematic reviews of randomised controlled trials (RCTs) looking at medical cannabinoids for the treatment of pain, spasms, or feeling sick (with or without meta-analysis). The review did not specify the precise traits of the populations, sample sizes, or The use of medical cannabinoids, such as cannabis, nabilone, and dronabinol, for the treatment of pain, motion sickness, and spasticity in cancer patients was the intervention in this systematic review. The The evidence indicates that chronic pain, chemotherapy- related nausea and vomiting, and spasticity related to long-term neurological disorders like multiple sclerosis are the conditions where medical cannabinoids are believed to be effective. The adverse events that medical cannabinoids most frequently cause are more severe than any potential advantages for the conditions they are intended to treat. Even when The authors collected information on the quantity of RCTs, the total number of patients, the particular topic of focus, the baseline features, the cannabinoid treatment, the control therapy, the risk-of-bias tool employed to evaluate the As many studies registered users of marijuana who have a lower risk of adverse events, the study emphasises that the rate of complications is probably underreported. The study also suggests that uncommon adverse events Evidence level V and A quality © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 4

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality environments. purpose of the study was to compare the efficiency of medical cannabinoids and conventional pain management techniques in the treatment of pain. compared to other active actions, problems are more frequent than withdrawals as a result of adverse events. The advantages of medical cannabis for nausea and vomiting are getting close to clinically significant improvement. However, the advantages of medical cannabinoids for pain are nearly clinically significant and range greatly in strength. RCTs, the risk of bias discovered, additional quality issues, and results (benefits and harms). The efficacy of the treatment was evaluated by the authors using standard mean difference evaluations, respondent rates, mean variation in measures of sign and symptoms, patient-reported advancement, and mean change in measures of indications and signs. might have gone unreported, including psychosis, cannabinoid hyperemesis syndrome, and amotivational syndromes. The study also points out that research on spasticity primarily pertains to people with multiple sclerosis, while research on vomiting and feeling nauseous only pertains to people who are © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 5

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality receiving chemotherapy. The authors also point out that patient preferences for spasticity and nausea and vomiting have consistently improved more than the conditions' actual effects have. Blake, A., Wan, B. A., Malek, L., DeAngelis, C., Diaz, P., Lao, N & O’Hearn, S. (2017). A selective review of medical cannabis in cancer pain management. Systematic review The review examined five research studies that examined the impact of cannabidiol (CBD) or tetrahydrocannabino l (THC) on reducing cancer pain. Participants with Studies looked at the effectiveness of THC oil capsules, THC:CBD oromucosal spray (nabiximols), or THC Cannabis was found to be strongly linked with a reduction in cancer-related pain in a total of four of the five studies. In some studies, higher THC levels were linked to greater pain relief. According to one study, substantial pain relief can be obtained at doses as The studies used a variety of measurements to assess pain relief, including a 4-point pain scoring system, the brief pain inventory (BPI), the numerical The primary limitation of the investigations under consideration was the small sample size, which left some of them with insufficient Evidence level V and A quality © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 6

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Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality severe cancer who had neuropathic or chronic pain were included in the studies. The study samples, which ranged from 10 to 360 patients, were relatively small. Hospitals and clinics were just two of the settings where the studies were carried out. oromucosal sprays as cancer pain relievers. In the studies, various THC and CBD doses—ranging from 2.7 to 43.2 mg/day for THC and 0 to 40 mg/day for CBD—were given. small as 2.7-10.8 mg THC combined with 2.5-10.0 mg CBD. However, the evidence remains uncertain as to whether higher doses offer better pain relief. The studies noted that drowsiness, mental fogginess, hypotension, nausea, and vomiting were frequent adverse effects. rating scales (NRS), and pain diaries. Patients indicated their level of pain using these measures at various points during the study. statistical power. More double-blind, placebo- controlled studies with more samples are required to determine the ideal dosage and effectiveness of various cannabis-based treatments. Pawasarat, Ian M.; Schultz, Emily M.; Frisby, Justin C.; Mehta, Samir; Angelo, Mark A.; Hardy, Samuel S.; Kim, Tae Won B. (2020). The Efficacy of Medical Marijuana Retrospective chart review At our facility, 575 patients received certification during this time. The following conditions led to the exclusion of 288 of these patients: nononcologic evaluation, The purpose of the study was to describe how MMJ affects opioid consumption and relief of symptoms in the oncologic population. 232 patients were located [95/232 MMJ(-); 137/232 MMJ(+)]. Only MMJ(+) greatly enhanced sentimental ESAS; pain, physical, and total ESAS substantially improved for both total MMJ(-) and MMJ(+) users. While it stayed constant (45-45 Examining medical records for ESAS allowed for the measurement of both physical and psychological symptoms as well as the The study has its limitations. Measures based on patient feedback were used to first determine how often patients used marijuana. Similar to that, Evidence level 1 and A quality © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 7

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality in the Treatment of Cancer-Related Pain incomplete medical documentation, using marijuana at the moment of certification, in- patient situation, and individuals without both authorization and latest visit information. 61 eligible patients out of the remaining 293 patients chose not to purchase MMJ, leaving 232 patients to be divided into two groups based on their reported, regular cannabis use following their initial certification visit. During palliative care visits, the following standardized mg/day MME, p = 0.522) in MMJ(+), opioid intake increased by 23% (97.5-120 mg/day MME, p = 0.004) in MMJ(-). In mild-moderate- MMJ(-) and MMJ(+), the physical and overall ESAS improved. In MMJ(-), pain and psychological signs got worse, whereas in MMJ(+), pain stayed the same and emotional symptoms got better. While MMJ(+) opioid consumption decreased by 33% (45-30 mg/day MME, p = 0.935), MMJ(-) opioid usage increased by 29% (90-126 mg/day MME, p = 0.012). Severe-MMJ(-) and MMJ(+) pain, physical, emotional, and overall ESAS scores improved; opioid consumption decreased by 22% in conversion of opiate consumption into morphine milligramme equivalents (MME). There were only a few differences that were clinically significant. MMJcertificatio n and the most recent visit to a hospice were statistically significantly correlated, according to Wilcoxon signed-rank tests. it was assumed that all opiates were filled and used. It was acceptable to assume that the medicines were administered as directed because they were in the patient's best interests. We are unable however, be sure that all drugs, including opioids and MMJ, were taken exactly as directed. Second, data on nonopioid adjuvant treatments were not gathered because EMR © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 8

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality incidents were examined from encompassed patients' technological medical records: cancer evaluation, therapy history, patient-completed ESAS score, review of medications (dosage, the rate, way of administration), and evaluation of MMJ usage. MMJ(-) (135-106 mg/day MME, p = 0.124) along with 33% in MMJ(+) (90-60 mg/day MME, p = 0.124). were examined for patient use of MMJ and opioids. As a result, it is unclear what effect these other nonopioid treatments and drugs will have. Third, due to the non- synthetic nature of MMJ, its effectiveness may vary depending on the precise cannabinoid focus. All MMJ(+) patients received MMJ from the NJMMPR, so © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 9

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Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality the strain variations are thought to be minimal. Additionally, since purchasing MMJ in New Jersey is subject to strict regulations, the registry's data collection is accurate, which reduces the drawbacks of using a database. Fourth, the ESAS is a subjective evaluation method, and a variety of confounding © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 10

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality variables (such as family circumstances or new treatments) may have affected patient-reported scores. Petzke, F., Tölle, T., Fitzcharles, M. A., & Häuser, W. (2022). Cannabis-based medicines and medical cannabis for chronic neuropathic pain. Mixed methods The systematic review examined randomized controlled trials (RCTs) that looked at the use of medical marijuana (MC) and cannabis-based medicines (CbMs) for treating chronic neuropathic pain. The application of CbMs and MC for chronic neuropathic pain was the treatment that was studied. The review discovered that the utilization of CbMs and MC for chronic neuropathic pain is only partially supported by the available research. The conclusions reached by the systematic reviews included in the analysis varied, as did the types of CbMs and MC examined, the length of the studies, and the outcomes examined. While some systematic reviews discovered an apparent increase in pain relief when CbMs and MC were used, The included RCTs used a variety of measures, but the most frequent outcome measure was the proportion of patients who reported at least 30% pain relief. The systematic review discovered a number of limitations, such as variations in study design and methodology, distinctions between the types of CbMs and MC examined, heterogeneity in outcome indicators, a Evidence level 1 and A quality © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 11

Johns Hopkins Nursing Evidence-Based Practice Individual Evidence Summary Tool (Appendix G) EBP Question: In oncology patients experiencing pain, does the use of medical marijuana compared to standard pain management result in better pain relief Author, date, and title Type of evidence (eg: RCT) Population, size, and setting Intervention Study Findings that help answer the EBP question Measures used Limitations Evidenc e level and quality others did not. dearth of long- term follow-up data, and a low level of general quality of evidence. © 2022Johns Hopkins Health System/Johns Hopkins School of Nursing P a g e | 12

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