Various drug therapy approaches for refractory chronic neuropathic pain are reasonable and depend on many variables such as patient characteristics and values. For Mr Wilson, it might be reasonable to trial an increased dose of either 90 mg of duloxetine daily or 75 mg of pregabalin in the morning and 150 mg at night for 3 months while weighing the potential for benefits and adverse effects. 24 , 25
Licensed producer: Regulated by Health Canada; requires prescribers to authorize medical cannabis via a medical document
Overall, there are many unknowns and uncertainties about the optimal role of cannabinoids in older adults for refractory neuropathic pain. Until more robust data are available, ensure other nonpharmacologic and pharmacologic therapies are optimized and that patients have failed at least 3 other agents before initiating cannabinoid therapy. Patients might be curious and want to explore cannabinoid therapy, so it is important to screen for cannabinoid use, monitor for potential adverse effects, and engage with patients. In addition, cannabinoid-related tools for practice exist to assist family physicians who seek practical guidance for delivering patient care.
Bringing evidence to practice: diabetic neuropathic pain management and cannabinoid therapy
Cannabinoid therapies can cause dizziness. A systematic review found 3 systematic reviews of cannabinoids versus placebo assessing this adverse effect. 12 The largest systematic review included 41 randomized controlled trials (RCTs) comprising 4243 participants and found an increased risk of dizziness (odds ratio of 5.09, 95% CI 4.10 to 6.32). 14 Increased dizziness with cannabinoid therapy was also found by Wade et al (3 RCTs including 666 participants; 32% vs 11% experienced dizziness; number needed to harm of 5) and by Mücke et al (4 RCTs including 823 patients), who found a numerical, although not statistical, increase in dizziness (risk difference of 3%, 95% CI −2% to 8%). 15 , 16 Furthermore, cannabinoid therapy is active in the central nervous system (CNS) and it can interact with other CNS-active drugs. The American Geriatric Society Beers criteria recommend avoiding the use of 3 or more CNS-active drugs. 17 Mr Wilson is currently taking 4 CNS-active drugs (ie, pregabalin, zopiclone, duloxetine, cannabis oil), which increases his risk of harm, including dizziness.
Approximately 18% of Canadian adults use cannabis, which has increased from 14% since the legalization of recreational marijuana. 1 However, less than 2% of Canadians are registered medical cannabis users. 2 , 3 Chronic pain is a common reason for using cannabis. 4 , 5 Because neuropathic pain, a subset of chronic pain, affects approximately 8% of patients and is challenging for physicians and patients to manage adequately, an understanding of cannabinoid therapies (ie, prescription cannabinoids or cannabis) is important (Box 1). 6 – 9 This article will review the evidence for cannabinoids in refractory neuropathic pain and highlight tools to assist family physicians who seek practical guidance in advising, authorizing, prescribing, and monitoring cannabinoids. We acknowledge that there are various viewpoints on the role of cannabinoids and we offer multiple considerations.
Cannabis: Marijuana; available legally from a licensed producer or licensed retailer
Screening for cannabinoid use, even in older adults, is important given the prevalence of cannabis use. Patients might contemplate self-medicating with cannabis for various reasons, including viewing cannabis as a “natural” (and therefore “safe”) alternative, or for managing medical conditions not adequately controlled by their current drug therapy. 9 Prescription cannabinoids (ie, nabiximols and nabilone), when dispensed by a community pharmacy, are captured by provincial or territorial electronic prescription databases. Cannabis is not captured by these databases, which makes it easy to miss unless it is specifically asked about, as was the case with Mr Wilson. When screening, it might be helpful to ask patients separately about medical and recreational (or nonmedical) cannabis or marijuana. Also, prompting patients by asking about specific products such as “CBD oil” or “topical cannabis” might be useful, as these products are not always viewed as medications by patients.
If alternative cannabinoid therapy is explored (see Table 1 for cannabinoid product details 9 and the full version of the RxFiles cannabinoid treatment chart available online from CFPlus * ), Mr Wilson should likely be titrated off or given a reduced dose of duloxetine or pregabalin to minimize additive CNS adverse effects. 9 Prescription cannabinoids are preferred over cannabis, as most RCTs assessed these products, dosing guidance is available, provincial and territorial electronic prescription databases capture these products aiding in cannabinoid screening, and the products meet prescription-level quality standards. However, cost might be prohibitive, especially with nabiximols. It would be important to initiate the cannabinoid at a low dose and increase it every few days or weekly, and a reasonable trial duration would be approximately 3 months. In general, the best approach will be patient-centred.
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The spinal cord contains millions of nerve “intersections” that distribute signals to every part of the body. The area of the spinal cord that is damaged will determine what side-effects develop and where.
Learn what makes CBD so useful for treating neuropathic pain, how to use it effectively, and what other measures you can do to get the best chances of finding relief from your pain.
The causes of neuropathic pain can range from neurological issues such as multiple sclerosis or a stroke to nutritional deficiencies and diabetes.
What Are The Side-Effects of CBD?
Neuropathic pain is caused by damage or dysfunction of the nerve cells. There are many causes for nerve damage in the body, such as:
Updated on October 20, 2021
For this reason, it’s a good idea to work out the dose yourself to find out what’s best for you and your symptoms.
What is a Spinal Cord Injury?
The location of the damage to the spinal cord will determine which areas of the body are affected.
Spinal cord injuries can have debilitating and life-altering consequences. Injuries can cause varying levels of paralysis, spasticity, loss of sensation, muscle weakness, and nerve pain that can persist for the rest of that person’s life.