Content uploaded by Anuj Bhatia
Author content
All content in this area was uploaded by Anuj Bhatia on Sep 28, 2017
Content may be subject to copyright.
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1
Copyright © 2017 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000002110
Neuropathic pain (NP) is common with a preva-
lence of 7% to 8% of the population.1 Challenges
in management of NP include a high failure rate
with available pharmacotherapy.2 It is acknowledged that,
on average, for every 3 patients who receive treatments for
NP, only one has analgesic benet.3 In the last decade, the
use of cannabis and selective cannabinoids (synthetic can-
nabinoids containing only tetrahydrocannabinol [THC] and
cannabis-based medicinal extracts containing a combina-
tion of THC and cannabidiol [CBD]) has gained popular-
ity for the treatment of NP.4 Cannabinoid receptors (CB1
and CB2) have been linked to processes in pain modulation
whereby activity at these receptors causes inhibitory effects
on pain responses.5,6 Furthermore, endocannabinoids have
been shown to interact with other receptor systems includ-
ing γ-aminobutyric acid, serotonergic, adrenergic, and opi-
oid receptors, many of which are involved in the analgesic
mechanisms of common NP medications.7
There is a lack of consensus regarding the role of selec-
tive cannabinoids in treating NP that is refractory to recom-
mended rst and second-line medications (anticonvulsants,
antidepressants, opioids). In its most recent published
guidelines, the Canadian Pain Society advocates for the use
of selective cannabinoids as the third-line option for NP
whereas the Special Interest Group on NP of the International
Association for the Study of Pain has provided a weak
recommendation against the use of these medications for
N P. 8,9 This dichotomy of opinion originates from conicting
results of randomized controlled trials (RCTs) involving the
BACKGROUND: There is a lack of consensus on the role of selective cannabinoids for the treat-
ment of neuropathic pain (NP). Guidelines from national and international pain societies have
provided contradictory recommendations. The primary objective of this systematic review and
meta-analysis (SR-MA) was to determine the analgesic efcacy and safety of selective cannabi-
noids compared to conventional management or placebo for chronic NP.
METHODS: We reviewed randomized controlled trials that compared selective cannabinoids
(dronabinol, nabilone, nabiximols) with conventional treatments (eg, pharmacotherapy, physical
therapy, or a combination of these) or placebo in patients with chronic NP because patients with
NP may be on any of these therapies or none if all standard treatments have failed to provide
analgesia and or if these treatments have been associated with adverse effects. MEDLINE,
EMBASE, and other major databases up to March 11, 2016, were searched. Data on scores
of numerical rating scale for NP and its subtypes, central and peripheral, were meta-analyzed.
The certainty of evidence was classied using the Grade of Recommendations Assessment,
Development, and Evaluation approach.
RESULTS: Eleven randomized controlled trials including 1219 patients (614 in selective can-
nabinoid and 605 in comparator groups) were included in this SR-MA. There was variability
in the studies in quality of reporting, etiology of NP, type and dose of selective cannabinoids.
Patients who received selective cannabinoids reported a signicant, but clinically small, reduc-
tion in mean numerical rating scale pain scores (0–10 scale) compared with comparator groups
(−0.65 points; 95% condence interval, −1.06 to −0.23 points; P = .002, I2 = 60%; Grade
of Recommendations Assessment, Development, and Evaluation: weak recommendation and
moderate-quality evidence). Use of selective cannabinoids was also associated with improve-
ments in quality of life and sleep with no major adverse effects.
CONCLUSIONS: Selective cannabinoids provide a small analgesic benet in patients with chronic
NP. There was a high degree of heterogeneity among publications included in this SR-MA. Well-
designed, large, randomized studies are required to better evaluate specic dosage, duration of
intervention, and the effect of this intervention on physical and psychologic function. (Anesth
Analg 2017;XXX:00–00)
Selective Cannabinoids for Chronic Neuropathic Pain:
A Systematic Review and Meta-analysis
Howard Meng, MD,* Bradley Johnston, PhD,†‡§‖ Marina Englesakis, MLIS,¶ Dwight E. Moulin, MD,#
and Anuj Bhatia, MBBS, MD, FRCPC, FRCA, FFPMRCA, FIPP, EDRA, CIPS*
From the *Department of Anesthesia and Pain Management, University
Health Network-Toronto Western Hospital, University of Toronto, Toronto,
Ontario, Canada; †Department of Anaesthesia and Pain Medicine and ‡Child
Health Evaluative Sciences, The Research Institute, The Hospital for Sick
Children, Toronto, Ontario, Canada; §Institute of Health Policy, Management
and Evaluation, Dalla Lana School of Public Health, University of Toronto,
Toronto, Ontario, Canada; ‖Department of Clinical Epidemiology &
Biostatistics, McMaster University, Hamilton, Ontario, Canada; ¶Library and
Information Services, Toronto General Hospital, University Health Network,
Toronto, Ontario, Canada; and #Department of Clinical Neuro Sciences and
Oncology Earl Russell Chair Pain Research, Western University, London
Regional Cancer Program, London, Ontario, Canada.
Accepted for publication March 7, 2017.
Funding: This study was performed with nancial support from the
Department of Anesthesia and Pain Management at Toronto Western Hospital.
The authors declare no conicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Address correspondence to Anuj Bhatia, MBBS, MD, FRCPC, FRCA, FFPM-
RCA, FIPP, EDRA, CIPS, Department of Anesthesia and Pain Management,
University Health Network-Toronto Western Hospital, University of Toron-
to, Toronto, Ontario, Canada. Address e-mail to anuj.bhatia@uhn.ca.
META-ANALYSIS
E
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
2 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
use of small study populations, different types of selective
cannabinoids, varying periods of follow-up, a range of dos-
ages, and inclusion of chronic pain syndromes with unclear
neuropathic characteristics. There have also been recent
attempts to synthesize available evidence on analgesic and
adverse-effect prole of selective cannabinoids in patients
with NP.10,11 However, the methodologies and conclusions
of these reviews are hampered by inclusion of trials that
enrolled participants with heterogeneous phenotypes (neu-
ropathic and non-NP), variability in assessment of domains
of pain, and absence of meta-analysis resulting in lack of
information on effect size and its condence limits.
A systematic review and meta-analysis (SR-MA) of this
topic, by synthesizing the available evidence, would help
arrive at conclusions regarding the benets and risks of
selective cannabinoids as well as dose-response effects.
The primary objective of this SR-MA was to determine the
analgesic efcacy of selective cannabinoids compared with
conventional management or placebo for chronic NP after
at least 2 weeks following commencement of treatment.
Clinical recommendations based on the guidelines from the
Grade of Recommendations Assessment, Development, and
Evaluation (GRADE) Working Group based on the result of
this SR-MA have also been provided.
METHODS
This SR-MA was conducted according to the recommenda-
tions of the Cochrane Collaboration12 and it is reported as
per the Preferred Reporting Items for Systematic Reviews
and Meta-Analysis guidelines. This SR-MA was registered
with PROSPERO (an international prospective register of
systematic reviews; #CRD42016036310).
Search Strategy and Study Selection
We conducted comprehensive, serial searches of the lit-
erature through March 11, 2016. The following data-
bases were searched: EMBASE, 1947 onward; MEDLINE,
1946 onward; MEDLINE In-Process and Other Non-
Indexed Citations (all using the OvidSP Platform); and
Cochrane Database of Systematic Reviews. PROSPERO
and Cochrane Central Register of Controlled Trials were
included to identify reviews or trials that may have
been published but missed during the initial search
on MEDLINE and EMBASE. We also searched Google
Scholar (rst 200 search results were reviewed) to com-
pliment search results from the aforementioned data-
bases with the objective of accessing all content relevant
to the topic. Proceedings of the major annual meetings of
anesthesiology and pain societies (American Society of
Anesthesiologists, European Society of Anaesthesiology,
International Association for the Study of Pain, American
Society of Regional Anesthesia and Pain Medicine,
European Society of Regional Anesthesia and Pain
Therapy, and World Institute of Pain) in the last 2 years
were also searched. We also searched for RCTs in the meta-
register of Controlled Trials (www.clinicaltrials.gov). We
restricted our search to trials involving human subjects
and manuscripts published in English language. Finally,
experts with clinical and research experience on the role
of selective cannabinoids for NP were also consulted.
For EMBASE and MEDLINE, both controlled vocabulary
terms (EMBASE-Emtree; MEDLINE-MeSH) and text word
searching were conducted for each of the following search
segments: cannabinoid (dronabinol, nabilone, nabiximols,
THC, CBD, THC-CBD, THC/CBD); pain (hyperalgesia,
allodynia, dysesthesia, paresthesia); nerve dysfunction
(neuropathic, neuropathy, neuropathies); RCT (random
allocation, placebo). We applied a highly sensitive search
strategy to identify studies. Details of our search strategy
are provided in Supplemental Digital Content 1, Table 1,
http://links.lww.com/AA/B747. We complemented our
search by reviewing the bibliographies of every selected
article to look for possible additional articles that had not
been retrieved by our electronic search. Two authors (H.M.
and A.B.) independently evaluated titles, abstracts, and
full texts according to the inclusion criteria. All instances
of discordance were discussed between the investigators
to reach a consensus.
Criteria for Considering Trials for This Review
Trials. Type: We considered only RCTs for this review that
compared the effect of selective cannabinoids (dronabinol,
nabilone, and nabiximols) containing synthetic THC or a
combination of extracted THC and CBD versus placebo or
standard treatment.
Follow-up Period: Trials with a follow-up period of at
least 2 weeks following initiation of treatment were included.
Diagnosis of NP: Trials that reported on diagnosis of cen-
tral and/or peripheral NP based on etiology (eg, multiple
sclerosis and diabetes mellitus), clinical presentation, vali-
dated questionnaires for NP, and/or investigations includ-
ing quantitative sensory testing (QST) were included.
We prespecied eligibility criteria using the population,
intervention, comparator, and outcomes as follows.
Participants: Only trials on human subjects above
18 years of age that had NP for at least 3 months were
included in this SR-MA. Intensity of pain had to be moder-
ate or severe (4 or higher on a 0–10 numerical rating score
[NRS] or ≥40/100 for Visual Analog Scale [VAS] for pain).
Participants enrolled in these studies may have been on
other types of analgesics but pain level and doses needed to
be stable prior to study enrollment.
Interventions and Comparators: Intervention was
dened as administration of any of the 3 prescription selec-
tive cannabinoids (dronabinol, nabilone, and nabiximols)
for at least 2 weeks in addition to the baseline pain regimen.
The intended maximum daily dose of the selective cannabi-
noid in the trial methodology and the daily mean dose used
were extracted. The comparators were placebo or standard
management (pharmacotherapy [antidepressants, anticon-
vulsants, anti-inammatories, opioids], physical therapy,
or a combination of these) for the treatment of NP because
patients with NP may be on any of these therapies, or none,
if all standard treatments have failed to provide analge-
sia and/or if these treatments have been associated with
adverse effects. Among open-label extended trials follow-
ing an experimental RCT study period, only the RCT study
period results were extracted and used for this review. We
excluded reviews on cannabis and other selective nonpre-
scription cannabinoids due to the lack of information on
chemical composition and dose administered to participants.
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 3
Outcomes: The primary outcome was intensity of pain
recorded after a minimum of 2 weeks following initiation of
selective cannabinoid and placebo/comparator administra-
tion, expressed on an NRS (0—no pain to 10—worst pos-
sible pain). Intensity scores reported on a VAS (0—no pain
to 100—worst possible pain) were transformed to a 0 to 10
NRS scale. So as to be inclusive given the paucity of well-
designed trials, we chose to include trials that assessed the
primary outcome at a wide range of time intervals because
the duration of analgesic effect of selective cannabinoids
depends on the interventional regimen (usually slow titra-
tion in the rst few days following initiation of therapy).
The following were considered as secondary outcomes if
measured on validated scales: presence or absence of anal-
gesia dened as reduction in pain scores (NRS/VAS) by
≥30% at 2 weeks or more after initiation of intervention,
quality of life (QoL), physical function, psychological func-
tion, sleep, overall patient satisfaction, and the incidence
of adverse effects of selective cannabinoids (eg, dizziness,
somnolence, muscle spasms, worsening pain, dry mouth).
Risk of Bias Assessment for Individual Trials
Two review authors (H.M. and A.B.) independently
assessed the risk of bias for each included study using the
Cochrane Collaboration’s instrument for assessing the risk
of bias. Any disagreement was resolved through discussion
or, if necessary, arbitration by a third reviewer (D.E.M.).
The risk of bias instrument assesses the following domains:
generation of the allocation sequence, allocation conceal-
ment, blinding of investigators and participants, blinding
of outcome assessors, incomplete outcome data, selective
outcome reporting, and other sources of bias that have
less empirical evidence of bias but together may be consid-
ered important (unequal distribution of prognostic factors,
industry funding, industry authorship, trial stopped early).
Each item was classied as low, unclear, or high risk of bias.
A decision to classify “overall bias” as low, unclear, or high
was made by the reviewers using the following method:
• High: any trial with a high risk of bias listed on 3 or
more domains.
• Unclear: any trial with a high risk of bias listed on
more than 1 but less than 3 domains.
• Low: any trial with a high risk of bias on none or 1
domain and with no signicant methodologic con-
cerns that may have affected the study results.
We also intended to use a funnel plot (for assessment of its
asymmetry to assess publication biases [citation bias, selec-
tive outcome reporting]) and Begg’s and Egger’s tests if a
sufcient number of studies (10 or more) were available to
apply these tests.
Data Collection
The reference data, populations, and outcomes were
extracted from the articles into prespecied tables using a
standardized data extraction form. The data-collection form
was pilot-tested before its use. We extracted information
on studies’ general characteristics (including design, num-
ber of arms, and primary outcomes), participants (char-
acteristics of the populations, sample size, duration, and
intensity of pain), and experimental intervention (type of
selective cannabinoid, doses, and administration regimes).
Dichotomous outcomes were extracted as the presence or
absence of neuropathic scale and QST for the diagnosis of
NP. For continuous data (pain NRS scores), we extracted
means and standard deviations (SDs) from tables or graphs
provided in the publications. If not reported, the SDs were
obtained from condence intervals (CIs) or P values that
related to the difference between means in the 2 groups.
Median values and interquartile ranges were converted to
mean and SD (if data appeared to be normally distributed)
using accepted techniques.12 We also contacted authors
of studies included in our SR-MA when we needed more
information about their analysis or reported results.
Data Synthesis and Analysis
We expected heterogeneity because of diverse populations
with NP and doses of selective cannabinoids administered,
and therefore, we used DerSimonian and Laird random
effects meta-analysis models. Heterogeneity was assessed
with the Q test, and Higgins I2 statistic was used to quan-
tify it (I2 >50% indicates substantial heterogeneity). The
estimated mean effect of each study of these outcomes was
calculated with the respective 95% CI, and the pooled effect
was then assessed. A P value of < .05 was considered sig-
nicant for the analysis of the primary outcome (difference
between pain scores). Bonferroni adjustment for multiple
testing was not performed as per recommendations in the
Cochrane Handbook.12 The Mantel-Haenszel method was
used for calculating the pooled relative risk (risk ratio) with
corresponding 95% CI. Investigation of sources of hetero-
geneity was based on analysis of prespecied subgroups
for the primary outcome including type of selective canna-
binoid (THC-CBD versus THC) and quality of trials (high
versus unclear or low risk of bias). We performed random-
effects meta-regression of the standardize mean difference
(effect size) using both a restricted maximal likelihood
approach, which assumes a normal distribution, and the
DerSimonian and Laird method, which assumes a non-nor-
mal distribution, for between-study variance.
A sample size calculation was performed to estimate
the number of patients required to detect a difference of
1.5, 1, or 0.5 points (on the 0–10 NRS for pain) between
the selective cannabinoid and comparator groups with
a SD of 2.0. Sample sizes of 40, 86, and 338 subjects per
group, respectively, were required to obtain results with a
probability of type I error of 5% and type II error of 10%.
It should be recognized that the power is likely to be sub-
stantially lower for the subgroup analysis because of lesser
number of observations. All statistical analyses were per-
formed with the Review Manager (RevMan version 5.2.5;
The Nordic Cochrane Centre, The Cochrane Collaboration,
Copenhagen, Denmark) and SAS version 9.3 (The SAS
Institute, Cary, NC).
Quality of Evidence
The quality of evidence was assessed with GRADE method-
ology for the primary outcome. The quality of evidence was
classied as high, moderate, low, or very low for each out-
come based on the risk of bias, inconsistency, indirectness,
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
4 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
Table 1. Characteristics of Included Studies on Selective Cannabinoids
First
Author,
Year Pain Diagnosis
Diagnosis of
Neuropathic
Pain Type of Pain
Duration of
Pain in Years
(Range or SD)
Baseline Pain
NRS (Range
or SD)
Age in Years
(Range),
Gender (M/F)
Number of
Subjects in
Each Group
(Can/Com) Active Rx, Route Comparator
Duration of
Treatment Remarks
Svendsen,
200419
Multiple
sclerosis
Clinical and
QST
Central 4.5 (0.3–12) 5.5 (3.0–8.0) 50 (20–55);
10/14
24 (24/24) Dronabinol
po—daily dose
2.5–10 mg for
3 wk
Placebo 3 weeks
(15–21 d)
Crossover trial
(treatments
separated by a
3-wk washout
period);
pre-existing
neuropathic
pain medication
not continued
(except
paracetamol)
Berman,
200422
Neuropathic pain
from brachial
plexus root
avulsion
Clinical Central 5.0
(0.9–18.6)a
6.8 ± 1.4 46 (29–63);
46/2
48 (48/48) THC-CBDb,c mean
number of
sprays/d in
each group: 8
Placebo 2 wk Crossover trial
(three 2-wk
treatments;
no washout
period between
treatments;
dpre-existing
neuropathic
pain medication
continued
Rog,
200516
Multiple
sclerosis
Clinical and
NPS
Central 11.6 (1.6–36) 6.5 ± 1.6 49.2 (26.9–
71.4); 14/52
66 (34/32) THC-CBDb: mean
number of
sprays/d: 9.6
Placebo 5 weeks Pre-existing
neuropathic
pain medication
continued
Nurmikko,
200715
Neuropathic pain
of multiple
etiologies
Clinical and
NPS
Peripheral 6.4 ± 5.7
(Can)
6.2 ± 6.4
(Com)
7.3 ± 1.4
(Can); 7.2 ±
1.5 (Com)
52.4 ± 15.8
(Can); 54.3 ±
15.2 (Com);
51/74
125 (63/62) THC-CBDb: mean
number of
sprays/d: 10.9
± 6.8
Placebo 5 wk Pre-existing
neuropathic
pain medication
continued
Frank,
200823
Neuropathic pain
of multiple
etiologies
Clinical Central (n =
30) and
peripheral
(n = 66)
6.4 ± 5.8
years
6.7 ± 1.4 50.1 y (range
23–84); 46/50
96 (96/96) Nabilone po 2 mg
daily
Dihydrocodeine
240 mg
daily
6 wk Crossover trial;
all adjuvant
analgesics
(except
dihydrocodeine)
allowed
Selvarajah,
201017
Neuropathic
pain-diabetic
neuropathy
Clinical and
NTSS-6
Peripheral >0.5 y Can: 5.6 ± 2.7
Com: 4.5 ± 2.2
Can: 58.2 ± 8.8
years
Com: 54.4 ±
11.6 years;
19/11
30 (15/15) THC-CBDb: up to
4 sprays/d
Placebo 12 weeks
(titration
in rst 2
wk and
maintenance
for 10 wk)
Pre-existing
neuropathic
pain medication
continued
(Continued)
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 5
Toth,
201220
Neuropathic
pain-diabetic
neuropathy
Clinical and
DN4
Peripheral 7.1 ± 7.3 y 5.8 ± 1.8 Can: 60.8 ±
15.3 y
Com: 61.6 ±
14.6 y;
14/12e
26 (13/13) Nabilone
1–4 mg/d
Placebo 5 weeks
(following a
4-wk run-in
phase to
identify
responders)
Pre-existing
neuropathic
pain medication
continued;
enriched
enrollment
randomized
withdrawal design
Langford,
201313
Multiple sclerosis Clinical Central 5.5 ± 5.5 y 6.6 ± 1.4 49.0 ± 10.5 y;
109/230
339
(167/172)
THC-CBDb: mean
daily dose of
THC/CBD spray
was 8.8 ± 3.9
sprays
Placebo 14 wk Pre-existing
neuropathic
pain medication
continued
Serpell,
201418
Neuropathic pain
of multiple
etiologies
Clinical Peripheral 5.5 ± 5.9 y ≥4/10 NRS 57.3 ± 14.2;
96/150
246
(128/118)
THC-CBDb:
mean daily dose of
THC/CBD spray
was 8.9 sprays
Placebo 15 wk Pre-existing
neuropathic
pain medication
continued
Lynch,
201414
Neuropathic pain-
chemotherapy-
induced
Clinical Central and
peripheral
1.4 years
(range not
provided)
6.8 ± 1.2 56.0 ± 10.8;
3/15
18 (18/18) THC-CBDb: mean
daily dose of
THC/CBD spray
was 8 sprays
Placebo 4 wk Crossover trial
(treatments
separated by a
2-wk washout
period);
pre-existing
neuropathic
pain medication
continued
Turcotte,
201521
Multiple
sclerosis
Clinical and
DN4
Central 4.5 y (2.3–5.8
y)
7.7 ± 1.4 45.5 ± 10.8;
2/13
15 (8/7) Nabilone: 2 mg/d Placebo 9 wk (initial
4 wk for
titration)
Pre-existing
neuropathic
pain medication
continued
Abbreviations: Can, cannabinoid; CBD, cannabidiol; Com, comparator; DN4, Douleur Neuropathique 4 questionnaire; NP, neuropathic pain; NRS, Numerical Rating Scale; NTSS-6, Neuropathy Total Symptom Score-6; QST,
quantitative sensory testing; THC-CBD, δ-9-tetrahydrocannabinol (27 mg/mL) and cannabidiol (25 mg/mL).
aTime since last surgical intervention.
bEach 100 μL spray delivers 2.7 mg of THC and 2.5 mg of CBD.
cTwo active treatment groups (THC-CBD and THC) but data extracted only for THC-CBD group.
dMaximum 24-h dose allowed was 48 sprays: 129.6 mg/120 mg of THC-CBD or 129.6 mg of THC.
eGreater proportion of women randomized to the nabilone group than placebo.
Table 1. Continued
First
Author,
Year Pain Diagnosis
Diagnosis of
Neuropathic
Pain Type of Pain
Duration of
Pain in Years
(Range or SD)
Baseline Pain
NRS (Range
or SD)
Age in Years
(Range),
Gender (M/F)
Number of
Subjects in
Each Group
(Can/Com) Active Rx, Route Comparator
Duration of
Treatment Remarks
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
6 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
imprecision, and publication bias. A summary table was
constructed with the GRADEpro guideline development
tool (http://www.guidelinedevelopment.org/; Evidence
Prime Inc, Hamilton, ON, Canada).
RESULTS
Search Results
From the initial 1298 records identied through database
searching, 980 records were screened but 959 of these were
excluded because the publications were not RCTs or failed to
report any of our primary or secondary outcomes. Twenty-
one full-text articles were assessed for eligibility, and 10
were excluded because the study settings did not meet our
inclusion criteria. Eleven RCTs consisting of 1219 patients
(614 in selective cannabinoid and 605 in comparator groups)
were included for the systematic review and data from 10 of
these were subjected to meta-analysis (Table1, Figure1).13–23
Trial, Participants, and Intervention
Characteristics
Spectrum of Neuropathic Pain Syndromes. The median
(range) sample size of the 11 RCTs was 48 (15–339) patients.
All the trials evaluated patients with NP but there was
variation in distribution of pain and its etiology. Five
trials enrolled patients with central NP—the etiology was
multiple sclerosis in 4 of these trials13,16,19,21 and avulsion
injuries to the brachial plexus in the fth trial.22 Four trials
included patients with peripheral NP—the etiology was
diabetes in 2 of these trials,17,20 and patients with multiple
etiologies for peripheral NP were included in 2 trials.15,18
Two trials enrolled patients with NP that was both central
and peripheral—NP was secondary to chemotherapy in one
of these trials14 and multiple etiologies in the other.23 Three
trials included patient populations with multiple etiologies
for NP (Table1).15,18,23
In the trials included in this SR-MA, the diagnosis
of NP was based on clinical criteria (eg, presence of allo-
dynia, hyperalgesia, numbness) in all trials but some of
the included trials also used validated screening tools for
NP. The screening tools used were Douleur Neuropathique
4 questionnaire,20,21 Neuropathic Pain Score,15,16 and
Neuropathy Total Symptom Score-6.17 One trial also used
QST to supplement clinical diagnostic criteria.19 Four other
studies used QST as 1 of the outcomes but not as a selection
criterion.14,15,18,19 The duration of NP ranged from 6 months
to over 11 years and the intensity of pain was moderate-to-
severe for patients in all the trials included in this review.
The exclusion criteria were fairly similar in all the studies
included in this review but 1 study excluded patients with
NP who also had depression.19 Patients with severe con-
comitant illness, seizures, and history of substance abuse
were excluded in all studies.
Selective cannabinoids were used as an adjunct (and
not primary) analgesic for NP in all the studies included
in this review. Five studies allowed for continuation of all
previous analgesics prior to enrollment,13–16,20 but 1 study
required all patients to stop taking dihydrocodeine 2 weeks
prior to initiation of the trial (although all other analgesics
were allowed), presumably because dihydrocodeine was
the comparator medication in the trial.23 One study allowed
use of all analgesics except for paracetamol (acetamino-
phen),18 1 study did not allow use of any other analgesic
Figure 1. Preferred Reporting Items for
Systematic Review and Meta-Analyses
(PRISMA) owchart for studies included
in the review.
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 7
except paracetamol,19 and 1 study did not clearly identify
whether patients were allowed to use concurrent medica-
tions but patients had undergone an adequate trial of tricy-
clic antidepressants prior to enrollment.17
Selective Cannabinoids and Comparators Used
in the Trials
Three selective cannabinoids were assessed in the 11
included trials (1 trial was on dronabinol,19 3 trials were on
nabilone,20,21,23 and 7 trials were on nabiximols13–18,22) and the
duration of treatment ranged from 2 to 15 weeks (Table1).
Daily dose for dronabinol ranged from 2.5 to 10 mg,19 the
daily dose for nabilone was between 1 and 4 mg,20,21,23 and
the mean daily dose for nabiximols sprays was 8.3 sprays
(ie, 22.4 mg of THC and 20.8 mg of CBD) with a range of 4
to 10.9 sprays. One trial had 2 active groups (THC and THC-
CBD) and we extracted data for the THC-CBD group.22 All
trials used placebos for comparison with the active treat-
ment except 1 trial that allowed a daily dose of 240 mg of
dihydrocodeine in the comparison group.23 Participants
were allowed to continue medications for relieving NP in
all the trials except 1 study.19
Risk of Bias Assessment of Included Studies
Overall risk of bias was assessed as low in 10 of 11 trials
(Supplemental Digital Content 2, Table 2, http://links.
lww.com/AA/B748).17 The trial deemed to have a high
risk of bias did not adequately describe the procedure for
generation of randomization, concealment of allocation,
and blinding of participants.17 There was no difference in
opinion between the 2 reviewers for assessment of risk of
bias for all 11 trials. Quality of reporting24 was good in 8 tri-
als,13–16,18,19,21,22 fair in 2 trials,20,23 and poor in 1 trial.17
Primary Outcome: Pain Scores
The primary outcome was intensity of pain after a mini-
mum of 2 weeks following initiation of study treatments,
expressed on an 11-point NRS. All studies included in this
review except 1 reported this outcome.18 Serpell et al18 chose
to report the proportion of patients achieving more than
30% reduction in intensity of NP as compared to baseline
scores.
Out of the 11 studies included in this review, 6 demon-
strated analgesic superiority of selective cannabinoids com-
pared to placebo based on change in NRS pain scores,15,16,19–21
or on proportion of patients achieving more than 30% reduc-
tion in intensity of pain as compared to baseline scores.18
Meta-analysis of data from the 10 trials that reported pain
scores revealed a small reduction of pain scores with selec-
tive cannabinoids when compared to placebo or dihydro-
codeine in patients with NP (mean difference −0.65 points;
95% CI, −1.06 to −0.23 points; P = .002, I2 = 60%) (Table 2,
Figure2).13–16,18–23
Comparison of Different Selective Cannabinoid
Types
We examined results for the 3 types of selective cannabi-
noids evaluated in these trials. Only 1 trial evaluated anal-
gesic potential of dronabinol in patients with central NP
and it reported superiority of this selective cannabinoid
over placebo.19 Three trials evaluated analgesic efcacy
of nabilone in NP.20,21,23 Two of these trials (1 trial enrolled
patients with central NP21 and the other trial enrolled
patients with peripheral NP20) concluded that use of nabi-
lone was associated with analgesic benet in NP. The third
trial on nabilone enrolled patients with mixed central and
peripheral NP and it demonstrated analgesic inferiority of
nabilone in comparison to dihydrocodeine.23 Meta-analysis
of data from these 3 trials revealed no signicant reduction
of the 11-point pain NRS with nabilone when compared to
placebo or dihydrocodeine in patients with NP (mean dif-
ference −1.22 points; 95% CI, −2.79 to 0.36 points; P = .13;
I2 = 85%) (Figure3A). Seven trials13–18,22 evaluated analgesic
efcacy of nabiximols in NP and 613–17,22 of these reported
pain scores. Two of these trials (one for central NP16 and the
other for peripheral NP15) reported analgesic superiority of
nabiximols over placebo. The other 5 trials did not show
analgesic benet with nabiximols (2 on central NP,13,22 2 on
peripheral NP,17,18 and 1 on mixed central and peripheral
NP14). Meta-analysis of data from the 6 trials that reported
pain scores revealed a signicant but clinically small reduc-
tion of the 11-point pain NRS with nabiximols when com-
pared to placebo in patients with NP (mean difference
−0.50 points; 95% CI, −0.89 to −0.12 points; P = .010, I2 =
43%) (Figure3B).
Efficacy of Selective Cannabinoids in Central
and Peripheral Neuropathic Pain
We conducted meta-analyses to see whether the effect of
selective cannabinoids differed depending on the location
of NP—central, peripheral, and combined central-periph-
eral (Table 2). Two of 5 studies involving patients with
central NP reported signicantly lower pain scores in the
selective cannabinoid group.16,21 Meta-analyses of the data
from the 5 trials on central NP demonstrated signicant
analgesic benet with selective cannabinoids (mean differ-
ence −0.73 points; 95% CI, −1.26 to −0.20 points; P = .007, I2
= 51%) (Figure4A).13,16,19,21,22
Three of the 4 studies involving patients with periph-
eral NP reported signicantly lower pain scores favoring
selective cannabinoids.15,17,18,20 However, meta-analyses of
the data from the 3 trials on peripheral NP that involved
use of selective cannabinoids and reported pain scores did
not demonstrate analgesic benet (mean difference −0.72
points; 95% CI, −2.04 to 0.59 points; P = 0.28, I2 = 75%)
(Figure 4B).15,17,20 Two studies of selective cannabinoids in
patients with mixed central and peripheral NP did not dem-
onstrate analgesic superiority of selective cannabinoids over
the comparators—1 of these trials involved the comparison
of nabiximols against placebo14 and the other compared nab-
ilone against dihydrocodeine.23
Secondary Outcomes
A variety of domains associated with pain were assessed
by trials on selective cannabinoids included in this review
(Table 2). Five of the 8 studies13,19,20,22,23 that assessed QoL
demonstrated an improvement in this parameter with
selective cannabinoids (questionnaires used to assess
QoL included Short Form-36,14,17,19,23 European Quality
of Life—5 Domains index score,17,18,20 and General Health
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
8 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
Table 2. Outcomes Reported in Included Studies on Selective Cannabinoids
First Author, Year Primary Outcome Secondary Outcome(s) Adverse Events Remarks
Svendsen,
200419
Median pain intensity score in the
last (third) week of treatment
Dronabinol: 4 (IQR 2.3–6)
Placebo: 5 (IQR 4–6.4)
Improvements in Dronabinol group
(versus placebo) in:
• Median radiating pain intensity
and pain relief score
• QoL (SF-36: bodily pain and
mental health domains)
• QST
No difference between groups in:
• Rescue analgesia
• Physical functioning (EDSS)
More patients had AE
(dizziness, headache,
tiredness, myalgia)
during active treatment,
especially in the rst
week of treatment; 17%
of patients in dronabinol
group could not tolerate
10 mg od
Diagnosis of central pain
established by history,
examination, QST
Berman, 200422 Mean pain intensity score in the
last (second) week of treatment
THC-CBD: 6.1 ± 1.4
Placebo: 6.6 ± 1.4
Improvements in THC-CBD group
(versus placebo) in:
• Sleep quality
• SF-MPQ PRI and VAS
• PDI: similar in 3 groups
• GHQ-12 score
Common adverse effects in
active groups: dizziness,
somnolence, dysgeusia,
nausea, euphoria
3 withdrawals during
the study: Placebo:
1—N&V during placebo
administration;
1—anxiety and
paranoia, experienced
while taking placebo
THC-CBD: 1—feeling faint
Rog, 200516 Mean pain intensity score in the
last (fth) wk of treatment
THC-CBD: 3.85 ± 2.1
Placebo: 4.96 ± 2.15
Improvements in THC-CBD group
(versus placebo) in:
• NPS score
• PGIC
• Sleep quality
No difference between groups in:
• Neuropsychologic outcomes
More patients on THC-CBD
than placebo reported
dizziness, dry mouth, and
somnolence; cognitive side
effects were limited
to long-term memory
storage
Nurmikko,
200715
Mean pain intensity score in the
last (fth) wk of treatment:
THC-CBD: 5.8 ± 1.4
Placebo: 6.7 ± 1.5
Improvements in THC-CBD group
(versus placebo) in:
• NPS composite score
• Sleep quality
• QST (dynamic and punctate
allodynia)
• Physical function (PDI)
• PGIC
Sedative and
gastrointestinal side
effects were reported
more commonly by
patients on THC-CBD
Withdrawals due to AE:
-THC-CBD: 11 (19%)
patients
Placebo: 2 (3%) patients
Frank, 200823 Mean VAS over the last 2 (fth and
sixth) wk of treatment period
Nabilone: 6 ± 2.4
Dihydrocodeine: 5.9 ± 2.4
Improvements in nabilone group
(versus placebo) in:
• QoL (nabilone superior to
dihydrocodeine for physical
function but dihydrocodeine
superior for bodily pain domain)
No difference between groups in:
• Mental functioning
• Sleep quality
• Psychometric function
More N&V with nabilone
and more tiredness
and nightmares with
dihydrocodeine
33 patients failed to
complete the trial and
the cohort studied
had a variety of
neuropathic pain
syndromes
Selvarajah,
201017
Mean total pain scores in the last
(12th) wk of treatment:
Can: 4 ± 2.9
Com: 2.5 ± 2.9
No difference between groups in:
• MPQ
• QoL (SF-36, EQ-5D)
• Six patients (group not
specied) withdrew
because of adverse
effects
• Patients with severe
depression in both groups
had signicant analgesic
benet in response to the
interventions
Toth, 201220 Mean daily pain score in the last
(5th) wk of treatment
Can: 3.5 ± 1.3
Com: 5.4 ± 1.7
Improvements in nabilone group
(versus placebo) in:
• Anxiety (HADS-A)
• Sleep quality (MOSSSPI)
• QoL (EQ-5D)
• PGIC and PTSS
Mild-to-moderate: dizziness
and drowsiness most
common
Potential unmasking
occurred in 6 patients
Langford, 201313 Patients with >30% reduction in pain
NRS compared to baseline:
Can: 50%
Com: 45%
Mean daily pain score in the last
(14th) wk of treatment
Can: 4.5 ± 2.2
Com: 4.7 ± 2.3
No difference between groups in:
• Sleep quality
• QoL (BPI-SF)
• PGIC
Mild-to-moderate: dizziness,
vertigo, drowsiness,
fatigue, nausea, and dry
mouth most common
Large placebo effect
(Continued)
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 9
Questionnaire –1222). Only one15 of the 3 studies that
assessed physical function15,19,22 reported an improvement
in this domain. Six of the 7 studies that assessed quality of
sleep found an improvement in this parameter.13,15,16,18,20,22
Only 116 of the 316,20,23 studies that measured anxiety using
validated questionnaires reported an improvement in the
Anxiety subscale on psychological function based on the
Hospital Anxiety and Depression Scale. Five of the 6 stud-
ies that included satisfaction of participants as 1 of the out-
comes reported positive results for this parameter.15,16,18,20,21
Three of the 4 studies demonstrated improvement in QST
prole (rise in thresholds) of the participants with selective
cannabinoids.15,18,19
Adverse Effects
All 11 studies included in this review collected data on
adverse effects with selective cannabinoids and study
medications. The majority of reported adverse effects with
selective cannabinoids were mild to moderate. The most
common adverse effects with selective cannabinoids were
dizziness/lightheadedness, somnolence, and dry mouth.
Adverse effects usually occurred at the onset of treatment
and subsided over time, indicating development of toler-
ance (Table2).
We also assessed reports of severe adverse effects requir-
ing withdrawal from the trials. These included confusion
in 2 patients20 and headaches in 1 patient on nabilone.21
In a study with a crossover design, 4 participants (out of
96) on nabilone withdrew from the trial due to intolerance
whereas 8 participants on dihydrocodeine ceased taking
this medication.23 Two patients developed severe adverse
events from selective cannabinoids (agitation and para-
noid ideation).16 In another study, 11 (18%) patients with-
drew from the nabiximols group because of adverse effects
compared to 2 (3%) in the placebo group.15 All other studies
demonstrated similar patient withdrawal rates between the
trial arms.
There did not appear to be a correlation between the
maximum dose (48 sprays per day) allowed for nabiximols
and incidence or severity of adverse effects because the dose
range utilized per 24 hours by participants in studies on
nabiximols was fairly low (4–11 sprays).
Serpell, 201418 Patients with >30% reduction in pain
NRS compared to baseline:
Can: 28%
Com: 16%
Improvements in THC-CBD group
(versus placebo) in:
• Sleep quality (NRS)
• PGIC
• NPS
• BPI-SF
• QoL (EQ-5D)
• QST (dynamic allodynia)
No difference between groups in:
• QST (punctate allodynia)
Mild-to-moderate:
dissociation and
disorientation most
common
Lynch, 201414 Mean daily pain score in the last
(fourth) wk of treatment
Can: 6.0 ± 1.2
Com: 6.4 ± 1.2
No difference between groups in:
• QoL (SF-36)
• QST (dynamic and punctate
allodynia)
Mild: fatigue, dizziness, dry
mouth, nausea
Study was signicantly
underpowered
Turcotte, 201521 VAS for pain intensity
Can: 3.5 ± 1.4
Com: 5.6 ± 1.4
Vas for impact of pain on daily
activities
Improvements in nabilone group
(versus placebo) in:
• PGIC
Mild: dizziness, drowsiness,
dry mouth
Combination of gabapentin
and nabilone evaluated
Abbreviations: BPI-SF, Brief Pain Inventory—Short Form; EDSS, expanded disability status scale score; EQ-5D, European Quality-of-Life 5 Domains; GHQ-12,
General Health Questionnaire-12; HADS-A, Anxiety subscale of the Hospital Anxiety and Depression Scale; IQR, interquartile range; MOSSSPI, Medical Outcomes
Study sleep scale problems index; N&V, nausea and vomiting; ND, no difference; NPS, neuropathic pain score; NRS, numerical rating score; PPT, pressure pain
threshold; PRI, pain rating index; PTSS, pain treatment satisfaction scale; QoL, quality of life; QST, quantitative sensory testing; SF-MPQ, short for m McGill
questionnaire; PDI, pain disability index; PGIC, patient’s global impression of change; VAS, Visual Analog Scale.
Table 2. Continued
First Author,
Year Primar y Outcome Secondary Outcome(s) Adverse Events Remarks
Figure 2. Forest plot of analgesic efcacy (pain Numerical Rating Scores) of selective cannabinoids.
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
10 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
Heterogeneity
For the primary outcome, the I2 statistic was 60% for
the meta-analysis of pain NRS from all selective canna-
binoid RCTs, it was 85% for comparison of mean pos-
tintervention pain scores for trials on nabilone, and 43%
for comparison of mean postintervention pain scores for
trials on nabiximols. These results indicate moderate-
to-high heterogeneity. Several characteristics of these
studies may have contributed to heterogeneity in our
review including types of patient populations, timing of
assessing primary outcome, and variations in dose. To
explore heterogeneity, we conducted subgroups using
meta-regression and a sensitivity analysis and found no
significant difference based on central versus peripheral
and on risk of bias.
We performed meta-regression analysis to assess
whether there was a significant interaction between loca-
tion of pain (central versus peripheral) and treatment
effects of selective cannabinoids. We found no significant
difference in effect size between studies on selective
cannabinoids that enrolled participants with central
pain compared to studies that enrolled participants
with peripheral pain (P = .998 and .958 when assessed
using normal and non-normal distribution assumptions,
respectively).
We performed a sensitivity analysis by removing the
1 trial with a high risk of bias.17 This trial also reported
a significant effect of depression on NP scores with
patients in both arms who had more depression also had
a more pronounced response to the study treatments.
Meta-analysis of data from the other 9 trials on selec-
tive cannabinoids that had a low risk of bias (ie, after
excluding 1 trial with a high risk of bias17) showed that
the significant but clinically small reduction in pain NRS
in patients with NP remained (−0.70 points; 95% CI,
−1.10 to −0.31 points; P = .0005, I2 = 57%) (Supplemental
Digital Content 3, Figure 1, http://links.lww.com/AA/
B749).13–16,19–23
Figure 4. A, Forest plot of analgesic efcacy (pain Numerical Rating Scores) of trials on selective cannabinoids in patients with central neuro-
pathic pain. B, Forest plot of analgesic efcacy (pain Numerical Rating Scores) of trials on selective cannabinoids in patients with peripheral
neuropathic pain.
Figure 3. A, Forest plot of analgesic efcacy (pain Numerical Rating Scores) of trials on nabilone. B, Forest plot of analgesic efcacy (pain
Numerical Rating Scores) of trials on nabiximols.
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 11
Publication Bias
We also evaluated probability of publication bias in tri-
als on selective cannabinoids for NP. The funnel plot
(Supplemental Digital Content 4, Figure 2, http://links.
lww.com/AA/B750) was asymmetrical suggesting the pos-
sibility of publication bias. Although other causes including
clinical heterogeneity could be responsible for this nding,
we decided to perform Begg’s and Egger tests for publica-
tion bias but the P values for publication bias were non-
signicant (P = .371 and .103, respectively). This suggests
that there was no publication bias. It is also important to
acknowledge that there were only 10 studies in our meta-
analysis and 10 is the minimum recommended number of
studies for constructing a funnel plot.25,26
Recommendations
Based on the quality of the evidence included in this review
and the strength of effect, it can be recommended that
selective cannabinoids may be used as adjunct analgesics
in patients with NP syndromes (GRADE: weak recommen-
dation; moderate quality evidence) (Supplemental Digital
Content 5, Table 3, http://links.lww.com/AA/B751).
Selective cannabinoids may be associated with improve-
ment in QoL, sleep, patients’ reports of impression of posi-
tive change, and improved sensory and pain thresholds
with psychometric testing. The overall small analgesic
benet and the associated adverse effects associated with
use of selective cannabinoids should be discussed with
patients and their preferences and values considered before
prescribing selective cannabinoids. Further research in this
eld is justied because there is a lack of information about
appropriate dosages and duration of treatment, impact of
these medications on physical and psychologic functioning,
and adverse effects.
DISCUSSION
This is the rst SR-MA of RCTs that focuses on the anal-
gesic efcacy of selective cannabinoids when used as
adjuncts in relieving refractory central and peripheral NP
of moderate-to-severe intensity. It reveals that daily doses
of 2.5 to 10 mg of dronabinol, 1 to 4 mg of nabilone, and 8.3
sprays of nabiximols when administered over 2 to 15 weeks
are associated with analgesic benet compared to placebo
at 2 weeks or more following initiation of treatment. The
reduction in mean NRS pain scores (0–10 scale) in patients
receiving selective cannabinoids compared to placebo is
signicant but clinically small. The quality of evidence is
moderate and the strength of recommendation is weak for
analgesic efcacy of selective cannabinoids in this clinical
setting. Among the different selective cannabinoids, use of
nabiximols and dronabinol, but not nabilone, conferred an
analgesic benet. Evaluation of subgroup results of analge-
sic impact of selective cannabinoids on different locations
of NP (central versus peripheral) did not reveal a signi-
cant difference. For secondary outcomes, use of selective
cannabinoids was associated with improvements in QoL
and sleep, and enhanced patient satisfaction but the impact
on physical and psychologic function was unclear. Serious
adverse effects were rare with the doses of selective canna-
binoids used in these trials.
The role of selective cannabinoids in relieving chronic
pain has been evaluated in a few narrative reviews over the
last few years but no SR-MAs on their role in NP have been
reported.10,11,27–29 Conclusions of these reviews vary with 1
review suggesting that selective cannabinoids have equian-
algesic effect to codeine and are associated with unwanted
side effects,27 whereas a meta-analysis of trials on selective
cannabinoids for MS-related pain revealed signicant pain
relief compared to placebo.28 Other recent systematic reviews
on heterogeneous pain populations (in terms of etiologies and
presentations) demonstrated analgesic superiority of selective
cannabinoids and cannabis in 2 reviews11,29 or were incon-
clusive.10 Selective cannabinoids and cannabis preparations
used in trials included in these reviews varied in formulation
(eg, smoked cannabis, vaporized cannabis, fatty acid amide
hydrolase inhibitors, oral mucosal sprays, and oral canna-
bis extracts) making it difcult to understand and establish
whether there was a dose-response relationship. Our SR-MA
is clinically relevant because it is the rst synthesis of pub-
lished data to exclusively focus on recent trials on chronic NP
that involved use of selective, prescription cannabinoids.
Population Included in This Review
There was a moderate degree of clinical and statistical (60%)
heterogeneity among the trials included in this SR-MA. We
included trials on selective cannabinoids for patients with
central NP pain because this type of pain can be extremely
challenging to relieve. NP was assessed using accepted
methods (clinical assessment in all studies and use of vali-
dated questionnaires for NP or QST in 1 study). However,
current ability to reliably diagnose central NP is uncertain.30
One of the trials on central NP included in our SR-MA
included only patients with sensory abnormalities at the
maximal pain site but patients with multiple sclerosis can
also have spasm-related pain.19 Spasm-related pain has been
considered as nonneuropathic by some investigators.19
Efficacy of Selective Cannabinoids in Relieving
Neuropathic Pain
Dose-Response Effect. Nabiximols. A self-titration dosing
schedule was chosen by investigators of trials on nabiximols
(THC-CBD sprays) included in our SR-MA because there
is high intersubject variability in the bioavailability of
nabiximols.13–18,22 The recommended dose range is between
1 and 48 sprays per day but the mean daily dose used by
participants included in this SR-MA was 8.3 sprays.31 This
suggests that only a few patients will progress to the upper
limit of the allowed dose range. Self-titration also enables
patients to achieve their individual optimum therapeutic
dose by balancing analgesia against adverse effects and
allowing variation of dose depending on the levels of pain
and activity. However, allowing wide dose ranges makes it
difcult to ascertain presence or absence of a dose-response
effect. It should also be acknowledged that although the
therapeutic effects of cannabis have often been attributed to
THC, the second major constituent of the trial medication—
CBD has been shown to have effects, which may be additive
to those of THC in pain relief in animal models, and CBD
also has the potential to ameliorate some of the psychoactive
effects of THC.32
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
12 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
Nabilone. Nabilone is a selective cannabinoid that is admin-
istered through the oral route. Some authors have also
questioned the appropriateness of trials of selective can-
nabinoids using oral administration due to the variability
in their gastrointestinal absorption and crossover designs
because of their long half-lives.27 The recommended daily
therapeutic dose of nabilone varies from 1 to 4 mg. Of the
3 trials on nabilone included in our SR-MA, the 2 trials that
reported analgesic benet with nabilone allowed exible
dosing of nabilone (1–4 mg per day),20 or a xed daily dose
of nabilone of 2 mg,21 but another trial that also allowed a
xed daily dose of 2 mg did not report any analgesic ben-
et.23 We conclude that it is not possible to dene a spe-
cic dose of nabilone that is associated with an analgesic
response in patients with NP and gradual escalation of dose
titrated to analgesic benet is recommended.
Magnitude of Analgesic Effect and Probability of
Treatment Success With Selective Cannabinoids
Our SR-MA found that selective cannabinoids were associated
with a signicant but small analgesic benet of change (reduc-
tion) in pain by −0.65 points (95% CI, −1.06 to −0.23 points; P =
.002) on an 11-point NRS for pain. However, patients enrolled
in the trials included in our SR-MA had moderate-to-severe
refractory NP despite the use of recommended therapies.8,9
It is recognized that treatment of NP, and in particular syn-
dromes caused by central nervous system lesions, is difcult
and randomized trials evaluating treatments of central pain
are limited.33 The pain reduction seen in this study is compa-
rable to the effect of other drugs used in the treatment of NP
conditions.34 A meta-analysis of more than 2700 patients with
various painful conditions suggested approximately a 30% or
a reduction by 2 points in the 11-point NRS for pain as being
clinically signicant but it notably did not include patients
with NP, in which “relatively small decreases in pain intensity
are often highly valued by the patients.”35 One trial included
in our SR-MA reported that the numbers needed to treat to
achieve a 50% reduction in central pain in at least 1 patient was
3.7 (95% CI, 2.2–13.0),16 similar to that obtained in the trial on
dronabinol that was also included in our SR-MA (3.5; 95% CI,
1.9–24.8).16,19 It is important to recognize that these numbers
needed to treat are signicantly lower (ie, better) compared to
those for some rst-line medications for treatment of NP.9
Central Versus Peripheral Neuropathic Pain
Meta-analysis of data on analgesic impact of selective cannabi-
noids on central and peripheral NP suggested a small analge-
sic benet in patients with central NP only but meta-regression
analysis revealed that the location of pain did not inuence
analgesic efcacy of selective cannabinoids. The pathologic
mechanisms of NP in these 2 locations may be different with
sensitization in spinal cord and brain playing a more important
role in central NP. Pain associated with brachial plexus injury
and multiple sclerosis, although considered to be central, can
have different phenotypes (related to spasms, plaques in the
central nervous system, and musculoskeletal pain).22 These
factors may explain the reason for 1 of the trials in our SR-MA
that found a lack of analgesic benet with nabilone over dihy-
drocodeine in a population with central and peripheral NP
syndromes secondary to a variety of etiologies.23
Impact of Coanalgesic Therapy
All trials included in this SR-MA except 1 allowed con-
tinuation of existing analgesic regimes.19 Depriving a
patient of therapies for NP during a placebo-controlled
trial is debatable. Clinical practice is moving toward com-
bination therapies due to the realization that multiple
mechanisms play a role in chronic NP.36 Experimental
studies have also shown that THC may not be an effective
analgesic when used alone but it displays a pronounced
synergistic effect when used with an opioid.37 Cannabis
may also have synergistic effects with opioids with a
recent publication suggesting that cannabis may be effec-
tive in weaning patients with chronic postsurgical pain
from high-dose opioids.38
Impact of Selective Cannabinoids on
Nonanalgesic Domains of Neuropathic Pain
Five13,19,20,22,23 of the 7 trials13,14,17,19,20,22,23 included in this
review demonstrated a positive effect on QoL despite a
relatively short duration of treatment in most of the studies
while 120 of 3 studies16,20,23 on psychologic function reported
an improvement in the Anxiety subscale of Hospital Anxiety
and Depression Scale. It is possible that the measures used
to detect changes in mood were not adequately sensitive to
detect milder degrees of psychologic impairment because
potential participants who had signicant psychologic mor-
bidities were excluded from the trials. Alternatively, the
paradoxical effects of THC, or the ability of CBD to block
some of the psychomimetic effects of THC, may explain the
lack of change in mood. Assessment of mood is important in
any trial involving use of selective cannabinoids because of
their known anxiolytic action,39,40 while there are also con-
cerns about the ability of selective cannabinoids to induce
psychosis and schizophrenia.41
Six13,15,16,18,20,22 of the 7 studies13,15,16,18,20,22,23 included in
our SR-MA reported better quality of sleep with selective
cannabinoids while 515,16,18,20,21 out of the 6 studies13,15,16,18,20,21
that included assessment of patient satisfaction or global
impression of change reported positive results. This nding,
despite a lack of corresponding signicant change in mood,
suggests that patients felt a benet from reduction in pain,
improvement in quality of sleep, or both.16
Cannabis for Neuropathic Pain
To ensure comprehensiveness of our efforts to evaluate role
of selective cannabinoids in NP, we also reviewed the evi-
dence for cannabis (smoked or vaporized medical marijuana)
in relieving NP. We found 6 RCTs that evaluated smoked or
vaporized marijuana of various strengths against placebos
for treatment of NP (Supplemental Digital Content 6, Table
4, http://links.lww.com/AA/B752; Supplemental Digital
Content 7, Table 5, http://links.lww.com/AA/B753).42–47 Two
studies enrolled patients with HIV NP,42,43 1 study included
patients with posttraumatic NP,45 1 study included patients
with diabetic neuropathy,44 and another 2 studies enrolled
patients with NP syndromes secondary to a variety of etiolo-
gies (complex regional pain syndrome type I, thalamic stroke,
spinal cord injury, peripheral neuropathy, radiculopathy, or
trauma).46,47 Four studies examined peripheral NP42–45 and
2 studies examined a mix of central and peripheral NP.46,47
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 13
Crossover trial design was used for all 6 studies except 1.42 All
studies had similar participant inclusion criteria as studies on
selective cannabinoids included in our SR-MA.
Overall bias was low in these 6 studies on cannabis
(Supplemental Digital Content 8, Table 6, http://www.
links.lww.com/AA/B754). Interventions in all 6 studies
were of short duration (up to 5 days). Dose of THC per
day ranged from 1.875 to 34 mg.44,48 Similar to the RCTs on
selective cannabinoids included in our SR-MA, cannabis
preparations were used as an adjunctive medication in the 5
studies. All studies demonstrated signicant pain reduction
with cannabis compared to placebo. Diversity in methodol-
ogy and reporting of pain intensity ruled out the prospect
of performing a meta-analysis. Similar to selective canna-
binoids, escalation in strength of THC for cannabis has not
clearly been demonstrated to provide superior analgesia
and result in worsened neuropsychologic performance.46
Secondary outcomes for improvement in anxiety and
depression/mood were reported with cannabis in 243,45 of
343,45,46 studies. One study also reported improvement in
sleep.45 QST testing was performed in 3 studies and there
was no evidence of change in thresholds toward normal
in any of these studies.42,46,47 Two studies reported higher
participant satisfaction with cannabis.46,47 Finally, almost all
adverse events relating to the interventions were considered
mild to moderate. Adverse effects were similar to effects
with selective cannabinoids, and only 1 study reported that
a single participant withdrew due to psychosis.43 Detailed
results for 5 out of 6 of these RCTs have been recently pub-
lished in a narrative review.48
Adverse Effects of Selective Cannabinoids
It is unclear whether use of selective cannabinoids is asso-
ciated with signicant adverse effects. Data on this aspect
may be affected by the type of selective cannabinoid, its
dose, and the comparator used in a trial. A review of 31
studies on adverse effects of medical cannabinoids revealed
an increase in nonserious adverse events when compared to
placebo.49 However, 1 trial included in our SR-MA reported
that the number of patients with adverse events decreased
during active treatment.19 This observation may be due to
increasing tolerance to the drug over time but 17% of the
patients were not able to tolerate the maximum allowed
dose of dronabinol19 or other selective cannabinoids. This
observation also suggests that adverse effects may prevent
attainment of therapeutic levels of selective cannabinoids.
Long-term safety data in use of selective cannabinoids
and cannabis for NP are limited. A recent long-term safety
review of nabilone use for posttraumatic stress disor-
der patients cited 2 of our included studies (limited by a
trial duration of only 9 weeks)20,21 and highlighted similar
adverse effects.50 Data from an open-label follow-up for 1
year of 104 patients with multiple sclerosis who were taking
nabiximols (mean of 6.2 sprays/day) for spasticity reported
predominantly gastrointestinal adverse effects. Twenty-one
of 22 reported adverse effects were considered nonserious,
while 1 was serious due to fall resulting in fracture.51 A
1-year safety study on cannabis (average 2.5 g/day) with
12.5% THC for pain reported an increased risk of nonseri-
ous adverse events and risk of chronic bronchitis.52
Recreational use of cannabis suggests that it has some
potential for dependence.53 Heavy, regular recreational can-
nabis smoking at a young age in vulnerable subjects may
also be associated with an increased risk of subsequently
developing schizophrenia.54 It is also believed that mental
illness may be aggravated by cannabis. For this reason,
patients with a history of signicant psychiatric illness were
excluded from trials included in this SR-MA. This limits the
generalizability of results of these trials and of this SR-MA
because patients with signicant levels of pain often have
coexisting mood disorders.
Limitations of Current Evidence
Despite our rigorous attempts to identify all current evi-
dence, there remain several unanswered questions regard-
ing efcacy of selective cannabinoids in patients with NP.
We are unable to comment on the ideal proportions of THC
and CBD in nabiximols preparations because there is a sig-
nicant variation in amounts of THC and CBD content used
in trials. The dose per administration and daily maximum
limits also differed across RCTs in our SR-MA. Furthermore,
analgesia was assessed over a wide range of time periods
after initiation of study interventions. The diagnosis of NP
was primarily clinical and other means of diagnosis includ-
ing QST and validated questionnaires were not used con-
sistently. Finally, the effect of selective cannabinoids on
physical disability, psychological disability, sleep, and on
QoL was also not assessed rigorously.
Suggestions for Future Research
Future RCTs conducted with larger enrollment may be able
to better quantify the analgesic potential of selective canna-
binoids for NP. One particular concern regarding selective
cannabinoids is the variability in content, dosing, and route
of administration. Analgesic impact and adverse effects of
different proportions of THC and CBD should be assessed in
trials. It is important to evaluate the efcacy of this interven-
tion in NPs of various etiologies (central and peripheral) that
cause moderate-to-severe pain intensities. Diagnosis needs to
be standardized and conrmed through the use of validated
NP questionnaires (eg, Douleur Neuropathique 4 question-
naire, Leeds assessment of neuropathic symptoms and signs).
Synthesized data from our SR-MA showed that nabiximols
have an analgesic effect, whereas nabilone may not relieve
NP. To further understand the analgesic potential of selec-
tive cannabinoids, we propose a multicenter RCT on patients
with NP with 4 treatment arms: CBD, THC/CBD, nabilone,
and placebo. We propose these 4 groups because it may yield
further insight in the debate concerning which selective can-
nabinoid provides greater analgesic effect. The sample size
for this trial would be at least 70 patients per group (ie, 280
patients in all) for an expected difference between pain NRS
(0–10 scale) means of 1.8 and the within-group SD of 3. This
sample size has been determined to give a 90% chance of
rejecting the null hypothesis of no difference between means
at an α of .0125 and using a Bonferroni adjustment to the
size of the test to compensate for multiple comparisons. Pain
scores should be measured at multiple time intervals after ini-
tiation of intervention: acutely (eg, at 1–2 weeks after initia-
tion of therapy), intermediate (eg, at 1 month), and long-term
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
14 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
E META-ANALYSIS
(eg, at 3, 6, 12 months and beyond). Stratication of patient
data based on degree of pain relief would allow for reporting
of proportion of signicant versus limited responders to the
intervention and further isolate patient characteristics that
are more responsive to the intervention. Important second-
ary outcome measurements to include in this proposed trial
are as follows: emotional functioning, physical functioning,
patient satisfaction with treatment (all assessed using vali-
dated questionnaires), and meticulous attempts to identify
and record adverse effects. These recommendations are in
accordance with the core outcome domains of the IMMPACT
guidelines for designing clinical trials to evaluate interven-
tions for chronic pain conditions.55
CONCLUSIONS
There was moderate quality evidence to suggest nabiximols
is effective in reducing NP. There was no signicant differ-
ence on the analgesic impact of selective cannabinoids on
different locations of NP. Selective cannabinoids may have
a role as coanalgesic therapy for refractory NP. Challenges
to overcome in subsequent studies include ensuring that tri-
als are blinded (patients, clinical team, data collectors and
assessors, data analysts) with standardization of pain diag-
nosis, length of treatment, assessment of dose-response,
homogeneity of patient population, and inclusion of QoL
indicators. E
DISCLOSURES
Name: Howard Meng, MD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Name: Bradley Johnston, PhD.
Contribution: This author helped analyze the data and write the
manuscript.
Name: Marina Englesakis, MLIS.
Contribution: This author helped in negotiation, development,
revision, and running of database search strategies; management of
citations; and documentation of searches and search results.
Name: Dwight E. Moulin, MD.
Contribution: This author helped analyze the data and write the
manuscript.
Name: Anuj Bhatia, MBBS, MD, FRCPC, FRCA, FFPMRCA, FIPP,
EDRA, CIPS.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
This manuscript was handled by: Honorio T. Benzon, MD.
REFERENCES
1. Bouhassira D, Lantéri-Minet M, Attal N, Laurent B, Touboul C.
Prevalence of chronic pain with neuropathic characteristics in
the general population. Pain. 2008;136:380–387.
2. Torrance N, Ferguson JA, Afolabi E, et al. Neuropathic pain
in the community: more under-treated than refractory? Pain.
2013;154:690–699.
3. Harden RN. Chronic neuropathic pain. Mechanisms, diagnosis,
and treatment. Neurologist. 2005;11:111–122.
4. Russo EB. Cannabinoids in the management of difcult to treat
pain. Ther Clin Risk Manag. 2008;4:245–259.
5. Kelly S, Jhaveri MD, Sagar DR, Kendall DA, Chapman V.
Activation of peripheral cannabinoid CB1 receptors inhibits
mechanically evoked responses of spinal neurons in nonin-
amed rats and rats with hindpaw inammation. Eur J Neurosci.
2003;18:2239–2243.
6. Ibrahim MM, Rude ML, Stagg NJ, et al. CB2 cannabinoid recep-
tor mediation of antinociception. Pain. 2006;122:36–42.
7. Manzanares J, Julian M, Carrascosa A. Role of the cannabi-
noid system in pain control and therapeutic implications for
the management of acute and chronic pain episodes. Curr
Neuropharmacol. 2006;4:239–257.
8. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy
for neuropathic pain in adults: a systematic review and meta-
analysis. Lancet Neurol. 2015;14:162–173.
9. Moulin D, Boulanger A, Clark AJ, et al; Canadian Pain Society.
Pharmacological management of chronic neuropathic pain:
revised consensus statement from the Canadian Pain Society.
Pain Res Manag. 2014;19:328–335.
10. Fitzcharles MA, Baerwald C, Ablin J, Häuser W. Efcacy, toler-
ability and safety of cannabinoids in chronic pain associated
with rheumatic diseases (bromyalgia syndrome, back pain,
osteoarthritis, rheumatoid arthritis): a systematic review of
randomized controlled trials. Schmerz. 2016;30:47–61.
11. Lynch ME, Ware MA. Cannabinoids for the treatment of chronic
non-cancer pain: an updated systematic review of randomized
controlled trials. J Neuroimmune Pharmacol. 2015;10:293–301.
12. Higgins JP GS. Cochrane Handbook for Systematic Reviews
of Interventions Version 5.1.0. Mar 2011. Available at: http://
handbook.cochrane.org/chapter_4/4_guide_to_the_contents_
of_a_cochrane_protocol_and_review.htm. Accessed October
25, 2016.
13. Langford RM, Mares J, Novotna A, et al. A double-blind, ran-
domized, placebo-controlled, parallel-group study of THC/
CBD oromucosal spray in combination with the existing
treatment regimen, in the relief of central neuropathic pain in
patients with multiple sclerosis. J Neurol. 2013;260:984–997.
14. Lynch ME, Cesar-Rittenberg P, Hohmann AG. A double-blind,
placebo-controlled, crossover pilot trial with extension using
an oral mucosal cannabinoid extract for treatment of chemo-
therapy-induced neuropathic pain. J Pain Symptom Manage.
2014;47:166–173.
15. Nurmikko TJ, Serpell MG, Hoggart B, Toomey PJ, Morlion BJ,
Haines D. Sativex successfully treats neuropathic pain char-
acterized by allodynia: a randomized, double-blind, placebo-
controlled clinical trial. Pain. 2007;133:210–220.
16. Rog DJ, Nurmikko TJ, Friede T, Young CA. Randomized, con-
trolled trial of cannabis-based medicine in central pain in mul-
tiple sclerosis. Neurology. 2005;65:812–819.
17. Selvarajah D, Gandhi R, Emery CJ, Tesfaye S. Randomized
placebo-controlled double-blind clinical trial of cannabis-
based medicinal product (Sativex) in painful diabetic neurop-
athy: depression is a major confounding factor. Diabetes Care.
2010;33:128–130.
18. Serpell M, Ratcliffe S, Hovorka J, et al. A double-blind, random-
ized, placebo-controlled, parallel group study of THC/CBD
spray in peripheral neuropathic pain treatment. Eur J Pain.
2014;18:999–1012.
19. Svendsen KB, Jensen TS, Bach FW. Does the cannabi-
noid dronabinol reduce central pain in multiple sclerosis?
Randomized double blind placebo controlled crossover trial.
BMJ. 2004;329:253.
20. Toth C, Mawani S, Brady S, et al. An enriched-enrolment, ran-
domized withdrawal, exible-dose, double-blind, placebo-
controlled, parallel assignment efcacy study of nabilone as
adjuvant in the treatment of diabetic peripheral neuropathic
pain. Pain. 2012;153:2073–2082.
21. Turcotte D, Doupe M, Torabi M, et al. Nabilone as an adjunctive
to gabapentin for multiple sclerosis-induced neuropathic pain:
a randomized controlled trial. Pain Med. 2015;16:149–159.
22. Berman JS, Symonds C, Birch R. Efcacy of two cannabis based
medicinal extracts for relief of central neuropathic pain from
brachial plexus avulsion: results of a randomized controlled
trial. Pain. 2004;112:299–306.
23. Frank B, Serpell MG, Hughes J, Matthews JN, Kapur D.
Comparison of analgesic effects and patient tolerability of nabi-
lone and dihydrocodeine for chronic neuropathic pain: ran-
domized, crossover, double blind study. BMJ. 2008;336:199–201.
24. Harris RP, Helfand M, Woolf SH, et al; Methods Work Group,
Third US Preventive Services Task Force. Current methods of
the US Preventive Services Task Force: a review of the process.
Am J Prev Med. 2001;20:21–35.
25. Borenstein, M. Chapter 11 Software for publication bias. In:
Rothstein HR, Sutton AJ, Borenstein M, eds. Publication Bias
Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Cannabinoids for Chronic Neuropathic Pain
XXX 2017 • Volume XXX • Number XXX www.anesthesia-analgesia.org 15
in Meta-Analysis – Prevention, Assessment and Adjustments.
Chichester, UK: John Wiley & Sons Ltd, 2005.
26. Higgins JP, Green S. Recommendations on testing for funnel
plot asymmetry. Cochrane Handbook for Systematic Reviews
of Interventions 2011. Available at: http://handbook.cochrane.
org/chapter_10/10_4_3_1_recommendations_on_testing_for_
funnel_plot_asymmetry.htm. Accessed January 16, 2017.
27. Campbell FA, Tramèr MR, Carroll D, Reynolds DJ, Moore RA,
McQuay HJ. Are cannabinoids an effective and safe treatment
option in the management of pain? A qualitative systematic
review. BMJ. 2001;323:13–16.
28. Iskedjian M, Bereza B, Gordon A, Piwko C, Einarson TR. Meta-
analysis of cannabis based treatments for neuropathic and mul-
tiple sclerosis-related pain. Curr Med Res Opin. 2007;23:17–24.
29. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for
medical use: a systematic review and meta-analysis. JAMA.
2015;313:2456–2473.
30. Kurtzke JF. Rating neurologic impairment in multiple scle-
rosis: an expanded disability status scale (EDSS). Neurology.
1983;33:1444–1452.
31. Notcutt W, Price M, Miller R, et al. Initial experiences with
medicinal extracts of cannabis for chronic pain: results from 34
‘N of 1’ studies. Anesthesia. 2004;59:440–452.
32. Russo EB, McPartland JM. Cannabis is more than simply
delta(9)-tetrahydrocannabinol. Psychopharmacology (Berl).
2003;165:431–432.
33. Finnerup NB, Gottrup H, Jensen TS. Anticonvulsants in central
pain. Expert Opin Pharmacother. 2002;3:1411–1420.
34. Sindrup SH, Jensen TS. Efcacy of pharmacological treatments
of neuropathic pain: an update and effect related to mechanism
of drug action. Pain. 1999;83:389–400.
35. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM. Clinical
importance of changes in chronic pain intensity measured on an
11-point numerical pain rating scale. Pain. 2001;94:149–158.
36. Woolf CJ. Dissecting out mechanisms responsible for periph-
eral neuropathic pain: implications for diagnosis and therapy.
Life Sci. 2004;74:2605–2610.
37. Naef M, Curatolo M, Petersen-Felix S, Arendt-Nielsen L,
Zbinden A, Brenneisen R. The analgesic effect of oral delta-
9-tetrahydrocannabinol (THC), morphine, and a THC-
morphine combination in healthy subjects under experimental
pain conditions. Pain. 2003;105:79–88.
38. Meng H, Hanlon JG, Katznelson R, Ghanekar A, McGilvray
I, Clarke H. The prescription of medical cannabis by a transi-
tional pain service to wean a patient with complex pain from
opioid use following liver transplantation: a case report. Can J
Anesth. 2016;63:307–310.
39. Korem N, Zer-Aviv TM, Ganon-Elazar E, Abush H, Akirav I.
Targeting the endocannabinoid system to treat anxiety-related
disorders. J Basic Clin Physiol Pharmacol. 2016;27:193–202.
40. Blessing EM, Steenkamp MM, Manzanares J, Marmar CR.
Cannabidiol as a potential treatment for anxiety disorders.
Neurotherapeutics. 2015;12:825–836.
41. Andrade C. Cannabis and neuropsychiatry, 2: the longitudi-
nal risk of psychosis as an adverse outcome. J Clin Psychiatry.
2016;77:e739–e742.
42. Abrams DI, Jay CA, Shade SB, et al. Cannabis in painful HIV-
associated sensory neuropathy: a randomized placebo-con-
trolled trial. Neurology. 2007;68:515–521.
43. Ellis RJ, Toperoff W, Vaida F, et al. Smoked medicinal cannabis
for neuropathic pain in HIV: a randomized, crossover clinical
trial. Neuropsychopharmacology. 2009;34:672–680.
44. Wallace MS, Marcotte TD, Umlauf A, Gouaux B, Atkinson JH.
Efcacy of inhaled cannabis on painful diabetic neuropathy.
JPain. 2015;16:616–627.
45. Ware MA, Wang T, Shapiro S, et al. Smoked cannabis for
chronic neuropathic pain: a randomized controlled trial. CMAJ.
2010;182:694–701.
46. Wilsey B, Marcotte T, Deutsch R, Gouaux B, Sakai S, Donaghe
H. Low-dose vaporized cannabis signicantly improves neuro-
pathic pain. J Pain. 2013;14:136–148.
47. Wilsey B, Marcotte T, Tsodikov A, et al. A randomized, placebo-
controlled, crossover trial of cannabis cigarettes in neuropathic
pain. J Pain. 2008;9:506–521.
48. Deshpande A, Mailis-Gagnon A, Zoheiry N, Lakha SF. Efcacy
and adverse effects of medical marijuana for chronic noncancer
pain: systematic review of randomized controlled trials. Can
Fam Physician. 2015;61:372–381.
49. Wang T, Collet JP, Shapiro S, Ware MA. Adverse effects
of medical cannabinoids: a systematic review. CMAJ.
2008;178:1669–1678.
50. Long-term nabilone use: a review of the clinical effectiveness and
safety. Canadian Agency for Drugs and Technologies in Health; 2015.
Available at: https://www.cadth.ca/long-term-nabilone-use-
review-clinical-effectiveness-and-safety-0. Accessed Jan 20, 2017.
51. Flachenecker P, Henze T, Zettl UK. Long-term effectiveness and
safety of nabiximols (tetrahydrocannabinol/cannabidiol oro-
mucosal spray) in clinical practice. Eur Neurol. 2014;72:95–102.
52. Ware MA, Wang T, Shapiro S, Collet JP; COMPASS Study Team.
Cannabis for the management of pain: assessment of safety
study (COMPASS). J Pain. 2015;16:1233–1242.
53. Copeland J, Pokorski I. Progress toward pharmacotherapies for
cannabis-use disorder: an evidence-based review. Subst Abuse
Rehabil. 2016;7:41–53.
54. Arseneault L, Cannon M, Poulton R, Murray R, Caspi A, Moftt
TE. Cannabis use in adolescence and risk for adult psychosis:
longitudinal prospective study. BMJ. 2002;325:1212–1213.
55. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the
clinical importance of treatment outcomes in chronic pain clini-
cal trials: IMMPACT recommendations. J Pain. 2008;9:105–121.
