UK specialists have reacted to guidance deterring doctors from prescribing cannabis medicines for chronic pain due to a “lack of evidence”.
The International Association for the Study of Pain (IASP) said in a statement on 16 March, that due to a lack of evidence from ‘high quality research’, it could ‘not endorse’ the general use of cannabinoids to treat pain.
The body which brings together worldwide scientists, clinicians, healthcare providers and policymakers, to support the treatment and prevention of chronic pain, also published a list of research priorities in order to determine the efficacy and safety of cannabis medicines.
“While IASP cannot endorse the general use of cannabinoids for treatment of pain at this time, we do not wish to dismiss the lived experiences of people with pain who have found benefit from their use,” said Andrew Rice, professor of pain research at Imperial College London and chair of the IASP’s Presidential Task Force on Cannabis and Cannabinoid Analgesia.
He added: “This is not a door closing on the topic, but rather a call for more rigorous and robust research to better understand any potential benefits and harms related to the possible use of medical cannabis, cannabis-based medicines and synthetic cannabinoids for pain relief, and to ensure the safety of patients and the public through regulatory standards and safeguards.”
The statement was followed in quick succession by the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists (ANZCA) releasing new guidance urging doctors not to prescribe cannabis for patients with chronic, non-cancer pain unless they are enrolled in a clinical trial.
ANZCA, a professional society made up of almost 8,000 anesthesiologists and pain management specialists which sets standards for pain medicine in Australia and New Zealand, said there was a “critical lack of evidence” that cannabis provides a “consistent benefit for any type of chronic non-cancer pain”.
With the UK’s Advisory Council for the Misuse of Drugs (ACMD) recently stating that the IASP report would have a ‘powerful influence’ on the prescribing of cannabis-based medicines for pain, the move could be seen as a setback for millions of patients who use these medicines for chronic pain across the globe.
A “blinkered” approach to medicine
Professor Mike Barnes, an honorary neurologist and chair of the Medical Cannabis Clinicians Society, who obtained the first permanent license to prescribe medical cannabis in the UK, accused the IASP of taking a “blinkered” approach to medicine.
In his view, the statement shows a lack of compassion for patients who suffer from debilitating pain and have exhausted all other treatments.
“It is a great pity that the IASP has chosen to downplay the overwhelming evidence of efficacy and safety of cannabis for pain,” he commented.
“The IASP needs to look beyond their narrow, blinkered view of medicine and show some compassion for those in severe and chronic pain for whom no licensed medicine helps. Cannabis works and, as importantly, is safe.
“Are they saying that millions of people around the globe who use cannabis for pain every day are just wrong and misguided?”
Disappointing but inevitable
One of the country’s leading pain specialists, Dr Anthony Ordman, honorary clinical director of Integro Medical Clinics, a private pain clinic which is expert in using cannabis medicines, told Cannabis Health that he understood the IASP stance would be “disappointing” for many patients.
“Many people around the world living with long-term pain conditions – and many other conditions which are not fully managed by conventional medicines – must have felt very frustrated by the position statement on cannabis medicines,” he said.
“Many will have tried cannabis medicines, and benefitted, and would like to see these become more widely available.”
Despite this Dr Ordman said that on balance, the IASP’s decision not to endorse the use of cannabinoids was understandable – as was the current stance of other regulatory bodies such as UK’s NICE (National Institute for Health and Care Excellence) – due to the lack of “high quality” evidence in support of the routine use of cannabis medicines.
Also to be taken into consideration, he said, are the potential risks facing doctors who prescribe unlicensed medicines.
Cannabis medicines are legal in the UK, but are not yet standard licensed medicines. This means when prescribing an unlicensed medication, the individual clinician is held responsible should anything go wrong or a patient decide to make a claim against the doctor in the future.
“Unfortunately this is an inevitable stage we have to go through before we can give cannabis medicines to everyone who needs them,” Dr Ordman continued.
“Medicine gatekeepers such as NICE and the IASP are correct not to endorse these medicines, they have a huge responsibility to keep patients safe and doctors safe and, indirectly, to protect prescribers.”
“The fact is that we have no ‘Grade A’ randomised control trial (RCT) evidence on the safety and efficacy of these medicines to satisfy the requirements of IASP, NICE and so on.
He added: “On the other hand there is still plenty of supporting material in the medical literature, and there are also a number of reputable medical experts who have stated that the ‘Grade A’ randomised control study is not appropriate for the needs of treating long-term pain.”
Dr Ordman, a former president of the Pain Medicine Section of the Royal Society of Medicine, who recently left the NHS to practice privately has himself treated dozens of patients who report having benefited from using cannabis medicines for long-term pain.
“I have spent the last 25 years as a pain specialist struggling to help some people, and sometimes feeling very frustrated that we don’t have the right conventional medications to help them,” he said.
“Often all of the conventional medicines have failed to work, or imposed intolerable side effects, while patients have told me that they have been helped by cannabis medicines, particularly with long-term pain conditions such as fibromyalgia.”
He continued: “Cannabis medicines are not going to work for everybody and I can’t promise they’re 100 percent safe – any more than conventional medicines – but we make sure that the balance between a patient’s suffering and the benefit they stand to gain from cannabis medicines, almost certainly outweighs any non-specific risk.”
However, this decision is one which must be shared with the patient, and prescribing clinicians take great efforts to ensure patients fully understand the risks when taking unlicensed medicines.
According to Dr Ordman, the NHS would not currently have the time or resources needed to safely treat and support the millions of patients who could stand to benefit from medical cannabis.
“Doctors are taking a degree of professional risk when they prescribe any medicine and each patient’s case must be assessed in detail,” he said.
“In our clinic we can fully inform the patient of the risks of unlicensed medicines, but that takes a considerable amount of work, effort and scrutiny. The NHS – even if it had access to these medicines – simply doesn’t have the time or resources to do that for more than a very few patients.”
The IASP is now calling for the delivery of a ‘comprehensive research agenda’.
Previous president of IASP Dr Lars Arendt-Nielsen, who established and co-chaired the Task Force said: “Priorities include identifying patients with pain who may receive the most benefit from cannabis or cannabinoids, and who may be at risk of the most harm.
“It is also necessary to expand the range of chemical entities tested, identify appropriate doses and their effects, and determine optimal delivery methods.”
Real world evidence
While more research is welcome, it’s as yet unclear where the money for this will come from.
As Dr Ordman pointed out, RCTs – usually funded by “big pharma” – cost millions, and drug companies are unlikely to stump up the cash when they don’t stand to profit from cannabis medicines.
“It’s now up to somebody to generate the research,” he said.
“But at present, it’s difficult to see where that funding will come from, especially with Covid-19 taking up so much of our resources.”
Professor Barnes, meanwhile, is among those who believe too much weight is applied to RCTs, when discussing the safety and efficacy of cannabis medicines for certain conditions.
He argued that as a botanical medicine, cannabis does not need to be treated with the same rigour and regulation as a pharmaceutical product and pointed to existing “real world evidence” reported by patients across the globe.
“The problem is that they are acting in ignorance of the benefit of the plant and dismissing real world evidence in favour of a pharmaceutical paradigm,” he added.
“Cannabis is not a pharmaceutical product, but a botanical product and needs to be assessed as such.”
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