Prevalence and Characteristics of Medicinal Cannabis Use among Chronic Pain Patients; A Post- Legalization Study in a Tertiary Care Setting in Thailand

Raviwon Atisook; Chanya Mochadaporn; Pratamaporn Chanthong; Pinyo  Sriveerachai; Nantthasorn  Zinboonyahgoon

doi:10.33192/smj.v76i1.265605

Authors

Raviwon Atisook Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Chanya Mochadaporn Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Pratamaporn Chanthong Department of Palliative Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Pinyo Sriveerachai Department of Palliative Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
Nantthasorn Zinboonyahgoon Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

DOI:

https://doi.org/10.33192/smj.v76i1.265605

Keywords:

Cannabis, prevalence, chronic pain, quality of life, side effect of cannabis, cancer pain, noncancer pain

Abstract

Objective: Cannabinoid products have been applied for numerous medical conditions, including chronic pain. Thailand was the first country in South East Asia to legalize medical cannabinoids. This study aims to explore prevalence, characters, attitude, side effects of medical cannabinoid use, and pain-related outcome among the chronic cancer and non-cancer pain population at Siriraj Hospital.

Materials and Methods: 200 chronic cancer pain and 670 chronic noncancer pain patients were collected by questionnaires and interviews. Data included demographic data, clinical diagnosis, pain treatment, knowledge, attitude, pattern of use, side effects and quality of life of cannabinoid extracts.

Results: Prevalence of active cannabis user was 15% in chronic cancer pain and 3.1% in noncancer pain. Oil extract sublingual was the most common form. Pain control was the most common initial reason for usage. No serious side effects were reported. Common side effects were dry oral mucosa, drowsiness, and headache. The most common source was obtained from friends. 36% of the patients believed they had enough understanding of medical cannabis, while 68.5% agreed that it is appropriate to use in Thailand. In cancer patients, the Edmonton Symptom Assessment System (ESAS) subscale for lack of appetite, anxiety, and subscale for a brief pain inventory (BPI) for enjoyment of life were higher among active users. In patients with noncancer pain, only the mood subscale BPI was lower among active users.

Conclusion: Medical cannabis usage is common compared with general population in Thai patients with chronic pain and may be associated with increased pain interference and cancer-related symptoms. Nonmedical license prescription and nonmedical license cannabis products were common in Thailand.

References

Pagotto U, Marsicano G, Cota D, Lutz B, Pasquali R. The emerging role of the endocannabinoid system in endocrine regulation and energy balance. Endocr Rev. 2006;27(1):73-100.

Maroon J, Bost J. Review of the neurological benefits of phytocannabinoids. Surg Neurol Int. 2018;9:91.

Freeman TP, Hindocha C, Green SF, Bloomfield MA. Medicinal use of cannabis based products and cannabinoids. Bmj. 2019;365.

Mucke M, Phillips T, Radbruch L, Petzke F, Hauser W. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database Syst Rev. 2018;3:CD012182.

Sledzinski P, Zeyland J, Slomski R, Nowak A. The current state and future perspectives of cannabinoids in cancer biology. Cancer Med. 2018;7(3):765-75.

Bar-Lev Schleider L, Mechoulam R, Lederman V, Hilou M, Lencovsky O, Betzalel O, et al. Prospective analysis of safety and efficacy of medical cannabis in large unselected population of patients with cancer. Eur J Intern Med. 2018;49:37-43.

Srisubat A SC, Sirsuma S, Aukaranun V, Lusawat A PA, Lakanapichonchat L, Apiwattanakul M, et al. Guidance on cannabis for medical use (edition 3/2020) [Internet]. Department of Medical Services, Ministry of Public Health of Thailand. 2020 2020 [Available from: https://drive.google.com/drive/folders/17hpzEQAPGTEZlr47QDpBUidvKRdy7y87.

Zinboonyahgoon N, Srisuma S, Limsawart W, Rice ASC, Suthisisang C. Medicinal cannabis in Thailand: 1-year experience after legalization. Pain. 2021;162(Suppl 1):S105-s9.

Stella B, Baratta F, Della Pepa C, Arpicco S, Gastaldi D, Dosio F. Cannabinoid Formulations and Delivery Systems: Current and Future Options to Treat Pain. Drugs. 2021;81(13):1513-57.

Mitsungnern ฐ, Tonanon ก, Kotruchin แ, Vannaprasaht ส. Prevalence and clinical characteristics of cannabis exposing patients between pre- and post-medical cannabis legalization era in 2019. Thai Journal of Emergency Medicine. 2021;2(2):17-36.

Aviram J, Samuelly-Leichtag G. Efficacy of Cannabis-Based Medicines for Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Physician. 2017;20(6):E755-E96.

Wong SSC, Chan WS, Cheung CW. Analgesic Effects of Cannabinoids for Chronic Non-cancer Pain: a Systematic Review and Meta-Analysis with Meta-Regression. J Neuroimmune Pharmacol. 2020;15(4):801-29.

Ware MA, Adams H, Guy GW. The medicinal use of cannabis in the UK: results of a nationwide survey. Int J Clin Pract. 2005;59(3):291-5.

Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: A review. Drug Alcohol Depend. 2017;177:1-13.

Hajizadeh M. Legalizing and Regulating Marijuana in Canada: Review of Potential Economic, Social, and Health Impacts. Int J Health Policy Manag. 2016;5(8):453-6.

Mohiuddin M, Blyth FM, Degenhardt L, Di Forti M, Eccleston C, Haroutounian S, et al. General risks of harm with cannabinoids, cannabis, and cannabis-based medicine possibly relevant to patients receiving these for pain management: an overview of systematic reviews. Pain. 2021;162(Suppl 1):S80-S96.

Narcotics Act (No. 7) B.E. 2562 (2019) TGG, Vol. 136, Part 19 a, published 18 February B.E. 2562. (in Thai).

Thai Association for the Study of Pain. TASP's statement on the use of medical cannabinoids [Internet], Thai Association for the Study of Pain. 2020. [Available from: http://www.tasp.or.th/news_files/.

Assanangkornchai S, Thaikla K, Talek M, Saingam D. Medical cannabis use in Thailand after its legalization: a respondent-driven sample survey. PeerJ. 2022;10:e12809.

Kalayasiri R, Boonthae S. Trends of cannabis use and related harms before and after legalization for recreational purpose in a developing country in Asia. BMC Public Health. 2023;23(1):911.

Prevalence side effect in cannabis product use (In Thai language) after three months Cannabis acts launched in Thailand from Ramathibodi Poison Center [pdf file] published 20 Aug 2019: Ramathibodi Poison Center; 2019. . 2019.

Food and Drug Administration. The safety report of cannabis product use (reported December 5 2019) [Internet], Food and Drug Administration, Narcotic Control Division, Ministry of Public Health of Thailand. 2020 2019 [Available from: http://cannabis.fda.moph.go.th/conclusionreport072019/.

Chinda M, Jaturapatporn D, Kirshen AJ, Udomsubpayakul U. Reliability and validity of a Thai version of the edmonton symptom assessment scale (ESAS-Thai). J Pain Symptom Manage. 2011;42(6):954-60.

Chaudakshetrin P. Validation of the Thai Version of Brief Pain Inventory (BPI-T) in cancer patients. J Med Assoc Thai. 2009;92(1):34-40.

Howlett AC, Barth F, Bonner TI, Cabral G, Casellas P, Devane WA, et al. International Union of Pharmacology. XXVII. Classification of cannabinoid receptors. Pharmacol Rev. 2002;54(2):161-202.

Fellermeier M, Eisenreich W, Bacher A, Zenk MH. Biosynthesis of cannabinoids. Incorporation experiments with (13)C-labeled glucoses. Eur J Biochem. 2001;268(6):1596-604.

Sano K, Mishima K, Koushi E, Orito K, Egashira N, Irie K, et al. Delta 9-tetrahydrocannabinol-induced catalepsy-like immobilization is mediated by decreased 5-HT neurotransmission in the nucleus accumbens due to the action of glutamate-containing neurons. Neuroscience. 2008;151(2):320-8.

Fisher E, Moore RA, Fogarty AE, Finn DP, Finnerup NB, Gilron I, et al. Cannabinoids, cannabis, and cannabis-based medicine for pain management: a systematic review of randomised controlled trials. Pain. 2021;162(Suppl 1):S45-S66.

Busse JW, Vankrunkelsven P, Zeng L, Heen AF, Merglen A, Campbell F, et al. Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline. Bmj. 2021;374:n2040.

Kosiba JD, Maisto SA, Ditre JW. Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis. Soc Sci Med. 2019;233:181-92.

Bhaskar A, Bell A, Boivin M, Briques W, Brown M, Clarke H, et al. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. J Cannabis Res. 2021;3(1):22.

Wang L, Hong PJ, May C, Rehman Y, Oparin Y, Hong CJ, et al. Medical cannabis or cannabinoids for chronic non-cancer and cancer related pain: a systematic review and meta-analysis of randomised clinical trials. Bmj. 2021;374:n1034.

Pratt M, Stevens A, Thuku M, Butler C, Skidmore B, Wieland LS, et al. Benefits and harms of medical cannabis: a scoping review of systematic reviews. Syst Rev. 2019;8(1):320.

Huestis MA, Solimini R, Pichini S, Pacifici R, Carlier J, Busardo FP. Cannabidiol Adverse Effects and Toxicity. Curr Neuropharmacol. 2019;17(10):974-89.

Aviram J, Pud D, Gershoni T, Schiff-Keren B, Ogintz M, Vulfsons S, et al. Medical cannabis treatment for chronic pain: Outcomes and prediction of response. Eur J Pain. 2021;25(2):359-74.

Angkurawaranon C, Jiraporncharoen W, Likhitsathian S, Thaikla K, Kanato M, Perngparn U, et al. Trends in the use of illicit substances in Thailand: Results from national household surveys. Drug Alcohol Rev. 2018;37(5):658-63.

Martell K, Fairchild A, LeGerrier B, Sinha R, Baker S, Liu H, et al. Rates of cannabis use in patients with cancer. Curr Oncol. 2018;25(3):219-25.

Lunn S, Diaz P, O'Hearn S, Cahill SP, Blake A, Narine K, et al. Human Pharmacokinetic Parameters of Orally Administered Delta(9)-Tetrahydrocannabinol Capsules Are Altered by Fed Versus Fasted Conditions and Sex Differences. Cannabis Cannabinoid Res. 2019;4(4):255-64.

Prevalence side effect in cannabis product use (In Thai language) after three months Cannabis acts launched in Thailand from Ramathibodi Poison Center [internet] published 20 Aug 2019: Ramathibodi Poison Center; 2019 [Available from: https://www.rama.mahidol.ac.th/poisoncenter/sites/default/files/public/%E0%B8%81%E0%B8%A3%E0%B8%93%E0%B8%B5%E0%B8%9C%E0%B8%B9%E0%B9%89%E0%B8%9B%E0%B9%88%E0%B8%A7%E0%B8%A2%E0%B8%AA%E0%B8%B1%E0%B8%A1%E0%B8%9C%E0%B8%B1%E0%B8%AA%E0%B8%81%E0%B8%B1%E0%B8%8D%E0%B8%8A%E0%B8%B2%E0%B8%A8%E0%B8%B9%E0%B8%99%E0%B8%A2%E0%B8%A2%E0%B9%8C%E0%B8%9E%E0%B8%B4%E0%B8%A9%E0%B8%A7%E0%B8%B4%E0%B8%97%E0%B8%A2%E0%B8%B2%20%E0%B8%A1%E0%B8%B4%E0%B8%A2%20%E0%B8%96%E0%B8%B6%E0%B8%87%20%E0%B8%AA%E0%B8%84%2065%2022Dec2022.pdf.