Smoked cannabis for chronic neuropathic pain: a randomized controlled trial

Background

Chronic neuropathic pain affects 1%–2% of the adult population and is often refractory to standard pharmacologic treatment. Patients with chronic pain have reported using smoked cannabis to relieve pain, improve sleep and improve mood.

Methods

Adults with post-traumatic or postsurgical neuropathic pain were randomly assigned to receive cannabis at four potencies (0%, 2.5%, 6% and 9.4% tetrahydrocannabinol) over four 14-day periods in a crossover trial. Participants inhaled a single 25-mg dose through a pipe three times daily for the first five days in each cycle, followed by a nine-day washout period. Daily average pain intensity was measured using an 11-point numeric rating scale. We recorded effects on mood, sleep and quality of life, as well as adverse events.

Results

We recruited 23 participants (mean age 45.4 [standard deviation 12.3] years, 12 women [52%]), of whom 21 completed the trial. The average daily pain intensity, measured on the 11-point numeric rating scale, was lower on the prespecified primary contrast of 9.4% v. 0% tetrahydrocannabinol (5.4 v. 6.1, respectively; difference = 0.7, 95% confidence interval [CI] 0.02–1.4). Preparations with intermediate potency yielded intermediate but nonsignificant degrees of relief. Participants receiving 9.4% tetrahydrocannabinol reported improved ability to fall asleep (easier, p = 0.001; faster, p < 0.001; more drowsy, p = 0.003) and improved quality of sleep (less wakefulness, p = 0.01) relative to 0% tetrahydrocannabinol. We found no differences in mood or quality of life. The most common drug-related adverse events during the period when participants received 9.4% tetrahydrocannabinol were headache, dry eyes, burning sensation in areas of neuropathic pain, dizziness, numbness and cough.

Conclusion

A single inhalation of 25 mg of 9.4% tetrahydrocannabinol herbal cannabis three times daily for five days reduced the intensity of pain, improved sleep and was well tolerated. Further long-term safety and efficacy studies are indicated. (International Standard Randomised Controlled Trial Register no. ISRCTN68314063)Chronic neuropathic pain has a prevalence of 1%–2%,¹ and treatment options are limited.² Pharmacotherapy includes anticonvulsants, antidepressants, opioids and local anesthetics,^3,4 but responses vary and side effects limit compliance.Cannabis sativa has been used to treat pain since the third millennium BC.⁵ An endogenous pain-processing system has been identified, mediated by endogenous cannabinoid ligands acting on specific cannabinoid receptors.⁶ These findings, coupled with anecdotal evidence of the analgesic effects of smoked cannabis,⁷ support a reconsideration of cannabinoid agents as analgesics.Oral cannabinoids such as tetrahydrocannabinol, cannabidiol and nabilone have, alone and in combination, shown efficacy in central^8,9 and peripheral¹⁰ neuropathic pain, rheumatoid arthritis¹¹ and fibromyalgia.¹²The analgesic effects of smoked cannabis remain controversial, although it is used by 10%–15% of patients with chronic noncancer pain¹³ and multiple sclerosis.¹⁴ Clinical trials are needed to evaluate these effects, given that the risks and benefits of inhaled cannabinoids may differ from oral agents. To date, three small clinical trials of the analgesic efficacy of smoked cannabis have been reported.^15–17 All studies were conducted in residential laboratories, and participants smoked multiple doses of the drug at each time point. No study adequately reported data related to adverse events.We conducted a clinical trial using a standardized single-dose delivery system to explore further the safety and efficacy of smoked cannabis in outpatients with chronic neuropathic pain.     

Relation Between the Heat-Induced Increase of F0 Fluorescence and a Shift in the Electronic Equilibrium at the Acceptor Side of Photosystem 2

F₀ fluorescence and thermoluminescence (TL) were recorded simultaneously on various dark-adapted leaf samples. Above 40 °C, a sharp peak of TL coincided with the onset of the heat-induced F₀ rise. It results from a back-transfer of an electron from the secondary Q_B ^-to the primary acceptor Q_A of photosystem 2, followed by a luminescence-emitting recombination with Tyr-D¹. This demonstrates that the critical temperature at which the F₀ starts rising also corresponds to a shift towards the left of the Q_A↔Q_B ^- equilibrium. This revised version was published online in August 2006 with corrections to the Cover Date.     

Heat stress induces in leaves an increase of the minimum level of chlorophyll fluorescence, Fo: A time-resolved analysis

A time-resolved study of the effects of heat stress (23 to 50°C) on F_o level of chlorophyll fluorescence of leaves having different antenna content has been performed in order to elucidate the causes of heat induced increase of F_o in vivo. The multi-exponential deconvolution of the decays after a picosecond flash at F_o have shown that the best fit in both wild-type and the mutant chlorina F2 of barley leaves is obtained with three components in the temperature range utilized (100, 400 and 1200 ps at 23°C). In intermittent light greened pea leaves, a fourth long lifetime component (4 ns at 23°C) is needed. The comparison of the three types of leaves at 23°C shows that the content of the LHCII b complex does not affect the lifetimes of the two main components (100 and 400 ps) and affects their preexponential factors. This result suggests that in the PS II unit the exciton transfer from LHC IIb to the rest of the antenna is irreversible. The effects of heat stress on individual lifetime components, T_i, included several changes. Utilizing for PS II unit an extended ‘Reversible Radical Pair’ model, having three compartments, to interpret the variations of T_i and A_i induced by temperature increases, it can be inferred that heat determines: (i) an irreversible disconnection of a monor antenna complex which is not the LHC IIb complex, this effect is induced by temperatures higher than 40°C; (ii) a decrease of the quantum efficiency of Photosystem II photochemistry which is due to several effects: a decrease of the rate of charge separation, an increase of P⁺I^- recombination rate constant and a decrease of the stabilization of charges. These effects on Photosystem II photochemistry start to occur above 30°C and are partially reversible.     

A dye-binding induced conformational transition of poly-(methacrylic acid) by Auramine O in aqueous solutions. I. Experimental results

Binding of auramine O to poly-(methacrylic acid) (PMA) has been established over a large range of C⁰_p/C⁰_d values using spectroscopic methods (UV absorption and visible fluorescence emission spectra), equilibrium and sedimentation dialysis, potentiometric and viscosimetric titrations. All the results show qualitative agreement with those obtained previously with the system crystal violet-PMA although the binding seems to be less strong for auramine O than for crystal violet. From dialysis experiments binding isotherms were obtained at three different degrees of neutralization α'; at α' = 0.10 the results could be fitted to a Langmuir isotherm but at α' equal to 0.40 and 0.65 deviations with respect to such an isotherm occur. The results of potentiometric and viscosimetric titrations confirm that the conformational transition which the dye-free PMA exhibits upon ionization is affected by the dye binding. The region in which the conformational transion occurs is broadened and is less sharply defined in the presence of auramine O.     

Thermoluminescence studies on the facultative crassulacean-acid- metabolism plant Mesembryanthemum crystallinum L.

Thermoluminescence (TL) signals were measured from leaves of the facultative CAM (crassulacean acid metabolism) plant Mesembryanthemum crystallinum L.. Following the induction of CAM by salt treatment, a TL band at 46 °C was induced, which was charged by a single-turnover flash. The intensity of the 46 °C-band depends on the number of excitation flashes and oscillates with a period of four. A similar band was induced in C₃ plants by far-red illumination. Under CAM conditions, the intensity of the 46 °C-band underlies a diurnal rhythm. The maximal intensity of the 46 °C-band is observed in the morning after onset of the light and in the evening. At around 12 a.m. it is suppressed. The intensity of the 46 °C-band relates to diurnal changes in the ratio of dihydroxy acetone phosphate/3-phosphoglycerate (DHAP/PGA) which is an indicator of the energy status of the chloroplast. During high-intensity illumination, the 46 °C-band disappears, but it is restored in the dark. We propose that the 46 °C-band is an indicator of the metabolic state of the leaf, originating from photosystem II centres initially in the S₂(S₃)Q_B oxidation state, in which the electron acceptor Q_B becomes reduced either by reverse electron flow or reduction of the plastoquinone pool via an NAD(P)H plastoquinone oxidoreductase. We present evidence that the redox state of the electron-transport chain is different under conditions of CAM compared to C₃ metabolism and that changes induced by CAM can be monitored by measuring the amplitude of the 46 °C-band after flash excitation. Received: 7 August 1997 / Accepted: 22 December 1997