El cannabis en el dolor crónico ¿una indicación respaldada por evidencia científica?
Palabras clave:
cannabis, marihuana medicinal, dolor crónico
Resumen
Las controversias del cannabis medicinal se basan en múltiples factores. Mientras la legalidad de su uso es respaldada por algunas leyes gubernamentales, la desaprobación de parte de las agencias controladoras de medicamentos más importantes del mundo permanece constante. Se plantea a la fecha si hay evidencia científica fiable y actualizada que desapruebe el uso del cannabis para el dolor crónico. Para esto se utilizó herramientas de búsqueda como Pubmed, Google Scholar y Science Direct para la revisión de la literatura en internet. Las conclusiones de más de 30 artículos encontrados en la web se asemejan en la determinación de la gran necesidad de mayor evidencia científica para reafirmar la seguridad y confiabilidad del uso del cannabis para el dolor crónico incluyendo el dolor musculoesquelético, el relacionado con el cáncer, el neuropático, el de tipo y origen inespecíficos. Se revisaron también los efectos secundarios, las interacciones medicamentosas, la estandarización de embalaje y el control y vías de administración. Debido a la escasez de estudios clínicos bien diseñados con muestras sustanciales y tiempo de duración, factores imprescindibles para la calidad y fiabilidad, se concluye que no existe actualmente evidencia científica para aprobar o desaprobar su uso con fines médicos.
Citas
1. Centers for Disease Control and Prevention. Marijuana and public health: what are the health effects of Marijuana [internet]. USA: CDC; 2018. [citado 12 Abr 2018] Disponible en: https://www.cdc.gov/marijuana/index.htm.
2. Bridgeman MB, Abazia DT. Medicinal cannabis: History, pharmacology, and implications for the acute care setting. P T. 2017;42(3):180-8.
3. US Departament of Justiced, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) controlled substances Act: Subchapter I Control and enforcement. Parte B: Authority to control; standars and schedules [internet]. EEUU: US Departament of Justiced. [citado 10 Feb 2018] Disponible en: www.deadiversion.usdoj.gov/21cfr/21usc/812.htm.
4. Liang D, Bao Y, Wallace M, Grant I, Shi Y. Medical Cannabis Legalization and Opioid Prescriptions: Evidence on US Medicaid Enrollees during 1993-2014. Addiction. 2018 Jul 10.
5. United States. Department of Justice, Drug Enforcement Administration. Drug scheduling [internet]. United States: Department of Justice. (cited 2018 Feb 10). Available from: https://www.dea.gov/druginfo/ds.shtml
6. U.S. Food and Drug Administration. FDA and marijuana [internet]. Silver Spring: US Departament of Health and Human Services. (cited 2017 Dic. 26). Available from: https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm
7. European Medicines Agency. EU/3/16/1621: Public summary of opinion on orphan designation Delta-9-tetrahydrocannabinol and cannabidiol from extracts of the Cannabis sativa L. plant for the treatment glioma [Internet]. London: European Medicines Agency; 2016. (cited 2017 Dic. 17). Available from: http://www.ema.europa.eu/docs/en_GB/document_library/Orphan_designation/2016/04/WC500204483.pdf
8. Bestrashniy J, Winters KC. Variability in medical marijuana laws in the United States. Psychol Addict Behav. 2015; 29(3):639–42.
9. Sznitman SR, Bretteville-Jensen AL. Public opinion and medical cannabis policies: examining the role of underlying beliefs and national medical cannabis policies. Harm Reduct J. 2015; 12:46.
10. Codas M, González V, Madrazo C, Benítez G, Chamorro L, Scott C et al. Automedicación en Itapúa: nuestra realidad. Rev. Nac. (Itauguá) [Internet]. 2015 (citado 8 Mar. 2017);7(1):28-31. Disponible en: http://scielo.iics.una.py/pdf/hn/v7n1/v7n1a05.pdf
11. National Institute on Drug Abuse. Drug facts: marijuana as medicine (Internet). US: National Institute on Drug Abuse; 2018 (cited 2017 Dic. 17). Available from: https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/df-marijuana-medicine.pdf
12. ProCon.org. Should marijuana be a medical option? [Internet]. Santa Mónica: ProCon, 2016 [updated 2018 Mar 29; cited 2018 May 25]. Available from. https://medicalmarijuana.procon.org/view.answers.php?questionID=001325
13. MacDonald K, Pappas K. Why not pot?: a review of the Brain-based risks of cannabis. Innov Clin Neurosci. 2016; 13(3-4):13–22.
14. Pertwee RG, Howlett AC, Abood ME, Alexander SP, Di Marzo V, Elphick MR, et al. International Union of Basic and Clinical Pharmacology. LXXIX. Cannabinoid receptors and their ligands: beyond CB1 and CB2. Pharmacol Rev. 2010; 62(2):588–631.
15. Bridgeman MB, Abazia DT. Medicinal cannabis: History, pharmacology, and implications for the acute care setting. P T. 2017;42(3):180-8.
16. Merrick J, Lane B, Sebree T, Yaksh T, O'Neill C, Banks SL. Identification of Psychoactive Degradants of Cannabidiol in Simulated Gastric and Physiological Fluid. Cannabis and Cannabinoid Research [Internet]. 2016 (cited 2017 Mar 8); 1(1):102-12. Available from: https://www.liebertpub.com/doi/pdf/10.1089/can.2015.0004
17. Stout SM, Cimino NM. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: a systematic review. Drug Metab Rev. 2014; 46(1): 86-95.
18. Karila L, Roux P, Rolland B, Benyamina A, Reynaud M, Aubin HJ, Lancon Ch. Acute and long-term effects of cannabis use: a review. Curr Pharm Des Research [Internet]. 2014 (cited 2017 Mar 8); 20: 4112-8. Available from: http://www.antoniocasella.eu/archila/Karila_2014.pdf
19. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. 2017.
20. Nugent SM, Morasco BJ, O'Neil ME, Freeman M, Low A, Kondo K, et al. The effects of cannabis among adults with chronic pain and an overview of general harms: A systematic review. Ann Intern Med. 2017; 167(5):319-31. doi: 10.7326/M17-0155.
21. Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose death: 1999–2009. Drug Alcohol Depend. 2013; 131(3):263–70. doi: 10.1016/j.drugalcdep.2012.11.018
22. Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, et al. Opioid-sparing effect of cannabinoids: A systematic review and meta-analysis. Neuropsychopharmacology. 2017; 42(9):1752-65. doi: 10.1038/npp.2017.51.
23. Australian Government, Department of Health, Therapeutic Goods Administration. Guidance for the use of medicinal cannabis in the treatment of chronic non-cancer pain in Australia [internet]. Woden ACT: Australian Government, Department of Health, Therapeutic Goods Administration. 2017. (cited 2018 Mar 8). Available from: https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-chronic-non-cancer-pain-australia.pdf
24. Fitzcharles MA, Ste-Marie PA, Ablin JN, Shir Y. AB1133: Comparison of canadian and Israeli rheumatologists' understanding of cannabinoid use as a therapy for rheumatic diseases. Ann. Rheum. Dis. 2014; 73(Suppl 2):1177. doi: 10.1136/annrheumdis-2014-eular.2511.
25. Ablin JN, Elkayam O, Fitzcharles MA. Attitudes of Israeli rheumatologists to the use of medical cannabis as therapy for rheumatic disorders. Rambam Maimonides Med J. 2016;7(2): e0012. doi: 10.5041/RMMJ.10239.
26. Lee G, Grovey B, Furnish T, Wallace M. Medical cannabis for neuropathic pain. Curr Pain Headache Rep. 2018;22(1):8. doi: 10.1007/s11916-018-0658-8.
27. Perrot S, Trouvin AP. Cannabis for musculoskeletal pain and arthritis: Evidence is needed. Joint Bone Spine. 2018. pii: S1297-319X(18)30047-2. doi: 10.1016/j.jbspin.2018.03.004.
28. Häuser W, Petzke F, Fitzcharles MA. Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management - An overview of systematic reviews. Eur J Pain. 2018; 22(3):455-70. doi: 10.1002/ejp.1118.
29. Fitzcharles MA, Baerwald C, Ablin J, Häuser W. Efficacy, tolerability and safety of cannabinoids in chronic pain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis): A systematic review of randomized controlled trials. Schmerz. 2016;30(1):47-61. doi: 10.1007/s00482-015-0084-3.
30. Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015 ;313(24):2456-73. doi: 10.1001/jama.2015.6358.
31. Häuser W, Fitzcharles MA, Radbruch L, Petzke F. Cannabinoids in pain management and palliative medicine: An overview of systematic reviews and prospective observational studies. Dtsch Arztebl Int. 2017;114(38):627-34. doi: 10.3238/arztebl.2017.0627.
32. Jemos C, Villa J, Zuniga Guerrero A, Guardamagna VA, Omodeo Sale E. 4CPS-231: The use of cannabis oil in oncological pain: analysis of the outcomes in real practice at a cancer centre. Eur J Hosp Pharm. 2018; 25(Suppl 1):A149.
33. Blake A, Wan BA, Malek L, DeAngelis C, Diaz P, Lao N, et al. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017;6(Suppl 2):S215-S222. doi: 10.21037/apm.2017.08.05.
34. Gertsch J. Analytical and pharmacological challenges in cannabis research. Planta Med. 2018;84(4):213. doi: 10.1055/s-0044-101051.
35. Abuhasira R, Shbiro L, Landschaft Y. Medical use of cannabis and cannabinoids containing products - Regulations in Europe and North America. Eur J Intern Med. 2018; 49:2-6. doi: 10.1016/j.ejim.2018.01.001.
36. Krcevski-Skvarc N, Wells C, Häuser W. Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation. Eur J Pain. 2018;22(3):440-54. doi: 10.1002/ejp.1147.
2. Bridgeman MB, Abazia DT. Medicinal cannabis: History, pharmacology, and implications for the acute care setting. P T. 2017;42(3):180-8.
3. US Departament of Justiced, Drug Enforcement Administration, Diversion Control Division. Title 21 United States Code (USC) controlled substances Act: Subchapter I Control and enforcement. Parte B: Authority to control; standars and schedules [internet]. EEUU: US Departament of Justiced. [citado 10 Feb 2018] Disponible en: www.deadiversion.usdoj.gov/21cfr/21usc/812.htm.
4. Liang D, Bao Y, Wallace M, Grant I, Shi Y. Medical Cannabis Legalization and Opioid Prescriptions: Evidence on US Medicaid Enrollees during 1993-2014. Addiction. 2018 Jul 10.
5. United States. Department of Justice, Drug Enforcement Administration. Drug scheduling [internet]. United States: Department of Justice. (cited 2018 Feb 10). Available from: https://www.dea.gov/druginfo/ds.shtml
6. U.S. Food and Drug Administration. FDA and marijuana [internet]. Silver Spring: US Departament of Health and Human Services. (cited 2017 Dic. 26). Available from: https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421163.htm
7. European Medicines Agency. EU/3/16/1621: Public summary of opinion on orphan designation Delta-9-tetrahydrocannabinol and cannabidiol from extracts of the Cannabis sativa L. plant for the treatment glioma [Internet]. London: European Medicines Agency; 2016. (cited 2017 Dic. 17). Available from: http://www.ema.europa.eu/docs/en_GB/document_library/Orphan_designation/2016/04/WC500204483.pdf
8. Bestrashniy J, Winters KC. Variability in medical marijuana laws in the United States. Psychol Addict Behav. 2015; 29(3):639–42.
9. Sznitman SR, Bretteville-Jensen AL. Public opinion and medical cannabis policies: examining the role of underlying beliefs and national medical cannabis policies. Harm Reduct J. 2015; 12:46.
10. Codas M, González V, Madrazo C, Benítez G, Chamorro L, Scott C et al. Automedicación en Itapúa: nuestra realidad. Rev. Nac. (Itauguá) [Internet]. 2015 (citado 8 Mar. 2017);7(1):28-31. Disponible en: http://scielo.iics.una.py/pdf/hn/v7n1/v7n1a05.pdf
11. National Institute on Drug Abuse. Drug facts: marijuana as medicine (Internet). US: National Institute on Drug Abuse; 2018 (cited 2017 Dic. 17). Available from: https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/df-marijuana-medicine.pdf
12. ProCon.org. Should marijuana be a medical option? [Internet]. Santa Mónica: ProCon, 2016 [updated 2018 Mar 29; cited 2018 May 25]. Available from. https://medicalmarijuana.procon.org/view.answers.php?questionID=001325
13. MacDonald K, Pappas K. Why not pot?: a review of the Brain-based risks of cannabis. Innov Clin Neurosci. 2016; 13(3-4):13–22.
14. Pertwee RG, Howlett AC, Abood ME, Alexander SP, Di Marzo V, Elphick MR, et al. International Union of Basic and Clinical Pharmacology. LXXIX. Cannabinoid receptors and their ligands: beyond CB1 and CB2. Pharmacol Rev. 2010; 62(2):588–631.
15. Bridgeman MB, Abazia DT. Medicinal cannabis: History, pharmacology, and implications for the acute care setting. P T. 2017;42(3):180-8.
16. Merrick J, Lane B, Sebree T, Yaksh T, O'Neill C, Banks SL. Identification of Psychoactive Degradants of Cannabidiol in Simulated Gastric and Physiological Fluid. Cannabis and Cannabinoid Research [Internet]. 2016 (cited 2017 Mar 8); 1(1):102-12. Available from: https://www.liebertpub.com/doi/pdf/10.1089/can.2015.0004
17. Stout SM, Cimino NM. Exogenous cannabinoids as substrates, inhibitors, and inducers of human drug metabolizing enzymes: a systematic review. Drug Metab Rev. 2014; 46(1): 86-95.
18. Karila L, Roux P, Rolland B, Benyamina A, Reynaud M, Aubin HJ, Lancon Ch. Acute and long-term effects of cannabis use: a review. Curr Pharm Des Research [Internet]. 2014 (cited 2017 Mar 8); 20: 4112-8. Available from: http://www.antoniocasella.eu/archila/Karila_2014.pdf
19. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: The current state of evidence and recommendations for research. Washington, DC: The National Academies Press. 2017.
20. Nugent SM, Morasco BJ, O'Neil ME, Freeman M, Low A, Kondo K, et al. The effects of cannabis among adults with chronic pain and an overview of general harms: A systematic review. Ann Intern Med. 2017; 167(5):319-31. doi: 10.7326/M17-0155.
21. Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose death: 1999–2009. Drug Alcohol Depend. 2013; 131(3):263–70. doi: 10.1016/j.drugalcdep.2012.11.018
22. Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, et al. Opioid-sparing effect of cannabinoids: A systematic review and meta-analysis. Neuropsychopharmacology. 2017; 42(9):1752-65. doi: 10.1038/npp.2017.51.
23. Australian Government, Department of Health, Therapeutic Goods Administration. Guidance for the use of medicinal cannabis in the treatment of chronic non-cancer pain in Australia [internet]. Woden ACT: Australian Government, Department of Health, Therapeutic Goods Administration. 2017. (cited 2018 Mar 8). Available from: https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-treatment-chronic-non-cancer-pain-australia.pdf
24. Fitzcharles MA, Ste-Marie PA, Ablin JN, Shir Y. AB1133: Comparison of canadian and Israeli rheumatologists' understanding of cannabinoid use as a therapy for rheumatic diseases. Ann. Rheum. Dis. 2014; 73(Suppl 2):1177. doi: 10.1136/annrheumdis-2014-eular.2511.
25. Ablin JN, Elkayam O, Fitzcharles MA. Attitudes of Israeli rheumatologists to the use of medical cannabis as therapy for rheumatic disorders. Rambam Maimonides Med J. 2016;7(2): e0012. doi: 10.5041/RMMJ.10239.
26. Lee G, Grovey B, Furnish T, Wallace M. Medical cannabis for neuropathic pain. Curr Pain Headache Rep. 2018;22(1):8. doi: 10.1007/s11916-018-0658-8.
27. Perrot S, Trouvin AP. Cannabis for musculoskeletal pain and arthritis: Evidence is needed. Joint Bone Spine. 2018. pii: S1297-319X(18)30047-2. doi: 10.1016/j.jbspin.2018.03.004.
28. Häuser W, Petzke F, Fitzcharles MA. Efficacy, tolerability and safety of cannabis-based medicines for chronic pain management - An overview of systematic reviews. Eur J Pain. 2018; 22(3):455-70. doi: 10.1002/ejp.1118.
29. Fitzcharles MA, Baerwald C, Ablin J, Häuser W. Efficacy, tolerability and safety of cannabinoids in chronic pain associated with rheumatic diseases (fibromyalgia syndrome, back pain, osteoarthritis, rheumatoid arthritis): A systematic review of randomized controlled trials. Schmerz. 2016;30(1):47-61. doi: 10.1007/s00482-015-0084-3.
30. Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015 ;313(24):2456-73. doi: 10.1001/jama.2015.6358.
31. Häuser W, Fitzcharles MA, Radbruch L, Petzke F. Cannabinoids in pain management and palliative medicine: An overview of systematic reviews and prospective observational studies. Dtsch Arztebl Int. 2017;114(38):627-34. doi: 10.3238/arztebl.2017.0627.
32. Jemos C, Villa J, Zuniga Guerrero A, Guardamagna VA, Omodeo Sale E. 4CPS-231: The use of cannabis oil in oncological pain: analysis of the outcomes in real practice at a cancer centre. Eur J Hosp Pharm. 2018; 25(Suppl 1):A149.
33. Blake A, Wan BA, Malek L, DeAngelis C, Diaz P, Lao N, et al. A selective review of medical cannabis in cancer pain management. Ann Palliat Med. 2017;6(Suppl 2):S215-S222. doi: 10.21037/apm.2017.08.05.
34. Gertsch J. Analytical and pharmacological challenges in cannabis research. Planta Med. 2018;84(4):213. doi: 10.1055/s-0044-101051.
35. Abuhasira R, Shbiro L, Landschaft Y. Medical use of cannabis and cannabinoids containing products - Regulations in Europe and North America. Eur J Intern Med. 2018; 49:2-6. doi: 10.1016/j.ejim.2018.01.001.
36. Krcevski-Skvarc N, Wells C, Häuser W. Availability and approval of cannabis-based medicines for chronic pain management and palliative/supportive care in Europe: A survey of the status in the chapters of the European Pain Federation. Eur J Pain. 2018;22(3):440-54. doi: 10.1002/ejp.1147.
