Pain, the unpleasant emotional or sensory experience that results from potential or actual tissue damage, is a major cause of human suffering and one of the main manifestations of disease and injury. In the United States (US), an estimated 25 million adults live with chronic pain (Bigand et al., 2019). Despite the various types of traditional pain management treatments available, there are still patients with inadequate pain control. Unrelieved pain, especially for a prolonged time, affects all aspects of an individual’s life, resulting in diminished well-being and quality of life. Nurses are uniquely positioned to consolidate up-to-date knowledge on available pain management options and educate patients to optimize their pain relief. Since the legalization of marijuana in parts of the world, new information about medicinal cannabis use for pain relief continues to increase. Although the use of marijuana remains controversial, clinical trials have found evidence of its effectiveness in pain control (Bigand et al., 2019). This paper aims to compare three articles that discuss the use of cannabis and cannabinoids (CBN) for chronic pain management and provide an informed opinion on its use in nursing practice. This will be achieved by providing a background on the subject, a review and analysis of three articles related to the topic, and recommendations for nursing practice based on the articles.
Background
Chronic pain is defined as pain that persists for three or more months despite medical treatment or other interventions (Ignatavicius et al., 2021). This type of pain significantly impacts an individual’s quality of life negatively. It impairs the ability to perform daily tasks, can cause immobility, decreases the ability to perform activities of daily living, and may eventually cause one to lose independence. Other undesirable effects of Unmanaged pain include sleep deprivation, anxiety, and depression, which can contribute to increased pain perception (Bigand et al., 2019). Opioids, a drug class currently used to treat severe chronic pain, presents a danger to patients suffering from chronic pain. Dependence and tolerance tend to develop with long-term use leading to the need for higher doses to achieve similar levels of pain control. This has the potential to result in abuse, addiction, and use of Dependence doses outside the recommended safe ranges. This has led to increased cases of opioid overdose, with some resulting in casualties, necessitating research for alternative safer chronic pain treatment options (Bigand et al., 2019).
Medicinal marijuana has the potential to be a safer alternative to opioids. The main active components that can be extracted from the cannabis plant are cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) (Collins, 2020). THC is part of the plant that causes a euphoric feeling, while CBD does not (Collins, 2020). Although marijuana can cause a euphoric effect like opioids, it does not suppress the respiratory system, and there have been zero reported cases of fatal overdoses with the sole use of medicinal cannabis (Pettinato, 2017). The recent legalization of cannabis in parts of the world allows for additional treatment for those with unmanaged pain (Bigand et al., 2019; Collins, 2020; Pettinato, 2017). With the legalization of marijuana, there have been increased reports on the effectiveness of medicinal cannabis, but concerns remain on the possibility of higher potency cannabis having psychiatric side effects (Bigand et al., 2019).
Literature Review
Three articles were reviewed for this paper, Bigand et al. (2019), Susan E. Collins (2020), and Maria Pettinato (2017). The first article by Bigand et al., (2019) is a qualitative descriptive study on adults who use cannabis with their opioid medication and guidelines for best practice. Nurses should be aware of the most current evidence and policies specific to their place of employment regarding cannabis use. Recent research data shows an increased prevalence of psychiatric disorders, including psychosis and exacerbation of bipolar disorder by increasing the incidences of manic episodes. Other effects of heavy cannabis use include increased suicidal tendencies and long-term effects on cognitive functioning. Nurses have a role in making patients aware that cannabis is not free of potential adverse effects despite its benefits in chronic pain management. Caution should be taken when combining cannabis with opioids as the risk of adverse effects increases in cases of overdose involving both compounds. Advancement in technology and research makes it possible to study and test patients for particular genes that participate in various gene-drug interactions and predispose some in the population to higher risks of adverse effects. These gene-drug interactions can also be used to determine appropriate dosages for individuals based on the characteristics of their opioid receptors and their abilities to metabolize and excrete the active metabolites in cannabis (Bigand et al., 2019).
The second article by Collins (2020) is a meta-analysis of studies on CBD oil for chronic pain that highlight its effectiveness. The author notes that little research support CBD as a standalone treatment but rather as an addition to an already established treatment. In an Italian study of 614 adults, it was discovered that including oral and vaporized CBD oil and THC is a safe and effective treatment of chronic pain management. In an 11-patient cohort experiencing neuropathic pain, adding CBD and THC with spinal cord stimulation improved their pain relief. A sample size of 3 participants who used topical cannabis for wound pain combined with sunflower oil resulted in decreased pain and decreased opioid use. Susan E. Collins (2020) found that in the studies she reviewed, samples were small, dosing was inconsistent, and no repeat studies were performed. This has presented a challenge in determining the appropriate doses for over-the-counter (OTC) and prescription cannabis products. This result in non-standardized dosing and government-recommended daily allowance available; patients are left with the burden of researching or blindly following product label instructions. Increasing research is making it possible to safely use cannabis and its products to manage chronic pain and reduce the usage of opioids.
The third article by Pettinato (2017) provides information about the different strains of cannabis that can be used for medicinal purposes and basic dosing information for nurses and other healthcare providers. It highlights the importance of the role a nurse plays by giving valid answers and valid information to patients on the use of cannabis to treat various disorders. With the increased use of cannabis as a pain management option, it is imperative for all healthcare providers to gain education on the various strains, doses, and conditions that can be managed using medicinal marijuana to make them better placed to educate patients on medicinal cannabis use. The main strains of cannabis used for medicinal purposes are Cannabis sativa, C. indica, and C. ruderalis. These strains have varying levels of THC and CBD. The higher THC ratio indicates a more psychotropic effect. Patients who do not want the euphoric effect can use strains with minimal THC content and a higher percentage of other beneficial properties like CBD. Indica strains provide a higher CBD content which will help patients with inflammation, muscle spasms, and pain with relief from anxiety and promotion of sleep. Dosing guidelines provided advocate for using a self-titrating model due to their unique endogenous cannabinoid system and tolerance. Starting at a lower dose of THC helps prevent an increased euphoric effect on patients who are cannabis-naïve which may result in an anxiety-provoking paranoia. The most common adverse reactions are dizziness and fatigue, which improved over time with no occurrence of withdrawal symptoms on sudden discontinuation of cannabis use. High doses of THC are associated with anxiety and paranoia, with dry mouth occurring in rare cases. Medicinal cannabis generally has fewer adverse effects when compared with opioids; no fatal overdoses have been reported with cannabis used alone.
Similarities in the Literature
All three articles discussed cannabis as an alternative treatment for pain management to opioids and its effectiveness for pain relief. The impacts of the legalization of cannabis on current and future studies are discussed in all three articles as well as the need for healthcare providers to be well-informed about the use and effects of cannabis. Two articles by Collins (2020) and Pettinato (2017) discussed the need for standard dosing and different preparations available for use, while articles by Bigand et al. (2019) and Pettinato (2017) discussed the side effects of the use of cannabis.
Differences in Literature
The article by Pettinato (2017) served as a general guideline for dosing and to provide information to healthcare providers regarding different strains of cannabis and their different effects. Bigand et al. (2019) provided adverse effects of cannabis use without in-depth reasoning for their potential cause. Pettinato (2017) provided reasons for dosing and the adverse effects stated in the article by Bigand et al. (2019). Compared to the other two articles, Collins (2020) solely focused on the studies that showed the effectiveness of cannabis use in the management of chronic pain.
Cannabis and/or Cannabinoids: Best Practice in Chronic Pain Management
It is clear from the literature that despite the controversy, the medicinal use of cannabis has the potential to benefit patients with chronic pain and improve their quality of life. I agree with the dosing guidelines stated by Pettinato (2017) to slowly start at a low THC dose and titrate as per the patient’s needs. Medicinal cannabis needs healthcare providers’ guidance and non-judgemental support and application in their pain management plan.
Conclusion
Nurses must be informed of and adopt the best nursing practices for implementing cannabis use in pain management for patients with chronic pain. Bigand et al. (2019) and Collins (2020) believe that the addition of cannabis to an established treatment plan is beneficial to those with unrelieved chronic pain. The use of cannabis has shown promising benefits in the literature. All three articles used in this paper showed statistics on the effectiveness of cannabis in relieving pain through findings in many pieces of research. Nurses and other healthcare professionals play a vital role in educating patients on the safe and effective use of medicinal cannabis. More research is needed to make cannabis a safer and more effective alternative for chronic pain management.
References
Bigand, T., Anderson, C. L., Roberts, M. L., Shaw, M. R. (2019). Benefits and adverse effects of cannabis use among adults with persistent pain. Nursing Outlook., 67(3), 223-231. https://doi-org.uml.idm.oclc.org/10.1016/j.outlook.2018.12.014
Collins, S. E., (2020). CBD Oil and Chronic Pain. The Alabama Nurse., 47(4), 16-18.
Pettinato, M., (2017). Medicinal cannabis: A primer for nurses. Nursing., 47(8), 40-47. https://doi.org/10.1097/01.NURSE.0000521022.07638.35
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