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Federal government websites often end in. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. NCBI Bookshelf. Opioids are commonly prescribed to treat and manage chronic and severe pain; however, their potential for abuse and dependency is a concern. Chronic and unrelenting pain can have significant psychological, physical, and emotional stress on individuals. Several strategies are employed to mitigate intractable pain that does not respond to nonsteroidal anti-inflammatory drugs NSAIDs , with opioids being widely recognized as the cornerstone of pain management protocols. In recent years, there has been emerging and growing evidence indicating the potential efficacy of cannabinoids in managing chronic pain. This activity offers an overview of the signs and symptoms of adverse events and the crucial aspects of monitoring, intervention, and other pertinent considerations in opioid therapy and cannabinoids for patients with chronic pain. These key points are indispensable for fostering effective collaboration among interprofessional team members responsible for patient care. Objectives: Identify patients with chronic pain and provide education regarding the limitations of opioids and cannabinoids, including potential incomplete pain relief, mechanisms of action, and associated risks and adverse effects, emphasizing the importance of multimodal treatment approaches. Elucidate the signs and symptoms of opioid-related drug abuse by identifying behavioral changes in individuals, such as social withdrawal, increased secrecy, or sudden financial difficulties, in order to ensure the optimal effectiveness and safety of opioid and cannabinoid treatment. Identify and navigate legal issues associated with cannabis use by thoroughly understanding the potential benefits, risks, and State regulations governing its use for both medical and recreational purposes. Assess patients' pain levels, treatment response, functional outcomes, and potential adverse effects of opioid and cannabinoid therapy, ensuring ongoing monitoring and optimization of pain management strategies. Access free multiple choice questions on this topic. In the human body, pain is an inherent alarm system that activates when there is actual or potential damage, directing an individual's attention toward the issue. Pain encompasses various elements, including nociception, the perception of pain, suffering, and pain behaviors. Although pain is a fundamental mechanism, it can become burdensome when it persists for an extended period, leading to suffering and pain-related behaviors. Chronic and unrelenting pain can cause psychological, physical, and emotional distress, adding further strain to individuals. The search for an ideal pain relief medication has been an ongoing endeavor since ancient times, as certain types of pain still lack definitive treatment options. Several strategies have been developed to address intractable pain that does not respond to nonsteroidal anti-inflammatory drugs NSAIDs , with opioids being the mainstay in many pain management protocols. In recent years, there has been growing and promising evidence suggesting the potential effectiveness of cannabinoids in the management of chronic pain. Endogenous opioids are produced in the body physiologically, which help in pain modulation. They achieve this by decreasing calcium influx in the presynaptic membrane and increasing potassium influx in the postsynaptic membrane. These exogenous opioids have a dual mechanism of action. First, they work to change the perception of pain in the brain and then increase the pain threshold in the spinal cord. By targeting both mechanisms, exogenous opioids can provide effective pain relief for individuals. Physicochemical properties, such as lipid solubility and fraction un-ionized, play a significant role in determining the distribution of drugs in the body and their rate of access to the biophase where drug receptors are located. The pharmacokinetic and pharmacodynamic properties of opioids belonging to the fentanyl group, methadone, and morphine are essential considerations due to their distinctive features. Alfentanil and remifentanil exhibit relatively short equilibration half-lives of approximately 1 minute between plasma and the effect site. In comparison, fentanyl and sufentanil have longer equilibration half-lives of nearly 6 minutes. Methadone has a relatively short half-life of approximately 8 minutes. However, among opioids, morphine exhibits a longer equilibration half-life of 2 to 3 hours, whereas morphineglucuronide M6G demonstrates the slowest plasma-effect site transfer, with an equilibration half-life of approximately 7 hours. Morphine milligram equivalents MME serve as a measure to assess the relative potency and safety of opioids for pain management. The absorption of transdermal fentanyl can be influenced by factors such as heat and other considerations. Buprenorphine, being a partial agonist, does not follow MME conversion guidelines. The use of MME should be approached cautiously, considering the potential variations in pharmacogenetics. Similar to opioids, endocannabinoids are synthesized physiologically and released in the body by synapses to act on the cannabinoid receptors present on presynaptic endings. They perform the following essential actions related to pain modulation: \[12\] \[13\] \[14\]. Marijuana is a dried mixture of extracts derived from the cannabis plant. It is essential to understand the difference between cannabis, cannabinoids, and cannabidiol CBD. Cannabis is typically used to refer to products obtained from the Cannabis sativa plant. Specific cannabinoid-based treatments, which include nabilone, dronabinol, and CBD, have gained approval as medical interventions for specific indications. CBD is a non-psychoactive component found in the cannabis plant, whereas 9-tetrahydrocannabinol THC is the primary psychoactive component found in cannabis. The pharmacokinetic properties of marijuana vary depending on its route of administration. Pulmonary inhalation of marijuana through the lungs rapidly causes a maximum plasma concentration within minutes. Subsequently, psychiatric effects begin within seconds to a few minutes after inhalation, peak after 15 to 30 minutes, and then gradually diminish over the course of 2 to 3 hours. On the other hand, oral ingestion of marijuana causes psychiatric effects that typically occur between 30 and 90 minutes. The effects reach their maximum after 2 to 3 hours and last about 4 to 12 hours. One of the primary concerns with opioid use for pain management is the risk of drug abuse and addiction. This often involves the damage of the glutaminergic and dopaminergic pathways in the brain. Furthermore, there are other adverse effects of opioid use, in addition to the risk of addiction, including immunosuppression, obesity, respiratory depression, constipation, and miosis. The significant association between addiction and withdrawal can lead to various physical and psychological effects. In individuals with addiction issues, differentiating between chronic pain stemming from other causes and pain resulting from withdrawal can be challenging. However, certain symptoms, such as yawning, sweating, lacrimation, and piloerection, are more strongly associated with drug withdrawal rather than the pain caused by other conditions. Opioid withdrawal can exacerbate baseline pain caused by other disorders. In the case of withdrawal from short-acting opioids, the duration is typically brief. This is why physical symptoms peak in intensity within 36 to 72 hours and then diminish in severity. NOWS is a potentially life-threatening condition characterized by withdrawal symptoms in newborns exposed to opioids during gestation. Cannabis has faced significant restrictions primarily due to its psychotropic effect, often associated with recreational use and the resulting social stigma. As a result, cannabis remains illegal in numerous countries and is classified as a Schedule I status in the United States. Furthermore, cannabis cultivation and production have been prohibited for nearly 75 years, creating barriers to conducting comprehensive research and inhibiting its potential medical applications. The addictive potential of cannabis is often underestimated, despite its widespread use as a psychotropic substance. CUD is one of the leading causes of addiction in adolescents. The psychoactive compound THC, found in cannabis, has been associated with various health concerns, including cardiovascular disease, acute pancreatitis, cannabinoid hyperemesis syndrome, and lung disease when smoked. Furthermore, cannabis use during pregnancy has been associated with an increased risk of neonatal morbidity and death. The drug interactions of opioids are widely known, and it is essential to exercise vigilance regarding the potential drug interactions of cannabis. The mortality risk further increases fold for MED exceeding 90 mg. In comparison, CBD has been shown to provide pain relief with fewer adverse reactions than opioids. A typical dosage of CBD for pain relief is around 5 mg twice daily, with a maximum recommended dosage of up to 40 mg daily. The second and third steps of the World Health Organization's step ladder for pain management involve the use of opioids. The efficacy of opioids in managing these conditions has been proven through randomized clinical trials RCT for some of these conditions. However, several US states have legalized its use in certain medical conditions. Several studies have demonstrated that MC helps reduce the opioid dosage for patients undergoing treatment for non-cancer pain. It can also be substituted in place of opioids to achieve therapeutic benefits. Several cannabinoids are available, including CBD, dronabinol, and nabilone, each with specific indications. CBD has been approved for treating refractory seizures in patients with Lennox-Gastaut syndrome, tuberous sclerosis, and Dravet syndrome. Nabilone is indicated for patients with refractory CINV. Marijuana use can lead to various symptoms and effects if used by an inexperienced user in large doses. These symptoms can include anxiety, paranoia, depersonalization, depressed mood, illusions, and hallucinations. In addition, studies have shown that marijuana use can affect blood flow to the temporal lobe of the brain in smokers. As a precautionary measure, ASRA recommends delaying elective surgery for at least 2 hours after smoking cannabis. Legal issues surrounding the use of cannabis have indeed hindered research progress and contributed to delays in fully understanding its potential benefits and risks. While some states and countries have legalized cannabis use for medical and recreational purposes, there are still significant variations in the legal status of cannabis across different regions. Opioid use disorder has become an epidemic in the United States recently. In addition, respiratory depression associated with opioid use is one of the primary factors contributing to fatal overdoses, which has resulted in a significant loss of lives. Given these challenges related to opioid use, there is a pressing need to find a safer and more effective alternative for pain management, particularly for patients with chronic and terminal diseases. This alternative should minimize the risks of drug misuse, dependence, and overdose while offering superior efficacy and a more favorable benefit-to-risk ratio than opioids. Chronic pain can significantly affect an individual's lifestyle due to its somatic and psychological effects. Therefore, optimal chronic pain management often requires a multidisciplinary approach involving healthcare professionals such as pain medicine specialists, internists, and psychiatrists. This condition is addressed well by using potent analgesics, including opioids, which can provide effective pain relief. However, it is essential to closely monitor patients by scheduling regular follow-up visits to assess their response to treatment, address any emerging adverse effects, and make necessary adjustments in dosage as needed. For accurate conversion and appropriate dosing of opioids, pharmacists should be consulted as they possess the expertise to provide precise dosing information for the prescribed medications and perform medication reconciliation to prevent potential drug interactions. Moreover, due to the potentially fatal effects of opioids, patients should be thoroughly educated about the adverse signs and symptoms associated with opioid use and the potential for drug abuse and dependence. Nurses are vital in monitoring patients for respiratory depression, a potential adverse effect of opioid use. Pain management specialists are responsible for monitoring and managing the patient's pain and ensuring the accurate dosing of prescribed medications. They utilize various tools such as clinical examinations and validated questionnaires such as the Pain Assessment in Advanced Dementia PAINAD or the Dallas pain questionnaire for back pain to evaluate the severity and characteristics of pain in patients. In the case of opioid overdose, the involvement of critical care physicians and emergency medicine clinicians plays a crucial role. The incidence of CBD toxicity has been reportedly increasing; therefore, it is recommended to consult the Poison Control Center or a medical toxicologist for the latest information and guidance in cases of suspected toxicity. An interprofessional team approach involving clinicians such as physicians, nurses, nurse practitioners, and physician assistants , specialists, pharmacists, and toxicologists is highly beneficial in improving the outcomes related to cannabis and opioids for pain management and preventing adverse effects. Pain is a common and chief complaint among patients in both ambulatory and hospital settings. Clinicians effectively manage pain by obtaining a thorough history from the patient, conducting a comprehensive physical examination, investigating for accurate diagnosis appropriately, and incorporating evidence-based medicine for treating pain. Healthcare professionals should examine the etiology of pain in their patients. For managing acute musculoskeletal pain and inflammation, healthcare professionals should consider prescribing NSAIDs as the initial pain relief approach before recommending opioids or cannabis to patients. Intraarticular injection of corticosteroids is recommended for patients in cases of osteoarthritis. Fibromyalgia should be considered in patients exhibiting multiple tender points during a physical examination and with standard laboratory results. Regarding treatment, FDA-approved medications, such as duloxetine, pregabalin, and milnacipran, can be prescribed to help manage fibromyalgia symptoms. The first-line medications for treating trigeminal neuralgia are carbamazepine and oxcarbazepine. Diabetic neuropathy or postherpetic neuralgia responds well to gabapentin medication. The healthcare team can monitor the misuse of cannabis and opioids using the prescription drug monitoring program PDMP. Disclosure: Noman Khalid declares no relevant financial relationships with ineligible companies. Disclosure: Preeti Patel declares no relevant financial relationships with ineligible companies. Disclosure: Abhishek Singh declares no relevant financial relationships with ineligible companies. You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls \[Internet\]. Search term. Affiliations 1 Shaikh Zayed Hospital Lahore. Continuing Education Activity Opioids are commonly prescribed to treat and manage chronic and severe pain; however, their potential for abuse and dependency is a concern. Introduction In the human body, pain is an inherent alarm system that activates when there is actual or potential damage, directing an individual's attention toward the issue. Function Opioids Endogenous opioids are produced in the body physiologically, which help in pain modulation. They perform the following essential actions related to pain modulation: \[12\] \[13\] \[14\] Decrease the release of neurotransmitters. Modulate CB1 receptors within central nociception processing areas and the spinal cord, which results in analgesic effects. Issues of Concern Opioids One of the primary concerns with opioid use for pain management is the risk of drug abuse and addiction. P-glycoprotein substrates: CBD and THC can act as substrates and inhibitors of P-glycoprotein, potentially increasing the concentration of drugs such as digoxin and loperamide. Antiepileptic drugs: Concurrent use of CBD with valproate and clobazam can increase the risk of sedation and hepatotoxicity. Sirolimus: P-glycoprotein inhibitors can increase sirolimus concentrations and the risk for toxicities. Simultaneous use of P-glycoprotein inhibitors should be avoided. Caution is advised when using them together. Clinical Significance Opioids The second and third steps of the World Health Organization's step ladder for pain management involve the use of opioids. Other Issues Marijuana use can lead to various symptoms and effects if used by an inexperienced user in large doses. Enhancing Healthcare Team Outcomes Chronic pain can significantly affect an individual's lifestyle due to its somatic and psychological effects. Nursing, Allied Health, and Interprofessional Team Interventions Pain is a common and chief complaint among patients in both ambulatory and hospital settings. Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Pain Suppl. Robertson SA. What is pain? J Am Vet Med Assoc. Woolf CJ. What is this thing called pain? J Clin Invest. Loeser JD, Melzack R. Pain: an overview. Availability and utilization of opioids for pain management: global issues. Ochsner J. Medical cannabis for the reduction of opioid dosage in the treatment of non-cancer chronic pain: a systematic review. Syst Rev. Current research on opioid receptor function. Curr Drug Targets. Martin WR. Pharmacology of opioids. Pharmacol Rev. Pharmacokinetic-pharmacodynamic modeling of opioids. J Pain Symptom Manage. Curr Pain Headache Rep. Role of the cannabinoid system in pain control and therapeutic implications for the management of acute and chronic pain episodes. Curr Neuropharmacol. Endocannabinoids and pain: spinal and peripheral analgesia in inflammation and neuropathy. Prostaglandins Leukot Essent Fatty Acids. J Clin Neurophysiol. Grotenhermen F. Pharmacokinetics and pharmacodynamics of cannabinoids. Clin Pharmacokinet. Cellular and molecular mechanisms involved in the neurotoxicity of opioid and psychostimulant drugs. Brain Res Rev. Glutamate release in the nucleus accumbens core is necessary for heroin seeking. J Neurosci. Neurorobiology and evidence-based biological treatments for substance abuse disorders. CNS Spectr. Opioid Use Disorder. Estimated costs of prescription opioid analgesic abuse in the United States in a societal perspective. Clin J Pain. Association of personality disorders, family conflicts and treatment with quality of life in opiate addiction. Eur Addict Res. Review of the effect of opioid-related side effects on the undertreatment of moderate to severe chronic non-cancer pain: tapentadol, a step toward a solution? Curr Med Res Opin. AAPS J. Opioid misuse in gastroenterology and non-opioid management of abdominal pain. Nat Rev Gastroenterol Hepatol. Wolff K, Perez-Montejano R. Opioid neonatal abstinence syndrome: controversies and implications for practice. Curr Drug Abuse Rev. Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol. Cold Spring Harb Perspect Med. JAMA Pediatr. Phytochemistry of Cannabis sativa L. Prog Chem Org Nat Prod. Front Pharmacol. Adverse effects of medical cannabinoids: a systematic review. Cannabis and Cannabinoids for Chronic Pain. Curr Rheumatol Rep. Hashemi D, Gray K. Cannabis Use Disorder in Adolescents. Cannabis use and cannabis use disorder. Nat Rev Dis Primers. Cannabis Addiction and the Brain: a Review. J Neuroimmune Pharmacol. J Pain. J Addict. Maternal marijuana use, adverse pregnancy outcomes, and neonatal morbidity. Am J Obstet Gynecol. Effects of regular cannabis use on neurocognition, brain structure, and function: a systematic review of findings in adults. Am J Drug Alcohol Abuse. Carr D, Schatman M. Am J Public Health. Chronic pain patients' perspectives of medical cannabis. Emerging Use of Epidiolex Cannabidiol in Epilepsy. J Pediatr Pharmacol Ther. ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids. Reg Anesth Pain Med. Pharmaceuticals Basel. Phase I studies of sirolimus alone or in combination with pharmacokinetic modulators in advanced cancer patients. Clin Cancer Res. Biomed Res Int. An Sist Sanit Navar. Nalamachu S. An overview of pain management: the clinical efficacy and value of treatment. Am J Manag Care. Fitzgibbon DR. Clinical use of opioids for cancer pain. Efficacy of opioids for chronic pain: a review of the evidence. Ann Surg. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. Cannabis as a substitute for prescription drugs - a cross-sectional study. J Pain Res. Upregulation of spinal cannabinoidreceptors following nerve injury enhances the effects of Win 55, on neuropathic pain behaviors in rats. Br J Pharmacol. The CB 2 receptor and its role as a regulator of inflammation. Cell Mol Life Sci. Cannabinoid receptor-specific mechanisms to alleviate pain in sickle cell anemia via inhibition of mast cell activation and neurogenic inflammation. Clin Gastroenterol Hepatol. Harm Reduct J. Associations between medical cannabis and prescription opioid use in chronic pain patients: A preliminary cohort study. PLoS One. Golub V, Reddy DS. Adv Exp Med Biol. N Engl J Med. JAMA Neurol. Dean L, Kane M. Medical Genetics Summaries \[Internet\]. Cannabinoids: Therapeutic Use in Clinical Practice. Int J Mol Sci. Sports Health. Mack A, Joy J. Marijuana as Medicine? The Science Beyond the Controversy. J Am Med Dir Assoc. Epidemiology of cannabidiol related cases reported in the National Poison Data System - Am J Emerg Med. Pain Pract. J Orthop Sports Phys Ther. Watson JC, Sandroni P. Central Neuropathic Pain Syndromes. Mayo Clin Proc. Phillips E, Gazmararian J. Implications of prescription drug monitoring and medical cannabis legislation on opioid overdose mortality. J Opioid Manag. Cannabis Versus Opioids for Pain. In: StatPearls \[Internet\]. In this Page. Bulk Download. Related information. Recent Activity. Clear Turn Off Turn On. Follow NCBI.

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