Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions.

Background: One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual. Systematic Review Registration: PROSPERO no. 135886.

Why a distinct medical stream is necessary to support patients using cannabis for medical purposes.

BACKGROUND: Since 2001, Canadians have been able to obtain cannabis for medical purposes, initially through the Access to Cannabis for Medical Purposes Regulations (ACMPR). The Cannabis Act (Bill C-45) came into force on October 17, 2018, replacing the ACMPR. The Cannabis Act enables Canadians to possess cannabis purchased from a licensed retailer without authorization for either medical or nonmedical purposes. The Cannabis Act is currently the guiding legislation which governs both medical and nonmedical access. The Cannabis Act contains some improvements for patients but is essentially the same as its previous legislation. Beginning in October 2022, the federal government is conducting a review of the Cannabis Act and is questioning whether a distinct medical cannabis stream is still required, given the ease of access to cannabis and cannabis products. Although there is overlap in the reasons for medical and recreational cannabis use, the distinct legislation of medical versus recreational use of cannabis in Canada may be under threat. MAIN BODY: A large segment of the medical, academic, research, and lay communities agree that there is a need for distinct medical and recreational cannabis streams. Perhaps most importantly, separation of these streams is necessary to ensure that both medical cannabis patients and healthcare providers receive the required support needed to optimize benefits while minimizing risks associated with medical cannabis use. Preservation of distinct medical and recreational streams can help to ensure that needs of different stakeholders are met. For example, patients require guidance in the form of assessing the appropriateness of cannabis use, selection of appropriate products and dosage forms, dosing titration, screening for drug interactions, and safety monitoring. Healthcare providers require access to undergraduate and continuing health education as well as support from their professional organizations to ensure medical cannabis is appropriately prescribed. Although there are challenges in conducing research, as motives for cannabis use frequently straddle boundaries between medical versus recreational cannabis use, maintenance of a distinct medical stream is also necessary to ensure adequate supply of cannabis products appropriate for medical use, to reduce stigma associated with cannabis in both patients and providers, to help enable reimbursement for patients, to facilitate removal of taxation on cannabis used for medical purposes, and to promote research on all aspects of medical cannabis. CONCLUSION: Cannabis products for medical and recreational purposes have different objectives and needs, requiring different methods of distribution, access, and monitoring. HCPs, patients, and the commercial cannabis industry would serve Canadians well to continue to advocate to policy makers to ensure the continued existence of two distinct streams and must strive to make ongoing improvements to the current programs.

The impact of early palliative care on the quality of life of patients with advanced pancreatic cancer: The IMPERATIVE case-crossover study.

PURPOSE: Pancreatic cancer is a lethal disease. Many patients experience a heavy burden of cancer-associated symptoms and poor quality of life (QOL). Early palliative care alongside standard oncologic care results in improved QOL and survival in some cancer types. The benefit in advanced pancreatic cancer (APC) is not fully quantified. METHODS: In this prospective case-crossover study, patients ≥ 18 years old with APC were recruited from ambulatory clinics at a tertiary cancer center. Patients underwent a palliative care consultation within 2 weeks of registration, with follow up visits every 2 weeks for the first month, then every 4 weeks until week 16, then as needed. The primary outcome was change in QOL between baseline (BL) and week 16, measured by Functional Assessment of Cancer Therapy - hepatobiliary (FACT-Hep). Secondary outcomes included symptom control (ESAS-r), depression, and anxiety (HADS, PHQ-9) at week 16. RESULTS: Of 40 patients, 25 (63%) were male, 28 (70%) had metastatic disease, 31 (78%) had ECOG performance status 0-1, 31 (78%) received chemotherapy. Median age was 70. Mean FACT-hep score at BL was 118.8, compared to 125.7 at week 16 (mean change 6.89, [95%CI (-1.69-15.6); p = 0.11]). On multivariable analysis, metastatic disease (mean change 15.3 [95%CI (5.3-25.2); p = 0.004]) and age < 70 (mean change 12.9 [95%CI (0.5-25.4); p = 0.04]) were associated with improved QOL. Patients with metastatic disease had significant improvement in symptom burden (mean change -7.4 [95%CI (-13.4 to -1.4); p = 0.02]). There was no difference in depression or anxiety from BL to week 16. CONCLUSION: Palliative care should be integrated early in the journey for patients with APC, as it can improve QOL and symptom burden. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03837132.

Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions

One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual.

Pilot study of a survey to identify the prevalence of and risk factors for chronic neuropathic pain following breast cancer surgery.

PURPOSE/OBJECTIVES: To provide a preliminary determination of the prevalence rate of women who suffer from neuropathic pain post breast surgery (PPBS) and explore potential risk factors associated with its development. DESIGN: Prospective, quantitative, longitudinal survey. SETTING: Breast health clinic in western Canada. SAMPLE: A convenience sample of 17 women undergoing breast cancer surgery. METHODS: The Brief Pain Inventory was administered before surgery and 2 days, 10 days, and 3 months postsurgery. Demographic data also were collected preoperatively. Analysis included determining prevalence of PPBS; descriptive analyses on age, gender, and body mass index (BMI); presence of acute postoperative pain; type of surgery; and two-tailed t tests on age and BMI. MAIN RESEARCH VARIABLES: The symptom experience of chronic PPBS. FINDINGS: Twenty-three percent of the sample developed PPBS. Younger age (50 years or younger), more invasive surgery, acute postoperative pain, and less analgesic use during the acute postoperative period were factors associated with the development of PPBS. CONCLUSIONS: Additional research is required to confirm the significance of these potential risk factors in the development of PPBS. IMPLICATIONS FOR NURSING: Nurses are ideally situated to identify early signs of PPBS. In addition, nurses play a key role in the education of patients and healthcare professionals and can facilitate increased awareness about the possibility of developing PPBS, enabling earlier and more effective treatment of PPBS.

Caregiver thoughts and feelings in response to different perspective-taking prompts.

Both conceptual and empirical evidence in the caregiving literature suggest that "how" informal caregivers are prompted to think about patient experiences can impact their ability to achieve perceptual agreement with patients on symptom events. Researchers have begun to test the effects of different clinical questions with caregivers or a proxy on their perceptual agreement with patient self-reports. However, there are gaps in understanding caregivers' underlying thoughts and feelings when they are prompted to take different vantage points on the patient's symptom experiences. To assess these thoughts and feelings, content analysis was performed on verbal responses to an open-ended interview schedule, in which caregivers were questioned about their thoughts and feelings in one of three randomly assigned instructional conditions-neutral, imagine-patient, and imagine-self perspective-taking. Responses were classified into one of five cue categories: patient-oriented, caregiver-oriented, generalized other, feeling distanced, and other. Caregivers tended to respond to patient symptom experiences in ways that suggest it is innate for caregivers in intimate relationships to make an effort to imagine the patient's viewpoint on symptom events. When caregivers were prompted to imagine the patient's perspective, "labeling" processes were also triggered that denote a categorization process in which caregivers interpreted the meaning of simple patient information arising in the care situation. A large portion of caregivers in the neutral and imagine-patient conditions reported feeling distanced from patients in light of perceived communication difficulties.

Asking the right question of informal caregivers about patient symptom experiences: multiple proxy perspectives and reducing interrater gap.

Recent conceptual work on multiple proxy perspectives indicates that clinicians should be more reflective in terms of how they question or prompt informal caregivers to report on patient illness experiences. There are different ways in which therapeutic questions might be posed that can influence perceptual agreement between patients and caregivers. The purpose of this randomized, between-subjects study was to test the hypothesis that "The interrater gap between patient self-assessment and caregiver assessment on patient multidimensional symptom experiences will be reduced when caregivers are prompted to imagine-patient perspective-take." We also tested the hypothesis that "Regardless of the perspective-taking prompt provided to the caregiver, gender will have no impact on patient and caregiver discrepancy scores on patient symptom experiences." This study comprised a convenience sample of 126 dyads consisting of breast and prostate cancer patients, and their informal caregivers. Patients provided self-reports on the abbreviated Memorial Symptom Assessment Scale (MSAS). Informal caregivers also completed the abbreviated MSAS under one of three randomly assigned instructional set conditions: neutral, imagine-patient perspective-taking, and imagine-self perspective-taking. The imagine-patient prompt was effective in reducing caregiver discrepancy across symptoms and underlying dimensions in comparison to the imagine-self prompt. However, the least discrepancy between patients and caregivers occurred in the neutral condition. The greatest discrepancy by caregivers occurred in imagine-self condition. For the most part, there was no significant interaction effect between caregiver gender and induced perspective-taking across each of the symptoms and underlying frequency, severity, and distress. These results lend support for Pickard and Knight's multiple proxy perspectives model in that different perspective-taking prompts can result in varying levels of perceptual agreement, of which clinicians need to be aware to deliver sensitive patient and family centered care.

"Changing lanes": facilitating the transition from curative to palliative care.

Little empirical work has been conducted assessing the perspectives of nurses regarding the barriers, facilitators, and strategies associated with achieving quality patient care at the end of life. A grounded theory study was conducted examining nursing behaviours and social processes inherent in the provision of quality end-of-life care from the perspective of generalist nurses (n = 10) working in an acute care setting. An inductively derived preliminary model, "creating a haven for safe passage", was developed based on the findings from this study and has been published elsewhere (1). This article provides a detailed description of one of the subprocesses of the model regarding the transition from curative to palliative care--the subprocess of "facilitating and maintaining a lane change". The various strategies which nurses used to effect a lane change, as well as the facilitators and barriers they encountered in this process, are presented. The consequences associated with both successful and unsuccessful lane changes are reported.

Parental experiences of adult child death from cancer.

BACKGROUND: Although parents experience the death of adult children diagnosed with cancer, most of the literature on adult child death has examined the issues of violent death or suicide. Where death from cancer has been studied, the focus has been mainly on psychological outcomes. Little is known about parents' experiences with this phenomenon. OBJECTIVE: To understand parents' experience of having an adult child die from cancer. DESIGN: Descriptive-exploratory study utilizing semistructured interviews with parents of 10 adult children who had died of cancer. SETTING: Parents who had lost a child to cancer were interviewed in their own home or in the interviewer's office. ANALYSIS: Interviews were recorded, transcribed, and analyzed. Latent content analysis and constant comparison techniques were used to develop coding labels, which were then classified into categories and subcategories. RESULTS: Parents experienced a tension between their strong desire to "parent" their child, and their recognition that their child was an autonomous adult, sometimes with a spouse and family who took precedence over them. Parents of a dying child felt helpless, and sometimes were excluded/unacknowledged by health care professionals. To cope, they reconfigured their parent role using various strategies. After the death of their child further reconfiguring takes place, including preserving memories of the child, and talking about him/her. Continuing family and social relationships influence this stage. CONCLUSION: The conflict of wishing to "parent" a dying adult child while recognizing the child's autonomy creates uncertainty for parents at an already stressful time. Facilitating parent-child communication during the illness is important. After the death of the adult child parents may continue to face difficulty with their perceived role in society (parent and/or bereaved person), and sometimes within their family. Health care professionals should make greater efforts to include the parents of the dying adult in the circle of care. The bereavement experience of these parents is intense and long-lasting. Further research is needed regarding the ways in which health care providers can best assist parents to successfully integrate this profound loss.