ABSTRACT: Abstract Introduction Emergency staff members have a unique role in providing episodic care to marginalized populations. The lesbian, gay, bisexual, and transgender (LGBT) community is a marginalized population that is routinely encountered by ED staff. Implicit prejudice may influence emergency staff interactions and contribute to distrust of health care providers by some members of the LGBT community...

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Abstract Introduction Emergency staff members have a unique role in providing episodic care to marginalized populations. The lesbian, gay, bisexual, and transgender (LGBT) community is a marginalized population that is routinely encountered by ED staff. Implicit prejudice may influence emergency staff interactions and contribute to distrust of health care providers by some members of the LGBT community. The purpose of our study is to evaluate aggregate ED health care team member's knowledge and attitudes toward lesbian, gay, bisexual, and transgender people pre- and post-cultural competency training education. Methods A pre-/post-intervention design was used to assess the impact of LGBT cultural competency training. The Ally Identity Measure (AIM) was administered to an unmatched sample of ED nurses, nurse practitioners, unit secretaries, and physicians. Consisting of 3 domains— knowledge and skills, openness and support, and awareness of oppression experienced by the LGBT community (Cronbach's alphas of 0.76 to 0.88)—the AIM assessed for aggregate differences among our staff pre- and post-cultural competency training. Results Pre-survey data revealed 85.3 % (n = 81) of staff had no previous LGBT education specific to the needs of the population. Post-survey data collected between 3 to 5 months after the education intervention demonstrated a total index mean increase of 8.8% (P < 0.001) in the areas of knowledge and skills, openness and support, and awareness of oppression regarding the LGBT community. Discussion Status post-cultural competency training, the AIM results indicated that our team's collective knowledge about challenges facing the LGBT community increased, and the aggregate scores reflected more openness, support, and awareness of oppression by our staff. This elevated self-awareness and increased knowledge may aid in creating a more open, supportive patient experience for the LGBT community members seeking care at our facility. Unlabelled Box Contribution to Emergency Nursing Practice • The current state of scientific knowledge on lesbian, gay, bisexual, and transgender (LGBT) education and training indicates the need for further research on the impact of this cultural competency training. • The main findings of this research suggests that educational interventions show potential for creating an increase in awareness of LGBT issues, leading to more open and accepting attitudes toward LGBT patients and their family members. • Key implications for emergency nursing practice from this research are how assumptions about a person's gender identity or sexual orientation can have an unintended impact on the nurse-patient relationship and how LGBT cultural competency education can provide emergency nurses strategies to meet the cultural needs of LGBT patients.

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As the health care needs of the lesbian, gay, bisexual, and transgender (LGBT) population become increasingly important, health care professionals require appropriate academic and clinical training in preparation for the increased demand for culturally competent care. Nurses are of particular interest, as they are the core direct caregivers in many health care settings. This article explores the national climate around LGBT individuals and their related health needs. Educators and administrators who work with future nurses should strive to ensure they foster the development of knowledgeable practitioners who will be able to implement best practices in LGBT patient care. Attention should be paid to providing students with diverse clinical placements, access to LGBT interest groups, and clear expectations for LGBT-sensitive nursing care plans and course outcomes selection that promote cultural competence. Recommendations for nursing education and curricular reform are discussed. [J Nurs Educ. 2013;52(4):198–203.]

OBJECTIVES: To define and give an overview of the importance of lesbian, gay, bisexual, and transgender (LGBT) cultural competency and offer some initial steps on how to improve the quality of care provided by oncology nursesand other health care professionals. DATA SOURCES: A review of the existing literature on cultural competency. CONCLUSION: LGBTpatients experience cancer and several other diseases at higher rates than the rest of the population. The reasons for these health care disparities are complex and include minority stress, fear of discrimination, lower rates of insurance, and lack of access to quality, culturally competent care. Addressing the health care disparities experienced by LGBTindividuals and families requires attention to the actual needs, language, and support networks used by patients in these communities. Training on how to provide quality care in a welcoming and non-judgmental way is available and can improve health equity. IMPLICATIONS FOR NURSING PRACTICE: Health care professionals and institutions that acquire cultural competency training can improve the overall health of LGBT patients who currently experience significant health care disparities.
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tri-citites- natalie,danielle,alex

identities doesn't end in tbe world of ser- vices for tbe aging. LGBTQ elders instead tend to be ignored, as if tbey do not—can- not—exist. Tbe overlapping issues of HIV and AIDS in elder populations are too of- ten tbe only issues discussed; witb sexu- ality and LGBTQ persons avoided by geri- atric and aging professionals.

Tbe broader cultural notion tbat sex- ual desire ends in old age still bolds sway in geriatric institutions. As a na- tion, we bave long dismissed tbe reality of sexual desire a n d erotic bebavior in elder populations.

Conclusion: The results of this study suggest that LGBT education using simulation may be ef- fective for nursing students and nurses from the point of concern for LGBT population. It is hy- pothesized that future LGBT educational programs might need more detailed information from both care recipients and nurses. Finally, LGBT education needs to be included in the nursing education curriculum.
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Aims and objectives: To examine the effectiveness of an integrated motivational interviewing and physical exercise programme on pain, physical and psychological function, quality of life, self-efficacy, and compliance with exercise for community-dwelling older persons with chronic pain. Background: Chronic pain is common among older persons. Indeed, motivation for managing pain is poor, and may cause negative consequences. Motivational interviewing maybe effective in treating chronic pain. Design: Single-blinded randomised control study. Methods: Older persons with chronic pain ( n = 56) were recruited from two elderly community centres. They were blinded from the group allocation. The programme was conducted by an motivational interviewing-trained physiotherapist and registered nurses. Participants in the experimental group received an 8-week integrated motivational interviewing and physical exercise programme, while the control group received regular activities in the centre. Motivational interviewing used open-ended questions to encourage participants to express and recognise their pain and behaviours and professional feedback was given accordingly. Pain intensity, pain self-efficacy, anxiety, happiness, depression, mobility and quality of life were measured before and after the motivational interviewing and physical exercise programme. Attendance and compliance rate of the programme was calculated in the experimental group. Results: Significant improvements in pain intensity, pain self-efficacy, anxiety, happiness and mobility after the motivational interviewing and physical exercise programme (all p < 0· 05) for experimental group, while no significant improvement in control group except on the happiness scale. Regarding group differences in the outcome measures, the change scores on pain intensity, state anxiety and depression were significantly better in the experimental group. Conclusion: Motivational interviewing and physical exercise programme is effective in improving pain, physical mobility, psychological well-being and self-efficacy for community-dwelling older persons with chronic pain. Relevance to clinical practice: Motivational interviewing is a feasible counselling technique whose content can be modified based on target group to change maladaptive behaviours, elicit ambivalences and enhance self-efficacy for making changes. Thus, promoting motivational interviewing and physical exercise programme to older persons with pain is effective and important. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)

To determine if medical marijuana provides pain relief for patients with chronic noncancer pain (CNCP) and to determine the therapeutic dose, adverse effects, and specific indications.

There is evidence for the use of low-dose medical marijuana in refractory neuropathic pain in conjunction with traditional analgesics. However, trials were limited by short duration, variability in dosing and strength of delta-9-tetrahydrocannabinol, and lack of functional outcomes. Although well tolerated in the short term, the long-term effects of psychoactive and neurocognitive effects of medical marijuana remain unknown. Generalizing the use of medical marijuana to all CNCP conditions does not appear to be supported by existing evidence. Clinicians should exercise caution when prescribing medical marijuana for patients, especially in those with nonneuropathic CNCP.

This review examines evidence for the effectiveness of cannabinoids in chronic noncancer pain (CNCP) and addresses gaps in the literature by: considering differences in outcomes based on cannabinoid type and specific CNCP condition; including all study designs; and following IMMPACT guidelines. MEDLINE, Embase, PsycINFO, CENTRAL, and clinicaltrials.gov were searched in July 2017. Analyses were conducted using Revman 5.3 and Stata 15.0. A total of 91 publications containing 104 studies were eligible (n = 9958 participants), including 47 randomised controlled trials (RCTs) and 57 observational studies. Forty-eight studies examined neuropathic pain, 7 studies examined fibromyalgia, 1 rheumatoid arthritis, and 48 other CNCP (13 multiple sclerosis-related pain, 6 visceral pain, and 29 samples with mixed or undefined CNCP). Across RCTs, pooled event rates (PERs) for 30% reduction in pain were 29.0% (cannabinoids) vs 25.9% (placebo); significant effect for cannabinoids was found; number needed to treat to benefit was 24 (95% confidence interval [CI] 15-61); for 50% reduction in pain, PERs were 18.2% vs 14.4%; no significant difference was observed. Pooled change in pain intensity (standardised mean difference: -0.14, 95% CI -0.20 to -0.08) was equivalent to a 3 mm reduction on a 100 mm visual analogue scale greater than placebo groups. In RCTs, PERs for all-cause adverse events were 81.2% vs 66.2%; number needed to treat to harm: 6 (95% CI 5-8). There were no significant impacts on physical or emotional functioning, and low-quality evidence of improved sleep and patient global impression of change. Evidence for effectiveness of cannabinoids in CNCP is limited. Effects suggest that number needed to treat to benefit is high, and number needed to treat to harm is low, with limited impact on other domains. It seems unlikely that cannabinoids are highly effective medicines for CNCP.

Interventions to enhance physical activity (PA) participation are needed given the high prevalence of under-activity and inactivity (CDC, 2001) and related occurrence of negative health consequences among the general adult population (Kung, Hoyert, Xu, & Murphy, 2008). Preliminary support for a therapeutic technique called Motivational Interviewing (MI) suggests promise for application to enhance PA participation (Burke, Arkowitz, & Menchola, 2003). Given the need for interventions to enhance PA and the preliminary support for MI as an intervention to increase PA, the aims of the current study were to: (a) determine if web-based MI is effective in enhancing PA participation, and (b) assess the mechanisms by which web-based MI enhances PA through changes in targeted cognitive variables. Participants (n= 23, under-active or inactive adults) engaged in four web-based MI sessions. Steps per day, PA, and cognitive variables were assessed across time. Efficacy of MI in enhancing PA participation was demonstrated through: (a) increases in steps per day (t[22]= 2.085, p = 0.049); (b) increases in total PA energy expenditure per week( χ2= 8.430, p = 0.015); and (c) increases in moderate intensity PA energy expenditure per week ( χ2= 13.853, p = 0.001). 

Background: Counselor behaviors that mediate the efficacy of motivational interviewing (MI) are not well understood, especially when applied to health behavior promotion. We hypothesized that client change talk mediates the relationship between counselor variables and subsequent client behavior change. Methods: Purposeful sampling identified individuals from a prospective randomized worksite trial using an MI intervention to promote firefighters’ healthy diet and regular exercise that increased dietary intake of fruits and vegetables ( n = 21) or did not increase intake of fruits and vegetables ( n = 22). MI interactions were coded using the Motivational Interviewing Skill Code (MISC 2.1) to categorize counselor and firefighter verbal utterances. Both Bayesian and frequentist mediation analyses were used to investigate whether client change talk mediated the relationship between counselor skills and behavior change. Results: Counselors’ global spirit, empathy, and direction and MI-consistent behavioral counts (e.g., reflections, open questions, affirmations, emphasize control) significantly correlated with firefighters’ total client change talk utterances ( rs = 0.42, 0.40, 0.30, and 0.61, respectively), which correlated significantly with their fruit and vegetable intake increase ( r = 0.33). Both Bayesian and frequentist mediation analyses demonstrated that findings were consistent with hypotheses, such that total client change talk mediated the relationship between counselor’s skills—MI-consistent behaviors [Bayesian mediated effect: aβ = .06 (.03), 95% CI = .02, .12] and MI spirit [Bayesian mediated effect: aβ = .06 (.03), 95% CI = .01, .13]—and increased fruit and vegetable consumption. Conclusion: Motivational interviewing is a resource- and time-intensive intervention, and is currently being applied in many arenas. Previous research has identified the importance of counselor behaviors and client change talk in the treatment of substance use disorders. Our results indicate that similar mechanisms may underlie the effects of MI for dietary change. These results inform MI training and application by identifying those processes critical for MI success in health promotion domains. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)

Background: Physical activity can confer many benefits on cancer survivors, including relief of persistent symptoms related to cancer treatment. Objectives: To evaluate the effect of a motivational interviewing (MI) intervention on increasing physical activity (Community Healthy Activities Model Program for Seniors questionnaire) and improving aerobic fitness (6-minute walk), health (Medical Outcomes Study Short-Form 36), and fatigue (Schwartz Cancer Fatigue Scale) in cancer survivors. A secondary purpose was to evaluate whether the effect of MI on physical activities depended on self-efficacy. Methods: Fifty-six physically inactive adult cancer survivors (mean = 42 months since completion of treatment) were assigned randomly to intervention and control groups. The MI intervention consisted of one in-person counseling session followed by two MI telephone calls over 6 months. Control group participants received two telephone calls without MI content. Outcomes were measured at baseline, 3 months, and 6 months, and were analyzed using multilevel modeling. Results: The results of the MI intervention explained significant group differences in regular physical activities (measured in caloric expenditure per week), controlling for time since completion of cancer treatment (p < .05). Aerobic fitness, physical and mental health, and fatigue were not different between groups. In the intervention group, individuals with high self-efficacy for exercise at baseline increased their physical activity more than those with low self-efficacy (p < .05). In the control group, increases in physical activity did not depend on self-efficacy. Discussion: Use of MI may increase physical activity in long-term cancer survivors, especially in persons with high self-efficacy for exercise. Multilevel modeling analysis revealed individual changes that would not have been shown by analysis of group means. Future studies with larger samples or more intense MI interventions may show changes in aerobic fitness, physical and mental health, and fatigue. (PsycINFO Database Record (c) 2016 APA, all rights reserved) (Source: journal abstract)

Objectives: The purpose of this study was to explore Motivational Interviewing (MI) applied through Co-Active Life Coaching (CALC) skills on obese adults' (ages 35 to 55) weight, waist circumference, self-esteem, functional health status, quality of life, self-efficacy, physical activity, and nutrition. Design: A single-subject multiple-baseline method research design was utilised. Method: One volunteer Certified Professional Co-Active (CPCC) coach provided 18 35-minute weekly coaching sessions with eight women residing in London, Ontario whose BMI was ≥30. Measures included weight, waist circumference, the Rosenberg Self-Esteem Scale, Short-Form 36 (SF-36) Health Survey, World Health Organization Quality of Life Questionnaire, self-efficacy questionnaires. The International Physical Activity Questionnaire, and two three-day dietary intakes. Participants returned six months after their final coaching session for a follow-up weigh-in and waist circumference measurement. Visual inspection was used to analyse weight and waist circumference to determine whether changes were observed. Statistical interpretations were used to analyse the remaining measures to determine whether a clinically significant change was made. Results: Visual inspection indicated a change in weight and waist circumference. Clinically significant changes were observed in participants' self-esteem, functional health status, quality of life, self-efficacy, physical activity, and nutrition. At the six-month follow-up, three participants had gained weight (although two participants were still below their baseline weight), one participant continued to lose weight and four participants maintained the weight lost during the intervention phase. Conclusions: MI using CALC skills is a behavioural intervention that is an effective tool in aiding individuals to conquer their battle with weight. (PsycINFO Database Record (c) 2017 APA, all rights reserved) (Source: journal abstract)

P.N.
Despite a number of reviews advocating psychotherapy for the treatment of depression, there is relatively little evidence based on randomised controlled trials that specifically examines its efficacy in older people.

Depression is a common problem facing older people and is often associated with loneliness, physical illness and pain. The condition can last for some years and causes considerable distress and illness. A significant majority of depressed elders do not receive treatment because of difficulty in recognition of the condition. Not only can it present with lowered mood but may also present with physical problems including sleep disturbance, loss of appetite, loss of interest, anxiety and lack of energy. Psychotherapy is recognised as a treatment for mild depression. In this review we included seven small trials, involving a total of 153 participants, that examined psychotherapeutic treatments for depression in older people. Five trials compared a form of cognitive behavioural therapy (CBT) against control conditions, and the findings showed that CBT was more effective than control. Two individual trials compared CBT against psychodynamic therapy, with no significant difference in effectiveness indicated between the two approaches. Our review shows that there is relatively little research in this field and care must be taken in generalising what evidence there is to clinical populations.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004853.pub2/full

Purpose of review: The purpose of this study was to provide the most up-to-date scientific evidence of the potential analgesic effects, or lack thereof, of the marijuana plant (cannabis) or cannabinoids, and of safety or tolerability of their long-term use.

Recent findings: We found that inhaled (smoked or vaporized) cannabis is consistently effective in reducing chronic non-cancer pain. Oral cannabinoids seem to improve some aspects of chronic pain (sleep and general quality of life), or cancer chronic pain, but they do not seem effective in acute postoperative pain, abdominal chronic pain, or rheumatoid pain. The available literature shows that inhaled cannabis seems to be more tolerable and predictable than oral cannabinoids. Cannabis or cannabinoids are not universally effective for pain. Continued research on cannabis constituents and improving bioavailability for oral cannabinoids is needed. Other aspects of pain management in patients using cannabis require further open discussion: concomitant opioid use, medical vs. recreational cannabis, abuse potential, etc.

Keywords: Marijuana; Medical cannabis; Medical marijuana; Medicinal cannabis; Medicinal marijuana; Recreational cannabis; Recreational marijuana.

https://pubmed.ncbi.nlm.nih.gov/28983880-cannabis-and-cannabinoids-for-chronic-pain/?from_term=marijuana+chronic+pain&from_page=1&from_pos=2 
TC: Natalie, Alex, Danielle 

To determine the efficacy of antidepressant medication compared with placebo in the treatment of depression in older patients.

The search strategy incorporated: electronic literature searches of databases held by the Cochrane Collaboration Depression, Anxiety and Neurosis Review Group (CCDAN) (see Collaborative Review Group Search Strategy). Reference lists of related reviews and references of located studies. Contact was made with authors working in the field.

All randomised, placebo controlled trials using antidepressants in the treatment of the presenting episode of depression in patients described as elderly, geriatric senile or older adult.

Two types of data were extracted (if available) from each study. The first type of data was dichotomous data, this consisted of recovered/not recovered. The second, continuous data,included: Hamilton Depression Rating Scale (HAM‐D), Montgomery‐Asberg Rating Scale (MADRS) and other depression rating scale scores. An analysis using Peto Odds ratios for the dichotomous data and weighted mean difference for continuous data was performed using RevMan 3.1. The presence of heterogeneity of treatment effect was assessed.

Seventeen trials contributed data to the analyses comparing the efficacy of antidepressant treatment and placebo. Analyses of efficacy were based on 245 patients treated with Tricyclic antidepressants (223 with placebo), 365 patients treated with SSRIs (372 with placebo) and 58 patients treated with MAOIs (63 with placebo). The results using a fixed effect model, for the three groups respectively were, TCAs; OR: 0.32 (95% CI: 0.21,0.47), SSRIs; OR; 0.51 (95% CI: 0.36,0.72), MAOIs: OR 0.17 (95% CI: 0.07,0.39).

TCAs, SSRIs and MAOIs are effective in the treatment of older community patients and inpatients likely to have severe physical illness. At least six weeks of antidepressant treatment is recommended to achieve optimal therapeutic effect. There is little evidence concerning the efficacy of low dose TCA treatme
nt. Further trials are required before low dose TCA treatment is routinely recommended.
Spokane Paige Tia Becky Chloe

The aims of this review were to examine the efficacy of antidepressant classes, to compare the withdrawal rates associated with each class and describe the side effect profile of antidepressant drugs for treating depression in patients described as elderly, geriatric, senile or older adults, aged 55 or over.

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR‐Studies) was searched (2003‐08‐13). Reference lists of relevant papers and previous systematic reviews were hand searched for published reports and citations of unpublished studies.

Only randomised controlled trials were included. Trials had to compare at least two active antidepressant drugs in the treatment of depression.

Reviewers extracted data independently. In examining efficacy, the reviewers assumed that people who died or dropped out had no improvement. Withdrawal rates irrespective of cause and specifically due to side effects were compared between drug classes. Relative risk (RR) for dichotomous data and weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Qualitative side effect data were reported in terms of ratios of side effects and percentage of patients experiencing specific side effects.

A total of 32 trials provided data for inclusion in the review in terms of efficacy, withdrawal and side effect analysis. We were unable to find any differences in efficacy when comparing classes of antidepressants. Tricyclic antidepressants (TCAs) compared less favourably with selective serotonin reuptake inhibitors (SSRIs) in terms of numbers of patients withdrawn irrespective of reason (RR: 1.23, CI 1.05 to 1.43) and number withdrawn due to side effects (RR: 1.36, CI 1.09 to 1.70). Further analyses demonstrated that TCA related antidepressants had similar withdrawal rates to SSRIs irrespective of reason of withdrawal (RR: 1.49, CI 0.74 to 2.98) or withdrawal due to side effects (RR: 1.07, CI 0.43 to 2.70). The qualitative analysis of side effects showed a small increased profile of gastro‐intestinal and neuropsychiatric side effects associated with classical TCAs.

Our findings suggest that SSRIs and TCAs are of the same efficacy. However, we have found some evidence suggesting that TCA related antidepressants and classical TCAs have different side effect profiles and are associated with differing withdrawal rates when compared with SSRIs. The review suggests that classical TCAs are associated with a higher withdrawal rate due to side effect experience, although these results must be interpreted with caution due to the heterogeneity of the drugs and patient populations.

Depression is a relatively common experience in older adults. The syndrome is associated with considerable distress, morbidity and service commitment. Approximately two thirds of patients presenting with severe forms will respond to antidepressant treatment and the last twenty years has witnessed a great increase in the number of these drugs. Older, frail people are particularly vulnerable to side effects. 

Objectives

The aims of this review were to examine the efficacy of antidepressant classes, to compare the withdrawal rates associated with each class and describe the side effect profile of antidepressant drugs for treating depression in patients described as elderly, geriatric, senile or older adults, aged 55 or over. 

Search methods

The Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR‐Studies) was searched (2003‐08‐13). Reference lists of relevant papers and previous systematic reviews were hand searched for published reports and citations of unpublished studies. 

Selection criteria

Only randomised controlled trials were included. Trials had to compare at least two active antidepressant drugs in the treatment of depression. 

Data collection and analysis

Reviewers extracted data independently. In examining efficacy, the reviewers assumed that people who died or dropped out had no improvement. Withdrawal rates irrespective of cause and specifically due to side effects were compared between drug classes. Relative risk (RR) for dichotomous data and weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Qualitative side effect data were reported in terms of ratios of side effects and percentage of patients experiencing specific side effects. 

Main results

A total of 32 trials provided data for inclusion in the review in terms of efficacy, withdrawal and side effect analysis. We were unable to find any differences in efficacy when comparing classes of antidepressants. Tricyclic antidepressants (TCAs) compared less favourably with selective serotonin reuptake inhibitors (SSRIs) in terms of numbers of patients withdrawn irrespective of reason (RR: 1.23, CI 1.05 to 1.43) and number withdrawn due to side effects (RR: 1.36, CI 1.09 to 1.70). Further analyses demonstrated that TCA related antidepressants had similar withdrawal rates to SSRIs irrespective of reason of withdrawal (RR: 1.49, CI 0.74 to 2.98) or withdrawal due to side effects (RR: 1.07, CI 0.43 to 2.70). The qualitative analysis of side effects showed a small increased profile of gastro‐intestinal and neuropsychiatric side effects associated with classical TCAs. 

Authors' conclusions

Our findings suggest that SSRIs and TCAs are of the same efficacy. However, we have found some evidence suggesting that TCA related antidepressants and classical TCAs have different side effect profiles and are associated with differing withdrawal rates when compared with SSRIs. The review suggests that classical TCAs are associated with a higher withdrawal rate due to side effect experience, although these results must be interpreted with caution due to the heterogeneity of the drugs and patient populations. 

https://doi.org/10.1002/14651858.CD003491.pub2

TC Miguel, Rachel, David, Monique

Depression is a relatively common experience in older adults. The syndrome is associated with considerable distress, morbidity and service commitment. Approximately two thirds of patients presenting with severe forms will respond to antidepressant treatment and the last twenty years has witnessed a great increase in the number of these drugs. Older, frail people are particularly vulnerable to side effects.
https://doi.org/10.1002/14651858.CD003491.pub2

PMID: 30488174 DOI: 10.1007/s40266-018-0616-5

Data sources: In April 2014, MEDLINE and EMBASE searches were conducted using the terms chronic noncancer pain, smoked marijuana or cannabinoids, placebo and pain relief, or side effects or adverse events.

Objective: To review the pharmacology, indications, and laws related to medical marijuana use.

Evidence review: The medical literature on medical marijuana was reviewed from 1948 to March 2015 via MEDLINE with an emphasis on 28 randomized clinical trials of cannabinoids as pharmacotherapy for indications other than those for which there are 2 US Food and Drug Administration-approved cannabinoids (dronabinol and nabilone), which include nausea and vomiting associated with chemotherapy and appetite stimulation in wasting illnesses.

Findings: Use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence. Six trials that included 325 patients examined chronic pain, 6 trials that included 396 patients investigated neuropathic pain, and 12 trials that included 1600 patients focused on multiple sclerosis. Several of these trials had positive results, suggesting that marijuana or cannabinoids may be efficacious for these indications.

Conclusions and relevance: Medical marijuana is used to treat a host of indications, a few of which have evidence to support treatment with marijuana and many that do not. Physicians should educate patients about medical marijuana to ensure that it is used appropriately and that patients will benefit from its use.

Objective: To determine if medical marijuana provides pain relief for patients with chronic noncancer pain (CNCP) and to determine the therapeutic dose, adverse effects, and specific indications.

Data sources: In April 2014, MEDLINE and EMBASE searches were conducted using the terms chronic noncancer pain, smoked marijuana or cannabinoids, placebo and pain relief, or side effects or adverse events.

Study selection: An article was selected for inclusion if it evaluated the effect of smoked or vaporized cannabinoids (nonsynthetic) for CNCP; it was designed as a controlled study involving a comparison group, either concurrently or historically; and it was published in English in a peer-review journal. Outcome data on pain, function, dose, and adverse effects were collected, if available. All articles that were only available in abstract form were excluded. Synthesis A total of 6 randomized controlled trials (N = 226 patients) were included in this review; 5 of them assessed the use of medical marijuana in neuropathic pain as an adjunct to other concomitant analgesics including opioids and anticonvulsants. The 5 trials were considered to be of high quality; however, all of them had challenges with masking. Data could not be pooled owing to heterogeneity in delta-9-tetrahydrocannabinol potency by dried weight, differing frequency and duration of treatment, and variability in assessing outcomes. All experimental sessions in the studies were of short duration (maximum of 5 days) and reported statistically significant pain relief with nonserious side effects.

Conclusion: There is evidence for the use of low-dose medical marijuana in refractory neuropathic pain in conjunction with traditional analgesics. However, trials were limited by short duration, variability in dosing and strength of delta-9-tetrahydrocannabinol, and lack of functional outcomes. Although well tolerated in the short term, the long-term effects of psychoactive and neurocognitive effects of medical marijuana remain unknown. Generalizing the use of medical marijuana to all CNCP conditions does not appear to be supported by existing evidence. Clinicians should exercise caution when prescribing medical marijuana for patients, especially in those with nonneuropathic CNCP.

Recent findings: We found that inhaled (smoked or vaporized) cannabis is consistently effective in reducing chronic non-cancer pain. Oral cannabinoids seem to improve some aspects of chronic pain (sleep and general quality of life), or cancer chronic pain, but they do not seem effective in acute postoperative pain, abdominal chronic pain, or rheumatoid pain. The available literature shows that inhaled cannabis seems to be more tolerable and predictable than oral cannabinoids. Cannabis or cannabinoids are not universally effective for pain. Continued research on cannabis constituents and improving bioavailability for oral cannabinoids is needed. Other aspects of pain management in patients using cannabis require further open discussion: concomitant opioid use, medical vs. recreational cannabis, abuse potential, etc.

Purpose of review: The purpose of this study was to provide the most up-to-date scientific evidence of the potential analgesic effects, or lack thereof, of the marijuana plant (cannabis) or cannabinoids, and of safety or tolerability of their long-term use.

Recent findings: We found that inhaled (smoked or vaporized) cannabis is consistently effective in reducing chronic non-cancer pain. Oral cannabinoids seem to improve some aspects of chronic pain (sleep and general quality of life), or cancer chronic pain, but they do not seem effective in acute postoperative pain, abdominal chronic pain, or rheumatoid pain. The available literature shows that inhaled cannabis seems to be more tolerable and predictable than oral cannabinoids. Cannabis or cannabinoids are not universally effective for pain. Continued research on cannabis constituents and improving bioavailability for oral cannabinoids is needed. Other aspects of pain management in patients using cannabis require further open discussion: concomitant opioid use, medical vs. recreational cannabis, abuse potential, etc.

Symptom management in older adults, including pain and distressing non-pain symptoms, can be challenging. Medications can cause side effects that worsen quality of life or create other symptoms, and polypharmacy itself can be detrimental in older adults. Cannabinoids may offer a way of managing selected symptoms with fewer side effects. Medical marijuana is an important area of study for older adults because of the side effects of other medications. It is also important for Baby Boomers, who are likely to have more experience with marijuana than older adults of previous generations. Therefore, geriatricians should understand medical marijuana's clinical indications, adverse effects, and legal context. This article reviews the evidence regarding indications for and risks of medical marijuana use in older adults.