Best Evidence Topics
Report by: Lucy Adcock
Institution: LTHT
Date Completed: April 2014
Three Part Question
What is the evidence for Nabilone in the treatment of pain for Palliative patients?
Clinical Scenario
Sitting in Chronic Pain MDT. A patient presented by one consultant, another consultant suggests
adding in Nabilone for neuropathic pain. I wondered, is there a role for our population and where
the evidence base lies for use in pain?
Pharmacology of Synthetic Cannabinoids
2 main cannabinoid receptors (CB1, CB2). May be activated by endogenous and synthetic
cannabinoids.
CB1 primarily in terminals of central and peripheral neurons, controlling levels of
neurotransmitters (ACh, NA, D2, 5HT, GABA, D-aspartate and cholecystokinin).
CB2 mainly expressed in immune cells, affecting cytokine release.
3 synthetic CB1/CB2 agonists:
Nabilone, licensed 1981, for chemotherapy induced N&V.
Dronabinol, 1985, anti-emetic and appetite stimulant (AIDS patients)
Sativex (oral mucosal spray), 2005, prescribed for neuropathic pain in MS and adjunctive
analgesia for adults with advanced cancer.
Adverse effects incl: light-headedness, dry mouth, fatigue, myalgia, palpitations.
Search Strategy
Medline/Embase
1. Cannabinoids exp AND pain exp AND palliat* (limit humans and English)
2. Nabilone AND cancer AND pain (limit humans and English)
3. Nabilone AND pain (limit humans and English)
Cross referencing in relevant articles
Search Outcome
Several review articles discuss potential for use.
1 original article
Few original articles with some relevance to palliative population
Relevant Paper(s)
Author,
date and
country
Maida et al,
2008 Canada
Patient
group
Study type
Outcomes
Key results
Study
Weaknesses
Cancer
patients
referred to
SPCT Jan 05Oct 06.
Prospective
observational.
Edmonton
Symptom
Assessment
Scale (ESAS),
Palliative
Performance
Scale (PPS),
Morphine
Sulphate
Equivalence
(MSE) use,
other
analgesic use.
112 patients,
65 untreated,
47 treated (24
for pain).
Open label, no
randomisation,
groups not
comparable.
Treated:Mean
pain 7.1 ->3.0
(adj) –
p<0.001
Don’t specify
how they
decided who
to treat.
Untreated:Mean
pain 5.6 -> 5.5
N=11.
No
documentation
of pain type
Small
numbers
Intention to
treat model.
Wissel J et
al, 2006,
Germany
MS patients
with
spasticityrelated pain
Placebocontrolled,
double-blind,
cross-over
11-Point-BoxTest
Turcotte et
al, 2011
Canada
MS induced
neuropathic
pain, on doses
>1800mg/day
gabapentin
and
inadequate
pain relief.
Randomised,
placebocontrolled,
double-blind.
VAS daily
pain rating.
Toth C et al,
2012,
Canada
Diabetic
peripheral
neuropathy,
pain score
Randomised,
placebocontrolled,
double-blind
VAS
functional
impact rating.
VAS, HADS,
Medical
Outcomes
Study Sleep
Significant
decrease in
pain (p<0.05).
NO change in
spasticity,
motor function
or ADLs
15 patients.
Pain
significantly
reduced in
treatment
group
(p<0.001)
1 patient
dropped out in
treatment arm
due SEs
N=37
26/37 had
>30% pain
(unable to
obtain full
paper)
Small
numbers
Nonresponders
were
eliminated
>4/10
Reynolds &
Osborn,
2013, UK
Man with
poorly
controlled
chronic pain
2’ to facial
tumour
resection
Scale,
European QoL
index
Case study
reduction in
first 4wk open
label phase. 13
continued
nabilone for 5
more weeks
and effect
sustained.
(p<0.05). Mean
reduction of
pain 1.27.
2 subjects
discontinued
due to SE in
first phase.
Pain improved,
managed to
reduce opioids
and ketamine
doses.
from
subsequent
stats.
Small
numbers.
Single case
study
“Results of a Phase III study (N = 177) comparing Sativex, THC-predominant extract and placebo
in intractable pain due to cancer unresponsive to opiates (Johnson and Potts 2005) demonstrated
that Sativex produced highly statistically signify cant improvements in analgesia (Table 1), while
the THC predominant extract failed to produce statistical demarcation from placebo, suggesting
the presence of CBD in the Sativex preparation was crucial to attain significant pain relief.”
-Above ‘study’ is basis for approval in Canada for Sativex in the treatment of intractable cancer
pain.
Clinical Bottom Line
Potential for use. Insufficient trial evidence for regular or first line use. Might be worth considering,
particularly within licensed population.
References
Maida V et al; Adjunctive Nabilone in Cancer Pain and Symptom Management:A Prospective
Observational Study Using Propensity Scoring; J Support Oncol 2008;6:119-124.
Wissel J et al; Low dose treatment with synthetic cannabinoid Nabilone significantly reduces
spasticity-related pain. A double-blind placebo-controlled cross-over trial; Journal of Neurology
2006; 253(10): 1337-1341.
Turcotte D et al; A randomised, double-blinded, placebo-controlled study evaluating the efficacy
and safety of nabilone as an adjunctive to gabapentin in managing multiple sclerosis induced
neuropathic pain; Conference:5th Joint Triennial Congress of the European and Americas
Committee for Treatment and Research in Multiple Sclerosis 2011.
(Above also presented in 18th Annual Conference of Rehabilitation in MS 2013)
Toth C et al; An enriched-enrolment, randomised withdrawal, flexible-dose, double-blind, placebocontrolled, parallel assignment efficacy study of nabilone as adjuvant in the treatment of diabetic
peripheral neuropathic pain; Pain 2012;153:2073-2082.
Reynolds TD, Osborn HL; The use of cannabinoids in chronic pain; BMJ case reports 2013.
Johnson JR, Potts R. 2005. Cannabis-based medicines in the treatment of cancer pain: a
randomised, double-blind, parallel group, placebo-controlled, comparative study of the efficacy,
safety and tolerability of Sativex and Tetranabinex in patients with cancer-related pain.; 2005
March 8-11; Edinburgh, Scotland.