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Benefits and Harms of Cannabis in Chronic Pain Or Post-Traumatic Stress Disorder: a Systematic Review

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Benefits and Harms of Cannabis in Chronic Pain Or Post-Traumatic Stress Disorder: a Systematic Review 4 Department of Veterans Affairs Health Services Research & Development Service Evidence-based Synthesis Program Benefits and Harms of Cannabis in Chronic Pain or Post-traumatic Stress Disorder: A Systematic Review August 2017 Prepared for: Investigators: Department of Veterans Affairs Principal Investigator: Veterans Health Administration Devan Kansagara, MD, MCR Quality Enhancement Research Initiative Co-investigators: Health Services Research & Development Service Maya O’Neil Washington, DC 20420 Shannon Nugent Michele Freeman Prepared by: Allison Low Evidence-based Synthesis Program (ESP) Karli Kondo Portland VA Medical Center Camille Elven Portland, OR Bernadette Zakher Makalapua Motu’apuaka Devan Kansagara, MD, MCR, Director Robin Paynter Benjamin J. Morasco 4 Benefits and Harms of Cannabis in Chronic Pain or PTSD Evidence-based Synthesis Program PREFACE The VA Evidence-based Synthesis Program (ESP) was established in 2007 to provide timely and accurate syntheses of targeted healthcare topics of particular importance to clinicians, managers, and policymakers as they work to improve the health and healthcare of Veterans. QUERI provides funding for four ESP Centers, and each Center has an active University affiliation. Center Directors are recognized leaders in the field of evidence synthesis with close ties to the AHRQ Evidence-based Practice Centers. The ESP is governed by a Steering Committee comprised of participants from VHA Policy, Program, and Operations Offices, VISN leadership, field-based investigators, and others as designated appropriate by QUERI/HSR&D. The ESP Centers generate evidence syntheses on important clinical practice topics. These reports help: · Develop clinical policies informed by evidence; · Implement effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures; and · Set the direction for future research to address gaps in clinical knowledge. The ESP disseminates these reports throughout VA and in the published literature; some evidence syntheses have informed the clinical guidelines of large professional organizations. The ESP Coordinating Center (ESP CC), located in Portland, Oregon, was created in 2009 to expand the capacity of QUERI/HSR&D and is charged with oversight of national ESP program operations, program development and evaluation, and dissemination efforts. The ESP CC establishes standard operating procedures for the production of evidence synthesis reports; facilitates a national topic nomination, prioritization, and selection process; manages the research portfolio of each Center; facilitates editorial review processes; ensures methodological consistency and quality of products; produces “rapid response evidence briefs” at the request of VHA senior leadership; collaborates with HSR&D Center for Information Dissemination and Education Resources (CIDER) to develop a national dissemination strategy for all ESP products; and interfaces with stakeholders to effectively engage the program. Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP CC Program Manager, at [email protected]. Recommended citation: Kansagara D, O’Neil M, Nugent S, Freeman M, Low A, Kondo K, Elven C, Zakher B, Motu’apuaka M, Paynter R, Morasco BJ. Benefits and Harms of Cannabis in Chronic Pain or Post-traumatic Stress Disorder: A Systematic Review. VA ESP Project #05-225; 2017. This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the VA Portland Health Care System, Portland, OR, funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (eg, employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report. i Benefits and Harms of Cannabis for Chronic Pain or PTSD Evidence-based Synthesis Program TABLE OF CONTENTS EXECUTIVE SUMMARY Introduction ..................................................................................................................................... 1 Methods........................................................................................................................................... 1 Data Sources and Searches ......................................................................................................... 1 Study Selection ........................................................................................................................... 1 Data Abstraction and Quality Assessment .................................................................................. 2 Data Synthesis and Analysis ....................................................................................................... 2 Results ............................................................................................................................................. 2 Results of Literature Search ........................................................................................................ 2 Summary of Results for Key Questions...................................................................................... 2 Key Question 1. What are the effects of cannabis on health outcomes and healthcare utilization for adults who have chronic pain? ......................................................................... 2 Key Question 2. What are the effects of cannabis on health outcomes and healthcare utilization for adults who have PTSD? ................................................................................... 3 Key Question 3. What are the harms associated with cannabis use in adults? ....................... 3 Key Question 4. What are important areas of ongoing research and current evidence gaps in research on cannabis for chronic pain or PTSD, and how could they be addressed by future research? ................................................................................................................................. 5 Summary and Discussion ................................................................................................................ 5 Key Findings and Strength of Evidence ..................................................................................... 5 Summary of Evidence for the Benefits and Harms of Cannabis in Chronic Pain or PTSD Populations .................................................................................................................................. 6 Applicability ............................................................................................................................. 11 Research Gaps/Future Research ............................................................................................... 11 Conclusions ............................................................................................................................... 11 Abbreviations Table .................................................................................................................. 12 EVIDENCE REPORT Introduction ................................................................................................................................... 13 Methods......................................................................................................................................... 15 Topic Development ................................................................................................................... 15 Search Strategy ......................................................................................................................... 15 Study Selection ......................................................................................................................... 15 Data Abstraction ....................................................................................................................... 19 Quality Assessment ................................................................................................................... 19 ii Benefits and Harms of Cannabis for Chronic Pain or PTSD Evidence-based Synthesis Program Data Synthesis ........................................................................................................................... 19 Rating the Body of Evidence .................................................................................................... 19 Peer Review .............................................................................................................................. 20 Results ........................................................................................................................................... 21 Literature Flow.......................................................................................................................... 21 Key Question 1: What are the effects of cannabis on health outcomes and healthcare utilization for adults who have chronic pain? ..........................................................................
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