REVIEW

CURRENT
OPINION Use of cannabis and cannabinoids in palliative
care setting
Karthik AR and Sushma Bhatnagar

Purpose of review
Cannabis products have been used for various ailments since ancient times. But their use diminished in the
medical community due to the legal and social concerns of substance abuse. With evolving evidence of
their use in alleviating various symptoms, resurgence of interest in their medicinal use is seen in the past
Downloaded from http://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 12/07/2020

decade.
Recent findings
Clinical evidence for cannabis products in treating various ailments has been far from robust. Their use is
based on anecdotal and low-quality evidence. This review attempts to revisit the recent medical literature
available on the merits and demerits of cannabinoid use in palliative medicine.
Summary
A few symptoms in palliative care setting can be difficult to treat in a few patients with the available
treatment measures. Anecdotal reports and early clinical data have proved cannabinoids to be a promising
pharmacological option in managing this subset of patients. However, absence of robust clinical data in
proving that cannabinoids have definitely favorable risk–benefit ratio, precludes the inclusion of
cannabinoids in the routine recommendation for palliative symptom management. Before cannabinoids
enter the broader market with patient-driven and industry-driven hype, high-quality clinical evidence is
emergently needed.
Keywords
cannabinoids, medical cannabis, palliative care, symptom management

INTRODUCTION contributed to this resurgence of interest. Yet, can-

Cannabis (marijuana) is derived from plants belong-
ing to the genus Cannabis under the family Canna-
baceae. Cannabis has been associated with humans
for thousands of years both for medical and non-
medical uses. Archeologic evidence from ancient
China suggests that cannabis was used for various
medical conditions including constipation, pain,
and disorders of the female reproductive tract. Can-
nabis was used in various respiratory, gastrointesti-
nal, neurological, and urogenital diseases according
to the traditional Indian Ayurvedic medicine [1].
The use of cannabis in Western medicine dates back
to a few centuries ago. However, in the last century,
the use of cannabis for medical purposes has
decreased worldwide mainly because of its abuse
potential and legal restrictions.
In recent years, there has been a resurgence in
interest for using cannabis and cannabis-based med-
icines to treat a variety of medical conditions.
Decriminalization of cannabis by various countries,
evolving research, encouraging results from preclin-
ical data, and increased demand from patients have
nabis lacks widespread percolation into medical
science because of lack of high-quality clinical data.
THE SCIENCE BEHIND CANNABINOIDS
Cannabinoids encompass the endocannabinoid sys-
tem, phytocannabinoids, and the newer synthetic
cannabis-like agents. Anandamide and 2-arachido-
noylglycerol are the major endogenous ligands of
the cannabinoid system and are called endocanna-
binoids. They are degraded by the enzymes’ fatty-
Department of Onco-Anaesthesia and Palliative Medicine, Dr BR
Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical
Sciences, New Delhi, India
Correspondence to Sushma Bhatnagar, MD, Professor and Head,
Department of Onco-Anaesthesia and Palliative Medicine, Dr BR
Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical
Sciences, New Delhi 110029, India.
Tel: +91 11 2957 5209, þ91 98113 26453;
e-mail: sushmabhatnagar1@gmail.com
Curr Opin Anesthesiol 2020, 33:841–846
DOI:10.1097/ACO.0000000000000933

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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Pain medicine
KEY POINTS
 Cannabis products commonly used for recreational
purposes have been found to be useful in palliation of
symptoms of chronic diseases.
 However, current evidence supporting their use for
majority of symptoms in palliative care is anecdotal or
of low quality.
 Lack of high-quality evidence does not necessarily
preclude their role in palliation of symptoms, as
anecdotal evidence strongly favors them in difficult-to-
manage symptoms.
 There is an urgent need to standardize cannabinoid
formulations and provide high-quality evidence to
establish a favorable risk–benefit profile, if any.
 This need is time-bound as this has to happen before
industry-driven and patient-driven hype overcomes
robust scientific evidence leading to an opiate-
like crisis.
acid amide hydrolase and monoacylglycerol lipase,
&
respectively [2 ]. They act on the two cannabinoid
receptors – CB1 and CB2. These are G-protein cou-
pled receptors distributed in various tissues of the
body. CB1 receptors are predominantly found in the
central nervous system and are attributed for the
widely known psychotomimetic effects of cannabis.
However, CB1 receptors are not widely expressed in
the brain stem, explaining the reduced incidence of
respiratory depression with cannabinoids. CB2
receptors are expressed in the immune system and
hematopoietic cells. A less known CB3 receptor also
probably exists [3]. The endocannabinoid system is
involved in regulatory signaling of the central ner-
vous system, appetite, nociception, analgesia,
immunomodulation, and inflammation.
Phytocannabinoids are derived from the plants
of genus Cannabis – C. sativa, C. indica, and C.
ruderalis. Delta-9-tetrahydrocannabinol (THC) and
cannabidiol (CBD) are the two extensively studied
phytocannabinoids. Apart from THC and CBD,
Table 1. Approved cannabinoid medications
Compound Nature
Dronabinol (Marinol) Plant-derived THC
Nabilone (Cesamet) Synthetic THC
Nabiximols (Sativex) Balanced THC/CBD
Cannabidiol (Epidiolex) CBD
CBD, Cannabidiol; CINV, chemotherapy-induced nausea and vomiting; THC, delta-9-tetrahydrocannabinol.
842 www.co-anesthesiology.com
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there are numerous other compounds found in
&&
the cannabis plant [4 ]. They are either inade-
quately studied or clinically insignificant. THC is
a partial agonist at the CB1 receptor and is primarily
responsible for the psychological effects of canna-
binoids. CBD binds weakly at both the receptors and
is devoid of psychological effects. Indeed CBD
tends to antagonize the psychological effects of
THC. Pharmaceutical preparations contain varying
amounts of THC and CBD explaining the difference
in effects observed with various preparations. Vari-
ous synthetic compounds have been developed
mimicking effects of THC and CBD [3].
CANNABINOIDS FOR SYMPTOM
MANAGEMENT
Cannabinoids have been used for symptom man-
agement since time immemorial. They have become
notorious because of their recreational use and
abuse potential. Cannabinoids have been studied
for mitigating pain because of various causes includ-
ing cancer and neuropathic pain. They have been
used as agents for chemotherapy-induced nausea
and vomiting (CINV), in ameliorating cancer
anorexia, HIV related cachexia, and multiple sclero-
sis-associated spasticity. They are also postulated to
&&
have antitumor effects [4 ]. Their effects on the
neuropsychiatric domain combined with effects
on various other systems have been utilized in
improving the overall wellbeing and quality of life
(QOL) of patients with chronic illness. Some can-
nabinoids have been approved for certain indica-
tions (Table 1) in some countries but used off-label
for various other indications [5 ].
&
CHRONIC PAIN
Opioids have been the mainstay in treatment of
chronic cancer-related pain. Chronic neuropathic
pain has been traditionally managed with anticon-
vulsants and antidepressants among others. How-
ever, even with multiple analgesic medications,
certain subset of patients do not have satisfactory
Approved indication
CINV
Anorexia in HIV patients
CINV
Spasticity of multiple sclerosis
Seizures of Lennox–Gastaut and Dravet
syndrome in pediatric patients
Volume 33  Number 6  December 2020
 Use of cannabis and cannabinoids in palliative care setting AR and Bhatnagar
pain control. Given the widespread distribution of
cannabinoid receptors in the brain and nervous
tissue, cannabinoids have been tried for alleviating
pain. There are some anecdotal reports of cannabi-
noids being effective in this subset of ‘difficult to
treat’ patients. A case report of a schwannomatosis
patient with severe intractable pain not responding
to traditional multidrug regimen responded impres-
sively well to THC/CBD combination [6]. Cannabi-
noids have been found to be promising in pediatric
palliative care also [3].
Hauser et al. [7] performed a systematic review
and metaanalysis of randomized controlled trials
(RCTs) to assess the efficacy, tolerability, and safety
of cannabinoids in cancer pain. They included five
double-blind RCTs including 1534 participants with
moderate-to-severe cancer-related pain despite opi-
oid therapy. These studies did not include pain
arising because of cancer therapy. Out of these
studies, a metaanalysis was done on four studies
with 1333 patients. The primary outcomes studied
were pain relief of 50% or more from baseline,
patient-perceived global improvement, opioid dose
reduction, tolerability, and safety of cannabinoid
medications. The cannabinoids used were oromu-
cosal nabiximols or THC. This metaanalysis sug-
gested that nabiximols and THC had no effect on
pain and opioid consumption in cancer patients
who had inadequate pain control on opioids. They
found a clinically significant increase in neurologi-
cal side-effects by the said cannabinoids. They found
the quality of evidence to be very low for all trials
because of a high risk of bias, exclusion of hepatic
and renal insufficiency, and all the studies being
sponsored by the drug manufacturer. The trials did
not include opioid naı̈ve patients. All the trials used
the oromucosal route of administration of the drug.
This route is known for variability in pharmacoki-
netic parameters compared with the inhalational
route at a similar dose. Hence, this cannot be
accepted as robust evidence.
A recent systematic review and metaanalysis
&
carried out by Boland et al. [8 ] included six RCTs
with 1460 participants for qualitative analysis and
five RCTs with 1442 participants for meta-analysis.
This review was an improvisation of the previous
metaanalysis. It had a broader search strategy,
included unpublished articles, and the reviewers
contacted the original authors of the trials for addi-
tional findings and study design. Hence, the
reviewers claim a low risk of bias in this review.
The primary outcome was absolute change in mean
pain intensity. The reviewers claim this review to
provide good evidence that cannabinoids had no
role in cancer pain. The studies had a high number
of patient withdrawals and lost to follow-up. This
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might be another reason for the negative result in
addition to inadequate therapeutic efficacy.
A Cochrane review by Mucke et al. [9] on effect
of cannabinoids for adult neuropathic pain included
16 studies with 1750 participants. The cannabinoids
studied were oromucosal nabiximols, inhaled
herbal cannabis, nabilone and dronabinol. The can-
nabinoids were superior to placebo for substantial
(low-quality evidence) and moderate pain relief
(moderate-quality evidence). Hence, the reviewers
concluded that cannabinoids may be used as third
or fourth line of treatment for neuropathic pain
when established conventional therapies fail. A sub-
set of patients with neuropathic pain are likely to
benefit from long-term cannabinoid therapy. With
the available evidence, they are not to be used as first
line of treatment for neuropathic pain.
CHEMOTHERAPY-INDUCED NAUSEA AND
VOMITING
Cannabinoid receptors are widely distributed in the
emetic reflex pathway of the brain. Few decades ago,
decreased incidence of vomiting was seen in
patients receiving chemotherapy who were mari-
juana smokers. Subsequently, dronabinol and nabi-
lone were investigated for CINV. Similar to chronic
pain, there were anecdotal reports of excellent anti-
emetic action of cannabinoids in ‘difficult to treat
cases’ of CINV. However, since the advent of 5-HT3
antagonists, interest on cannabinoids as antiemetics
diminished [10]. Yet, cannabinoids have found
resurging importance in CINV because of their
ancillary effects such as mitigating anorexia which
is not seen with the popular antiemetics. The anti-
emetic efficacy of cannabinoids differed with the
type of chemotherapy used with the maximum
efficacy demonstrated against methotrexate as
opposed to doxorubicin or cyclophosphamide
&
[11 ]. A Cochrane review of 23 RCTs concluded that
cannabinoids were superior to placebo and similar
to conventional antiemetics in ameliorating CINV
[12]. Following successful results with a favorable
side-effect profile, dronabinol and nabilone were
approved for treating CINV. Dronabinol and nabi-
lone have been included in the National Compre-
hensive Cancer Network1 guidelines for CINV [13].
ANOREXIA AND CACHEXIA
The endocannabinoid system is known to have an
active role in the appetite-satiety system of the body.
Endocannabinoids have been found to stimulate
appetite through the CB1 receptors. Rimonabant,
a selective CB1 receptor inverse agonist, was found
to possess anorexic effects and was used to treat
www.co-anesthesiology.com 843
Pain medicine
obesity and metabolic syndrome [3,14]. But a few
years later it was withdrawn because of increased
suicidal ideation in its users. Anorexia and cachexia
are associated with many chronic illnesses includ-
ing cancer and AIDS. Treatment of anorexia
strongly influences patient satisfaction [15]. Loss
of appetite in cancer is multifactorial – patient-
related, tumor-related, and therapy-related.
Patient-related factors include early satiety, depres-
sion, anxiety, and fatigue. Tumor-related factors are
because of inflammatory cytokines, mechanical
bowel obstruction, malabsorption, and direct
tumor invasion leading to impaired gut function.
Cancer treatment may lead to anorexia because of
mucositis, radiation enteritis, dry mouth, nausea,
vomiting, diarrhea, or constipation [15]. Dronabi-
nol (THC) is approved for use in AIDS-related
anorexia and was widely used when effective anti-
retroviral therapy was still evolving. Evidence for
cannabinoids in cancer anorexia and cachexia is of
low quality. Cancer cachexia is complicated by
increased tumor cell turnover rate which is not
&
present in AIDS [11 ]. Progestins and corticosteroids
are the most commonly used orexigenic agents in
cancer cachexia. Dronabinol has been found to be
inferior to megestrol acetate for appetite improve-
ment and weight gain in cancer patients [15]. How-
ever, other cannabinoid agents and cannabis
extract as a whole should be rigorously tested under
controlled conditions before arriving on a final
decision as to the usefulness of this class of drugs
on a most distressing symptom.
ANTITUMOR EFFECTS
The emerging interest in using cannabinoids for
cancer treatment is to cure cancer itself. Cannabi-
noids have shown antitumor effects in various cell
culture and animal studies. The ability of cannabi-
noids to modulate tumor growth in various in-vitro
cancer cell lines appears to be dependent on the cell
type and drug dose. The endocannabinoid system is
closely associated with the immune system. Canna-
binoids can cause apoptosis, tumor cell cycle arrest
&
and inhibit angiogenesis in tumor cells [2 ]. These
actions are mediated by CB1 and CB2 receptors and
there seems to be a cannabinoid receptor-indepen-
dent pathway as well. Cannabinoids are also postu-
lated to act through the transient receptor potential
vanniloid receptor 1 (TRPV1) receptor. There have
been anecdotal clinical reports of tumor regression
with cannabinoids in acute lymphoblastic leukemia
and pilocytic astrocytoma. An unconventional
route of intratumor injection of THC found
improvement in recurrent glioblastoma multi-
forme. High-quality evidence in humans is still
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awaited to define this novel role of cannabinoids
&
in cancer [5 ].
OTHER EFFECTS AND OVERALL
WELLBEING
Nabiximols are approved for treatment of spasticity
&
because of multiple sclerosis [5 ]. A small retrospec-
tive case series of five patients reported improve-
ment of symptomatic paraneoplastic night sweats
with dronabinol [16]. Apart from addressing indi-
vidual symptoms in patients with chronic debilitat-
ing illnesses, cannabinoids have been found to gain
overall patient satisfaction scores and global wellbe-
ing. With a low-quality evidence cannabinoids were
superior to placebo for overall improvement, sleep
problems and psychological distress in patients with
neuropathic pain [9]. A retrospective observation of
332 cancer patients in the United States noted that
many patients with higher overall symptom scores
had a positive urine drug test for THC than those
patients with lower symptom scores [17]. This
denoted that patients were exposed to cannabinoids
from medical and nonmedical sources and were
aware of the emerging use of cannabis products
for symptom control. However, a metaanalysis by
Mucke et al. [18] concluded that cannabinoids did
not have a positive impact on health related QOL in
patients with cancer or AIDS.
PATHWAY FOR FURTHER RESEARCH
Cannabis medications have suffered the complica-
tions of the recreational use of cannabis. The sub-
stance abuse potential and the gray market
economics have forced governments worldwide to
enforce strict laws restricting the availability of can-
nabinoids. There have also been irregularities in the
taxonomy of cannabis products [19]. The cannabis
plant has over 1000 different strains and houses over
100 different phytocannabinoids. Even though THC
and CBD constitute the major substances and have
been widely studied, the variations in clinical effects
seen across various reports and studies may be
because of the interaction of the varying amounts
of these less known phytocannabinoids. Measures
such as weight % and volume % have been used in
denoting the potency of THC in dried products and
oils respectively. Breeding practices of the cannabis
plant have changed over the years such that the
dried plant had 3% THC three decades ago and now
has 15–30% THC [3]. As cannabis products are
legally restricted in many countries, researchers
depend on pharmaceutical preparations of varying
composition for clinical trials. Hence, the pharma-
codynamic effects observed are bound to vary
Volume 33  Number 6  December 2020
 Use of cannabis and cannabinoids in palliative care setting AR and Bhatnagar
among studies. Also, the effects of cannabis vary
depending on whether the patient is naı̈ve to can-
nabis or has had previous recreational exposure.
Apart from the varying composition of cannabis
products, the field is complicated by the various
routes available for cannabis administration. Can-
nabinoids can be administered orally, oromuco-
sally, as inhaled vapors and as a smoked product
&
[5 ]. Each of these routes has varying pharmacoki-
netic profiles. Most of the existing studies on can-
nabinoids have studied their use later in the disease
course after multiple treatment options have failed
rather than in early disease [20]. This might be a
factor responsible for negative results. Pharmacoge-
nomic studies have identified heterogeneity of sin-
gle-nucleotide polymorphisms in cannabinoid
pharmacokinetics among individuals and may be
responsible for varying responses across studies [21].
Research on cannabis products must take into con-
sideration these effects for the results to be valid
and reproducible.
Cannabis research is majorly funded by drug
manufacturing companies and hence there always
exists a possibility of bias for positive results. Inde-
pendent funding agencies should come forward to
fund studies on cannabis products to exclude bias. A
report identified that there existed marked differ-
ences between countries of the European Pain Fed-
eration in the approval and availability of
cannabinoids for medical use [22]. A report from
Italy noted that noncommercial preparations of
cannabis were prevalent with uncertainty of admin-
istered substances [23]. Canada has a 20-year history
of legalized cannabis access for medical use and
nearly 400 000 patients are registered under their
federal access program [24]. This can be a valuable
resource for healthcare professionals desirable of
understanding medical cannabis. Hence, cannabis
research should include centers from across all
countries worldwide using standardized drug prep-
arations. A cross-sectional survey [25] among Aus-
tralian general practitioners found that majority of
them were not comfortable in discussing cannabis
medications with patients though they felt that
there was wide scope for cannabis use in many of
their patients. This highlights the need for sensiti-
zation of the medical community regarding
cannabinoid use.
CONCLUSION
The ultimate aim of palliative care is to provide overall
comfort care to patients with chronic debilitating and
life-limiting illnesses. This has to be achieved by mul-
timodal and multidisciplinary measures with accept-
able side-effect profiles. Cannabinoids are promising
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
agents in mitigating some distressing symptoms of
palliative patients. Their use must be studied under
rigorous research conditions to unveil their fullest
potential. This kind of high-quality evidence is
urgently required. Until such robust clinical evidence
is available, the use of cannabinoids must be guarded
and reserved for specific instances.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Touw M. The religious and medicinal uses of Cannabis in China, India and
Tibet. J Psychoactive Drugs 1981; 13:23–34.
2. Dariš B, Tancer Verboten M, Knez Ž, Ferk P. Cannabinoids in cancer
& treatment: therapeutic potential and legislation. Bosn J Basic Med Sci
2019; 19:14–23.
A review covering the molecular basis of the antitumor effect of cannabinoids.
3. Splinter W. Novel approaches for treating pain in children. Curr Oncol Rep
2019; 21:11.
4. Turgeman I, Bar-Sela G. Cannabis for cancer : illusion or the tip of an iceberg:
&& a review of the evidence for the use of Cannabis and synthetic cannabinoids in
oncology. Expert Opin Investig Drugs 2019; 28:285–296.
An exhaustive review on the use of cannabinoids in oncology practice.
5. Steele G, Arneson T, Zylla D. A Comprehensive review of cannabis in patients
& with cancer: availability in the USA, general efficacy, and safety. Curr Oncol
Rep 2019; 21:10.
A review enumerating the current legal status of cannabinoids in the United States
and the available cannabinoids for clinical use.
6. Iorno V, Roberto A, Colantonio LB, et al. Including cannabinoids in the
treatment of painful schwannomatosis. Brain Behav 2018; 8:e01011.
7. Häuser W, Welsch P, Klose P, et al. Efficacy, tolerability and safety of
cannabis-based medicines for cancer pain: a systematic review with
meta-analysis of randomised controlled trials. Schmerz 2019;
33:424 – 436.
8. Boland EG, Bennett MI, Allgar V, Boland JW. Cannabinoids for adult cancer-
& related pain: systematic review and meta-analysis. BMJ Support Palliat Care
2020; 10:14–24.
A systematic review and metaanalysis on the use of cannabinoids for adult cancer
pain.
9. M€ ucke M, Phillips T, Radbruch L, et al. Cannabis-based medicines for chronic
neuropathic pain in adults. Cochrane Database Syst Rev 2018;
3:CD012182.
10. Wickham RJ. Nausea and vomiting: a palliative care imperative. Curr Oncol
Rep 2020; 22:1.
11. Briscoe J, Kamal AH, Casarett DJ. Top ten tips palliative care clinicians should
& know about medical cannabis. J Palliat Med 2019; 22:319–325.
Clinically useful tips on use of cannabinoids in palliative care.
12. Smith LA, Azariah F, Lavender VT, et al. Cannabinoids for nausea and vomiting
in adults with cancer receiving chemotherapy. Cochrane Database Syst Rev
2015; 11:CD009464.
13. National comprehensive cancer network1 clinical practice guidelines in
oncology (NCCN Guidelines1): Antiemesis: Version 2.2020 — April 23,
2020 available at https://www.nccn.org/professionals/physician_gls/pdf/
antiemesis.pdf. [accessed on July 8, 2020].
14. Richey JM, Woolcott O. Re-visiting the endocannabinoid system and its
therapeutic potential in obesity and associated diseases. Curr Diab Rep
2017; 17:99.
15. Childs DS, Jatoi A. A hunger for hunger: a review of palliative therapies for
cancer-associated anorexia. Ann Palliat Med 2019; 8:50–58.
www.co-anesthesiology.com 845
Pain medicine
16. Carr C, Vertelney H, Fronk J, Trieu S. Dronabinol for the treatment of
paraneoplastic night sweats in cancer patients: a report of five cases. J
Palliat Med 2019; 22:1221–1223.
17. Chang YD, Jung JW, Oberoi-Jassal R, et al. Edmonton symptom assessment
scale and clinical characteristics associated with cannabinoid use in oncology
supportive care outpatients. J Natl Compr Canc Netw 2019; 17:1059–1064.
18. M€ucke M, Weier M, Carter C, et al. Systematic review and meta-analysis of
cannabinoids in palliative medicine. J Cachexia Sarcopenia Muscle 2018;
9:220–234.
19. Teoh D, Smith TJ, Song M, Spirtos NM. Care after chemotherapy: peripheral
neuropathy, cannabis for symptom control, and mindfulness. Am Soc Clin
Oncol Educ Book 2018; 38:469–479.
20. Cyr C, Arboleda MF, Aggarwal SK, et al. Cannabis in palliative care: current
challenges and practical recommendations [published correction appears in
Ann Palliat Med. 2019 Apr;8(2):215-217]. Ann Palliat Med 2018; 7:463–477.
846 www.co-anesthesiology.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
21. Jose A, Thomas L, Baburaj G, et al. Cannabinoids as an alternative option for
conventional analgesics in cancer pain management: a pharmacogenomics
perspective. Indian J Palliat Care 2020; 26:129–133.
22. Krcevski-Skvarc N, Wells C, Häuser W. Availability and approval of cannabis-
based medicines for chronic pain management and palliative/supportive care
in Europe: a survey of the status in the chapters of the European Pain
Federation. Eur J Pain 2018; 22:440–454.
23. Corli O, Davoli E, Medana C, et al. Cannabis as a medicine: an update of the
Italian reality. Eur J Intern Med 2019; 60:e9–e10.
24. Arboleda MF, Prosk E, Cyr C, et al. Medical cannabis in supportive
cancer care: lessons from Canada. Support Care Cancer 2020;
28:2999 – 3001.
25. Karanges EA, Suraev A, Elias N, et al. Knowledge and attitudes of Australian
general practitioners towards medicinal cannabis: a cross-sectional survey.
BMJ Open 2018; 8:e022101.
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