HIV/AIDS and chronic pain

Evidence-based guidelines

Guidance on the suggested use of medical cannabis for HIV/AIDS and chronic pain

This evidence-based guidance was reviewed and approved on 10/8/2024.

There is limited evidence to support the conclusion that medical cannabis is effective for short-term treatment of symptoms of chronic painful HIV-associated neuropathy.

There is insufficient evidence to support the conclusion that oral cannabidivarin is effective for treatment of symptoms of chronic painful HIV-associated neuropathy.

There is limited evidence to support the conclusion that oral cannabinoids are effective in increasing appetite and caloric intake. There is insufficient evidence that it increases body weight in HIV/AIDS wasting syndrome.

There is moderate evidence to support the conclusion that medical cannabis and cannabinoids can have clinically significant beneficial effects in the management of chronic pain, particularly pain that is due to nerve damage or neuropathy. This is based on supportive findings from good to fair quality controlled clinical trials with very few opposing findings.

*Developed using level of evidence categories from the 2017 National Academies of Sciences, Engineering, and Medicine report on cannabis (National Academies of Sciences, Engineering, and Medicine, 2017d).

Symptoms associated with HIV infection include pain, headaches, reduced appetite, nausea, vomiting, weight loss, diarrhea, constipation, depression, and anxiety. These symptoms occur as both direct and indirect consequences of the HIV infection, as well as side effects of antiretroviral drugs used to treat the disease. Uncontrolled observational questionnaire data involving 143 patients with HIV who also used cannabis suggest substantial subjective benefit from the use of cannabis to manage many of the above symptoms (Woolridge et al., 2005).  

Controlled clinical trials showing a positive benefit of the use of medical cannabis to treat symptoms related to HIV are limited to short-term (5 days) treatment of painful peripheral neuropathy and HIV/AIDS wasting syndrome.  

In a 2007 study, 55 patients with HIV-related painful sensory neuropathy were randomized in a blinded fashion to smoke a 0.9 gm cannabis cigarette 3 times per day over 5 days containing 3.6% THC (active treatment), or an identical appearing 0.9 gm cannabis cigarette in which the THC had been chemically extracted (placebo). Patients receiving active treatment reported a 34% reduction in HIV-related neuropathic pain compared to 17% reduction for placebo. (Abrams et al., 2007). 

In a 2020 crossover, double-blinded, randomized study, 32 patients with HIV neuropathy received cannabidivarin (CBDV) 400 mg or placebo for 4 weeks with a 3 week washout period. There was no difference in pain intensity between CBDV and placebo treatment phases (Eibach 2020).

A systematic review published in 2015 identified four randomized controlled trials involving 255 patients with HIV/AIDS wasting syndrome. All four studies included dronabinol, with one investigating inhaled cannabis as well. Three trials were placebo-controlled, and one used the progestational agent, megestrol acetate, as the comparator. The review authors concluded that there was some evidence suggesting that cannabinoids were effective in causing weight gain in patients with  HIV/AIDS (Whiting et al., 2015). However, these studies were conducted in the 1990s, and it is unknown whether patients taking modern antiretroviral therapy (ART) would experience the same benefit.

While available evidence suggests clinically significant drug-drug interactions between ART and cannabinoids, robust evidence is lacking. Use a drug interaction tool or consult with a pharmacist when stopping, starting, or changing the dose of an ART agent or cannabinoid.

References

  1.  Abrams, D. I., Jay, C. A., Shade, S. B., Vizoso, H., Reda, H., Press, S., … Petersen,  K. L. (2007). Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology, 68(7), 515–521. doi: 10.1212/01.wnl.0000253187.66183.9c 
  2. Andreae, M. H., Carter, G. M., Shaparin, N., Suslov, K., Ellis, R. J., Ware, M. A., …  Sacks, H. S. (2015). Inhaled Cannabis for Chronic Neuropathic Pain: A Meta-analysis of Individual Patient Data. The Journal of Pain, 16(12), 1221–1232. doi: 10.1016/j.jpain.2015.07.009
  3. Grant, I. (2013). Medicinal Cannabis and Painful Sensory Neuropathy. AMA  Journal of Ethics, 15(5), 466–469. doi:10.1001/virtualmentor.2013.15.5.oped1-1305 
  4. Health Canada. (2018). Information for Health Care Professionals - Cannabis (marihuana, marijuana) and the cannabinoids. Retrieved from https://www.canada.ca/en/health-canada/services/drugs-medication/cannabis/information-medical-practitioners/information-health-care-professionals-cannabis-cannabinoids.html
  5. Maccallum, C. A., & Russo, E. B. (2018). Practical considerations in medical cannabis administration and dosing. European Journal of Internal Medicine, 49, 12–19. doi: 10.1016/j.ejim.2018.01.004 
  6. Portenoy, R. K., Ganae-Motan, E. D., Allende, S., Yanagihara, R., Shaiova, L.,  Weinstein, S., … Fallon, M. T. (2012). Nabiximols for Opioid-Treated Cancer  Patients With Poorly-Controlled Chronic Pain: A Randomized, Placebo Controlled, Graded-Dose Trial. The Journal of Pain, 13(5), 438–449. doi:  10.1016/j.jpain.2012.01.003 
  7. Russo, E. B. (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. British Journal of  Pharmacology, 163(7), 1344–1364. doi: 10.1111/j.1476-5381.2011.01238.x
  8. The National Academies of Sciences, Engineering, and Medicine. (2017a). The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. (Ch. 4-1). Doi: https://doi.org/10.17226/24625
  9. The National Academies of Sciences, Engineering, and Medicine. (2017b). The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. doi: https://doi.org/10.17226/24625
  10. Whiting, P. F., Wolff, R. F., Deshpande, S., Nisio, M. D., Duffy, S., Hernandez, A.  V., … Kleijnen, J. (2015). Cannabinoids for Medical Use. Jama, 313(24), 2456. doi:10.1001/jama.2015.6358
  11. Woolridge, E., Barton, S., Samuel, J., Osorio, J., Dougherty, A., & Holdcroft, A.  (2005). Cannabis Use in HIV for Pain and Other Medical Symptoms. Journal of  Pain and Symptom Management, 29(4), 358–367. doi: 10.1016/j.jpainsymman.2004.07.011 
  12. Zajicek, J. P., Hobart, J. C., Slade, A., Barnes, D., & Mattison, P. G. (2012).  Multiple Sclerosis and Extract of Cannabis: results of the MUSEC trial. Journal of Neurology, Neurosurgery & Psychiatry, 83(11), 1125–1132. doi: 10.1136/jnnp-2012-302468