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You are to use the design a question using the PICO framework to examine the topic above. For example with A nurse-led topic you may choose to explore if heart failure nurse-led clinics impact on the quality of life in patients with heart failure. Please be sure that you complete ALL sections of the PICO framework document.


PART 1: PICO WORKSHEET (1200 words)

Evidence-based practice of pain management

You are to use the design a question using the PICO framework to examine the topic above. For example with A nurse-led topic you may choose to explore if heart failure nurse-led clinics impact on the quality of life in patients with heart failure. Please be sure that you complete ALL sections of the PICO framework document.

PICO Worksheet and Search Strategy

Brief description of the problem or situation (50 words):

Chronic pain is a serious health condition usually affecting adults. In Australia, one in five adults suffers from chronic pain. Opiod painkillers (the usual medication given) are seen to be less effective in many cases. Medical cannabis can be a treatment alternative as it has both analgesic and anti-inflammatory properties.

Select five of the ‘best sources’ of information identified

Citation (APA):

Degenhardt, L., Lintzeris, N., Campbell, G., Bruno, R., Cohen, M., Farrell, M., & Hall, W.D. (2015). Experience of adjunctive cannabis use for chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study. Drug and Alcohol Dependence, 1 (147), 144-150.

Level of evidence: Level II, Primary literature, Level 1.c of JBI (Joanna Briggs) Annotation (100 words)

This article reported data from POINT (Pain and Opioids IN Treatment) study and included 1514 people from Australia who were prescribed a treatment of opioids for chronic pain (non-cancer). In this study they investigated the patterns of usage of cannabis. The study tried to correlate and assess the associations of demographic, pain etc among other patient characteristics and the subsequent use of cannabis for treatment of pain. The study came up with findings supporting that the use of cannabis for pain relief purposes is common in people having chronic pain (noncancer), and also report that the users experienced more pain relief when they used it along with opioids as compared to the usage of opioids alone.

Citation (APA): Lynch, M.E. & Campbell, F. (2011). Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. British Journal of Clinical Pharmacology, 72(5), 735-144.

Level of evidence: Level I, secondary literature, Level 1.a of JBI

Annotation (100 words) This was a systematic review of randomized controlled trials available in the literature. A systematic review was conducted according to the PRISMA guidelines for reporting systematic reviews on the use of cannabinoids for treatment of chronic pain (non-cancer). The cannabinoids included in the systematic review included smoked cannabis, extracts of cannabis based medications (oralmucosal), nabilone, dronabinol along with a THC analogue. For the study they included patients with chronic non-cancer pain conditions like neuropathic pain, rheumatoid arthritis, fibromyalgia etc. This systematic review of randomized controlled trials provided evidence supporting safety of cannabinoids in neuropathic pain along with giving preliminary evidence in rheumatoid arthritis and fibromyalgia. 

Citation (APA): Russo, E.B. (2008). Cannabinoids in the management of difficult to treat pain. Therapeutics and Clinical Risk Management, 4(1), 245-259.

Level of evidence: Level I, secondary literature, Level 1.a of JBI Annotation (100 words)

This article reviewed present status of peer reviewed research on the randomized controlled trials on the use of cannabinoids for pain treatment and also cannabinoid analgesia involving both the endocannabinoid system and specific non-receptor pathways. The review focused on various cannabinoids like Tetrahydrocannabinol and nabilone which are approved in various countries but await approval for usage in pain treatment. The review also discussed synthetically manufactured counterparts of cannabinoids like ajulemic acid and Sativex® , which is derivative of cannabis which contains equal proportions of THC (partial CB1) and cannabidiol. The review quotes that several methodologically structured randomized clinical trials have shown safety and efficacy of Sativex in chronic pain complications like central, peripheral neuropathic pain, cancer, rheumatoid arthritis etc. The review gives good evidence that use of cannabinoids in adjunct to usual treatment of pain appears promising.

Citation (APA): Hill, K.P. (2015). Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical Review. Journal of the American Medical Association. 313(24), 2474-2483.

Level of evidence: Level III, secondary literature, Level 1.b of JBI

Annotation (100 words)

This was a clinical review on the pharmacological aspect, indications, and the legal issues associated with the use of marijuana for medical treatment. They reviewed the available medical literature on medical marijuana dated from 1948 up till March 2015 via a search of MEDLINE wherein they gave stress on randomized clinical trials (twenty eight) of cannabinoids usage as treatment for indications other than those established. The review came up with findings with high quality evidence in support of the medical marijuana usage for chronic pain, neuropathic pain etc. Several of the trials discussed in the review showed positive trends and suggested that marijuana or cannabinoids may be efficacious.

Citation (APA): Mather, L.E., Rauwendaal, E.R., Moxham-Hall, V.L., & Wodak, A.D. (2013). (Re)introducing medicinal cannabis. Medical Journal of Australia. 199(11), 759-761.

Level of evidence: Level VII, secondary literature, Level 5.c of JBI

Annotation (100 words)

This above mentioned debate published from NSW, Australia tried to look in to medicinal utility of Cannabis based on its clinical efficacy, safety and cost-effectiveness. The report is based on several scientific evidence based studies which lead to the recommendation that medicinal cannabis can used for treatment of pain and other medical complications like neuropathic pain with acceptable side effects. The report clearly states that the medical utility of cannabis has been ignored for long and the current actions by the state legislative to allow the usage (under strict recommendations) of medical cannabis was long overdue.


Chronic pain is a commonly occurring medical complication that may result from neuropathic origins, various cancers, HIV, cardiovascular disorders or invasive surgeries and therapies. The available therapeutic and pharmacological treatments for pain are scarce and basically ineffective. Medical Cannabis or medical Cannabinoids (derived) are the class of agents used for pharmacological interventions. It has been shown to be efficacious in conditions like nausea (following chemotherapy) and recently the interest has been generated for its use in treatment of chronic pain conditions. Data from studies on cannabinoid systems and their crosstalk with the endocrinal pathways support the role of these cannabinoids are a potent analgesic. Use of medical cannabis as a therapeutic agent has been very restricted due to the ethical and legal issues involved. A very early systematic review by Campbell, Tramèr, Carroll, Reynolds, Moore & McQuay (2001) reported insuffuccient evidence and a need for more randomized controlled trials while the most recent ones identify their usage to be moderately beneficial in chronic pain management (Boychuk, Goddard, Mauro, & Orellana, 2015; Lynch & Campbell, 2011) . We conducted a structured literature review to determine evidence using the PICO model on usage of medical cannabis in chronic pain management in adults. PubMed and Cochrane Central Register of Controlled Trials were searched, with no language restriction. Search terms were reported and noted down. Various other data sources were also searched, including internet websites. 


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