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Treating Neuropathic Pain in Multiple Sclerosis (MS)

MS patients with neuropathic pain demonstrated improvement using the oral synthetic cannabinoid nabilone.
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Multiple sclerosis is a chronic demyelinating disease of the central nervous system (CNS). The severity and type of associated neurologic symptoms is dependent on the location and degree of myelin loss and axonal degeneration.1,2 Symptoms are characteristically progressive, relapsing and remitting, and may be associated with disability and impairment. Typical symptoms include: tremor, ataxia, muscle spasm, weakness, paralysis, difficulty speaking, constipation, loss of bladder control, and pain.3

Approximately 70% of MS patients suffer from pain and 8% of patients report that pain was the first noticeable symptom of the disease.3 Pain symptoms were more frequent among patients with higher EDSS scores or spinal cord involvement.3 Although pain in the MS population may not be more frequently reported than in the general population, pain intensity, the need for analgesia and the impact of pain on activities of daily living is reported to be higher in patients with MS.4-7 Paradoxically the most severe patients are often resistant to the standard therapy (i.e. topical analgesics, tricyclic antidepressants, gabapentenoids, opioids, etc.)

In this article, we will present case studies of multiple sclerosis patients with neuropathic pain improved with the oral cannabinoid nabilone. This synthetic nitrogen-substitution analogue of delta-9-tetrahydrocannabinol (THC), indicated for anorexia and nausea in cancer chemotherapy patients (Canada and United Kingdom), is also used off-label for pain management. It is more water soluble than THC. Compared to oral THC, it has a more rapid onset of action, longer duration of action, and shorter half-life.8,9

Recent theoretical and technological advances in neurobiology, neuroimaging, neurophysiology, the mapping of cannabinoid receptor sites, the discovery of both exogenous and endogenous ligands, and the investigations of the link between heavy metal toxicity and MS all seem to be converging.2,4,10-14 Despite these space age advances, some patients are as stubbornly resistant to treatment now as they were in the nineteenth century, when the disease was first scientifically described in the literature.

Table 1. Patient Characteristics Prior to Prolotherapy
Patient; MS class Date of Birth; Gender Dose of Nabilone Date of initial treatment; Duration up to date of data collection Neuropathy Pain Scale (0=none to 100=worst) Extra Notes
        Before After  
A
RR
07/26/39
Female
1mg/
night
June 8/05
14 months
43 31
  • nabilone helped dull the pain
  • overall sleeping is better now
  • Patient ceased anxiolytic medication
  • patient tapered opioid medication
B
AM
03/13/43
Male
1mg/night Mar 21/05 17 months    
  • Some relief at night
  • Able to control pain much better when nabilone is taken with oxycontin (opioid synergy)
C
SP
06/9/49
Male
0.5mg/
night
Dec 1/05
9 months
35 22
  • Helps in falling asleep
  • Increases overall comfort and reduces pain
  • Reduced muscle spasticity, anxiolytics, opioids
  • Increased range of movement and strength
D
AM
11/8/65
Male
1mg/
night
Mar 1/06
5 months
52 33
  • Reduction in overall pain
E
AM
02/07/67
Female
1mg/
night
Feb 3/06
6 months
60 40
  • Able to sleep better with no interruptions
  • After nabilone she was able to reduce the amounts of other medications
  • Decrease in anxiety and nausea
  • Less depressed
  • Increased range of movement-able to get out of her wheelchair and play with her daughter
F
SP
06/23/58
Female
1mg/
night
June 21/06 2 months    
  • Opioid sparing
    To early to tell, has not come back for check up yet
G
RR
06/16/44
Male
1mg/
night
July 4/05 13 months    
  • Promising. Temporarily stopped.
H
PP
11/2/34
Female
0.2mg/ night October 26/05
9 months
56 45
  • Able to sleep for first time in 10 years, highly sensitive to adverse drug reaction (ADR)
  • Dispensed as aqueous solution 0.2mg/ml titrated up to 30 drops qhs sublingual
  • Only prescription medication she is on now
I 06/28/62
Female
1mg/
night
Jan 24/05
4 months
63 39
  • Headaches and migraines completely gone
  • Says she feels like a completely different person
 

Could it be that the proper understanding of cannabinoid chemistry, neurobiology, and pharmacokinesis holds the key to unlocking the complex chimaera of the etiology, diagnosis and treatment of the different manifestations of MS?1,9,15-18 In fact, recent publications have indicated that cannabinoids may have significant efficacy in the treatment of chronic neuropathic pain in the MS population.18,19

Last updated on: November 6, 2012
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