Individual research recommendation details

Recommendation ID

NG144/2

Question

For children and young people with intractable cancer-related pain and pain associated with specific diseases (such as epidermolysis bullosa), what is the clinical and cost effectiveness of cannabis-based medicinal products as an add-on to standard treatment to improve symptoms compared with treatment with standard care?

Any explanatory notes
(if applicable)

Why the committee made the recommendations
Some evidence showed that CBD reduced chronic pain, but the treatment effect was modest (an average improvement of about 0.4 on a scale ranging from 0 to 10). The evidence did not show a reduction in opioid use in people prescribed medicinal cannabis. Because the number of people who might benefit is large and the cost potentially high, an economic model was developed to compare benefits with the potential costs. The model used data from the trials in the base-case analysis but also assumed a larger potential benefit from cannabis-based medicinal products in various sensitivity analyses. In all cases, the potential benefits offered were small compared with the high and ongoing costs, and the products were not an effective use of NHS resources. The evidence included CBD in combination with THC, THC alone, dronabinol and nabilone so the committee named these products in the recommendation. The committee also agreed that the recommendation should follow the evidence and specify adults.
There was no evidence for the use of CBD alone (either as a pure product or containing traces of THC). Therefore, the committee recommended that CBD should not be offered unless as part of a clinical trial. People who have fibromyalgia or persistent treatment-resistant neuropathic pain are often taking high doses of medicines for pain relief over long periods. These can cause nausea, drowsiness, mood disturbance and fatigue. The committee noted that this is a significant population of people with chronic pain (around 15%). They therefore made a research recommendation for CBD in adults with fibromyalgia or treatment-resistant neuropathic pain.
There was no evidence for intractable cancer-related pain or pain associated with painful childhood diseases. The committee agreed that cannabis-based medicinal products could potentially offer additional benefits for this group, for example, by allowing them to receive their care in an outpatient rather than an inpatient setting or by reducing the overall opioid use. They agreed to make a research recommendation to explore the clinical and cost effectiveness.

How the recommendations might affect practice
Prescriptions of cannabis-based medicinal products for chronic pain are currently rare. GPs refer people with chronic pain to specialist pain services where clinicians on the Specialist Register with expertise in this area decide whether cannabis-based medicinal products should be prescribed. The new recommendation might reduce the number of these prescriptions.
Full details of the evidence and the committee's discussion are in evidence review B: chronic pain.

Source guidance details

Comes from guidance

Cannabis-based medicinal products

Number

NG144

Date issued

November 2019

Other details