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The Medical Use of Marijuana in Human Immunodeficiency Virus or Acquired Immune Deficiency Syndrome
Among people living with HIV/AIDS (PLWHA), approximately 30% report using cannabinoids for medicinal purposes (1-3). There are decades-worth of anecdotal reports from PLWHA attesting to cannabis’ beneficial effects on mitigating the symptoms of the disease, common co-morbidities, and side effects of treatment, including cachexia, pain, and nausea. However, practitioners who treat PLWHA require sufficient knowledge of the clinical research surrounding the use of medical cannabis among PLWHA in order to develop an evidence-based opinion regarding its use. This report summarizes the high-quality evidence derived from clinical trials and prospective observational research that has investigated the impact of cannabis use on various health outcomes among PLWHA.
The bulk of clinical research on cannabinoids/cannabis use among PLWHA has focused on the potential of cannabinoids/cannabis to counter symptoms of cachexia, including appetite loss and weight loss. There is limited to moderate evidence to suggest that dronabinol, a synthetic pharmaceutical preparation of delta-9-tetrahydrocannabinol, the major psychoactive component of cannabis, may be effective in stimulating appetite and weight gain among patients suffering from HIV wasting syndrome. (In 1992, the US Food and Drug Administration approved dronabinol for the treatment of AIDS-related anorexia; this followed its approval of the drug in 1985 to treat nausea and vomiting associated with cancer chemotherapy (4).) Among 139 individuals with AIDS-related anorexia, 2.5mg capsules BID was found to significantly improve appetite, but not weight gain in one study (although it approached significance) compared to placebo (5). In another study involving 52 patients with AIDS, this dronabinol dose did not produce significant differences in weight gain when compared to treatment with megestrol acetate (6). (Megestrol acetate is a synthetic derivative of progesterone.) The former study performed a follow-up open-label trial of the long-term impacts of dronabinol, where all participants (placebo and treatment) were assigned 2.5 mg BID for 12 months after the initial trial. Substantial increases in appetite were recorded for each group, and weight gain remained approximately stable over the 12-month period (7). In another study involving 12 people with symptomatic HIV disease including weight loss, 5 mg dronabinol BID was associated with increased body fat and decreased symptom distress (both p < 0.05) and a trend towards both improved appetite and significant weight gain (8).
Among marijuana-experienced PLWHA, higher doses of dronabinol were well tolerated and appear to be effective in treating symptoms of cachexia. For example in a study of the acute effects of marijuana among 30 marijuana-experienced PLWHA with a clinically-significant loss of muscle mass, 10 and 20 mg doses were found to significantly increase caloric intake during the peak effect period, compared to a placebo (9). In one study of 10 PLWHA in an in-patient treatment program, a 10mg dose QID was associated with significantly increased body weight after four days compared to placebo (10), and, in another study involving seven regular marijuana smokers living with HIV/AIDS randomly assigned dronabinol or placebo, food intake was increased but not body weight during a 32-day observation period (11).
In addition to dronabinol, two double-blind placebo-controlled studies have evaluated the effect of smoked herbal cannabis on caloric intake and weight gain. In one study, smoked cannabis with varying THC concentrations (1.8, 2.8 and 3.9%; amount of herbal cannabis not stated) significantly increased caloric intake during peak effect period, or 1–3 hours after administration, compared to a placebo in 30 PLWHA with AIDS-related wasting. This effect was not observed in participants without muscle loss (9). In a follow-up study, marijuana cigarettes containing 2.0% and 3.9% THC increased daily caloric intake in a dose-dependent fashion, while the 3.9% dose significantly increased weight gain after four days (10). In both cases, marijuana cigarettes were provided by the United States National Institute on Drug Abuse.
Treatment (or placebo) was taken approximately 1-2 hours ahead of meal times in the above trials.
There has been increasing investigation into the impact of inhaled (i.e., smoked or vaporized) herbal cannabis on chronic neuropathic pain. Two randomized controlled trials have focused solely on HIV-associated neuropathy and have found evidence to support the use of smoked cannabis to ameliorate pain. In a study of 50 PLWHA living with painful HIV-associated neuropathy, approximately half (52%) of the participants in the treatment arm (3.56% THC smoked TID for five days) reported more than 30% reduction in pain levels, compared to approximately one-quarter (24%) of participants in the placebo arm (p<0.05). Median daily reduction in chronic pain was significantly higher for the treatment group (12). Similarly, another study found pain reduction to be significantly greater among participants who smoked cannabis (4% THC, titrated downwards or upwards depending on effect, QID) compared to those who smoked a placebo cigarette (0% THC) (13).
A recent meta-analysis of inhaled herbal cannabis for the treatment of neuropathic pain across a range of patient populations, which included the two trials among PLWHA, estimated that inhaled cannabis facilitates short-term reduction, i.e., between 5-6 hours and two weeks, in chronic neuropathic pain for every 1 in 5-6 treated patients (14).