Chronic pain and medical cannabis: Narrative review and practice considerations in persons living with HIV

Globally, 38 million persons live with human immunodeficiency virus (HIV) (PLWH), and a significant portion live with chronic pain. While not yet fully characterized, preliminary data suggest 40%-83% of PLWH experience chronic pain, and many report undertreatment. A growing body of literature suggests undertreatment of chronic pain in PLWH leads to adverse clinical outcomes, such as poor retention in HIV care, suboptimal adherence to antiretroviral therapy, and increased use of intravenous drug use (eg, heroin). Chronic pain experienced by PLWH ranges from neuropathic to musculoskeletal with different etiologies and treatment modalities for each. Although opioids have been used to achieve analgesia in PLWH, there is growing interest in alternative pain therapies. Recently, medical cannabis (delta-9-tetrahydrocannabinol [THC] and cannabidiol [CBD]) products have been of high interest. Anecdotal evidence exists for medical cannabis and pain relief; however, robust clinical trial data are limited due to scheduling restrictions within the United States. The purposes of this narrative review are to summarize key literature for pain in PLWH and medical cannabis, discuss pertinent dosage forms and dosing schedules, and summarize safety and efficacy considerations for PLWH. Finally, the authors provide recommendations on cannabis rescheduling and pharmacists' and healthcare providers' roles in its prescribing and indication. Medical cannabis and pharmaceutical preparations containing both THC and CBD are a viable alternatives to opioid analgesics in the treatment of neuropathic pain in PLWH. The risks of misuse and cannabis use disorder warrant careful consideration, yet the benefits of effective analgesia associated with cannabis may outweigh these risks. Cannabis rescheduling and subsequent expansions in pain management research are warranted, particularly for CBD-predominant and CBD-isolate medical cannabis products.