Critical Appraisal of Research Paper.

Part 4A: Critical Appraisal of Research

Conduct a critical appraisal of the four peer-reviewed articles you selected by completing the Evaluation Table within the Critical Appraisal Tool Worksheet Template. Choose a total of four peer- reviewed articles that you selected related to your clinical topic of interest in Module 2 and Module 3.Critical Appraisal of Research Paper.

ORDER A PLAGIARISM-FREE PAPER HERE

Note: You can choose any combination of articles from Modules 2 and 3 for your Critical Appraisal. For example, you may choose two unfiltered research articles from Module 2 and two filtered research articles (systematic reviews) from Module 3 or one article from Module 2 and three articles from Module 3. You can choose any combination of articles from the prior Module Assignments as long as both modules and types of studies are represented.Critical Appraisal of Research Paper.

Part 4B: Critical Appraisal of Research

Based on your appraisal, in a 1-2-page critical appraisal, suggest a best practice that emerges from the research you reviewed. Briefly explain the best practice, justifying your proposal with APA citations of the research.

Evaluation Table

Use this document to complete the evaluation table requirement of the Module 4 Assessment, Evidence-Based Project, Part 4A: Critical Appraisal of Research

Full APA formatted citation of the selected article. Article #1 Article #2 Article #3 Article #4

Baron, E. P., Lucas, P., Eades, J., & Hogue, O. (2018). Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort. The journal of headache and pain, 19(1), 37.Critical Appraisal of Research Paper.

Worley, M. J., Heinzerling, K. G., Shoptaw, S., & Ling, W. (2017). Volatility and change in chronic pain severity predict outcomes of treatment for prescription opioid addiction. Addiction (Abingdon, England), 112(7), 1202–1209. https://doi.org/10.1111/add.13782
Blake, A., Wan, B. A., Malek, L., DeAngelis, C., Diaz, P., Lao, N., & O’Hearn, S. (2017). A selective review of medical cannabis in cancer pain management. Annals of palliative medicine, 6(suppl 2), s215-s222.
Nugent, S. M., Morasco, B. J., O’Neil, M. E., Freeman, M., Low, A., Kondo, K., & Kansagara, D. (2017). The effects of cannabis among adults with chronic pain and an overview of general harms: a systematic review. Annals of internal medicine, 167(5), 319-331.Critical Appraisal of Research Paper.

Evidence Level *
(I, II, or III)
Level I Level II Level I Level I
Conceptual Framework

Describe the theoretical basis for the study (If there is no one mentioned in the article, say that here).
Not provided

Not provided Not provided Not provided
Design/Method

Describe the design and how the study was carried out (In detail, including inclusion/exclusion criteria). The researchers sent English and French electronic surveys to Tilray cancer patients using medicinal cannabis. They used the ID migraine questionnaire to assess the use of cannabis for migraine among patients who had headaches. The researchers performed a secondary analysis of clinical trials for addiction to prescription opioids. They obtained data from a 12 week and 4-week BUP-NLX stabilization and taper respectively.Critical Appraisal of Research Paper.
Inclusion criteria-18 years old, meet the DSM-IV criterion for opioid dependence with no unstable psychiatric or medical conditions.
Exclusion-heroin use in ≥ 4 days in the last month, previous heroin injection, or current dependence on any other substances. The researchers conducted a search for literature on Medline database for studies between 1975-2017 using the following keywords “cannabis”, “THC”, “CBD”, “Nabiximol”, “cancer”, and “pain”. The researchers searched for supporting literature in Cochrane, MEDLINE, and other sources from inception to 2017.Critical Appraisal of Research Paper.
Sample/Setting

The number and characteristics of
patients, attrition rate, etc. 16,675 cancer patients receiving Tilray
Medicinal cannabis for pain.

Patients with chronic pain (52% male, 88% Caucasian, 31% married). enrolled for the taper phase of BUP-NLX (n=125) between 2006 June to 2009 July in community clinics that had an affiliation with a national network of clinical trials across 10 cities in the US. Five studies with a double-blinded placebo-RCTs discussing the management of chronic pain in patients with advanced cancer using cannabinoids. The researchers included observational studies and intervention trials published in English and with adults as participants using cannabis preparations.Critical Appraisal of Research Paper.
Major Variables Studied

List and define dependent and independent variables Dependent-cannabis use method, cannabis frequency and quantity of use, highest education level, employment status, the prevalence of cannabis extract (capsules, drops), prescription drugs replaced with cannabis
Independent-pain
Dependent-sex, race, marital status.
Independent- opioid use and self-reported opioid use frequency Dependent- gender, and age
Independent- chronic pain response
Dependent-gender, age
Independent- QoL, outcomes of adverse effects, pain.
Measurement

Identify primary statistics used to answer clinical questions (You need to list the actual tests done). Pearson chi-squared tests or Fisher’s exact tests were used to comparing patients with headaches and non-headaches in each group. The researchers used a multilevel logistic regression, and a multilevel Poisson regression to examine opioid UDS, and opioid use frequency respectively.Critical Appraisal of Research Paper.
The researchers conducted a selective review of five studies that assessed the management of pain in patients with cancer. The review included information regarding the study population, interventions, pain response, and side effects. Two independent investigators abstracted literature and assessed for their quality, and used a standard criterion to grade them for their overall strength.
Data Analysis Statistical or
Qualitative findings

(You need to enter the actual numbers determined by the statistical tests or qualitative data). Of 2032 patients, 21 were managed with cannabis. Those with pain syndromes were 42.4% (n = 861): headache 3.7% (n = 75;), arthritis 9.3% (n = 188), and chronic pain 29.4% (n = 598;). At baseline, there was an increase in pain (OR = 2.38, p = .02), with high volatility for pain (OR = 2.43, p = .04) which was a great predictor of positive odds when tapering BUP-NLX. An increase in the intensity and volatility of pain (IRR = 1.40, p = .04) and (IRR = 1.66, p = .009) respectively were also great predictors of a greater frequency of self-reported use of opioids. The researchers found five studies that evaluated the effectiveness of THC: CBD, THC oil, and THC oromucosal sprays to manage cancer pain. They administered different doses ranging from 2.7–43.2 mg/day (THC) and (CBD) 0–40 mg/day. High THC doses were associated with increased relief of pain in doses as low as 2.7–10.8 mg for THC when combined with 2.5–10.0 mg CBD. The researchers also noted some side effects such as hypotension, drowsiness, vomiting, mental clouding, and nausea. The researchers found low-strength evidence to support the use of cannabis to alleviate neuropathic pain from 27 trials on chronic pain. The associated harms of cannabis use from 32 primary studies and 11 systematic reviews included short-term cognitive impairment, a high risk of motor vehicle accidents, and psychotic symptoms. In younger populations, associated harms are associated with adverse pulmonary effects

Findings and Recommendations

General findings and recommendations of the research Most patients used cannabis to manage chronic pain particularly migraines. Those with ID migraine and headaches preferred hybrid strains of cannabis, pain groups with high THCA/THC (tetrahydrocannabinolic acid/ tetrahydrocannabinol), low CBDA/CBD (cannabidiolic acid/cannabidiol) demonstrating the potential anti-emetic, analgesic, anti-inflammatory properties of THC. Further studies need to examine the dynamics associated with response to pain, particularly when supplementing the maintenance treatment of opioids with pain-specific medications or behavioral therapy.Critical Appraisal of Research Paper.

. There is scientific evidence that supports the use of medicinal cannabis to reduce neuropathic/ chronic pain in patients with advanced cancer. Further studies should be conducted using large sample sizes to determine the efficacy and optimal dosage of different therapies of medicinal cannabis.
The amount of evidence available to support the use of cannabis in alleviating neuropathic pain is insufficient. However, in the general population, evidence reveals that cannabis use is associated with a high risk of adverse effects on mental health.Critical Appraisal of Research Paper.

Appraisal and Study Quality

Describe the general worth of this research to practice.

What are the strengths and limitations of the study?

What are the risks associated with the implementation of the suggested practices or processes detailed in the research?

What is the feasibility of use in your practice? The findings of this study add to the existing knowledge of managing cancer patients with pain using medicinal cannabis.Critical Appraisal of Research Paper.

Limitations-the researcher’s used a survey design with self-reported data from patients who reportedly had other symptoms that they used medicinal cannabis to manage apart from headache. Thus, some of the responses provided might not have been specific for managing headaches only but other symptoms or both.
Strengths-the researchers used a large population sample which increases the reliability and applicability of the findings to larger populations.Critical Appraisal of Research Paper.
A major risk associated with the implementation of the suggested practice is that of misusing/dependence on medicinal cannabis by cancer patients. This study adds to the clinical knowledge on the effectiveness and efficacy of buprenorphine-naloxone (BUP-NLX) as the most viable pharmacotherapy to manage chronic pain in patients with addiction to prescription opioids.Critical Appraisal of Research Paper.
Strength-a large population sample which increases the reliability of the findings.
Limitation-since this study was a secondary analysis where the researchers tested hypotheses beyond the scope of the original clinical trials, its findings ought to be confirmed through a prospective design or a replication.Critical Appraisal of Research Paper.
A major risk associated with implementing this study is the high risk of opioid addiction when tapering BUP-NLX in the maintenance phase.
The findings of this study add to the clinical knowledge on the management of chronic pain in advanced cancer patients using medicinal cannabis.
Strength-the findings of the study support the effectiveness/role of medical cannabis in managing cancer pain.
Limitation- most studies lacked statistical power mostly due to a small number of participants

The findings of this study add to the clinical knowledge on the side effects associated with cannabis use in the management of chronic cancer pain.
Strength-the researchers used two independent investigators to assess and grade literature as a measure to reduce the risk/likelihood of bias.
Limitation-the researchers found very few methodologically rigorous trials and this limits the applicability of the findings to cancer patients with chronic pain.Critical Appraisal of Research Paper.

Key findings

Among 2032 patients, 21 illnesses were managed with cannabis and overall, pain syndromes accounted for 42.4% (n = 861): headache 3.7% (n = 75;), arthritis 9.3% (n = 188), and chronic pain 29.4% (n = 598;). All the 2032 participants were given an ID questionnaire with 68% (n = 343) responding with a 3 “Yes” responses, 20% (n = 102) giving 2 “Yes” responses (97% and 93%. 88% (n = 445) of patients who had headaches were managed for migraines using cannabis using the hybrid strains. At baseline, there was an increase in pain (OR = 2.38, p = .02), with high volatility for pain (OR = 2.43, p = .04) which was a great predictor of positive odds when tapering BUP-NLX. An increase in the intensity and volatility of pain (IRR = 1.40, p = .04) and (IRR = 1.66, p = .009) respectively were also great predictors of a greater frequency of self-reported use of opioids. The researchers found five studies that evaluated the effectiveness of THC: CBD, THC oil, and THC oromucosal sprays to manage cancer pain. They administered different doses ranging from 2.7–43.2 mg/day (THC) and (CBD) 0–40 mg/day. High THC doses were associated with increased relief of pain in doses as low as 2.7–10.8 mg for THC when combined with 2.5–10.0 mg CBD. The researchers also noted some side effects such as hypotension, drowsiness, vomiting, mental clouding, and nausea. The researchers found low-strength evidence to support the use of cannabis to alleviate neuropathic pain from 27 trials on chronic pain. The associated harms of cannabis use from 32 primary studies and 11 systematic reviews included short-term cognitive impairment, a high risk of motor vehicle accidents, and psychotic symptoms. In younger populations, associated harms are associated with adverse pulmonary effects.Critical Appraisal of Research Paper.

Outcomes

Most patients using opiates/opioids are substituted with cannabis. Demonstrating that medicinal cannabis is the most effective agent for managing chronic pain syndromes, headache, and migraine in cancer patients. Adults being managed for chronic pain using BUP-NLX) addiction to opioids is still at risk of opioid use and those with persistence to prolonged and high volatility to pain are less likely to prolong abstinence when tapering BUP-NLX. Medicinal cannabis reduces the intensity and severity of neuropathic/chronic pain in patients with advanced cancer. Medical cannabis can moderately alleviate pain in cancer patients with chronic pain and may result in the following side effects; risk of motor-vehicle accidents, and psychotic symptoms. In younger populations, associated harms are associated with adverse pulmonary effects.Critical Appraisal of Research Paper.

General Notes/Comments Medicinal cannabis has potent anti-inflammatory, analgesic, and anti-emetic properties and should be recommended for managing chronic pain syndromes, migraines, and headaches in cancer patients. When compared to opioid agonists, BUP-NLX is safer and has a diminished liability for abuse. Clinicians can use medicinal cannabis to manage neuropathic/chronic pain in patients with advanced cancer. Medical cannabis should be used cautiously for chronic pain management in cancer patients.Critical Appraisal of Research Paper.

Part 4B
Evidence from existing literature acknowledges that chronic pain is a common symptoms among patients and has a negative impact on the emotional, physical, and functional aspects of cancer patients and this explains why it is integral to have effective strategies to manage pain to restore and maintain QoL. As highlighted by Blake et al (2017), unfortunately, presently, the treatment regimens for neuropathic or chronic pain are heavily reliant on opioid analgesics and this is problematic for other patients since patients respond differently to drugs and side effects that can promote non-adherence. Besides, opioid use has also become a common issue associated with the likelihood of addiction and physiological tolerance. In the case of opioid withdrawal and relapse, issues in this population can even complicate with psychiatric and medical issues, which presents it as an issue of priority with regards to primary care, addiction treatment, and pain management.Critical Appraisal of Research Paper.
Empirical studies suggest medicinal cannabis as an effective and viable pharmacotherapy to manage chronic pain in cancer patients with opioid addiction. According to the study by Baron, (2018), medicinal cannabis, a psychoactive drug, is the most effective agent for managing chronic pain syndromes, headache, and migraine in cancer patients. Alternatively, the study by Worley et al (2017) recommends the use of BUP-NLX (buprenorphine-naloxone) as an alternative to chronic pain management in cancer patients with opioid addiction. BUP-NLX has a diminished liability for abuse and is safer compared to other full opioid agonists.Critical Appraisal of Research Paper.