Is nabilone (cannabinoid) safe for patients with bipolar disorder and chronic pain?

From the Guidelines

Nabilone should be used with extreme caution in patients with bipolar disorder who have chronic pain, due to its potential to trigger or worsen manic episodes, psychosis, and mood instability. While nabilone may help manage chronic pain symptoms, its psychoactive properties pose significant risks for patients with bipolar disorder 1. If considering nabilone, it should only be prescribed under close psychiatric supervision, starting at the lowest possible dose (1 mg twice daily, as indicated for other conditions) and gradually titrating up if needed, with careful monitoring for any signs of mood destabilization 1. Alternative pain management approaches should be exhausted first, including non-psychoactive medications (like certain anticonvulsants, SNRIs, or non-opioid analgesics), physical therapy, and psychological interventions. The risk-benefit assessment is crucial, as the potential pain relief must be weighed against the substantial risk of psychiatric decompensation. Regular monitoring of mood symptoms is essential if nabilone is prescribed, with frequent follow-up appointments to assess both pain control and psychiatric stability. Additionally, patients should be informed about the potential long-term side effects of cannabis and/or cannabinoid use, including GI, cardiovascular, respiratory, oncologic, and psychiatric risks, as well as the risk of cannabis use disorder and driving safety concerns 1. It is also important to consider the potential for liver enzyme elevation and drug-induced liver injury with cannabinoid use, particularly with high doses or prolonged use 1. Overall, the use of nabilone in patients with bipolar disorder and chronic pain requires careful consideration and close monitoring to minimize the risk of adverse effects. Key considerations include:

• Starting with a low dose and gradually titrating up as needed
• Close psychiatric supervision and regular monitoring of mood symptoms
• Exhausting alternative pain management approaches before considering nabilone
• Informing patients about the potential risks and side effects of cannabinoid use
• Careful consideration of the risk-benefit assessment and individual patient needs.

From the FDA Drug Label

• Cesamet should also be used with caution in patients with current or previous psychiatric disorders, (including manic depressive illness, depression, and schizophrenia) as the symptoms of these disease states may be unmasked by the use of cannabinoids

• Patients using Cesamet should be made aware of possible changes in mood and other adverse behavioral effects of the drug so as to avoid panic in the event of such manifestations

Nabilone may not be safe for patients with bipolar disorder and chronic pain. The FDA drug label recommends using Cesamet with caution in patients with current or previous psychiatric disorders, including manic depressive illness. The use of cannabinoids may unmask symptoms of these disease states. Patients should be made aware of possible changes in mood and other adverse behavioral effects of the drug. 2

From the Research

Safety of Nabilone in Bipolar Disorder with Chronic Pain

• The safety of nabilone, a synthetic cannabinoid, in patients with bipolar disorder and chronic pain is a topic of interest, with some studies suggesting its potential benefits in managing chronic pain and other symptoms 3.
• However, there is limited research specifically focusing on the use of nabilone in patients with bipolar disorder, and more studies are needed to fully understand its safety and efficacy in this population.
• A study published in 2014 found that nabilone was effective in reducing chronic pain and improving symptoms of posttraumatic stress disorder (PTSD) in a correctional population, with no evidence of abuse or reduction in efficacy 3.
• Another study published in 2018 discussed the use of antiepileptic mood stabilizers, including gabapentin, in dermatology, highlighting their potential effectiveness in managing chronic pruritus, neuropathic pain, and other conditions, but did not specifically address the use of nabilone in bipolar disorder 4.
• A review of bipolar disorders published in 2020 discussed the complexity of the condition and the various treatment options available, including lithium, antipsychotics, and anticonvulsants, but did not mention nabilone specifically 5.
• The use of gabapentin, an anticonvulsant, in bipolar disorder has been studied, with mixed results, and it is not recommended as a first-line treatment for bipolar disorder 6, 7.

Potential Benefits and Risks

• Nabilone may offer benefits in managing chronic pain and other symptoms in patients with bipolar disorder, but its safety and efficacy in this population are not well established.
• The potential risks of using nabilone in patients with bipolar disorder, including the risk of exacerbating manic or depressive symptoms, are not well understood and require further study.
• More research is needed to fully understand the potential benefits and risks of using nabilone in patients with bipolar disorder and chronic pain, and to determine its place in the treatment of this population 3.