a cannabis based medicine extract ( cbme ) was prepared as outlined in example 1 and contained approximately equal amounts of the cannabinoids thc and cbd and this was administered to patients with cancer related pain . a double blind , randomised , parallel group , placebo - controlled , comparative study of the efficacy , safety and tolerability of different cannabis based medicine extracts ( cbme ) was undertaken . the test articles that were studied were cbme thc : cbd ( 1 : 1 ) ( thc 27 mg / ml ), ( cbd 25 mg / ml ); cbme thc ( thc 27 mg / ml ); and matching placebo . the study population were patients who were hospice or hospital in or outpatients , aged 18 years or above , who had terminal cancer and were experiencing pain that was not responding adequately to strong opiate or opiate related therapy . the aim of the study was to determine whether the administration of either the combined thc and cbd or thc alone could be used to relieve pain in patients with cancer related pain . the primary outcome of the study was to compare each cbme versus the placebo in the change from baseline in the patient &# 39 ; s pain score at visit 3 . the use of escape analgesia was also measured as a co - primary end - point of the study . the secondary objectives of the study were to the use of regular maintenance medication , the dose of study medication and also whether there was a change from baseline in sleep disturbance , nausea , memory , appetite , concentration , brief pain inventory ( bpi ) scores and quality of life compared to placebo . unexpectedly the cannabis based medicine extract containing approximately equal quantities of thc and cbd produced a greater degree of pain relief than the cbme that contained thc alone . additionally patients that were administered the cbme containing approximately equal amounts of thc and cbd reported in their quality of life questionnaire a lesser degree of constipation in comparison to their baseline scores at the beginning of the trial . the features of the invention are illustrated further by reference to the following examples : medicinal cannabis was produced and prepared with reference to the method disclosed in wo 02 / 064109 ( example 15 ). the resulting plant material was processed as described in the flow chart below . the process of manufacture of a high thc or high cbd cannabis based medicine extract is described . the resulting extract is referred to as a cannabis based medicinal drug extract and is also classified as a botanical drug substance according to the us food and drug administration guidance for industry botanical drug products . the quantity of cannabinoid in the cbme can be accurately assessed by way of measurement by hplc with reference to the method disclosed in wo 02 / 064109 ( example 16 ). an example of an hplc chromatogram of a cbd - containing cbme produced using a high cbd medicinal cannabis plant extracted with co 2 is shown in fig1 . an example of an hplc chromatogram of a thc - containing cbme produced using a high thc medicinal cannabis plant extracted with co 2 is shown in fig2 . an example of an hplc chromatogram containing the relevant ratios of thc and cbd cbmes is shown in fig3 . assessment and comparison of the efficacy , safety and tolerabilty of cannabis based medicine extracts by way of a clinical trial in human patients with cancer related pain . a multi - centre , double blind , randomised , parallel group , placebo controlled , comparative study was undertaken in order to evaluate the efficacy , safety and tolerability of cannabis based medicine extracts ( cbme ) in patients with cancer related pain . the cannabis based medicine extracts contained either delta - 9 - tetrahydrocannabinol ( thc ) at a concentration of 27 mg / ml and cannabidiol ( cbd ) at a concentration of 25 mg / ml in ethanol : propylene glycol ( 50 : 50 ) excipient or delta - 9 - tetrahydrocannabinol ( thc ) at a concentration of 27 mg / ml in ethanol : propylene glycol ( 50 : 50 ) excipient . the cbme was presented in a pump action spray where each activation delivers 100 μl of spray , containing thc ( 2 . 7 mg ) and cbd ( 2 . 5 mg ). the subjects in the study were randomised equally to either one of the cannabis based medicine extracts or placebo . the placebo matched the appearance , smell and taste of the active formulation , but containing no active components . the excipient was ethanol : propylene glycol ( 50 : 50 ). again the placebo was presented in a pump action spray where each activation delivers 100 μl of spray . patient diary cards were required to be completed daily throughout the study . the patient could take strong opioid escape medication at any time throughout the study although other analgesic medications were required to be kept constant . the maximum dose of study medication that was allowed to be taken was 8 sprays at any one time or within any 3 hour interval , with a maximum of 48 sprays within any 24 hour interval . patients were randomised to receive either thc : cbd ( 1 : 1 ), thc or placebo . the randomisation was in the ratio of 1 : 1 : 1 ( thc : cbd ( 1 : 1 ), thc , placebo ). it should be noted that the terms 1 : 1 thc : cbd or equal amounts of thc : cbd refer to approximately equal . at the screening visit the patients were assessed for compliance with the inclusion or exclusion criteria and advised of the study requirements . once the patient had provided informed consent , eligible patients were asked to complete run - in diaries for a period of 2 days before returning for visit 1 . at visit 1 the patient &# 39 ; s previous medical history was taken along with assessment by two questionnaires . these were the brief pain inventory short form ( bpi - sf ) questionnaire and the european organisation for research and treatment of cancer ( eortc ) quality of life questionnaire ( qlq - c30 ). patients whose level of pain was equal to or greater than 4 on a bs - 11 pain score on at least one occasion per day during the 2 day run - in period and who fulfilled the study entry criteria and who were willing to continue were allocated a study number and dosing with study medication was commenced . patients were provided with a diary and instructed how to fill it in . assessments were to be made on a daily basis . patients were allowed to adjust their dose of study medication to achieve optimal pain control based on pain scores , adverse event profiles and escape medication usage . at visit 2 , approximately 7 to 10 days after visit 1 a review of the patient &# 39 ; s clinical status was undertaken which included pain control , adverse event profile , strong opioid escape medication usage , change in concomitant medication and change in strong opioid medication . at visit 3 , which took place approximately 14 to 20 days after visit 1 , the patient &# 39 ; s clinical status was again reviewed as detailed at visit 2 . the patients were also asked to complete the bpi - sf and qlq - c30 questionnaires . the box scale ( bs - 11 ) pain score where 0 equals “ no pain ” and 10 equals “ very bad pain ” were used as a primary measure of efficacy of the study medication for pain intensity . the patient diary asked patients to record bs - 11 scores for pain three times per day at morning ( on waking ), lunchtime and evening ( just prior to going to bed ). bs - 11 scores referring to the previous 24 hours were recorded daily in the evening for sleep , nausea , memory , concentration and appetite . the number of sprays of study medication and the time it was taken , the doses of regular maintenance medication that was taken and the dose and time of any escape medication taken was also recorded in the diary . some of the data collated from this study is described below . comparison of mean numeric rating score ( nrs ) pain scores at all assessment periods in patients with cancer related pain when administered a cannabis based medicine extract containing an approximately equal ratio of thc ( 27 mg / ml ) and cbd ( 25 mg / ml ) or thc ( 27 mg / ml ) in intention to treat ( itt ) population . the efficacy , safety and tolerability of two cannabis based medicine extracts were assessed as described above and the degree of pain at different times of the day was recorded by self assessment on a daily basis . the data was collated and statistical analysis was undertaken . patients assessed pain on a scale of 0 ( no pain ) to 10 ( extremely bad pain ). table 1 illustrates the mean 11 - point nrs pain scores at all assessment periods in the intention to treat ( itt ) population . the baseline is a mean of all days in the run - in period and the last 3 days is a mean of last three days on study medication . statistical analysis of this data is shown in tables 2 and 3 . table 2 details the analysis of covariance of the mean 11 - point nrs pain scores in the intention to treat ( itt ) population . the data displayed in the above two tables is for the change in baseline , which is the final result minus baseline scores . a value less than zero indicates a decrease in pain score from baseline . a difference from placebo of less than zero indicates a greater decrease from baseline in active treatment group compared with placebo . tables 4 and 5 summarise the nrs for pain by responders in the itt population . table 4 details the actual number of responders who had a reduction in pain score from baseline levels . the odds ratio ( or ) compares whether the probability of an event is the same for two groups . an or which is equal to 1 infers that the event is equally likely to occur in both groups . an or which is greater than 1 implies the event is more likely to occur in the first group and an or less than 1 implies that the event is less likely to occur in the first group . the data shown above illustrates that the study medication which contained approximately equal amounts of thc and cbd resulted in a greater change from the baseline in pain scores when compared to the study medication which contained thc alone . as such the statistical analysis data demonstrates that the 1 : 1 thc : cbd is shown statistically to be more efficacious than the thc alone . the data demonstrates that there is a higher degree of responders who experienced a greater than or equal to 30 % reduction in pain in the 1 : 1 thc : cbd group than in the thc alone group . comparison of mean numeric rating score ( nrs ) pain scores at all assessment periods in patients with cancer related pain when administered a cannabis based medicine extract containing an approximately equal ratio of thc ( 27 mg / ml ) and cbd ( 25 mg / ml ) or thc ( 27 mg / ml ) in per - protocol population . the efficacy , safety and tolerability of two cannabis based medicine extracts were assessed as described above and the degree of pain at different times of the day was recorded by self assessment on a daily basis . the data was collated and statistical analysis was undertaken . patients assessed pain on a scale of 0 ( no pain ) to 10 ( extremely bad pain ). table 6 illustrates the mean 11 - point nrs pain scores at all assessment periods in the per - protocol population . the baseline is a mean of all days in the run - in period and the last 3 days is a mean of last three days on study medication . statistical analysis of this data is shown in tables 7 and 8 . table 7 details the analysis of covariance of the mean 11 - point nrs pain scores in the per - protocol population . the data displayed in the above two tables is for the change in baseline , which is the final result minus baseline scores . a value less than zero indicates a decrease in pain score from baseline . a difference from placebo of less than zero indicates a greater decrease from baseline in active treatment group compared with placebo . tables 9 and 10 summarise the nrs for pain by responders in the per - protocol population . table 9 details the actual number of responders who had a reduction in pain score from baseline levels . the odds ratio ( or ) compares whether the probability of an event is the same for two groups . an or which is equal to 1 infers that the event is equally likely to occur in both groups . an or which is greater than 1 implies the event is more likely to occur in the first group and an or less than 1 implies that the event is less likely to occur in the first group . the data shown above illustrates that the study medication which contained approximately equal amounts of thc and cbd resulted in a greater change from the baseline in pain scores when compared to the study medication which contained thc alone . as such the statistical analysis data demonstrates that the 1 : 1 thc : cbd is shown statistically to be more efficacious than the thc alone . the data demonstrates that there is a higher degree of responders who experienced a greater than or equal to 30 % reduction in pain in the 1 : 1 thc : cbd group than in the thc alone group . because this data from the per - protocol population shows the same as the intention to treat population it means that the overall data set is robust . comparison of use of escape medication in patients with cancer related pain when administered a cannabis based medicine extract containing an approximately equal ratio of thc ( 27 mg / ml ) and cbd ( 25 mg / ml ) or thc ( 27 mg / ml ) in intention to treat ( itt ) population . the efficacy , safety and tolerability of two cannabis based medicine extracts were assessed as described above and the number of days in which escape medication was used was recorded . the data was collated and statistical analysis was undertaken . table 11 illustrates the mean doses per day and its change from baseline in the intention to treat ( itt ) population . the baseline is a mean of all days in the run - in period and the last 3 days is a mean of last three days on study medication . statistical analysis of this data is shown in tables 12 to 15 . table 12 details the analysis of number of days that escape medication was used in the intention to treat ( itt ) population . table 13 details the analysis of number of days that escape medication used in the intention to treat ( itt ) population when adjusted for baseline proportion of days . table 14 details analysis of covariance of the mean number of doses of escape medication used per day and the change from baseline in the intention to treat ( itt ) population . table 15 details the non - parametric analysis of the mean number of doses of escape medication used per day and change from baseline in the itt population . the data displayed in the above two tables is for the change in baseline , which is the final result minus baseline scores . a value less than zero indicates a decrease in pain score from baseline . a difference from placebo of less than zero indicates a greater decrease from baseline in active treatment group compared with placebo . the data for the use of escape medication in patients with cancer related pain in the intention to treat population shows that patients were equally as likely to use escape medication whether they were taking study medication containing approximately equal amount of thc and cbd or thc alone as they would be if they were taking the placebo . this data is important as it shows that there was no cumulative effect of the cannabinoids upon the opioid medication that the patients were already taking . this would enable doctors and health care workers therefore to still allow patients the use of their escape medication to treat breakthrough pain . comparison of use of escape medication in patients with cancer related pain when administered a cannabis based medicine extract containing an approximately equal ratio of thc ( 27 mg / ml ) and cbd ( 25 mg / ml ) or thc ( 27 mg / ml ) in per - protocol population . the efficacy , safety and tolerability of two cannabis based medicine extracts were assessed as described above and the number of days in which escape medication was used was recorded . the data was collated and statistical analysis was undertaken . table 16 illustrates the mean doses per day and its change from baseline in the per - protocol population . the baseline is a mean of all days in the run - in period and the last 3 days is a mean of last three days on study medication . statistical analysis of this data is shown in tables 17 to 20 . table 17 details the analysis of number of days that escape medication used in the per - protocol population . table 18 details the analysis of number of days that escape medication used in the per - protocol population when adjusted for baseline proportion of days . table 19 details analysis of covariance of the mean number of doses of escape medication used per day and the change from baseline in the per - protocol population . table 20 details the non - parametric analysis of the mean number of doses of escape medication used per day and change from baseline in the per - protocol population . the data displayed in the above two tables is for the change in baseline , which is the final result minus baseline scores . a value less than zero indicates a decrease in pain score from baseline . a difference from placebo of less than zero indicates a greater decrease from baseline in active treatment group compared with placebo . again the data for the per - protocol population correlates with the intention to treat population . summary of eortc qlq - c30 constipation scale in patients with cancer related pain when administered a cannabis based medicine extract containing an approximately equal ratio of thc ( 27 mg / ml ) and cbd ( 25 mg / ml ) or thc ( 27 mg / ml ) in intention to treat ( itt ) population . the efficacy , safety and tolerability of two cannabis based medicine extracts were assessed as described above and the degree of constipation as assessed by the eortc qlq - c30 constipation scale both at baseline during assessment in week 1 and at the end of the study . the data was collated and statistical analysis was undertaken . table 21 illustrates the observed data and the change from baseline in the intention to treat ( itt ) population . table 22 details the analysis of covariance of the degree of constipation as assessed by the eortc qlq - c30 constipation scale in the intention to treat ( itt ) population . the study described above was a phase iii trial and overall the study medication which contained approximately equal amounts of thc and cbd achieved a statistically significant improvement in comparison to placebo in pain as measured on a numerical rating scale ( p = 0 . 014 ), this was a primary endpoint of the study . a responder analysis showed that approximately 40 % of patients taking the study medication with approximately equal amounts of thc and cbd showed a greater than 30 % improvement in their pain ( p = 0 . 024 ). the study medication that contained thc alone did not show a significant effect in pain ( p = 0 . 24 ). the trial therefore suggests that the study medication that contains cbd along with thc is more effective at reducing cancer related pain than the study medication that contained thc alone . the analysis of the second primary endpoint showed that there were no significant changes in the use of escape medication in either of the study medications as compared with placebo . the improvements in pain were therefore attributable to the positive effects of the study medication containing approximately equal amounts of thc and cbd . the data also additionally shows that patients receiving the cbme containing approximately equal amounts of thc and cbd experienced a beneficial relief from opiate induced constipation . it can therefore be concluded that a medication that contains approximately equal amounts of thc and cbd offers a new treatment option in the treatment of pain in patients with cancer related pain , and for treatment of constipation . cleeland c . s ., et al . ( 1994 ) quality improvement guidelines for the treatment of acute pain and cancer pain . journal of the american medical association 274 , 1874 - 80 formukong e . a ., evans a . t . and evans f . j . ( 1988 ) analgesic and anti - inflammatory activity of constituents of cannabis sativa l . inflammation 12 ( 4 ), 361 - 371 holdcroft a . et al . ( 1997a ) pain relief with oral cannabinoids in familial mediterranean fever . anaesthesia 52 ( 5 ), 483 - 6 holdcroft a . et al . ( 1997b ) clinical trial experience with cannabinoids . pharm . sci . 3 , 546 - 550 those skilled in the art will recognize , or be able to ascertain using no more than routine experimentation , many equivalents to the specific embodiments of the invention described herein . such equivalents are intended to be encompassed by the following claims . all references disclosed herein are incorporated by reference in their entirety .
the present invention relates to treatment of cancer related pain and constipation . preferably the subject in need is administered a combination of the cannabinoids cannabidiol and delta - 9 - tetrahydrocannabinol . more preferably the cannabinoids are in a predefined ratio by weight of approximately 1 : 1 of cbd to thc .