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Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions
Daniela Furrer1,2,
Edeltraut Kröger ORCID: orcid.org/0000-0002-5653-39791,2,3,4,
Martine Marcotte1,
Nathalie Jauvin1,
Richard Bélanger3,5,
Mark Ware6,
Guillaume Foldes-Busque7,8,
Michèle Aubin1,2,5,
Pierre Pluye6 &
Clermont E. Dionne1,2,5
Chronic musculoskeletal pain (CMP) may lead to reduced physical function and is the most common cause of chronic non-cancer pain. Currently, the pharmacotherapeutic options against CMP are limited and frequently consist of pain management with non-steroidal anti-inflammatories, gabapentinoids, or opioids, which carry major adverse effects. Although the effectiveness of medical cannabis (MC) for CMP still lacks solid evidence, several patients suffering from it are exploring this therapeutic option with their physicians.
Little is known about patients' perceptions of their MC treatment for CMP. We aimed to increase this knowledge, useful for healthcare professionals and patients considering this treatment, by conducting a scoping literature review, following guidance by Arksey and O'Malley, to describe the views and perceptions of adult patients who had consumed MC to relieve chronic CMP.
Databases (PUBMED, EMBASE, Web of Science) and websites were searched using combinations of controlled and free vocabulary. All studies and study designs reporting on patients' perceptions regarding MC against CMP were considered. Studies had to include adult patients reporting qualitatively or quantitatively, i.e., through questionnaires, on MC use to treat CMP or other non-cancer pain, since studies reporting exclusively on perceptions regarding CMP were very rare. Study characteristics were extracted and limitations of the study quality were assessed. The review includes patients' demographic characteristics, patterns of MC use, perceived positive and negative effects, use of alcohol or other drugs, reported barriers to CM use, and funding sources of the studies.
Participants of the 49 included studies reported that MC use helped them to reduce CMP and other chronic non-cancer pain, with only minor adverse effects, and some reported improved psychological well-being.
In the included studies, men represent between 18 and 88% of the subjects. The mean age of participants in these studies (42/49) varied between 28.4 and 62.8 years old. The most common route of administration is inhalation.
MC users suffering from CMP or other chronic non-cancer pain perceived more benefits than harms. However, the information from these studies has several methodological limitations and results are exploratory. These user-reported experiences must thus be examined by well-designed and methodologically sound clinical or observational studies, particularly regarding CMP, where reports are very scarce.
Musculoskeletal pain is a condition affecting bones, muscles, ligaments, and joints, resulting from underlying diseases or health problems such as osteoarthritis, inflammatory rheumatic diseases, and fibromyalgia, although in many cases the exact cause cannot be identified (Arthritis Society, 2015a). Musculoskeletal pain is the most common type of severe long-term pain and it impacts on all aspects of life by typically affecting dexterity and mobility, and by limiting work and activities of daily living (Woolf et al., 2012). It has been recently reported that one in two American adults lives with a musculoskeletal disease (Yelin et al., 2016), and in Canada, approximately 17% of the adult population are affected, nearly half of whom (44%) are aged 65 years or older (Arthritis Society, 2015a). Some cases of musculoskeletal pain are of short duration and have no long-term consequences. Chronic musculoskeletal pain (CMP), which persists for more than 3 months (Task Force on Taxonomy of the International Association for the Study of Pain, 1994), however, is associated with a range of problems such as sleep disorders, depression, anxiety, fatigue, reduced quality of life, and inability to work or socialize (Moore et al., 2014). In the USA, the impact of CMP on the economy in terms of healthcare costs and lost productivity is estimated at US $304 billion for the year 2013 (Yelin et al., 2016).
Effective pharmacological therapeutic options for the relief of CMP are limited and the treatment remains suboptimal for many patients (Fitzcharles et al., 2016). Examples for this are the use of non-steroidal anti-inflammatories, gabapentinoids (e.g., pregabalin and gabapentin), or the antidepressants duloxetine and milnacipran, which have shown clinical efficacy in the treatment of fibromyalgia and may have benefit in osteoarthritis and low back pain. However, it is estimated that only about one-third of patients will have at least 50% pain relief with one of these agents used as monotherapy; due to significant adverse effects, patients often fail to achieve recommended doses, further diminishing the medications' effectiveness (Goldenberg et al., 2011). Opioids are also used to manage CMP, although the effectiveness of this approach remains uncertain (Petzke & Enax-Krumova, 2016; Schaefert et al., 2015) and the clinical management of CMP with opioids is challenging due to adverse effects such as dependence and/or addiction leading to possible overdose and death (Atluri et al., 2014; Ballantyne, 2015; Hauser et al., 2016; Tobin et al., 2016). It is therefore urgent to explore new treatment options to relieve pain in persons affected by CMP and thus improve their quality of life and social participation (Rowe & Caprio, 2013; Gereau et al., 2014; Lynch & Ware, 2015). Many persons for whom CMP is not satisfactorily relieved are turning to alternative therapies. Among these, the products derived from cannabis are perceived as an interesting analgesic option, both by some physicians and some patients (Elikottil et al., 2009; Boehnke et al., 2016), although its use remains controversial (Hosking & Zajicek, 2008; D'Souza & Ranganathan, 2015).
Cannabis and cannabinoids
The Cannabis sativa plant contains over 100 cannabinoids (ElSohly & Gul, 2014). The most abundant cannabinoid, delta-9-tetrahydrocannabinol (THC), is responsible for the main psychoactive effect of cannabis, but preclinical studies suggest that THC also has some analgesic and anti-inflammatory effects (Ashton, 2007). The second most abundant cannabinoid, cannabidiol (CBD), has antipsychotic effects and is not intoxicating (Niesink & van Laar, 2013; Zhu et al., 2006). Preclinical studies also support anti-inflammatory and analgesic effects of this compound (Burstein, 2015; Costa et al., 2007; Maione et al., 2011). The quantities and proportions of the different cannabinoids vary between different sources and preparations of cannabis (Ashton, 2001; de Meijer, 2014). Furthermore, there are differences between herbal preparations and consumption methods of cannabis regarding levels of individual cannabinoids, and between patients regarding the pharmacokinetics of these molecules (MacCallum & Russo, 2018). These differences affect treatment experiences (i.e., anxiety compared to relaxation), making it hard to come up with evidence-based information to guide physicians and patients on the most appropriate prescribing and dosing of cannabis for a given case (Beaulieu et al., 2016; Ko et al., 2016). Worldwide, several cannabinoid-based medicines are available in several countries. The first product, nabiximols (tradename Sativex®), contains the cannabinoids THC and CBD. The most common indication for its use is spasticity associated with multiple sclerosis. The second product, nabilone (tradename Cesamet®) contains a synthetic cannabinoid similar to THC and is used to alleviate nausea and vomiting associated with chemotherapy treatments. The third product, dronabinol (tradename Marinol®), is a synthetic cannabinoid chemically identical to THC and its main indications are anorexia associated with weight loss in patients with AIDS, as well as severe nausea and vomiting caused by cancer chemotherapy (Abuhasira et al., 2018). Quite recently, a product containing cannabidiol, Epidiolex®, has been approved by the US Food and Drug Administration for the treatment of Dravet syndrome and Lennox-Gastaut syndrome, which are severe epileptic encephalopathies.
Medical cannabis and musculoskeletal pain: gaps in knowledge
Given the confusion between the terms cannabis, cannabinoids, and cannabis for medical purposes, we will refer to the term "medical cannabis" (MC) in this review, in order to describe cannabis products (plant-based products or pharmaceutical products) used for CMP or other non-cancer chronic pain. Chronic pain in general, including CMP, is the most common reason given for the therapeutic use of MC among adults (Fitzcharles et al., 2016; Swift et al., 2005; Ware et al., 2005; Aggarwal et al., 2009; Arthritis Society, 2015b). The effectiveness of MC in the management of such pain, however, remains controversial. In a systematic review and meta-analysis on cannabinoids for medical use by Whiting et al., only 4 of the 79 trials included were judged at low risk of bias (Whiting et al., 2015). Individual studies suggested improvement in pain intensity, but most of the differences did not reach clinical significance and there was no clear evidence for an effect of the type of cannabinoid or the mode of administration. It is also important to note that different products were used in the individual studies, plant based or pharmaceutical, making comparisons between the studies even more difficult. Moreover, none of the studies assessed the long-term effects of cannabinoids.
In 2015, Lynch et al. published a systematic review of randomized controlled trials published since 2010 and examining cannabinoids for the treatment of chronic non-cancer pain, including CMP. They reported that seven out of the 11 included studies demonstrated a significant analgesic effect. Several trials also demonstrated improvement in secondary outcomes (e.g., sleep, muscle stiffness, and spasticity) (Lynch & Ware, 2015). Adverse effects most frequently reported, such as fatigue and dizziness, were mild to moderate in severity and generally well tolerated.
In 2017, the National Academies for Science, Engineering, and Medicine of the USA published an exhaustive review on the health effects of cannabis and cannabinoids and concluded that "there is conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment of chronic pain in adults", based on a review of reviews, following the conclusions of Whiting et al. (Whiting et al., 2015), as well as two primary studies (National Academies of Sciences E, and Medicine, 2017). It should be pointed out, however, that the conclusions reported in the paper of Whiting et al. should be regarded with caution, as most of the studies assessed in this systematic review showed a high risk of bias.
In 2018, Stockings et al. performed another systematic review and meta-analysis of 47 randomized controlled studies and 57 observational studies on cannabinoids for the treatment of chronic non-cancer pain and concluded that the evidence for the effectiveness of MC on chronic non-cancer pain is limited [pooled events rates for 50% reduction in pain were not significant: 18.2% (cannabinoids) vs 14.4% (placebo); moreover, the number needed to treat was high (NNT = 24; 95% CI: 15–61) and the number needed to harm was low (NNH = 6; 95% CI: 5–8)]. From the results of the reviewed studies, the authors considered it unlikely that cannabinoids would become an important treatment option in chronic non-cancer pain (Stockings et al., 2018). Similarly, Nugent et al. reported in their 2017 review that the utilization of MC to alleviate chronic pain might be associated with several harms, including increased risk for motor vehicle accidents, psychotic symptoms, and short-term cognitive impairment, in addition to negative impacts on the respiratory tract (Nugent et al., 2017).
Thus, available evidence on the effectiveness of MC against CMP and other chronic non-cancer pain remains limited and the results of systematic reviews are somewhat inconclusive. It is even more difficult to conclude about the use of cannabis specifically in the management of CMP because, according to three systematic reviews of clinical trials on cannabis (Fitzcharles et al., 2016; Stockings et al., 2018), only two clinical trials have focused exclusively on musculoskeletal conditions. The authors of these clinical trials reported that cannabinoids (nabilone or Sativex®) led to a significant decrease in some aspects of pain in patients with fibromyalgia (Skrabek et al., 2008) or rheumatoid arthritis (Blake et al., 2006). However, only a small number of patients were studied for a short period of time in these trials and further methodological limitations may have affected their quality (Aviram & Samuelly-Leichtag, 2017) (Fitzcharles et al., 2016; Stockings et al., 2018). In conclusion, more high-quality randomized controlled trials comparing herbal cannabis or pharmaceutical cannabinoids with established therapies or placebo are necessary to define their role in the management of CMP or other chronic pain (Fitzcharles et al., 2016).
Although the use of MC remains controversial, it is gaining popularity and legal frameworks for its use are increasingly seen under certain conditions in a growing number of countries, i.e., Australia, France, Israel, the Netherlands, the UK, New Zealand, Spain, Germany, 29 US states, and since 1999 in Canada (Aguilar et al., 2018), where "serious arthritis" was mentioned as one of the main diagnoses justifying a license to obtain cannabis for medical use in 2013 (Arthritis Society, 2015b). Several countries are therefore already confronted with increasing use of MC against CMP, including self-medication, even though its efficacy and safety are still unknown.
Two recent reviews reported on MC use in patients suffering from different diseases, including anxiety, depression, HIV/AIDS, pain, and multiple sclerosis, highlighting that pain is the most frequent reason for MC use and its increasing frequency in general and cannabis self-medication in particular (Kosiba et al., 2019; Park & Wu, 2017). However, we did not identify major reviews on the characteristics, motivations, perceptions, and expectations of patients with regard to the use of medical cannabis against musculoskeletal or other chronic non-cancer pain. Thus, a knowledge gap exists in our understanding of patients' characteristics and perceptions with regard to this use. Therefore, we conducted a scoping review to explore and describe these characteristics and perceptions of persons using MC against chronic non-cancer pain, including CMP. This review represents a first step towards a larger research program on this topic.
Eligibility criteria and selection of articles
The study protocol was submitted to the funding organizations and can be accessed through the corresponding author. Included studies had to comprise adults having used cannabis or cannabinoids for therapeutic purposes, including CMP or other chronic pain. Moreover, study samples had to have included at least several participants with chronic musculoskeletal or non-cancer pain. Qualitative, quantitative, and mixed methods studies were considered.
Studies that were specific to only one disease, other than musculoskeletal conditions or chronic non-cancer pain, such as HIV/AIDS, cancer, multiple sclerosis, epilepsy, inflammatory bowel disease, glaucoma, Tourette's syndrome, neuropathic pain, spinal cord injury, migraine, post-traumatic stress disorder, dementia, or mental illness, as well as palliative care, were excluded. Furthermore, all studies that did not report any patient perceptions or results—including clinical trials on the therapeutic or adverse effects of cannabis—were excluded. Books, meeting abstracts, editorials, letters, policy evaluations, or newspaper articles were also excluded. Initial eligibility was assessed by screening the titles and abstracts of retrieved references by three persons Daniela Furrer, Martine Marcotte, and Norma Perez. Then, full texts of eligible references were reviewed by three persons (Daniela Furrer, Martine Marcotte, and Rosa Martins). Included publications that reported about one study in two or more articles were combined into a single study, with one exception (see below). Thereafter, reference lists of relevant reviews and of included studies were hand searched for additional references following the same procedure.
Three large databases (MEDLINE, EMBASE, and Web of Science) were searched using keywords from the controlled vocabulary and free text, and combined to identify publications on users of cannabis for therapeutic purposes (see search strategies in Appendix 1). The searches were conducted during the second half of 2016, updated in June 2019, and were restricted to publications in English, French, or German with no other time limit.
This scoping review followed guidance by Arksey and O'Malley, Levac et al., and Colquhoun et al. (Arksey & O'Malley, 2005; Levac et al., 2010; Colquhoun et al., 2014) and examined the published knowledge regarding perceptions and experiences of MC users suffering from CMP or chronic non-cancer pain. Early search results revealed the scarcity of publications studying MC users for CMP specifically, and since CMP represents the most common etiology for chronic non-cancer pain, we expanded our search to all studies including patients using MC for chronic non-cancer pain (Podichetty et al., 2003). Moreover, given the scarcity of studies on the perceptions of users of MC, we decided to include both plant-based products and pharmaceutical products such as nabilone or nabiximols in the present review, similarly to some of the included studies (Hazekamp et al., 2013). As such, in the remainder of the manuscript, the abbreviation MC refers to both plant-based products and cannabis-derived medicine.
Data collection and quality appraisal
For this narrative synthesis, the following data were extracted by three persons into pre-determined Word files (Daniela Furrer, Martine Marcotte, and Rosa Martins) from the included studies: study design and setting, period of data collection, sample size, participants' age and sex, indications for MC consumption, patterns of MC use, perceived benefits and adverse effects of use, and financial support for the study. When available, MC consumption as a substitute for other drugs, as well as barriers to MC use, were also documented. No individual quality appraisal was performed, according to the guidance used (Arksey & O'Malley, 2005; Levac et al., 2010; Colquhoun et al., 2014), but multiple limitations of the included study designs are outlined in the discussion.
A total of 3639 references were first identified, and the full-text was screened for 201 articles, of which 52 publications reporting on 49 studies met the inclusion criteria (Fig. 1). In one publication (Perron et al., 2015), a sub-sample from a previous study (Ilgen et al., 2013) was used but, since study objectives and measures were different, they were treated as two different studies.
Flowchart of the scoping review
Characteristics of the included studies
The main characteristics of all included studies are summarized in Fig. 2.
Medical cannabis and musculoskeletal pain: scoping review key data
Among all included studies, only two examined the prevalence of cannabis use exclusively among patients suffering from CMP (Ste-Marie et al., 2016). Most of the studies focused on mixed samples that included patients with CMP (between 2 and 91% of participants) (31 studies) (Swift et al., 2005; Aggarwal et al., 2009; Hazekamp et al., 2013; Ilgen et al., 2013; Aggarwal et al., 2013a; Aggarwal et al., 2013b; Belle-Isle et al., 2014; Bottorff et al., 2011; Bruce et al., 2018; Coomber et al., 2003; Degenhardt et al., 2015; Erkens et al., 2005; Gorter et al., 2005; Haroutounian et al., 2016; Harris et al., 2000; Hoffman et al., 2017; Kilcher et al., 2017; Lucas & Walsh, 2017; Lynch et al., 2006; Nunberg et al., 2011; Ogborne et al., 2000; Pedersen & Sandberg, 2013; Piper et al., 2017; Reinarman et al., 2011; Schnelle et al., 1999; Sexton et al., 2016; Shiplo et al., 2016; Ste-Marie et al., 2012; Troutt & DiDonato, 2015; Walsh et al., 2013; Ware et al., 2003) or experiencing unspecified chronic non-cancer pain (between 24 and 97% of participants) (17 studies) (Boehnke et al., 2016; Perron et al., 2015; Alexandre, 2011; Bonn-Miller et al., 2014; Brunt et al., 2014; Corroon Jr. et al., 2017; Cranford et al., 2016; Crowell, 2017; Fanelli et al., 2017; Grella et al., 2014; Grotenhermen & Schnelle, 2003; Hazekamp & Heerdink, 2013; Reiman, 2009; Reiman et al., 2017; Shah et al., 2017; Webb & Webb, 2014; Zaller et al., 2015).
Funding information was reported in 28 of the 49 (57%) studies (Table 1); 23 studies were funded by research grants or governmental scholarships (Aggarwal et al., 2009; Perron et al., 2015; Ste-Marie et al., 2016; Aggarwal et al., 2013a; Aggarwal et al., 2013b; Belle-Isle et al., 2014; Bruce et al., 2018; Degenhardt et al., 2015; Erkens et al., 2005; Haroutounian et al., 2016; Harris et al., 2000; Hoffman et al., 2017; Lucas & Walsh, 2017; Pedersen & Sandberg, 2013; Sexton et al., 2016; Shiplo et al., 2016; Ste-Marie et al., 2012; Walsh et al., 2013; Brunt et al., 2014; Corroon Jr. et al., 2017; Cranford et al., 2016; Grella et al., 2014; Lavie-Ajayi & Shvartzman, 2018). Two studies were supported by non-governmental organizations (Hazekamp et al., 2013; Gorter et al., 2005). Five studies received mixed funding from research grants, non-governmental organizations, dispensaries or private foundations (Nunberg et al., 2011; Piper et al., 2017; Reinarman et al., 2011; Ware et al., 2003; Bonn-Miller et al., 2014; Lintzeris et al., 2018). Those five studies also had received funding from commercial cannabis interest or cannabis patient groups (Hazekamp et al., 2013; Gorter et al., 2005; Nunberg et al., 2011; Reinarman et al., 2011; Bonn-Miller et al., 2014; Lintzeris et al., 2018).
Table 1 Brief summary of included studies
Participants' characteristics
Participants' characteristics are described for each study in Table 1 and summarized in Table 4.
Patterns of MC use
Reported patterns of MC use for each study are presented in Table 2 and user experiences relating to the pattern or mode of use are shown in Table 3. The mode of cannabis administration was described in 36 studies. The most common form of MC consumption was inhalation (reported in 35 studies), either via smoking (joint or blunt, joint with tobacco, pipe, water pipe) or vaping (vaporizer) (Swift et al., 2005; Aggarwal et al., 2009; Hazekamp et al., 2013; Ste-Marie et al., 2016; Bottorff et al., 2011; Bruce et al., 2018; Coomber et al., 2003; Erkens et al., 2005; Haroutounian et al., 2016; Harris et al., 2000; Hoffman et al., 2017; Lucas & Walsh, 2017; Lynch et al., 2006; Ogborne et al., 2000; Piper et al., 2017; Reinarman et al., 2011; Schnelle et al., 1999; Sexton et al., 2016; Shiplo et al., 2016; Ste-Marie et al., 2012; Troutt & DiDonato, 2015; Walsh et al., 2013; Ware et al., 2003; Brunt et al., 2014; Cranford et al., 2016; Crowell, 2017; Fanelli et al., 2017; Grella et al., 2014; Grotenhermen & Schnelle, 2003; Shah et al., 2017; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Lintzeris et al., 2018; Reiman, 2007; Sagy et al., 2019). Reported smoking prevalence ranged from 20 (Erkens et al., 2005) to 91% (Cranford et al., 2016) and vaping prevalence from 7 (Crowell, 2017) to 53% (Shiplo et al., 2016). Ingested (cannabis tea, baked goods, oils, tinctures, tablets and capsules) (Hazekamp et al., 2013; Ste-Marie et al., 2016; Bruce et al., 2018; Erkens et al., 2005; Haroutounian et al., 2016; Hoffman et al., 2017; Lucas & Walsh, 2017; Lynch et al., 2006; Piper et al., 2017; Reinarman et al., 2011; Sexton et al., 2016; Troutt & DiDonato, 2015; Walsh et al., 2013; Ware et al., 2003; Brunt et al., 2014; Cranford et al., 2016; Crowell, 2017; Fanelli et al., 2017; Grella et al., 2014; Grotenhermen & Schnelle, 2003; Reiman et al., 2017; Shah et al., 2017; Zaller et al., 2015; Sagy et al., 2019) and topical administration (Ste-Marie et al., 2016; Bruce et al., 2018; Hoffman et al., 2017; Lucas & Walsh, 2017; Sexton et al., 2016; Cranford et al., 2016) were less common forms of MC use (reported in 25 and 6 studies, respectively). The reported prevalence of ingested MC varied from 0.5 (Sexton et al., 2016) to 70% (Erkens et al., 2005) and the prevalence of topical administration varied from 0.6 (Sexton et al., 2016) to 11% (Cranford et al., 2016). A combined mode of cannabis consumption (e.g., both smoked MC and edible MC products) was also reported (Haroutounian et al., 2016; Shiplo et al., 2016; Ste-Marie et al., 2012; Grotenhermen & Schnelle, 2003). Frequency and quantity of MC consumption was described in 23 (Swift et al., 2005; Aggarwal et al., 2009; Hazekamp et al., 2013; Coomber et al., 2003; Erkens et al., 2005; Harris et al., 2000; Lucas & Walsh, 2017; Lynch et al., 2006; Ogborne et al., 2000; Reinarman et al., 2011; Sexton et al., 2016; Shiplo et al., 2016; Troutt & DiDonato, 2015; Walsh et al., 2013; Ware et al., 2003; Bonn-Miller et al., 2014; Brunt et al., 2014; Cranford et al., 2016; Crowell, 2017; Grella et al., 2014; Shah et al., 2017; Zaller et al., 2015; Lintzeris et al., 2018) and 22 studies (Aggarwal et al., 2009; Hazekamp et al., 2013; Ste-Marie et al., 2016; Haroutounian et al., 2016; Harris et al., 2000; Lucas & Walsh, 2017; Lynch et al., 2006; Nunberg et al., 2011; Ogborne et al., 2000; Reinarman et al., 2011; Sexton et al., 2016; Shiplo et al., 2016; Ste-Marie et al., 2012; Troutt & DiDonato, 2015; Walsh et al., 2013; Bonn-Miller et al., 2014; Brunt et al., 2014; Cranford et al., 2016; Fanelli et al., 2017; Grotenhermen & Schnelle, 2003; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Sagy et al., 2019), respectively. Between 38 (Ware et al., 2003) and 90% (Brunt et al., 2014) of participants reported daily MC consumption. Consumed quantity of MC varied from 0.05 (Fanelli et al., 2017) to 1 gram per day (Harris et al., 2000).
Table 2 Patterns of medical cannabis use and utilization of medical cannabis as a substitute for prescription medications
Table 3 Perceived positive and negative effects
Medical cannabis used as a substitute for prescription medications
Of the 20 studies that examined the impact of MC use on the utilization of other prescribed medications (Boehnke et al., 2016; Swift et al., 2005; Bruce et al., 2018; Haroutounian et al., 2016; Lucas & Walsh, 2017; Lynch et al., 2006; Nunberg et al., 2011; Piper et al., 2017; Reinarman et al., 2011; Sexton et al., 2016; Troutt & DiDonato, 2015; Corroon Jr. et al., 2017; Crowell, 2017; Grella et al., 2014; Reiman, 2009; Reiman et al., 2017; Shah et al., 2017; Webb & Webb, 2014; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Sagy et al., 2019), 19 reported that MC consumption was accompanied by a decrease in the number and amount of prescribed drugs used, including opioids, antidepressants, anxiolytics and benzodiazepines, and non-opioid-based pain medication (Boehnke et al., 2016; Swift et al., 2005; Bruce et al., 2018; Haroutounian et al., 2016; Lucas & Walsh, 2017; Lynch et al., 2006; Nunberg et al., 2011; Piper et al., 2017; Reinarman et al., 2011; Sexton et al., 2016; Troutt & DiDonato, 2015; Corroon Jr. et al., 2017; Crowell, 2017; Grella et al., 2014; Reiman, 2009; Reiman et al., 2017; Webb & Webb, 2014; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Sagy et al., 2019) (Table 2). In twelve studies, it had been observed that participants discontinued their use of opioids or other prescription drugs following the start of MC consumption (Swift et al., 2005; Bruce et al., 2018; Haroutounian et al., 2016; Lucas & Walsh, 2017; Nunberg et al., 2011; Reinarman et al., 2011; Sexton et al., 2016; Corroon Jr. et al., 2017; Reiman, 2009; Webb & Webb, 2014; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Sagy et al., 2019), in a proportion varying from 6% (Webb & Webb, 2014) to 63% of participants (Lucas & Walsh, 2017). Participants also reported preferring the use of MC to prescription medication (Grella et al., 2014), mainly because of the adverse effects of their prescription drugs (Lynch et al., 2006).
Past and current use of cannabis and other licit and illicit substances
In 18 studies, 20 (Ste-Marie et al., 2016) to 90% (Harris et al., 2000) of participants reported that they had previously consumed cannabis recreationally or that they consumed it simultaneously to their therapeutic cannabis use (Swift et al., 2005; Hazekamp et al., 2013; Ste-Marie et al., 2016; Belle-Isle et al., 2014; Degenhardt et al., 2015; Erkens et al., 2005; Harris et al., 2000; Hoffman et al., 2017; Lucas & Walsh, 2017; Nunberg et al., 2011; Ogborne et al., 2000; Reinarman et al., 2011; Schnelle et al., 1999; Walsh et al., 2013; Ware et al., 2003; Grella et al., 2014; Grotenhermen & Schnelle, 2003; Shah et al., 2017; Lintzeris et al., 2018; Sagy et al., 2019) (Supplemental Table S1). One study reported that 29% of participants discovered the therapeutic effects of cannabis while using it recreationally (Swift et al., 2005). Six studies suggested that there might be a link between current MC use and past consumption of licit and illicit substances, as a proportion of MC users (3 to 89%) reported a past history of substance abuse, including alcohol, cocaine, amphetamines, hallucinogens, or other prescription drugs (Perron et al., 2015; Ilgen et al., 2013; Harris et al., 2000; Bonn-Miller et al., 2014; Grella et al., 2014; Zaller et al., 2015). Moreover, some MC users considered cannabis a substitute for alcohol (up to 26% of participants) (Lucas & Walsh, 2017) or illicit drugs (up to 16% of participants) (Zaller et al., 2015).
Reported barriers to the medical use of cannabis
Obstacles to the medical use of cannabis have been reported at several levels (Supplemental Table S2), including stigmatization from others (Ogborne et al., 2000; Piper et al., 2017), fear of discrimination (Belle-Isle et al., 2014), and physicians' unwillingness to recommend, certify, or authorize MC (Aggarwal et al., 2009; Belle-Isle et al., 2014; Lucas & Walsh, 2017; Pedersen & Sandberg, 2013). Some MC users expressed health concerns such as pulmonary health or fear of addiction (Swift et al., 2005; Hoffman et al., 2017; Piper et al., 2017; Grella et al., 2014), but no study explicitly investigated perceived addiction to cannabis as a treatment consequence. Difficulties in finding a consistent and affordable MC supply and fear of legal problems associated with MC consumption, e.g., driving after consumption, represent further obstacles to MC utilization (Swift et al., 2005; Aggarwal et al., 2009; Aggarwal et al., 2013a; Aggarwal et al., 2013b; Belle-Isle et al., 2014; Coomber et al., 2003; Hoffman et al., 2017; Lucas & Walsh, 2017; Ogborne et al., 2000; Piper et al., 2017; Alexandre, 2011; Grotenhermen & Schnelle, 2003; Lintzeris et al., 2018).
In the included studies, a majority of participants who used cannabis for therapeutic purposes to relieve pain were aged 28.4 to 62.8 years in average with a proportion of men varying between 18 and 88% (Table 4). The most frequent mode of cannabis administration was smoking. The majority of MC users consumed cannabis daily, in a quantity ranging between 0.05 and 1 gram/day. MC users from reviewed studies reported positive effects on symptoms alleviation in addition to "secondary outcomes" such as psychological well-being. Reported adverse effects associated with MC utilization were few and of minor intensity and were mainly associated with cannabis smoking, such as negative impacts on pulmonary health. MC users also reported a reduction in the use of prescription drugs for the management of chronic pain (Boehnke et al., 2016; Swift et al., 2005; Bruce et al., 2018; Haroutounian et al., 2016; Lucas & Walsh, 2017; Lynch et al., 2006; Nunberg et al., 2011; Piper et al., 2017; Reinarman et al., 2011; Sexton et al., 2016; Troutt & DiDonato, 2015; Corroon Jr. et al., 2017; Crowell, 2017; Grella et al., 2014; Reiman, 2009; Reiman et al., 2017; Webb & Webb, 2014; Zaller et al., 2015; Lavie-Ajayi & Shvartzman, 2018; Sagy et al., 2019).
Table 4 Patients' characteristics
Strengths and limitations of the review
To the best of our knowledge, this is the first comprehensive literature review on the perceptions of persons suffering from CMP or other chronic non-cancer pain, who used cannabis for therapeutic reasons. The information gathered in this review represents an opportunity to better understand the perspective of different types of MC users on the multiple dimensions of its consumption, in particular barriers, advantages, and drawbacks.
However, this review has several limitations, related principally to methodological weaknesses in an important proportion of the included studies.
Selection and recruitment of participants
For 41% of participants, they have been recruited at MC dispensaries, MC associations, or MC advocacy groups, including four studies performed in countries without a legal framework for access to MC (Swift et al., 2005; Coomber et al., 2003; Lintzeris et al., 2018; Pedersen et al., 2016). This might have introduced selection and information biases, as it has been reported that people who are already familiar with cannabis through recreational use, may use cannabis for medical reasons (Bigand et al., 2019; Lum et al., 2019). Indeed, among the about 30% of studies reporting on prior cannabis use, many MC users reported recreational cannabis use prior or simultaneously to MC use. Some MC users reported that it was during the recreational use of cannabis that they discovered its therapeutic effects. Moreover, people who are attending these centers may not use cannabis exclusively for medical reasons. In addition, MC users who had stopped MC consumption participated only marginally in these studies. Prevalence of adverse effects might therefore be underestimated. Furthermore, a subgroup of those studies, for which the source of funding was reported, was financially supported by cannabis interest or patient groups. This may have introduced a positive bias toward the use of cannabis against chronic pain. Therefore, we can argue that study participants were likely not representative of the general population with CMP or other chronic non-cancer pain, since a relevant subgroup of persons suffering from CMP or chronic non-cancer pain, but not considering MC as a therapeutic option, are not represented in the included studies. For instance, the mean age of MC users in the included studies (28.4-62.8 years) was lower than that of patients suffering from CMP, the incidence of which increases with age (Yelin et al., 2016). In addition, overall, the proportion of men in the included studies was higher than that of women, although CMP affects more often women than men (Yelin et al., 2016), suggesting a possible "gender effect": with cannabis consumption being more popular among men than women (Carliner et al., 2017) and considering that individuals who already have consumed cannabis seem to be more disposed to use it as a therapeutic agent, it is possible that men are more likely to use cannabis for therapeutic purpose than women (Swift et al., 2005).
Use of MC with a medical prescription, in a dispensary or in self-medication
In addition, in many studies, it was difficult to distinguish between qualified and self-identified MC users, as it was not specified whether MC use was endorsed by a physician-confirmed diagnosis. It was impossible to estimate the prevalence of each type of user in all selected studies and it was thus not possible to estimate the overall prevalence of self-medication in these studies. Prevalence of self-medication is an important aspect, as it is increasing (Park & Wu, 2017), but self-identified MC users may have different characteristics than qualified MC users. It may become important for physicians to consider the possibility of self-medication with cannabis among their patients with CMP or other chronic pain.
Other methodological concerns
The included studies also varied greatly in terms of objectives, methodology, and participants' populations, with 13 studies out of 49 (27%) having less than 100 participants. Data obtained during interviews or from questionnaires were self-reported and may suffer from recall or social desirability bias, while chart reviews may not have allowed to capture patient perceptions. The different legal frameworks regarding MC use across the different countries and periods of time might have influenced the availability and quality of MC, the sample size of the studies, and the availability of information on MC users. The conditions permitting to be registered as a MC user as well as access to MC vary between countries, states, and over time. For example, MC can be obtained from pharmacies in the Netherlands (Erkens et al., 2005; Brunt et al., 2014; Hazekamp & Heerdink, 2013), from special dispensaries in some states of the USA (Aggarwal et al., 2009; Aggarwal et al., 2013a; Piper et al., 2017; Troutt & DiDonato, 2015; Bonn-Miller et al., 2014; Grella et al., 2014; Zaller et al., 2015), and since 2013 from registered producers in Canada (Ste-Marie et al., 2016; Lucas & Walsh, 2017; Shiplo et al., 2016), as reflected in the included studies with participants recruited at dispensaries, registration clinics, or through online advertisement.
Chronic musculoskeletal pain
Although our scoping review aimed to report on MC users dealing with CMP, we identified only two studies that specifically assessed this type of chronic pain (Ste-Marie et al., 2016). The remaining studies comprised various proportions of participants suffering from CMP or non-specified chronic non-cancer pain. This heterogeneity among MC users may have influenced the reported information on MC consumption and its effects, since no distinction has been made relative to participants' disease. Considering that the pathophysiology of pain varies depending on the syndrome (McMahon et al., 2013), clinical characteristics of participants should be as homogeneous as possible in order to conclude on the effects of MC on participants' pain perception. It is thus somewhat reassuring that the two articles reporting specifically on patients suffering from CMP observed similar results as the other studies reporting on more heterogeneous populations. Indeed, among 1000 consecutive rheumatology patients, Ste-Marie et al. observed that 28 patients consumed MC. In agreement with the other studies, the authors observed that MC users were younger than the other patients of this clinic (52.8 vs. 62.8 years) and were more likely to be male (P = 0.051). In addition, MC users had previously consumed cannabis recreationally and 39.3% of the MC users reported to consume cannabis recreationally, in addition to MC (Ste-Marie et al., 2016).
Gaps in the literature
We identified some gaps in the literature that need to be addressed to better understand patients' utilization of MC against MCP and unspecified chronic non-cancer pain. First, future studies should include participants who have stopped MC consumption or do not want to consider it, in order to understand the reasons that lead to discontinuation or rejection of MC, such as stigmatization of cannabis users or onset of adverse effects associated with MC use. As an example, Zolotov et al. reported that among participants who consumed cannabis for medical reasons, including chronic non-cancer pain (47.5%), those who abandoned MC (20%) experienced more frequent adverse effects (dizziness, dehydrated mouth, fatigue, mild anxiety, and feeling "weird") than those who continued MC use (P < 0.05) (Zolotov et al., 2016).
Supported by a recent literature review, it would be interesting to better understand the point of view of physicians to identify the major factors which impact the decision of prescribing or not medical cannabis for patients who suffered from chronic pain (Gardiner et al., 2019). This would bring new knowledge on whether prescribers need support during the informed decision-making regarding the use of MC to treat CMP. The debate among physicians whether or not to prescribe MC is ongoing and has recently been presented in the literature (Caulley et al., 2018). Moreover, a changing legal framework for recreational cannabis may influence the perception of physicians regarding treatment with MC.
The use of MC as a substitute for other drugs, including opioids and other prescription medications, will need to be investigated for improved decision-making regarding MC prescribing, since opioids present serious, well-documented adverse effects. Currently, clinical guidelines in some countries, e.g., Canada, only support the use of MC for specific medical conditions, including neuropathic pain, palliative cancer pain, chemotherapy-induced nausea and vomiting, and spasticity related to multiple sclerosis or spinal cord injury, especially for those patients who do not respond to conventional therapies (Allan et al., 2018). Further randomized clinical trials that evaluate the efficacy and safety of MC in the management of CMP, other chronic pain or as substitute for opioids are urgently needed, but methodological challenges remain, including difficulties in participants' recruitment and follow-up, and the surveillance of adverse effects.
Although the included studies are frequently exploratory and might be biased by several factors, they describe the perspective of MC users and allow a better understanding of their attitudes and experiences regarding MC use against CMP and other chronic non-cancer pain. These users perceive MC to have more benefits than drawbacks regarding quality of life and adverse effects, and several report on the possibility that MC might decrease the use of some prescription drugs, particularly opioids. However, these user reported experiences must be examined by well-designed and methodologically sound clinical or observational studies before any conclusions can be drawn.
CMP:
THC:
Delta-9-tetrahydrocannabinol
CBD:
NNT:
Number needed to treat
HIV/AIDS:
Human immunodeficiency virus and acquired immune deficiency syndrome
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Ste-Marie PA, Shir Y, Rampakakis E, Sampalis JS, Karellis A, Cohen M, et al. Survey of herbal cannabis (marijuana) use in rheumatology clinic attenders with a rheumatologist confirmed diagnosis. Pain. 2016;157(12):2792–7. https://doi.org/10.1097/j.pain.0000000000000706.
Stockings E, Campbell G, Hall WD, Nielsen S, Zagic D, Rahman R, et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain. 2018;159(10):1932–54. https://doi.org/10.1097/j.pain.0000000000001293.
Swift W, Gates P, Dillon P. Survey of Australians using cannabis for medical purposes. Harm Reduct J. 2005;2(1):18. https://doi.org/10.1186/1477-7517-2-18.
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Tobin DG, Andrews R, Becker WC. Prescribing opioids in primary care: Safely starting, monitoring, and stopping. Cleve Clin J Med. 2016;83(3):207–15. https://doi.org/10.3949/ccjm.83a.15034.
Troutt WD, DiDonato MD. Medical cannabis in Arizona: patient characteristics, perceptions, and impressions of medical cannabis legalization. J Psychoactive Drugs. 2015;47(4):259–66. https://doi.org/10.1080/02791072.2015.1074766.
Walsh Z, Callaway R, Belle-Isle L, Capler R, Kay R, Lucas P, et al. Cannabis for therapeutic purposes: patient characteristics, access, and reasons for use. Int J Drug Policy. 2013;24(6):511–6. https://doi.org/10.1016/j.drugpo.2013.08.010.
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The authors are grateful to the pharmacists Norma Perez, MSc, and Rosa Martins, MSc., for their contribution during the screening of titles and abstracts and the review of eligible references.
This study received financial support from the Centre de recherche sur les soins et les services de première ligne de l'Université Laval (Edeltraut Kröger and study team), from the Réseau québécois de recherche sur le vieillissement – FRQS, and the Centre de recherche sur le vieillissement de Québec of the Centre Intégré Universitaire de la Santé et de Services Sociaux de la Capitale Nationale (CIUSSSCN), as well as logistic support from the Centre de recherche du CHU de Québec – Université Laval (Edeltraut Kröger and part of the study team). None of the financial contributors participated in collection, analysis, or interpretation of data or in writing the manuscript.
Centre d'excellence sur le vieillissement de Québec (CEVQ), Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale (CIUSSSCN), Québec, QC, Canada
Daniela Furrer, Edeltraut Kröger, Martine Marcotte, Nathalie Jauvin, Michèle Aubin & Clermont E. Dionne
Centre de Recherche du CHU de Québec-Université Laval, Québec, QC, Canada
Daniela Furrer, Edeltraut Kröger, Michèle Aubin & Clermont E. Dionne
Faculty of Pharmacy, Université Laval, Québec, QC, Canada
Edeltraut Kröger & Richard Bélanger
Hôpital du Saint-Sacrement, 1050 Chemin Ste-Foy, room L2-30, Québec, QC, G1S 4L8, Canada
Edeltraut Kröger
Faculty of Medicine, Université Laval, Québec, QC, Canada
Richard Bélanger, Michèle Aubin & Clermont E. Dionne
Faculty of Medicine, McGill University, Montréal, QC, Canada
Mark Ware & Pierre Pluye
School of Psychology, Université Laval, Québec, QC, Canada
Guillaume Foldes-Busque
Research Centre of the Centre Intégré de Santé et de Services Sociaux (CISSS) de Chaudière-Appalaches, Lévis, QC, Canada
Daniela Furrer
Martine Marcotte
Nathalie Jauvin
Richard Bélanger
Mark Ware
Michèle Aubin
Pierre Pluye
Clermont E. Dionne
DF performed part of the study selection and most of the synthesis of results and wrote subsequent drafts of the article; EK was the responsible supervisor for DF, wrote the protocol for the review, and was involved in all steps from the review to the writing of the article. MM and NJ both performed several steps of the review and commented on the article; RB, MW, GF-B, MA, and PP contributed to the research question at the origin of the review and to the writing at the article, while CED was involved in all steps of the review and the writing of the article and had the original research idea. The authors read and approved the final manuscript.
Correspondence to Edeltraut Kröger.
Ethics approval consent to participate
Edeltraut Kröger, Daniela Furrer, Martine Marcotte, Nathalie Jauvin, Richard Bélanger, Guillaume Foldes-Busque, Michèle Aubin, Pierre Pluye and Clermont E. Dionne declare that they have no conflict of interest relevant to the content of this study. Mark Ware took a leave of absence from McGill University in 2018, well after most of this review was performed, and is now the Chief Medical Officer at Canopy Growth, Canada. We want to stress that at no time Dr. Ware's new affiliation influenced any step of this scoping review. Having been critically involved in research and in raising interest in the knowledge gap and growing request of patients to use cannabis for the treatment of chronic pain, he continues to be a collaborator in this research. Daniela Furrer has started to work at the Quebec Ministry of Health in July 2019.
42238_2021_96_MOESM1_ESM.docx
Furrer, D., Kröger, E., Marcotte, M. et al. Cannabis against chronic musculoskeletal pain: a scoping review on users and their perceptions. J Cannabis Res 3, 41 (2021). https://doi.org/10.1186/s42238-021-00096-8
Non-cancer chronic pain
Perceived effects
Adverse effect


text:
The Pentagonal League is a defunct NCAA Division I ice hockey-only conference. The league was formed by Dartmouth, Harvard, Princeton and Yale as a way of determining which team, among the oldest ice hockey programs, was the best. The league is a precursor to the Ivy League.

History
The four schools involved can trace the beginning of their ice hockey teams to at least 1905 with Yale's inaugural season in 1895–96 serving as the unofficial dawn of college ice hockey. All four teams ere able to lay claim to a championship since their inception but no formal structure existed to dictate whether one team was superior to another. At the height of the depression, while many programs were in danger of ending, the ice hockey teams at four of the wealthiest institutions in the United States were able to stabilize their schedules by forming the Quadrangular League, an outgrowth of the previous Triangular Hockey League.

The four team league remained in place until 1943 when both Harvard and Princeton suspended their ice hockey programs due to America's participation in World War II. The league resurfaced after the war and was expanded by the addition of Army for the 1946–47 season, becoming the Pentagonal League. The Cadets left the league after two seasons and were promptly replaced by Brown. The league continued in this fashion until 1955, a year after the Ivy League was formally created.

Because the Ivy League never officially supported ice hockey as a sport, the Quadrangular and Pentagonal league are considered informal organizations and not recognized as NCAA conferences.

Members

† both Army and Dartmouth have changed their athletic team names in the years since the Pentagonal League was dissolved.

Membership timeline

See also
 Intercollegiate Hockey Association
 Intercollegiate Hockey League
 Triangular Hockey League

References

Defunct NCAA Division I ice hockey conferences
Sports in the Eastern United States

redpajama_set_name: RedPajamaWikipedia


⚙ D33932 [clang-format] Add support for case-insensitive header matching and use it to improve support for LLVM-style include sorting.
[clang-format] Add support for case-insensitive header matching and use it to improve support for LLVM-style include sorting.
Authored by chandlerc on Jun 6 2017, 3:56 AM.
We have gmock headers now, so it adds support for those to one of the categories.
LLVM does use 'FooTest.cpp' files to test 'Foo.h' so it adds that suffix for finding a main header.
At times the test file's case may not match the header file's case, so adds support for case-insensitive regex matching of these things.
all of LLVM's unittest '#include' lines.
feel free to tell me what all I need to be doing here.
Also add tests for these non-main categories?
Add test coverage for the case-insensitive category logic.
I think this TEST is only for main header sorting. Could you split tests for other categories into a separate TEST?
Update based on review comments.
Tried to address the test comment -- let me know if something else was intended.
Do we really need a flag here? Shouldn't we just always do this?
I have no opinion one way or the other. I opted to not change behavior for existing styles purely in the spirit of making as targeted of a change as I could..
Feel free to tell me how you want this to work / be tested.
Just make clang-format always do this. I don't think anyone is relying on the current behavior.
Update based an Daniel's feedback.
Well, someone did rely on case sensitive match. I thought case insensitive by default was just a Windows thing. Not anymore.
This rule became too greedy on latest revision. Now not only interfaces are prioritized but also all headers that start with [Ii].


The paper focuses on results of field trials for drone detection using CW (Continuous-Wave) radars operating in the C-band. The experiments have involved two different implementations of FMCW (Frequency-Modulated Continuous- Wave) radar and an implementation of CW noise radar. The theoretical comparison of the FMCW and noise radar, along with the description of their implementations is included. The obtained results are presented and discussed. For the conclusion, the limitations of each implementation are identified and recommendations for its usage in considered application are provided.


The cat and I are settling into our routine with fluids. If he feels poorly, he'll cooperate fully, sitting quietly down on the mats in his carrier and letting me freely operate. He won't even get up when we're finished. But if he's feeling good, he gets restless. He's not unhappy -- he's perfectly fine with having fluid dripped into him, purrs the whole time -- but he just doesn't want to stay still in this boring old box. He wants to explore the table, jump down on the floor, or alternatively climb up my arm and onto my shoulder. Purring. I'm trying to keep him in one place, but it's hard to hold a needle in place on a moving cat and get any leverage on said cat with just one other arm.
Wednesday night I came home to find that the bag of fluid -- "lactated Ringer's injection" -- had not been fully closed off the night before. All but the last 50 ml or so had leaked slowly out the tube and spread across my dining room table. Now, my table is an antique, solid oak, refinished by my father (who is a woodworker) in polyurethane and linseed oil. So having half a liter of fluid pool on it for 24 hours wasn't good for it, although not as bad as it might have been with a different kind of finish. I didn't have a tablecloth or anything like that. The table looks just the same, but I can feel the difference in the surface. You can feel that the wood soaked up the water and is curling at the cracks. I don't know if anything can be done about this, or should be done. I'll be asking my father.
But, setting aside the table, there was the more urgent problem of how my cat was going to get his fluids that night. 50 ml isn't enough for a single dose. So I called an emergency animal hospital and talked them into selling me another bag. They're not really supposed to sell it over the counter -- technically it's a medication -- but I hit a sympathetic receptionist. So out I went, at 9 pm, to bring some some lactated Ringer's injection. Animal ERs are a lot like human ERs -- there are a number of people sitting around in the lobby, some looking worried, some just looking tired, and a few people in scrubs outside in the parking lot, smoking.
The cat has rewarded me by being his purry, affectionate self all week, patting my face with his paw to ask for ear scratches and curling up on the bed at night. The vet said his test results showed further improvement, although they were still far from normal. I asked what his prognosis was, generally. She said he might have as long as a year.
I am glad for the somewhat encouraging news about your cat. And I hope your table will be okay!
Thank you! The one thing that's become clear over the past month is that there's no way to know how long he has. But right now he's happy.
I'm glad to hear that he's doing better, and it sounds like you've settled into a routine.
We have enough of a routine that he's started to avoid me when he notices me fiddling with things on the table. *sigh* Hopefully I'll figure out how to make this easier on him fairly soon.
Hugs to you and your cat. Make the most of the time you have. And take lots of pictures. My one regret when I lost Slash, was realizing I only had a few pictures.
Oh, I'm taking lots of pictures! I'm so glad I have a digital camera and can take as many as I like without running out of film, and can see them right away.
The things we do for love...I'm glad things are (sort of) okay. What happens if you have to go away for a few days?
What happens if you have to go away for a few days?
I asked my vet that, and she said that she had a list of pet sitters who had experience administering fluids to cats. Apparently this is a fairly common scenario with older cats.
Yay for happy kitty. And for improvement.
Too bad your table had to pay the price!


I'm 12 years old. I life in house with my parents, brother and 3 animals: dog, hamster, fish :). I have got a lot of friends and best friends. In my free time I love watch films, read books, rollerblade and read books. My favourite school subject is English, but I hate History and Maths, because they are boring.
After school, in Mondays I'm go to the theatrical lesson. In Thurdays I'm go the choir. I love them!
I have got a bit plans to my future: I want to learn some languages: English, German, French, Spanish, Russian and Korean. Once of my dreams is site see all the world, the most I want to visit to Hawaii, the USA and France. I want to live in a big city.
I' ve got only one problem to my future, because I'm not sure what' s job do I have.
My big dream it's about my family and friends that they would be healthy and happy.
What about your life in 2019?


text:
Famous Like Me > Actor > B > Kuno Becker
Profile of Kuno Becker on Famous Like Me
Name: Kuno Becker
Place of Birth: Mexico City, Distrito Federal, Mexico
Kuno Becker (born January 14, 1978 in Mexico City) is a Mexican actor.
Becker's career as an artist began at an early age, although not as an actor but as a musician. When he was six years old, he intended to become a professional violinist. After obtaining a scholarship, he travelled to Europe and began his studies in the famous Mozarteum of the city of Salzburg, Austria, where he spent several years studying the violin with internationally famous teachers such as Denes Zsigmondi and Rugiero Ricci.
At seventeen, however, Kuno made the decision to set aside his career as a violinist, in order to pursue what he now considers his greater passion, acting. He auditioned with more than 3,200 candidates, and was accepted as a student at the Centro de Educación Artística (CEA) of Televisa.
At the age of nineteen, after two years of drama studies, he obtained his first rôle in the telenovela Para Toda la Vida, with which he stayed for 120 episodes. He later participated in the telenovelas Pueblo Chico, Infierno Grande (with Verónica Castro and directed by José Alberto Castro), El Alma no Tiene Color (directed by Juan Osorio) Desencuentro (directed by Ernesto Alonso), Rencor Apacionado (directed by Lucero Suárez), Camila (directed byAngelli Nesma) and Soñadoras. In April 2000 Becker concluded the recording of the telenovela Mujeres Engañadas, his first lead rôle.
In addition to his work in television, Becker has participated in some plays with Televisa. In 1998 he worked in the musical comedy En Roma el Amor es Broma. At the time he was appearing in the telenovela Soñadoras, Becker toured several Mexican cities with his one-man show Culpas Prohibidas. In only a few years and thanks to the Televisa's high profile in Mexico, he has become one of the best-known young actors.
In the cinema he provided the voice of Cale in the Spanish-dubbing of the film Titan A.E., and also appeared in the 1997 film La Primera Noche. In 2002 Becker starred in the film La Hija del Canibal opposite the Argentine actress Cecilia Roth, and in 2005 he played the lead role of Santiago Munez for the film Goal!. Becker has said that now he wishes to concentrate solely on his film career, and is looking for new opportunities not only in Mexican films, but also internationally.
This content from Wikipedia is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article Kuno Becker

redpajama_set_name: RedPajamaCommonCrawl


LEGO Customer Services has updated their database and a lot of the instructions for the 2015 sets and also included were all this year's polybags that will be available. Instead of doing separate posts for all of them, here's a round-up of what you can expect to hit stores later this year. Some of them have already shown up at retailers as well as LEGO promos but I'll add them here since they are part of the 2015 LEGO polybag lineup. If they are already available, I'll add a note specifying how to obtain it. The only one that is missing an image is the LEGO DUPLO Snail (30218).
Note: These are only polybags with set 30xxx and does not include promotional minifigure polybags or ones that have set number 4xxxx.
Available at Target for $3.99.
Available now at LEGO Stores and [email protected] FREE with any LEGO Friends purchase.
Will be available at Toys R Us in near future.
Available at Target now for $3.99.
Available at LEGO Stores and [email protected] in April 2015 with unknown purchase.
Available at LEGO Stores and [email protected] in February with purhcase of $35 or more.


Arabic Diamond Lamp of iron and glass of various colors (blue, mustard, red, green). The package includes a Moroccan diamond shap lamp of colored crystal (does not include chain for hanging).
Light is a very important element in the decoration of the Arab world. This Arabicdiamond lamp of iron and crystal of various colors will introduce a set of colored light reflections creating a romantic and very relaxing.


text:
WHATSINPORT.COM: YOUR CRUISE GUIDE TO 1200 PORTS OF CALL
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Home | Cruise Ships | Port Expenses | Hints and Tips
Florianopolis Brazil Cruise Port
While in Florianopolis, the ship will be anchored off the north coast of Santa Catarina Island. Guests will be taken ashore via ship's tender to the jetty at the Yacht Club. The center of Florianopolis is 12 miles or a 20-minute drive away. Taxis are available at one of the nearby resort hotels.
Printable map to take along on your cruise.
Watch a destination video.
Live Nautical Chart with Wikipedia Markers
Port Location on Google Maps
Monthly Climate Averages for Florianopolis Brazil
Sightseeing:
Florianopolis was founded in 1726 by immigrants from the Azores, along with German and Italian settlers. Located on Santa Catarina Island, which is joined to the mainland by three bridges, the late 19th century pastel-colored, plastered buildings still recall faint "old world" images. The natural beauty of the island, its beaches and bays make Florianopolis a popular tourist center. Most visitors head straight for the island's 42 beaches, with the best ones, found on the north and west coast along with fashionable resorts and some of the best hotel facilities in the country. From here you can also take a flight to see the dramatic Iguacu Falls.
Florianopolis was named after Floriano Peixoto, former Brazilian President who defeated insurrection in the city in 1849. Among the city's historic buildings are three fortresses, the Jesuit Monastery and the 200-year-old Palacio Cruz e Souza, which houses the Historic Museum of Santa Catarina. The metropolitan cathedral stands at the highest point and overlooks the main square. The church features a life-size sculpture in wood of the flight into Egypt, originally from the Austrian Tyrol. Other attractions in the city include the Municipal Market and former Customs House, now converted to contain good craft stalls, art galleries and handicraft shops.
Tours Excursions Transportation:
In Florianópolis, a car is almost a must. You will get a lot more out of your visit with your own transportation, allowing you to explore and come and go as you please. Traffic is relaxed; speed limits and regulations strictly obeyed. Florianópolis is also extremely safe. You can safely park anywhere (though you should remove valuables from the car). Traffic can be very busy on weekends.
The island of Santa Catarina has an efficient bus service (R$2). Buses for the east coast and south island (including Lagoa and Joaquina) depart from the local bus terminal on Rua Antônio Luz.
Buses for the north depart from the local bus terminal on Rua Francisco Tolentino. Additional yellow microbuses (a little more expensive) follow the same routes: their advantages include air-conditioning, fewer stops and direct routes to the beaches.
Most visitors head straight for the island's 42 beaches, with the best ones found on the north and west coasts along with fashionable resorts and some of the best hotel facilities in the country.
Good shopping can be found in Florianopolis on Felipe Schmidt, an all-pedestrian street. Jurere Beach Resort features an Open-Air Shopping Center that is accessible from the jetty via a complimentary shopping shuttle by minivans offered by the merchants. Best items to shop for: local handicrafts and resort wear.
Portuguese spoken.
Cafes which offer free WiFi for customers are sparse.
Opening Hours and Holidays:
Basic hours for most stores and businesses are from 9am to 6pm, with an extended lunch hour from around noon to 2pm.
Many museums are closed on monday.
Holidays in Brazil
Help us to keep this page up to date: Mail us your suggestions
Thank you for printing this article! Please don't forget to come back to whatsinport.com for new and updated port guides.


Our Calgary Massage therapy service can benefit everyone. The benefits of massage are extensive. Massage therapy treatments will have a therapeutic affect and improve health by acting directly on the muscular, nervous, circulatory and lymphatic (immune) systems. Massage therapy is also effective in the control of pain, chronic or acute, in stress reduction, and in creating a sense of relaxation and well-being. Our registered, skilled practitioners can become an important and integral part of your health care team. We can build a comprehensive health care plan for all age's right from birth through your senior years. We can assist you in prevention of injury, healing from injury, relaxation, pregnancy, sickness, reducing your overall stress creating balance and harmony in your overall life.
Mobile massage is another piece in our comprehensive health care plan. Creating ease of access allowing you to focus your time and energy on what is important, you and your health. We travel so you don't have to. Eliminate the stress of travel time, sitting in traffic, finding parking, and enjoy your massage in the comfort of your own home or office. We bring everything required to give you the best massage possible, from your professional, courteous registered massage therapist to the table, linens, oils and music.
Are you looking for a way to increase employee productivity, boost morale or are searching for that special way to say thank you? We offer corporate massage or on site massage. We bring massage tables so your employees lay down and enjoy their massage or we have seated massage options so you do not have to leave your desk as well as Thai table massage to stretch out those aches and pains or reflexology to work on those tired stressed feet.
We can accommodate your group or event. Having a girl's night in, bridal party, birthday party, sporting event, charity event or trade show. We can help!


The Rachel Zoe spring/summer 2014 collection is perhaps one of the most versatile and wearable fashion lines unveiled at New York Fashion Week, which at the same time manages to maintain a high dose of classiness and gorgeousness. For the new warm season, Rachel Zoe apparently got inspired from Yves Saint Laurent, picturing some of the iconic pieces of the luxury fashion house in a modified manner. There you could see the YSL Saharienne jacket that came followed by a white leather bomber jacket, a zebra-printed caftan and cargo pants. Still, on the whole, the collection bore a safari mood, once again making this wonderful desert inspired tendency one of the hottest spring 2014 fashion trends!
Casual, yet classy, relaxed, yet perfectly balanced, the new Rachel Zoe spring/summer 2014 collection has pretty cool outfits for the bright days to come. Moreover, despite its well-defined theme, the line features fairy diverse styles, ranging from casual chic and safari mood to elegant ensembles, from monochrome pieces to wild zebra-patterned ones, from fine silk and delicate transparent fabrics to timeless denim and leather. With this step, Rachel Zoe captures the hearts of many fashionisers – those, who love to experiment with the modern trends and girls hopelessly in love with the classic and timeless style.
The safari theme of the Rachel Zoe spring/summer 2014 collection was well highlighted in the sequined tops, track pants, aqua leather mini dresses and safari jackets. Then, there came also denim shorts, pants and dresses, as well as leather ensembles and some flowing languid dresses either with intricate embroidery or with massive sequins. For fans of classic and feminine fashion, the line brings some smartly tailored pant suits and dresses, midi skirts paired with airy shirts, skirt suits featuring elegant crop tops and flirty short suits.
The Rachel Zoe spring/summer 2014 collection was glamorous and minimalist, sporty and safari, vintage and modern. Indeed, the mother-to-be talented fashion designer managed to ensure her collection's success for spring 2014!


Convert all the great work stored in your PDF to a Word document. Sponsored Links: Why use this PDF to Word document converter. This is a list of links to articles on software used to manage Portable Document Format ( PDF) documents.
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The distinction between the various functions is not entirely clear- cut; for example signatures, some viewers allow adding of annotations etc. There is reason for you to use this online PDF Word converter.
Microsoft Word is currently the most widely- used word processor on the market. Adobe' s own Acrobat DC and Acrobat Reader DC both offer an easy way to convert PDF files to Word documents. The full Acrobat DC has a standard version ( Windows only) that runs $ 12. The wise choice for your routine PDF to Microsoft Word document conversion.
Start making progress. For Mac users who work with the Pages app for word processing compatibility is to. Microsoft Word ( simply Word) is a word processor developed by was first released on October 25 1983 under the name Multi- Tool Word for Xenix systems.
In the process of doing so that' s what I' m going to explain here! Flip PDF to Word Converter Free is an accurate and totally free PDF to Doc utility. Here are the steps to follow: Click the Microsoft Office Button point to the arrow next to Save As, then click cently put them into a Word document that I needed to send to a client.
It can save the recognized text to Microsoft Word or RTF ( Rich Text Format).
Nov 05, · Select a save location. On the left side of the window, click the folder in which you want to store the PDF version of your Word file. Since the PDF is a different file type than the Word document, you can store the PDF in the same file location as the Word file.
How to Convert a PDF to a Word Document. This wikiHow teaches you how to convert a PDF document into an editable Microsoft Word document using Google Docs, Microsoft Word, or Adobe Acrobat Pro.


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TV Shows Home Town Season 5 Release Date & Updates
Home Town Season 5 Release Date & Updates
An American television show starring husband and wife Ben and Erin Napier Home Town premiered on March 21, 2017, on HGTV. The series works on the plot where the couple restores Southern Homes in Laurel, Mississipi.
Curious to what possibilities are awaiting you for Home Town Season Five?
Well, without further ado, let us get into all the information and updates we have on Home Town Season Five's scheduled release date, the potential plot, and who will be in the upcoming cast.
When is Home Town Season Five Release Date?
As you may all be guessing what the potential cast going to be like for Home Town Season Five is, we have all the news you would want to know before you start searching online about the next season because we have the answers you want to know.
Home Town premiered its fourth season on January 20, 2020. Whereas on November 13, 2019, The fifth season was announced with title Home Town Takeover which will release in the next year. It will be back with sixteen brand new episodes to keep us entertained. They will begin shooting as soon as the current spread is in control.
While there is no exact official release date but we can anticipate a release in the initial half of the next year.
What is Home Town Season Five Plot?
While you may all be wondering what the plot going to be like for Home Town Season Five is, we have all the information you would want to know before you binge-watch the upcoming season. So here you have it-
Having a viewer history of more than 30.4 million the show revolves around a married couple named Ben and Erin who are set in Laurel, Mississipi. They, with their imaginary and artistic views, turns age-old worn-out properties into modern homes.
We can also see in the finale episode the power couple visiting Richard T. Jones and his wife, Nancy to renovate their home after being destroyed by Tornado. They will also add a new Backyard for n more elegant look. They can also be seen working with other communities.
We will be back with more exciting and new updates as soon as shooting begins. Let us see what's in store for us in future.
For the rest, we will have to wait for the air date of the series in order to make accurate opinions and comments on the future of the show.