The clinical manifestations of neuropathic symptoms can range from pain, numbness, paraesthesia, or pruritus. ¹ Neuropathic pruritus is a type of chronic pruritus caused by the dysfunction of itch-sensing neurons and damage to the C-fibers and A-delta fibers.^1,2 Amyotrophic lateral sclerosis is a disorder characterized by the degeneration of upper and lower motor neurons leading to diffuse weakness and muscle wasting. There is growing evidence that amyotrophic lateral sclerosis is associated with small fiber neuron loss, which can be a cause of neuropathic pruritus.^2,3 The presentation of neuropathic pruritus has a large overlap with other causes of pruritus, but can include sensations such as pain, burning, tingling, or numbness in a distal-to-proximal pattern. ¹ Management of neuropathic pruritus begins with targeted investigations to look for reversible causes such as poorly controlled diabetes, thyroid disorders, or autoimmune conditions. The work up can also include nerve conduction studies and labs to rule out metabolic derangements such as uremia or hyperbilirubinemia. ² Chronic pruritus can be difficult to control and these symptoms can lead to decreased quality of life. ¹ The first-line treatments for non-cancer neuropathic symptoms include antidepressants and gabapentinoids. ⁴ Topical agents such as moisturizers, capsaicin and menthol also serve as useful adjuncts. ⁴ Given the lack of long-term efficacy of opioids in chronic non-cancer neuropathic pain, they are generally not recommended as first-line agents by international guidelines.^4,5 As an alternative to standard therapies, there is emerging evidence for the use of cannabinoid within palliative care.^4–6 The pharmacologically active components of cannabinoids include tetrahydrocannabinol (THC) and cannabidiol (CBD), which work as agonists on the endocannabinoid system. ⁷ The endocannabinoid system is a homeostatic regulator that is involved with many physiological function including neurotransmitter regulation, stress response, immune function, and nociceptive processing. ⁷ Tetrahydrocannabinol and cannabidiol work together synergistically and there is evidence that presence of cannabidiol may improve the tolerability of the psychoactive side effects of tetrahydrocannabinol. ⁷ Synthetic tetrahydrocannabinol products without cannabidiol such as nabilone are often limited by psychoactive side effects. ⁷ Balanced formulations such as nabiximol with both tetrahydrocannabinol and cannabidiol may be better tolerated as the CBD component helps mitigate the psychoactive side effects. ⁶

The evidence for cannabinoids is limited by small sample size, methodological design flaws, and lack of standardization of formulation and doses. ⁶ There are numerus examples in the literature where epidemiological and retrospective findings have not been borne out in trial conditions. ⁸ The strongest evidence comes from new trials with better trial design and stricter standardization of doses using pharmaceutical grade formulations. Based on international guidelines and multiple systematic reviews, cannabis has evidence for use in chemotherapy induced nausea and vomiting, multiple sclerosis spasticity, and intractable seizures in Dravet and Lennox-Gastaut syndromes.^5,7–9 There is also growing evidence for the use of cannabinoids in a wide range of neuropathic pain conditions, such as diabetic, HIV, and multiple sclerosis.^4–6 Although prescription cannabinoid products such as nabiximol are better studied, their use is limited by significant cost and lack of third-party drug coverage. With the legalization of medical cannabis in various parts of the world, patients are able to access medical cannabis products through avenues such as Licensed Producers. ¹⁰ Depending on the jurisdiction, Licensed Producers or their equivalents, are federally licensed distributors that undergo strict monitoring to ensure product quality and safety. ¹⁰