The Use of Cannabinoid Patch for Knee Osteoarthritis

This randomized, double-blind 2-arm parallel group study to determine the efficacy of a cannabinoid (CBD) patch on reducing pain in patients with knee osteoarthritis.

The aim of this study is to determine the efficacy of cannabinoid (CBD) patch on reducing pain and improving functional status in patients with knee osteoarthritis (OA). The investigators hypothesize that the use of CBD patch will provide superior pain relief to placebo patch. This will be a randomized, double-blind 2-arm parallel group study in 74 male and female subjects with pain from knee osteoarthritis. Site staff will document the patient's prior treatment for knee osteoarthritis and once the diagnosis has been made, they will be offered to enroll in the study.

After randomization, patients will either be prescribed CBD patch to be used topically for diagnosed knee osteoarthritis versus placebo patch. It will be performed at one site, the physician's office. The study coordinator will be in charge of keeping track of the different patches and all other study personnel and patients will be blinded to the treatment arm. The statistician will conduct the randomization. He will be unblinded and assign participant numbers.

Patients will be diagnosed in an office setting for knee osteoarthritis based on radiographs using the Kellgren Lawrence classification. It is the standard of care to obtain orthogonal knee radiographs when evaluating a patient for knee pain. This will be considered when assessing if the patient is eligible to participate given their pathology. This can be a new diagnosis or an already established diagnosis. The previous treatments that they have received will be noted in the patient charts while screened for eligibility.

Patients taking opioids only recently (less than 3 months) will be required to halt treatment at the time of study enrollment. Opioids don't have anti inflammatory properties so a washout period is not necessary. General patient demographics will be collected using the electronic medical record including: Age, Sex, BMI, Radiographic Osteoarthritis scale (Kellgren Lawrence), which will be put into database by the study investigators and co investigators.

Consent will be obtained by study personnel in the clinical office setting after meeting all study criteria and diagnosis of knee osteoarthritis based on exam and knee xrays. All patients diagnosed with knee osteoarthritis, and who are enrolled in the study, will be prescribed physical therapy that focuses on non-operative treatment such as low impact exercises and activity modification. The patients will not medicate with anti-inflammatory while enrolled in the study. Administration will follow a model of topical patch application which will consist of either the formulated CBD patch (35mg) or identical placebo patch. This patch will be applied to the arthritic knee directly central on the knee. In the event of patients with a diagnosis of bilateral knee OA, the patch will be placed on the knee that has visual analogue scale (VAS) \>3 but \<9. This patch will be placed daily for 24 hours and replaced each day. Including the initial enrollment visit, the patient will meet with the diagnosing orthopedic surgeon at various time points, and will also have remote check ins by study personnel to assess for adverse events and any issues they are having at 2, 4, and 8 weeks. The patient will have the patch for the first 4 weeks of the study followed by 4 weeks without patch which will conclude their participation at 8 weeks. The patients will all begin physical therapy as part of their routine clinical care within 1 week of beginning the study. During this time the patient will be distributed various surveys to measure patient outcomes. The investigators will be looking at pain as a primary endpoint using visual analogue scale with a 2 point difference deemed the minimal clinically important difference.

Subjects who are randomized to either group who have uncontrolled pain will be instructed to take a rescue medication, acetaminophen over the counter use Q 6 hours as needed will be allowed and recorded in a daily drug use diary which will be provided to them.

The patients will have contact information of the surgeon and residents to contact if any side effects are encountered. Compliance with patch use/application, side effects and adherence to physical therapy will also be recorded. Software with be used for both data collection and survey administration for confidential participation, which is a user-friendly HIPAA compliant service utilized by our health system. If the patient is unable to respond to the surveys via their phone app then hard copies of the survey will be given to them and collected by the investigator.

Eligibility Criteria:
Inclusion Criteria:

1. Age\>18 years old
2. Osteoarthritis diagnosed radiographically as Kellgren Lawrence classification 2-4
3. Visual analogue scale greater than 3 but less than 9
4. Subject is able to provide written informed consent prior to any study procedures or interventions.
5. Ability, in the opinion of the investigator, to understand the nature of the study and comply with protocol requirements including compliance with scheduled visits, treatment plan, and any other study procedures outlined in this protocol.
6. Able to wear a patch for 24 hours a day
7. Able to participate in physical therapy

Exclusion Criteria:

1. Subject presents with a visual analogue scale score less than 4 or greater than 8.
2. Subject is Pregnant.
3. Patient has known recent substance abuse or dependence on alcohol (regularly consumes 3 or more alcoholic drinks per day), narcotic analgesics, tranquilizers, or opioids; in the judgement of the investigator within the past 3 years.
4. Subject has had prior surgery to the studied lower extremity within 6 months.
5. Subject has a known history of allergy to CBD or its derivatives
6. Subject has a known history of allergic, idiosyncratic, or serious adverse reactions to acetaminophen.
7. Patient had recent steroid injection to the studied knee within the last 3 months
8. Subject has an inability to be available for follow up
9. Any patients with prior liver pathology including, cirrhosis, hepatitis, Hepatic Carcinoma, or elevated liver function tests will be excluded from the study group. Patients with elevated baseline transaminase levels above 3 times the upper limit of normal, accompanied by elevations in bilirubin above 2 times the upper limits of normal.
10. Subjects with a medical disorder, condition or history such that could impair the subject's ability to participate or complete this study in the opinion of the investigator.
11. Patient has chronic opioid dependency (taking opioid's \>3months), currently taking selective serotonin reuptake inhibitor or benzodiazepines.
12. Patient currently using CBD product and not willing to discontinue use 1 week prior to enrollment.