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Dosing, administering medical cannabis for chronic pain – Recommendations

In Physician’s Weekly, Assistant Professor Alan Bell of the University of Toronto unpacks consensus recommendations from 20 global experts on dosing and administering medical cannabis for chronic pain. Meanwhile, in a United States study, 65% of physicians reported being unable to answer patients’ questions about cannabis as a chronic pain treatment.

Four in five of the health care providers surveyed said patients had requested or asked about cannabis for chronic pain, with 72% reporting that they had been asked in the previous 30 days, reports Forbes: this article is summarised below.

Despite a need for more robust evidence, many patients with chronic pain are being treated with medical cannabis and cannabinoids, according to the Physician’s Weekly story published on 26 November 2021.

In the Journal of Cannabis Research, the Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain – which included the 20 experts from nine countries – published consensus-based recommendations on how to dose and administer medical cannabis for chronic pain using a modified Delphi process. The journal article was published in July.

“Currently, there is reluctance among clinicians to prescribe medical cannabis for chronic pain because there are no accepted guidelines on dosing and administration of this therapy,” says Alan Bell, a Task Force Member and assistant professor in the Department of Family and Community Medicine at the University of Toronto.

“The goal of our consensus recommendations is to provide direction on dosing and administering medical cannabis to give clinicians one more tool in their toolbox to treat chronic pain. These are important recommendations because medical cannabis is an alternative to opioids, which are associated with high potency but also high toxicity.”

Key medical cannabis recommendations

Per the recommendations, there was consensus for considering medical cannabis in patients with neuropathic, inflammatory, neoplastic and mixed pain.

Chronic pain can be treated with medical cannabis following one of three protocols based on patient characteristics – routine, conservative or rapid – and patients can be moved across protocols to help tailor approaches.

Using oral formulations, the Task Force recommends starting with cannabidiol (CBD) in most cases, because many patients benefit solely from CBD. Unlike tetrahydrocannabinol (THC), CBD does not have psychoactive properties, continues Bell in Physician’s Weekly.

The majority of patients can be treated using a routing protocol, in which patients are started on 5 mg of CBD twice daily and titrated by 10 mg every two to three days until they reach their goals, or up to 40 mg/day. THC should only be added if patients fail to respond to CBD.

Starting with 2.5 mg daily, THC may be titrated by 2.5 mg every two to seven days. THC should be capped at 40 mg daily.

A conservative protocol should be used when managing frail and elderly patients with chronic pain and for those with severe comorbidities or polypharmacy, continues Bell in Physician’s Weekly.

With this protocol, CBD is initiated at a dose of 5 mg once daily and titrated by 10 mg every two to three days until patients reach their goals, or up to 40 mg/day. At a CBD dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrating by 1 mg every seven days until a maximum daily dose of 40 mg/day of THC is reached.

Patients with severe pain, cancer and those with significant prior cannabis use can follow the rapid protocol, in which a CBD-THC balanced dose is initiated between 2.5 and 5 mg of each cannabinoid once or twice daily. The dose can be titrated by 2.5-5 mg of each cannabinoid every 2-3 days until patients reach their goals or to a maximum THC dose of 40 mg/day.

The consensus recommendations are flexible because chronic pain treatment is not one-size-fits-all. The Task Force developed algorithms to guide treatment based on individual patient characteristics.

The link to the full article in Physician’s Weekly is below.

 

Study details

Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process

Arun Bhaskar,Alan Bell, Michael Boivin, Wellington Briques, Matthew Brown, Hance Clarke, Claude Cyr, Elon Eisenberg, Ricardo Ferreira de Oliveira Silva, Eva Frohlich, Peter Georgius, Malcolm Hogg, Tina Ingrid Horsted, Caroline A MacCallum, Kirsten R Müller-Vahl, Colleen O’Connell, Robert Sealey, Marc Seibolt, Aaron Sihota, Brennan K Smith, Dustin Sulak, Antonio Vigano and Dwight E Moulin

Author affiliations: United Kingdom: Imperial College London, the Royal Marsden Hospital and the Institute of Cancer Research, both in London. Canada: University of Toronto, CommPharm Consulting, McGill University, University of British Columbia, the Stan Cassidy Centre for Rehabilitation, Cannabinoid Medicine Specialist in Victoria, CTC Communications and Western University. Brazil: Canopy Growth Corporation in São Paulo, and the Vertebralis Spine Center in Rio de Janeiro. Israel: The Technion, Israel Institute of Technology in Haifa. South Africa: Helen Joseph Hospital in Johannesburg. Australia: Pain Rehab in Noosa Heads, the Royal Melbourne Hospital, the University of Melbourne. Denmark: Clinic Horsted in Copenhagen. Germany: Hannover Medical School and the Centers for Pain Medicine in Munich. United States: Integr8 Health in Maine.

Published online in the Journal of Cannabis Research on 2 July 2021.

 

Abstract

Globally, medical cannabis legalisation has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomised control trials studying medical cannabis, indicating that expert guidance on how to dose and administer medical cannabis safely and effectively is needed.

Methods

Using a multistage modified Delphi process, 20 global experts across nine countries developed consensus-based recommendations on how to dose and administer medical cannabis in patients with chronic pain.

Results

There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic and mixed pain. Three treatment protocols were developed.

A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every two to three days until the patient reaches their goals, or up to 40 mg/day.

At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every two to seven days until a maximum daily dose of 40 mg/day of THC.

A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every two to three days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every seven days until a maximum daily dose of 40 mg/day of THC.

A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5 to 5 mg of each cannabinoid once or twice daily and titrates by 2.5 to 5 mg of each cannabinoid every two to three days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day.

Conclusions

In summary, using a modified Delphi process, expert consensus-based recommendations were developed on how to dose and administer medical cannabis for the treatment of patients with chronic pain.

 

Study shows most physicians lack knowledge of medical cannabis

A study of more than 400 health care professionals has revealed that most physicians lack knowledge of medicinal cannabis, with 65% saying that they have been asked about medical marijuana as a treatment for chronic pain but were unable to answer their patients’ questions, writes AJ Herrington in a Forbes story published on 24 November.

The quantitative research study, which was commissioned by cannabis healthcare brand Cannaceutica, surveyed 445 physicians who treat chronic pain, including general practitioners and specialists in fields such as orthopedics, rheumatology and sports medicine, about their knowledge of medical cannabis.

Physicians who participated in the study had from two to 35 years of practice and were at least somewhat knowledgeable about medical cannabis and at least somewhat likely to recommend it to their patients with chronic pain, assuming medical marijuana was legally available.

Vast majority of doctors asked about medical cannabis

An overwhelming majority (84%) of the health care providers surveyed said that their patients had requested or asked about cannabis for chronic pain, with 72% reporting that they had been asked in the previous 30 days.

Dr Daniele Piomelli, director of the Institute for the Study of Cannabis at the University of California, Irvine, said in a press release that the study “emphasises both the public interest around cannabis as an analgesic and the lack of reliable data and/or medical education about its correct use”.

The Forbes story continues: “In 2017, a National Academy of Science expert panel concluded that there was ‘substantial’ but not ‘conclusive’ evidence that cannabis and cannabinoids are effective in treating chronic pain in adults,” Piomelli continued.

“Five years later, we are still lacking the data needed to put this issue to rest, one way or another. It’s time we fill this gap.”

The study, which has not yet been published or peer reviewed, also found that nearly two-thirds (64%) of physicians said that patients themselves were their dominant source of information about cannabis, followed by the internet (44%) and medical journals (40%).

The survey reveals a glaring lack of knowledge about the therapeutic uses of cannabis among health care professionals, most of whom receive little to no education on medical marijuana or the endocannabinoid system in medical school.

Research is revealing increasing evidence and support for the therapeutic use of cannabis for chronic pain, according to the Forbes story. However, cannabis regulatory changes are outpacing the type of evidence many physicians need to feel confident about recommending cannabis to their patients.

The survey of health care professionals found that 81% of physicians believe that cannabis will play a role in the management of chronic pain in the future, but only one in four said that they were very likely to recommend medical marijuana for chronic pain today.

The link to the full article in Forbes is below.

 

Physician’s Weekly article – Recommendations for Dosing & Administering Medical Cannabis for Chronic Pain (Open access)

 

Journal of Cannabis Research article – Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process (Open access)

 

Forbes story – Study Shows Most Physicians Lack Knowledge Of Medical Cannabis (Limited access)

 

See also from the MedicalBrief archives

 

BMJ: New clinical guidelines for medical cannabis in pain relief

 

Physicians search for medicinal cannabis knowledge – Australia and SA

 

Biodata: First SA approval of trial investigating medical cannabis in management of chronic pain

 

Doctors still reluctant to prescribe medical cannabis – Canadian study

 

Interim advice on prescribing of cannabis-based products and cannabinoids

 

 

 

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