Aaron Sihota1, Brennan K Smith2, Sana-Ara Ahmed3, Alan Bell4, Allison Blain5, Hance Clarke6, Ziva D Cooper7, Claude Cyr8, Paul Daeninck9, Amol Deshpande10, Karen Ethans11, David Flusk12, Bernard Le Foll13,14,15,16,17,18,19, M-J Milloy19,20, Dwight E Moulin21, Vernon Naidoo22, May Ong20, Jordi Perez23, Kevin Rod24, Robert Sealey25, Dustin Sulak26, Zachary Walsh27, Colleen O'Connell28. 1. Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada. 2. Medical Division, CTC Communications, Mississauga, ON, Canada. 3. Medical Director, Anesthesiology and Interventional Chronic Pain, Ahmed Institute for Pain and Cannabinoid Research, Calgary, AB, Canada. 4. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. 5. Department of Anesthesia, Michael G DeGroote Pain Clinic, Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada. 6. Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada. 7. Department of Psychiatry and Biobehavioral Science, UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior University of California, Los Angeles, CA, USA. 8. Department of Family Medicine, McGill University, Montreal, QC, Canada. 9. Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, and CancerCare Manitoba, Winnipeg, MB, Canada. 10. Comprehensive Interdisciplinary Pain Program, Division of Physical Medicine, Toronto Rehabilitation Institute, Toronto, ON, Canada. 11. Department of Medicine, Section of Physical Medicine and Rehabilitation, University of Manitoba, Winnipeg, MB, Canada. 12. Faculty of Medicine, Memorial University of Newfoundland, St John's NL, Canada. 13. Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, ON, Canada. 14. Alcohol Research and Treatment Clinic, Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada. 15. Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada. 16. Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada. 17. Department of Psychiatry, University of Toronto, Toronto, ON, Canada. 18. Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada. 19. British Columbia Centre on Substance Use, Vancouver, BC, Canada. 20. Department of Medicine, University of British Columbia, Vancouver, BC, Canada. 21. Departments of Clinical Neurological Sciences and Oncology, Earl Russell Chair in Pain Medicine, Western University, London, ON, Canada. 22. General Practitioner, Lloydminster, AB, Canada. 23. Department of Anesthesia, McGill University, Montreal, QC, Canada. 24. FCFP Director Toronto Poly Clinic, Lecturer DFCM University of Toronto, Toronto, ON, Canada. 25. Cannabinoid Medicine Specialist, Victoria, BC, Canada. 26. Integr8 Health, Falmouth, ME, USA. 27. Department of Psychology, University of British Columbia, Vancouver, BC, Canada. 28. Department of Physical Medicine and Rehabilitation, Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada.
Abstract
AIMS: Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. RESULTS: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events. CONCLUSIONS: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.
AIMS: Opioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids. RESULTS: In patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events. CONCLUSIONS: This five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.