Arun Bhaskar1, Alan Bell2, Michael Boivin3, Wellington Briques4, Matthew Brown5,6, Hance Clarke7, Claude Cyr8, Elon Eisenberg9, Ricardo Ferreira de Oliveira Silva10, Eva Frohlich11, Peter Georgius12, Malcolm Hogg13,14, Tina Ingrid Horsted15, Caroline A MacCallum16, Kirsten R Müller-Vahl17, Colleen O'Connell18, Robert Sealey19, Marc Seibolt20, Aaron Sihota21, Brennan K Smith22, Dustin Sulak23, Antonio Vigano24, Dwight E Moulin25. 1. Pain Management Centre, Imperial College Healthcare NHS Trust, London, UK. 2. Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada. 3. CommPharm Consulting, Barrie, ON, Canada. 4. Canopy Growth Corporation, São Paulo, Brazil. 5. Department of Pain Medicine, The Royal Marsden Hospital, London, UK. 6. The Institute of Cancer Research, London, UK. 7. Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada. 8. Department of Family Medicine, McGill University, Montreal, QC, Canada. 9. Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel. 10. Vertebralis Spine Center, Rio de Janeiro, Brazil. 11. Department of Anaesthesiology and Pain Management, Helen Joseph Hospital, Johannesburg, South Africa. 12. Pain Rehab, Noosa Heads, Australia. 13. Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Australia. 14. Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia. 15. Clinic Horsted, Copenhagen, Denmark. 16. Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada. 17. Hannover Medical School, Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany. 18. Department of Physical Medicine and Rehabilitation, Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada. 19. Cannabinoid Medicine Specialist, Victoria, BC, Canada. 20. Algesiologikum- Centers for Pain Medicine, Day Clinic for Pain Medicine, Munich, Germany. 21. The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada. 22. CTC Communications, Medical Division, Mississauga, ON, Canada. 23. Integr8 Health, Falmouth, Maine, USA. 24. Department of Oncology, McGill University, Montreal, QC, Canada. 25. Departments of Clinical Neurological Sciences and Oncology, Earl Russell Chair of Pain Medicine, Western University, 800 Commissioners Road East, London, ON, N6A 5W9, Canada. Dwight.Moulin@lhsc.on.ca.
Abstract
BACKGROUND: Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed. METHODS: Using a multistage modified Delphi process, twenty 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 2 to 3 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 2 to 7 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 2 to 3 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 7 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 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 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.
BACKGROUND: Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed. METHODS: Using a multistage modified Delphi process, twenty 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 2 to 3 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 2 to 7 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 2 to 3 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 7 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 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 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.
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