Chronic pain patients can be treated with medical cannabis following one of three protocols based on patient characteristics, according to an international task force at the virtual PAINWeek meeting.
Citing limited clinician knowledge about medical cannabis treatment and the opioid crisis, one task force member said the recommendations are timely.
„We as a task force believe it’s extremely important to bring [medical cannabis] to patients,” Alan Bell, MD, of the University of Toronto, told MedPage Today. „Our main focus was to provide directions to clinicians.”
Medical cannabis has been suggested to treat chronic pain, the task force noted, but too many providers still do not utilize it because there has not been accepted guidelines about dosing and administration. Others prescribe medical cannabis without knowing how patients can properly dose.
„There’s a huge knowledge gap and no way clinicians can fall back on a specified dosing regimen,” Bell said.
Led by Arun Bhaskar, MD, of Imperial College Healthcare NHS Trust Pain Management Centre in London, the 20-clinician Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain used a modified Delphi process. Among their recommendations:
- Treat the majority of patients along the „routine” scale. This means starting patients with 5 mg of cannabidiol (CBD) twice daily. Tetrahydrocannabinol (THC) should only be introduced if patients do not respond to at least 40 mg of CBD daily, starting with 2.5-mg daily THC doses. THC doses should be capped at 40 mg daily.
- Frail and elderly patients, and those with severe co-morbidity or polypharmacy should be treated via a conservative route. This means starting the THC dosses at 1 mg daily and titrating up the THC more slowly.
- Patients suffering from severe pain and those who have significant prior cannabis consumption can follow the rapid protocol. This mean starting with a CBD-THC balanced dose of between 2.5-5 mg per each compound once or twice daily.
„Tailoring medical cannabis treatment to the individual is a critical component of successful treatment,” according to the group’s poster presentation at PAINWeek.
The task force recommends starting with CBD in most cases because they have seen many patients benefit solely from CBD. Unlike THC, CBD does not have psychoactive properties.
The task force encourages providers to consider medical cannabis for patients dealing with neuropathic, inflammatory, nociplastic, and mixed pain.
The task force did not set a maximum treatment age; many of its clinicians reported seeing best results among geriatric patients, Bell said. They did not set a minimum CBD treatment age, with many treating pediatric patients with high doses of CBD for epilepsy.
The task force did not set a minimum treatment age for THC because they could not come to an agreement, Bell said. That does not mean they endorse treating minors with THC; the brain’s neuroplasticity until age 25 eliminates that possibility, Bell said.
They suggested the best administration method is oral because of „ease of dosing and safety,” according to the poster.
They recommended pregnant and breastfeeding women, and people with psychotic disorders, not be administered medical cannabis. They also cautioned against mixing medical cannabis with anticoagulants, immunotherapy, or the epilepsy medication clobazam (Onfi, Sympazan, Frisium).
The task force needed 75% agreement to adopt any resolutions and Bell said they agreed to most of their recommendations on the first vote.
„There’s way too much of opioids being used for chronic pain despite a lack of evidence and the harms associated with opioids,” Bell said. „We feel this is a major barrier that we are trying to overcome…that may exist because of the knowledge gap” regarding medical cannabis.
The task force featured clinicians from North America, Brazil, Europe, Australia, and Africa, according to the poster. It also included clinicians „with many, many years” of clinical experience working with medical cannabis, Bell said, from practices ranging from primary care to oncology to pediatrics and more.
They began the consensus process by completing clinical practice surveys, then reviewed questions and attended two virtual meetings.