For patients with chronic pain in whom standard care is insufficient, physicians may consider trying non-inhaled medical cannabis or cannabinoids, according to a newly issued international guideline published in The BMJ.
“The increasing legalization of medical cannabis globally, escalating use by patients, lack of training in the use of medical cannabis or cannabinoids during formal medical education, and inconsistent guidance from professional associations and federal agencies have led to confusion regarding the role of medical cannabis in the management of chronic pain. In this guideline we have sought to address this confusion by asking what is the optimal, evidence-based use of medical cannabis or cannabinoids for chronic pain,” noted Jason W. Busse, DC, PhD, of the Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, Ontario, Canada, and fellow guideline authors.
This international guideline was developed by a panel that included general practitioners, a physical medicine and rehabilitation physician, internists, a pediatrician, a pediatric anesthesiologist, pharmacists, physicians specializing in pain management, clinical pharmacologists, a chiropractor, a rheumatologist, methodologists, and people living with chronic pain. Evidence was based on four systematic reviews of medical cannabis for chronic pain.
Chronic pain is defined as “pain that persists or recurs for 3 months or more,” and it affects approximately 20% of individuals living in North America, Australia, and Europe, and 10%-14% of those living in the U.K.
The guideline panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids added to standard care for patients with chronic non-cancer and cancer related pain.
“The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small-to-very-small improvements in self-reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small-to-modest risk of mostly self-limited and transient harms,” wrote the authors.
The recommendation applies to patients with cancer and non-cancer pain, neuropathic pain, nociceptive pain, and nociplastic pain. It may/may not apply to pediatric patients, veterans, patients with concurrent medical illness, and those receiving disability benefits or involved in litigation. Finally, the recommendation does not apply to inhaled medical cannabis, recreational cannabis, and patients receiving end-of-life care.
The panel reported confidence in the ability of non-inhaled medical cannabis or cannabinoids to:
- Effect small increases in the number of individuals with chronic pain who experienced important improvements in pain and quality of sleep.
- Effect small-to-very-small increases in the number of individuals with chronic pain experiencing cognitive impairment, vomiting, drowsiness, impaired attention, and nausea.
- Moderately increase the number of people with dizziness that increased with longer follow-up.
They also found high certainty evidence that non-inhaled medical cannabis and cannabinoids would not improve emotional, role, or social functioning.
Busse et al also summarized the key practical issues that characterize the use of cannabis in patients living with chronic pain:
- Consider previous cannabis experience and carefully monitor adverse events.
- Prefer cannabidiol-predominant preparations for younger or adolescent patients over tetrahydrocannabinol, due to uncertain effects on neurocognitive development.
- Recommend that patients avoid driving or operating machinery while initiating or changing dose of medical cannabis.
- Encourage discontinuation of medical cannabis in women considering pregnancy, those who are pregnant, and those who are breastfeeding, in favor of alternative therapy.
- Begin therapeutic trials with low dose, non-inhaled cannabidiol products and gradually increase the dose and tetrahydrocannabinol level depending on patients’ clinical responses and tolerance.
With data from 15 studies of adults with both cancer and non-cancer related chronic pain, Busse and colleagues also found moderate-to-high certainty evidence of the following:
- A greater preference for medical cannabis products with balanced ratios of THC:CBD or high CBD products, but not for high THC products.
- Influence of both positive and negative social consequences on the use of medical cannabis or cannabinoids.
- Concerns about adverse effects, addiction to, tolerance for, loss of control, or unusual behavior exist and are related to an unwillingness to use cannabis.
- Concerns that the cost of medical cannabis or cannabinoids is too high.
- The positive influence of recent legalization that has improved access to medical cannabis on their decision to pursue treatment for symptom relief.
Edeltraut Kröger, of the CN Hôpital St-Sacrement, and Clermont E. Dionne, PhD, of the Université Laval, both in Québec, Canada, stressed the need for clinician guidance in this area.
“This new patient-centered guidance can improve shared decision making: clinicians should emphasize the harms associated with vaping or smoking cannabis and, as recommended by other guidelines, suggest products with known compositions such as nabilone or nabiximols, discourage self-medication, and pay particular attention to vulnerable populations. Increased pharmacovigilance of all cannabis use remains a priority, along with an ambitious program of rigorous research on the short- and long-term effectiveness and safety of individual cannabis products for specific types of chronic pain,” they wrote in an accompanying editorial.
According to Kröger and Dionne, some methodological and ethical flaws in the trials used—including follow-up of less than 6 months, small sample sizes, industry funding, and the use of different outcome measures—may limit “the level of certainly in the evidence underpinning Busse and colleagues’ recommendations.”
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An international expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain.
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Their recommendation was based on a linked series of four systematic reviews of the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain.
Liz Meszaros, Deputy Managing Editor, BreakingMED™
The Michael G DeGroote Centre for Medicinal Cannabis Research funded the MAGIC Evidence Ecosystem Foundation to support the creation of this Rapid Recommendation. The central operating funding for the Michael G DeGroote Centre for Medicinal Cannabis Research is from a philanthropic gift to the Michael G DeGroote Initiative for Innovation in Healthcare. The centre receives no funding from industry.
Kroger and Dionne reported no disclosures.
Cat ID: 393
Topic ID: 392,393,393,435,730,138,192,146,397,922,925
