Each of the protocols - routine, conservative or rapid - titrates from lower to higher doses of non-psychoactive cannabidiol (CBD) and the psychoactive compound tetrahydrocannabinol (THC).
"The main issue we're trying to address is a barrier to the utilization of CBM - cannabinoid-based medicine. The barrier is clinicians just don't know how to dose it. They know it's a useful tool to have in your toolbox, but they don't know how to dose it. The literature is a dog's breakfast of a mish-mash of different trials," Dr. Alan Bell of the University of Toronto, in Canada, told Reuters Health by phone.
PAINWeek is organized by the American Academy of Pain Medicine, the American Chronic Pain Association, the American Pain Society, the American Society of Pain Educators, the National Association of Drug Diversion Investigators, the Power of Pain Foundation and the U.S. Pain Foundation.
In the absence of dose-finding trials, which have not been widely performed, Dr. Bell and several other clinicians working with chronic pain sought to develop a consensus on the topic.
The expert panel agreed that medical cannabis may be an option for patients with neuropathic, inflammatory, nociplastic and mixed pain. They also agreed on delivery methods: Oral oil or capsules should be preferred, but vaporized flowers or buds are indicated for breakthrough pain.
The protocols they suggest are fluid, so clinicians may shift among them as needed.
The routine protocol is suitable for most patients. The panel recommends starting patients on 5 mg CBD twice daily, titrating by 10mg CBD every two to three days up to 40 mg per day or until pain is under control.
Patients taking the 40 mg dose can add THC at 2.5 mg, titrating by 2.5 mg every two to seven days up to 40 mg per day.
The conservative protocol for patients sensitive to medical cannabis starts at 5 mg CBD once per day, titrating by 10 mg every two to three days up to 40 mg per day, or until pain is controlled. Once on the maximum dose of CBD, patients may add THC at 1 mg per day, titrating by 1 mg every week up to 40 mg per day.
The rapid protocol is for patients who are experienced with cannabis or who have severe pain. These patients start CBD and THC at 2.5 mg to 5 mg once or twice daily. Both cannabinoids are titrated by 2.5 mg to 5 mg every two to three days up to 40 mg per day, or until pain is controlled.
The panel did not reach consensus on the minimum age for administering THC. There was consensus, however, that CBD is appropriate for all ages and that no patient is too old for THC.
The work was a "labor of love" intended to simplify the use of cannabinoids as an alternative in clinics that prescribe opioids, Dr. Bell said.
The panel Dr. Bell and colleagues convened included physicians who prescribe cannabinoid-based medicine in North America, Western Europe and the United Kingdom, Israel, Australia, South Africa and Brazil.
To reach consensus, the experts employed a version of a Delphi process. They submitted questions to the panel for two rounds of answers, voting, commenting and tweaking their recommendations until a third and final round of voting. Recommendations that achieved agreement of 75% or greater were considered consensus.
"I think it's a valiant effort, but I'm not exactly sure how useful it is," said Dr. Donald Abrams, a professor emeritus of medicine at the University of California, San Francisco, who was not involved in the work. "My concern is that I don't think they'll see a desired effect with the CBD recommendations."
The protocols start CBD at 5 mg, but patients should start at 80 mg or thereabout, Dr. Abrams told Reuters Health by email. He also believes that CBD may be ineffective to treat pain if THC is not included. And the maximum recommended dosage of THC at 40 mg would "knock out a horse," Dr. Abrams said.
Dr. Abrams does agree that cannabinoids have a place in pain treatment. He was a member of a panel of 16 experts convened by the National Academy of Sciences, Engineering and Medicine to write The Health Effects of Cannabis and Cannabinoids in 2017. One of their findings was that "there was conclusive or substantial evidence that cannabis or cannabinoids are effective for the treatment of pain in adults; chemotherapy-induced nausea and vomiting and spasticity associated with multiple sclerosis." (https://nap.edu/24625)
Dr. Abrams has treated pain through his oncology practice, but cannabinoid-dosing recommendations are not useful in the current legal climate, he said. Under U.S. federal law, doctors are not allowed to prescribe cannabinoids, but Dr. Abrams has suggested that his patients visit a dispensary.
Marijuana is a Schedule I substance at the U.S. federal level, meaning that it has no accepted medical use. State laws differ, and 33 states plus the District of Columbia, Guam, Puerto Rico and the U.S. Virgin Islands have legalized medical marijuana.
Even if cannabinoids were federally legal, however, dosing recommendations may not be especially helpful, according to Dr. Abrams.
"I don't think this is a treatment that requires a package insert. I think most patients are going to be able to figure out how to use cannabis themselves. I think the attempt to pharmaceuticalize cannabis is unfortunate. It has been around for 3,000 years and people have figured out how to use it," Dr. Abrams said.
By Rob Goodier
SOURCE: https://bit.ly/3mZrkyc PAINWeek, September 11-13, 2020.
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