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Consensus-Based Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control
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  • Aaron Sihota,
  • Brennan Smith,
  • Sana-Ara Ahmed,
  • Alan Bell,
  • Allison Blain,
  • Hance Clarke,
  • Ziva Cooper,
  • Claude Cyr,
  • Paul Daeninck,
  • Amol Deshpande,
  • Karen Ethans,
  • David Flusk,
  • Bernard Le Foll,
  • M-J Milloy,
  • Dwight Moulin,
  • Vernon Naidoo,
  • May Ong,
  • Jordi Perez,
  • kevin ROD,
  • Robert Sealey,
  • Dustin Sulak,
  • Zachary Walsh,
  • Colleen O'Connell
Aaron Sihota
The University of British Columbia Faculty of Pharmaceutical Sciences
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Brennan Smith
CTC Communications Corp
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Sana-Ara Ahmed
Ahmed Institute for Pain and Cannabinoid Research
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Alan Bell
University of Toronto
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Allison Blain
McMaster University
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Hance Clarke
University of Toronto
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Ziva Cooper
UCLA
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Claude Cyr
McGill University
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Paul Daeninck
University of Manitoba
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Amol Deshpande
Toronto Rehabilitation Institute
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Karen Ethans
University of Manitoba
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David Flusk
Memorial University of Newfoundland
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Bernard Le Foll
Centre for Addiction and Mental Health
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M-J Milloy
British Columbia Centre on Substance Use
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Dwight Moulin
Western University
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Vernon Naidoo
General Practitioner
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May Ong
The University of British Columbia
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Jordi Perez
McGill University
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kevin ROD
University of Toronto
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Robert Sealey
Cannabinoid Medicine Specialist
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Dustin Sulak
Integr8 Health
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Zachary Walsh
The University of British Columbia
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Colleen O'Connell
Stan Cassidy Centre for Rehabilitation
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Abstract

Aims: Opioid misuse and overuse has 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 CBD-predominant oral extract in the daytime and consider adding 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 optimized. 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.

Peer review status:UNDER REVIEW

19 May 2020Submitted to International Journal of Clinical Practice
19 May 2020Assigned to Editor
19 May 2020Submission Checks Completed
27 Aug 2020Reviewer(s) Assigned
10 Sep 2020Review(s) Completed, Editorial Evaluation Pending