Discussion
Globally, cannabis is being used to support a reduction or cessation of opioid use for pain. This utilization of cannabis is occurring despite a lack of placebo-controlled, randomized clinical trials and highlights a practical unmet need for expert guidance on the safe co-management of cannabinoids and opioids. The aim of the present project was to develop consensus-based recommendations on how to safely and effectively manage cannabinoid initiation and titration with opioid tapering. The primary consensus findings are provided as an algorithm (Figure 2) to be applied in clinical practice by the health care team.
An important stipulation when considering these consensus-based recommendations is that a patient’s personal considerations should always be taken into account, and that the treating physician’s clinical rationale and individual assessment of the patient is paramount. Many of the consensus recommendations are presented as ranges to allow the health care professional to tailor the cannabinoid and opioid management strategy on an individual basis. Additionally, it is important to maximize psychological and physical therapy treatment interventions before initiation of cannabinoids or any additional pharmaceutical therapy.
A limitation of the consensus-based recommendations provided herein is that they are based primarily on expert opinion developed through a modified Delphi process, and not placebo-controlled, randomized clinical trials. However, as there is a lack of high-quality literature investigating opioids and medical cannabis, the authors of this document leveraged their real-world experience across tens of thousands of patient interactions to support the development of this guidance algorithm with a focus on safety. As new evidence becomes available related to the use of cannabinoids and opioids in patients with chronic pain, the recommendations made within this document will be updated and refined.
We also note that the education of health care professionals surrounding the safe and effective use of medical cannabis is lacking.72,73 We hope that the introduction of this algorithm will initiate more extensive conversations about key educational needs surrounding the safe and effective use of medical cannabis, which may include focused dialogue on the divergent, but perhaps complementary, physiological effects of CBD and THC that lead to the support of opioid tapering and improved pain control. We would recommend learning modules on chronic pain treatment with medical cannabis be completed before prescribing permission be granted.
The unmet need for expert guidance on co-managing cannabinoids and opioids prompted the development of this consensus-based document. Additionally, in the midst of an opioid crisis, the validation of strategies to reduce exposure to opioids is of interest for public health policy. We employed a modified Delphi process to add robustness to our scientific process as these expert consensus-based recommendations are derived primarily from real-world clinical experience in lieu of placebo-controlled, randomized clinical trials. This modified Delphi process led to the development of a series of consensus-based recommendations surrounding the introduction and titration of cannabinoids in concert with the tapering of opioids. These recommendations should be evaluated prospectively to examine if target reductions in opioids may be met. Future rigorous experimental studies in this area will be integral in helping shape formal guidelines.