The Modified Delphi Process
A modified Delphi process was used to develop this consensus guidance
document and associated algorithm.37–39 The methods
used for this report have been previously published in abstract
form.40 The participants were recruited based on
extensive clinical experience with prescribing and managing patients on
medical cannabis and/or extensive research expertise with cannabis. The
consensus process incorporated a five-step modified Delphi method
similar to previous reports41–43 and took place
between July 2019 and November 2019 (Figure 1 and Table 1). In step one
a core scientific committee of cannabinoid subject matter experts from
the United States and Canada (n = 9) identified key areas of focus. From
these areas of focus, an initial draft of consensus questions was
developed, and these questions were incorporated into four domains:
- When to consider introducing cannabinoids in patients with chronic
pain taking opioids
- How to introduce cannabinoids in patients with chronic pain taking
opioids
- When and how to taper opioids in patients with chronic pain taking
cannabinoids
- Evaluating clinical outcomes and guiding patient monitoring and safety
In step two the core scientific committee reviewed the initial draft of
questions and provided comments. Following the inclusion of the
suggested changes to the consensus questions, a teleconference was
conducted to gain verbal approval from the scientific committee to send
out the questions for review by the rest of the consensus summit
participants (n = 13).
In step three the consensus summit participants were provided a
reference package and sent the consensus questions for their review and
associated comments. Twelve of the 13 participants provided their
comments and suggestions.
Following the inclusion of these updates into the consensus questions,
step four was initiated and all summit invitees, which included the core
scientific committee and the participants, reviewed the consensus
questions and prevoted using an online software. Sixteen of the 22
summit invitees provided a prevote. These prevote results were then used
at the live event to focus the discussion on topics where a lack of
consensus was apparent. In step five a formal voting session took place
at an in-person meeting in Toronto, Canada: The Opioids and Cannabinoids
Consensus Summit. The voting was public but anonymous using live polling
software (Slido, www.slido.com). Nineteen participants took part in the
live voting session, however the opportunity to abstain from answering
questions was available.
For consensus to be declared, a predetermined threshold of ≥ 75% of the
voters had to agree on a specific answer, or, ≥ 75% of the voters had
to strongly agree or agree (or strongly disagree or disagree) on an
answer. This consensus threshold is similar to previous studies using a
modified Delphi method. 41,44 At the in-person event,
revisions to the questions and associated answers, and revotes, were
permitted. The voters were instructed that the patient they were
considering was a patient with chronic pain taking opioids who was not
currently using cannabis, recreationally or medically, to treat their
chronic pain. The voters were instructed that the termcannabinoids refers to the most studied of the cannabinoids, ie,
THC and CBD. The voters were instructed to assume there were no patient
access or financial limitations to consider when choosing a given
answer.