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.