Practical Strategies Using Medical Cannabis to Reduce Harms Associated With Long Term Opioid Use in Chronic Pain

Abstract

Background: Chronic non-cancer pain (CNCP) is estimated to affect 20% of the adult population. Current United States and Canadian Chronic non-cancer pain guidelines recommend careful reassessment of the risk-benefit ratio for doses greater than 90 mg morphine equivalent dose (MED), due to low evidence for improved pain efficacy at higher morphine equivalent dose and a significant increase in morbidity and mortality. There are a number of human studies demonstrating cannabis opioid synergy. This preliminary evidence suggests a potential role of cannabis as an adjunctive therapy with or without opioids to optimize pain control.Methods: In 2017, the Canadian Opioid Guidelines Clinical Tool was created to encourage judicious opioid prescribing for CNCP patients and to reevaluate those who have been chronically using high MED. Mirroring this approach, we draw on our clinical experiences and available evidence to create a clinical tool to serve as a foundational clinical guideline for the initiation of medical cannabis in the management of CNCP patients using chronic opioid therapy.Findings: Following principles of harm reduction and risk minimization, we suggest cannabis be introduced in appropriately selected CNCP patients, using a stepwise approach, with the intent of pain management optimization. We use a structured approach to focus on low dose cannabis (namely, THC) initiation, slow titration, dose optimization and frequent monitoring.Conclusion: When low dose THC is introduced as an adjunctive therapy, we observe better pain control clinically with lower doses of opioids, improved pain related outcomes and reduced opioid related harm.

Why doctors have a moral imperative to prescribe and support medical cannabis—an essay by David Nutt

“…As well as having specific medical benefits, the use of medical cannabis in other countries has had substantial collateral benefits. One particularly encouraging finding—especially given the continuing opioid epidemic in the US—is the possibility of reducing the use of opioid analgesics in patients with chronic pain 2324. Recent patient reported outcomes show that medical cannabis is regularly used as a substitution drug,25 with the most common medications substituted being opioids, anxiolytics or benzodiazepines,26 and antidepressants 27.…”

The pain conductor: brainstem modulation in acute and chronic pain

“…While brainstem pain modulatory systems may contribute to chronic pain, clinical targeting of these systems provides an opportunity for novel development of analgesic treatments. Currently available pharmacological interventions such as opioids and cannabinoids each target brainstem pain modulatory circuits, however these compounds can have significant deleterious adverse effects and addictive potential [49][50][51]. In contrast, there are a number of emerging techniques that may 'naturally' recruit cortical sites that modulate brainstem pain modulatory circuits to ultimately produce pain relief.…”

Ten reasons to consider cannabinoids in everyday clinical practice

“…Interestingly, patients not only report fewer side effects compared to using opioids but also express their preference for cannabinoids [19]. Therefore, cannabis-adjunct therapy may allow physicians to reach sufficient pain control using lower opioid doses and avoid their harmful consequences [35].…”