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. 2021 Apr 30:12:633168.
doi: 10.3389/fphar.2021.633168. eCollection 2021.

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

Caroline A MacCallum  1   2   3 , Lauren Eadie  1 , Alasdair M Barr  4 , Michael Boivin  5 , Shaohua Lu  1
Affiliations

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

Caroline A MacCallum et al. Front Pharmacol. .

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.

Keywords: cannabinoid based medicine (CBM); chronic pain; clinical tool; harm reduction; medical cannabis; morphine equivalent dose (MED); opioid substitution; safety.

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Conflict of interest statement

CM is the Medical Director of Greenleaf Medical Clinic and Chief Medical Officer for Translational Life Sciences. She is on the Board of Directors for the Green Organic Dutchman. She is an advisor to Andira, and previously Emerald Health Therapeutics, Vitality Biopharma, True Leaf and Strainprint. She has attended advisory board meetings for Syqe Medical, Shoppers Drug Mart, Resolve Digital Health, Scientus Pharma and MedReleaf. Additionally, she has provided medical consultation and/or received support for industry sponsored continuing medical education from: Aleafia, Spectrum, Tilray, Numinus, Aurora, and MD Briefcase. Lastly, she teaches medical cannabis to medical residents, fellows and pharmacy students at the University of British Columbia. AB reports grants and personal fees from Cannevert Therapeutics, grants from Global Cannabis Applications Corp, Emerald Health Therapeutics, and Entourage Biosciences, and personal fees from Medipure Pharmaceuticals and Vitality Biopharma, outside the submitted work; and has been a scientific advisor to Emerald Health Therapeutics, Cannevert Therapeutics, Global Cannabis Applications Corp, Medipure Pharmaceuticals, Vitality Biopharma and Oakum Cannabis Corp. MB has received an honorarium for educational development and was a paid speaker for Shoppers Drug Mart and Khiron. Additionally, MB has provided consulting work for Canopy, Tilray, Khiron, and Shoppers Drug Mart. SL has received speaker fees for Accredited Continuing Medical Education Programs from Lundbeck Canada and Otsuka Canada. MB was employed by CommPharm Consulting Inc. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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