Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Jason W Busse^{1

2

3

4}, Patrick Vankrunkelsven^{5

6}, Linan Zeng^{2

7}, Anja Fog Heen⁸, Arnaud Merglen⁹, Fiona Campbell¹⁰, Lars-Petter Granan¹¹, Bert Aertgeerts^{12

13}, Rachelle Buchbinder^{14

15}, Matteo Coen^{16

17}, David Juurlink^{18

19}, Caroline Samer^{20

21}, Reed A C Siemieniuk², Nimisha Kumar²², Lynn Cooper²³, John Brown⁴, Lyubov Lytvyn², Dena Zeraatkar^{2

24}, Li Wang^{2

3}, Gordon H Guyatt², Per O Vandvik⁸, Thomas Agoritsas^{2

25}

Affiliations

¹ Michael G DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON, Canada bussejw@mcmaster.ca.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
³ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
⁴ Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada.
⁵ Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium.
⁶ Department of Public Health and Primary Care, Katholieke Universiteiti Leuven, Leuven, Belgium.
⁷ Pharmacy Department/Evidence-based Pharmacy Centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
⁸ Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.
⁹ Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland.
¹⁰ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
¹² Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven.
¹³ CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium.
¹⁴ Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
¹⁵ Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia.
¹⁶ Division of General Internal Medicine, Department of Medicine, Geneva University Hospital, Geneva, Switzerland.
¹⁷ Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
¹⁸ Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁹ Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada.
²⁰ Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals.
²¹ Faculty of Medicine, University of Geneva, Switzerland.
²² Indiana University School of Medicine, Indianapolis, IN, USA.
²³ Canadian Injured Workers' Alliance, Thunder Bay, ON, Canada.
²⁴ Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
²⁵ Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland.

PMID: 34497062
DOI: 10.1136/bmj.n2040

Practice Guideline

Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Jason W Busse et al. BMJ. 2021.

. 2021 Sep 8:374:n2040.

doi: 10.1136/bmj.n2040.

Authors

Affiliations

¹ Michael G DeGroote Centre for Medicinal Cannabis Research, McMaster University, Hamilton, ON, Canada bussejw@mcmaster.ca.
² Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
³ Department of Anesthesia, McMaster University, Hamilton, ON, Canada.
⁴ Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, ON, Canada.
⁵ Belgian Centre for Evidence Based Medicine (CEBAM), Leuven, Belgium.
⁶ Department of Public Health and Primary Care, Katholieke Universiteiti Leuven, Leuven, Belgium.
⁷ Pharmacy Department/Evidence-based Pharmacy Centre, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
⁸ Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway.
⁹ Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland.
¹⁰ Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ Department of Pain Management and Research, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
¹² Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven.
¹³ CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium.
¹⁴ Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
¹⁵ Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Australia.
¹⁶ Division of General Internal Medicine, Department of Medicine, Geneva University Hospital, Geneva, Switzerland.
¹⁷ Unit of Development and Research in Medical Education, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
¹⁸ Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹⁹ Departments of Medicine and Pediatrics, University of Toronto, Toronto, ON, Canada.
²⁰ Division of Clinical Pharmacology and Toxicology, Geneva University Hospitals.
²¹ Faculty of Medicine, University of Geneva, Switzerland.
²² Indiana University School of Medicine, Indianapolis, IN, USA.
²³ Canadian Injured Workers' Alliance, Thunder Bay, ON, Canada.
²⁴ Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA.
²⁵ Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1211, Geneva, Switzerland.

PMID: 34497062
DOI: 10.1136/bmj.n2040

Abstract

Clinical question: What is the role of medical cannabis or cannabinoids for people living with chronic pain due to cancer or non-cancer causes?

Current practice: Chronic pain is common and distressing and associated with considerable socioeconomic burden globally. Medical cannabis is increasingly used to manage chronic pain, particularly in jurisdictions that have enacted policies to reduce use of opioids; however, existing guideline recommendations are inconsistent, and cannabis remains illegal for therapeutic use in many countries.

Recommendation: The guideline expert panel issued a weak recommendation to offer a trial of non-inhaled medical cannabis or cannabinoids, in addition to standard care and management (if not sufficient), for people living with chronic cancer or non-cancer pain.

How this guideline was created: An international guideline development panel including patients, clinicians with content expertise, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach. The MAGIC Evidence Ecosystem Foundation (MAGIC) provided methodological support. The panel applied an individual patient perspective.

The evidence: This recommendation is informed by a linked series of four systematic reviews summarising the current body of evidence for benefits and harms, as well as patient values and preferences, regarding medical cannabis or cannabinoids for chronic pain.

Understanding the recommendation: The recommendation is weak because of the close balance between benefits and harms of medical cannabis for chronic pain. It reflects a high value placed on small to very small improvements in self reported pain intensity, physical functioning, and sleep quality, and willingness to accept a small to modest risk of mostly self limited and transient harms. Shared decision making is required to ensure patients make choices that reflect their values and personal context. Further research is warranted and may alter this recommendation.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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Conflict of interest statement

Competing interests: All authors have completed the BMJ Rapid Recommendations interests disclosure form and a detailed, contextualised description of all disclosures is reported in appendix 2. As with all BMJ Rapid Recommendations, the executive team and The BMJ judged that no panel member had any financial conflict of interest. Personal, professional, and academic interests were minimised as much as possible, while maintaining necessary expertise on the panel to make fully informed decisions.

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Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

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Medical cannabis or cannabinoids for chronic pain: a clinical practice guideline

Authors

Affiliations

Abstract

Conflict of interest statement

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