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. 2024 Apr;9(2):669-687.
doi: 10.1089/can.2021.0156. Epub 2023 Mar 27.

Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions

Alan D Bell  1 , Caroline MacCallum  2 , Shari Margolese  3 , Zach Walsh  4 , Patrick Wright  5 , Paul J Daeninck  6   7 , Enrico Mandarino  3   8 , Gary Lacasse  5 , Jagpaul Kaur Deol  9 , Lauren de Freitas  10 , Michelle St Pierre  4 , Lynne Belle-Isle  5 , Marilou Gagnon  11 , Sian Bevan  12 , Tatiana Sanchez  4 , Stephanie Arlt  10 , Max Monahan-Ellison  13 , James O'Hara  14 , Michael Boivin  15 , Cecilia Costiniuk  16   17   18
Affiliations

Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions

Alan D Bell et al. Cannabis Cannabinoid Res. 2024 Apr.

Abstract

Background: One in five individuals live with chronic pain globally, which often co-occurs with sleep problems, anxiety, depression, and substance use disorders. Although these conditions are commonly managed with cannabinoid-based medicines (CBM), health care providers report lack of information on the risks, benefits, and appropriate use of CBM for therapeutic purposes. Aims: We present these clinical practice guidelines to help clinicians and patients navigate appropriate CBM use in the management of chronic pain and co-occurring conditions. Materials and Methods: We conducted a systematic review of studies investigating the use of CBM for the treatment of chronic pain. Articles were dually reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical recommendations were developed based on available evidence from the review. Values and preferences and practical tips have also been provided to support clinical application. The GRADE system was used to rate the strength of recommendations and quality of evidence. Results: From our literature search, 70 articles met inclusion criteria and were utilized in guideline development, including 19 systematic reviews and 51 original research studies. Research typically demonstrates moderate benefit of CBM in chronic pain management. There is also evidence for efficacy of CBM in the management of comorbidities, including sleep problems, anxiety, appetite suppression, and for managing symptoms in some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia, and arthritis. Conclusions: All patients considering CBM should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration, and administration routes for each individual. Systematic Review Registration: PROSPERO no. 135886.

Keywords: cannabinoid-based medicines; cannabinoids; cannabis; chronic pain; marijuana; sleep disorders.

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Conflict of interest statement

T.S., S.A., L.B.-I., M.S.P., S.B., M.M.E., L.F., J.K.D., and J.O. do not have any conflicts of interest. P.W. and G.L.'s employer, the Canadian AIDS Society, has received a grant from Canopy Growth Corporation to support the development of the clinical practice guidelines. Z.W. is an advisory board member of Multidisciplinary Association for Psychedelic Studies—Canada. He has received research support from DOJA and Tilray licensed producers of cannabis and is a former Director of Clinical Research for Indigenous Bloom cannabis company. S.M. is the co-owner of a start-up company (“Cannabiscotti, Inc.”) that will be applying for a cannabis processing license. She holds shares in Canopy Growth Corporation, Emblem Corp, and Aphria, Inc. She has received honorarium for research projects funded by Canopy Growth Corporation and Tilray. A.D.B. has received funding for consulting, speaking, and/or research from the following commercial organizations: Amgen, Bristol Myers Squibb, Janssen, AstraZeneca, Novartis, Pfizer, Bayer, Lilly, Boehringer Ingelheim, HLS Therapeutics, Spectrum Therapeutics, Sanofi, Bausch Health, Akcea, and Eisai. He holds shares in a wide variety of pharmaceutical companies and cannabis licensed producers. He has contributed, pro bono, to publications, position statements, and/or clinical practice guidelines from the following non-commercial organizations: Thrombosis Canada, Hypertension Canada, Heart and Stroke Foundation, Canadian Cardiovascular Society, and the Canadian Aids Society.

P.J.D. is a member of the Medical Advisory Board for Shoppers Drug Mart, a consultant for Reformulary Group, a member of the Speakers Bureau for Medical Cannabis Education for Shoppers Drug Mart and Spectrum Therapeutics, and participates in clinical trials for CancerCare Manitoba as per contract requirements. M.G. is the president and co-founder of the Harm Reduction Nurses Association. She was a board member of The Canadian HIV/AIDS Legal Network. She has received an honorarium payment from Merck for a presentation on HIV medication side-effects. C.M. is the Medical Director of Greenleaf Medical Clinic and 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, Shoppers Drug Mart, True Leaf, Resolve Digital Health, Doja, and Compass Cannabis Clinics. She teaches medical cannabis to medical residents and pharmacy students at the University of British Columbia. She has provided medical consultation and/or received support for industry-sponsored continuing medical education from: Canopy/Spectrum, Tilray, Strainprint, Scientus Pharma, Aurora, MedReleaf & MD Briefcase.

E.M. is the co-owner of a start-up company (“Cannabiscotti, Inc.”) that will be applying for a cannabis processing license, and is employed by MJardin Canada. C.C. has received cannabinoids from Tilray, Inc., for use in a clinical trial but has not received any grant support nor honoraria from the company. She has received research funding from Merck and Gilead, speaker honorarium from Gilead, and consultant fees from Viiv Healthcare. She has received funding to attend conferences from Gilead and Viiv Healthcare.

Figures

FIG. 1.
FIG. 1.
Suggested approach for adjunct cannabinoid use for opioid sparing. Adapted from Sihota et al.
FIG. 2.
FIG. 2.
Example of oral CBM Dosing and Titration Protocols. Reproduced with permission of Bhaskar et al. CBM, cannabinoid-based medicines.
See this image and copyright information in PMC

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