04/05/2023

Canadian clinical practice recommendations for cannabis use for chronic pain

Guidelines are designed to promote appropriate use of cannabinoid-based medicines for the management of chronic pain and concurrent conditions.

By Lu-Ann Murdoch, RPh, BScPhm, ACPR

Globally, 20% of individuals live with chronic pain and two-thirds of these report their pain to be moderate to severe.

Chronic pain often occurs concurrently with sleep problems, anxiety, depression, post-traumatic stress disorder (PTSD) and substance use disorders. Healthcare providers often report that they lack information on the risks, benefits and appropriate use of cannabinoid-based medicines for therapeutic purposes.

To help fill this information gap, Canadian clinical practice guidelines have been developed to assist clinicians and patients with appropriate use of cannabinoid-based medicines in the management of chronic pain and co-occurring conditions. In developing these guidelines, the authors examined literature focused on cannabis and cannabinoid-based medicines derived from the cannabis plant rather than synthetic pharmaceutical-grade cannabinoids.

Overall, cannabinoid-based medicines were found to have moderate benefit in chronic pain management. They also have evidence of efficacy in the management of comorbidities, including sleep problems, anxiety and appetite suppression, as well as for managing symptoms of some chronic conditions associated with pain including HIV, multiple sclerosis, fibromyalgia and arthritis.

Guideline Recommendations

Cannabinoid-based medicines are recommended in the following situations:

1. Chronic pain: As monotherapy, replacement or adjunct treatment for the management of chronic pain, including central and/or peripheral neuropathic pain, to improve pain outcomes in people living with chronic pain. (Strong Recommendation, Moderate-Quality Evidence)

2. As monotherapy, replacement or adjunct treatment in people living with chronic pain, for mobility in those not achieving adequate response to other modalities. (Weak Recommendation, Low-Quality Evidence)

3. HIV and chronic pain:For the management of muscular and neuropathic pain in people living with HIV who are not achieving adequate response, or those experiencing adverse effects to other treatment modalities. (Strong Recommendation, Moderate-Quality Evidence).

4. For the management of HIV-related symptoms, including nausea, anxiety, depression, lack of appetite and weight loss, in people living with HIV. Such use is for symptom management only and should not replace the use of antiretroviral therapies. (Strong Recommendation, Low-Quality Evidence)

5. Multiple sclerosis (MS) and chronic pain: As adjunct treatment for pain management in people with MS not achieving adequate response to other modalities. (Strong Recommendation, Moderate-Quality Evidence)

6. As adjunct treatment for the management of muscle spasm in people living with MS who are not achieving adequate response to other modalities. (Strong Recommendation, Moderate-Quality Evidence)

7. As adjunct treatment for the management of sleep disorder in people living with MS who are not achieving adequate response to other modalities. (Strong Recommendation, Low-Quality Evidence)

8. Arthritic condition and chronic pain: As adjunct treatment for the management of chronic pain in people living with arthritic conditions who are not achieving adequate response to other modalities. (Strong Recommendation, Low-Quality Evidence)

9. Fibromyalgia and chronic pain: As adjunct treatment for management of back pain, fibromyalgia pain or other chronic pain in people with fibromyalgia who are not achieving an adequate response to standard analgesics. (Strong Recommendation, Low-Quality Evidence)

10. Chronic headache and migraine: As an adjunct treatment for the management of chronic migraine or chronic headache, in those not achieving adequate response to other modalities. (Weak Recommendation, Low-Quality evidence)

11. Chronic pain and nausea: As monotherapy or adjunct treatment to reduce nausea in people living with chronic pain who are not achieving an adequate response with other treatment modalities. (Weak Recommendation, Low-Quality Evidence)

12. Sleep problems/sleep deprivation symptoms and chronic pain: As monotherapy, replacement or adjunct treatment, to improve sleep and symptoms of sleep deprivation in people living with chronic pain not responsive to, or intolerant of, other modalities or pharmacologic treatment. (Strong Recommendation, Moderate-Quality Evidence)

13. Chronic pain and appetite loss: THC-dominant cannabis is recommended for people with problematic loss of appetite in association with chronic pain, over no treatment. (Strong Recommendation, Low-Quality evidence)

14. Chronic pain and PTSD: To improve PTSD symptoms in people living with chronic pain not responsive to, or intolerant of, nonpharmacologic treatment. (Weak Recommendation, Low-Quality Evidence)

15. Chronic pain and anxiety: As adjunct therapy to improve symptoms of anxiety in people living with chronic pain not responsive to, or intolerant of, nonpharmacologic treatment. (Strong Recommendation, Moderate-Quality Evidence)

16. Chronic pain and depression: As adjunct therapy to improve symptoms of depression in people living with chronic pain who are experiencing unsatisfactory results from standard treatment. (Weak Recommendation, Moderate-Quality Evidence)

17. Chronic pain and unsatisfactory analgesia from opioid treatment: As adjunctive treatment to opioids for the management of chronic pain in those experiencing unsatisfactory analgesia from opioid treatment. (Strong Recommendation, Moderate-Quality Evidence)

18. Opioid sparing for people using opioids for chronic pain: As adjunct treatment among people using moderate/high doses of opioids ( > 50 morphine equivalent dose) for the management of chronic pain and/or to increase opioid sparing. (Strong Recommendation, Moderate-Quality Evidence)

19. As adjunct treatment for chronic pain among people using any dose of opioids who are not reaching chronic pain goals, areexperiencing opioid-related adverse events, or display risk factors for opioid-related harm. (Strong Recommendation, Low-Quality Evidence)

Throughout the guidelines, the authors provide practical tips and considerations for choice of cannabis dosage form, route of administration, dosing (routine dosing, conservative dosing, rapid dosing and dose titration), use of THC vs CBD, adverse effects, drug interactions, risks/benefits, monitoring patients for cannabis use disorder, and tapering/discontinuation of concomitant analgesics.

The guideline authors conclude that all patients considering use of cannabinoid-based medicines should be educated on risks and adverse events. Patients and clinicians should work collaboratively to identify appropriate dosing, titration and routes of administration for each individual.

Reference

1. Bell AD, MacCallum C, Margolese S, et al; and External Review Panel. Clinical practice guidelines for cannabis and cannabinoid-based medicines in the management of chronic pain and co-occurring conditions. Cannabis Cannabinoid Res 2023; Published online ahead of print, March 27, 2023. (accessed April 5, 2023).