New Guidelines Issued on Medical Cannabis for Chronic Pain
— International task force shares recommendations for dosing, administering
by Ryan Basen, Enterprise & Investigative Writer, MedPage Today September 13, 2020
Chronic pain patients can be treated with medical cannabis following one of three protocols based on patient characteristics, according to an international task force at the virtual PAINWeek meeting.
Citing limited clinician knowledge about medical cannabis treatment and the opioid crisis, one task force member said the recommendations are timely.
“We as a task force believe it’s extremely important to bring [medical cannabis] to patients,” Alan Bell, MD, of the University of Toronto, told MedPage Today. “Our main focus was to provide directions to clinicians.”
Medical cannabis has been suggested to treat chronic pain, the task force noted, but too many providers still do not utilize it because there has not been accepted guidelines about dosing and administration. Others prescribe medical cannabis without knowing how patients can properly dose.
“There’s a huge knowledge gap and no way clinicians can fall back on a specified dosing regimen,” Bell said.
Led by Arun Bhaskar, MD, of Imperial College Healthcare NHS Trust Pain Management Centre in London, the 20-clinician Global Task Force on Dosing and Administration of Medical Cannabis in Chronic Pain used a modified Delphi process. Among their recommendations:
- Treat the majority of patients along the “routine” scale. This means starting patients with 5 mg of cannabidiol (CBD) twice daily. Tetrahydrocannabinol (THC) should only be introduced if patients do not respond to at least 40 mg of CBD daily, starting with 2.5-mg daily THC doses. THC doses should be capped at 40 mg daily.
- Frail and elderly patients, and those with severe co-morbidity or polypharmacy should be treated via a conservative route. This means starting the THC dosses at 1 mg daily and titrating up the THC more slowly.
- Patients suffering from severe pain and those who have significant prior cannabis consumption can follow the rapid protocol. This mean starting with a CBD-THC balanced dose of between 2.5-5 mg per each compound once or twice daily.
“Tailoring medical cannabis treatment to the individual is a critical component of successful treatment,” according to the group’s poster presentation at PAINWeek.
The task force recommends starting with CBD in most cases because they have seen many patients benefit solely from CBD. Unlike THC, CBD does not have psychoactive properties.
The task force encourages providers to consider medical cannabis for patients dealing with neuropathic, inflammatory, nociplastic, and mixed pain.
The task force did not set a maximum treatment age; many of its clinicians reported seeing best results among geriatric patients, Bell said. They did not set a minimum CBD treatment age, with many treating pediatric patients with high doses of CBD for epilepsy.
The task force did not set a minimum treatment age for THC because they could not come to an agreement, Bell said. That does not mean they endorse treating minors with THC; the brain’s neuroplasticity until age 25 eliminates that possibility, Bell said.
They suggested the best administration method is oral because of “ease of dosing and safety,” according to the poster.
They recommended pregnant and breastfeeding women, and people with psychotic disorders, not be administered medical cannabis. They also cautioned against mixing medical cannabis with anticoagulants, immunotherapy, or the epilepsy medication clobazam (Onfi, Sympazan, Frisium).
The task force needed 75% agreement to adopt any resolutions and Bell said they agreed to most of their recommendations on the first vote.
“There’s way too much of opioids being used for chronic pain despite a lack of evidence and the harms associated with opioids,” Bell said. “We feel this is a major barrier that we are trying to overcome. that may exist because of the knowledge gap” regarding medical cannabis.
The task force featured clinicians from North America, Brazil, Europe, Australia, and Africa, according to the poster. It also included clinicians “with many, many years” of clinical experience working with medical cannabis, Bell said, from practices ranging from primary care to oncology to pediatrics and more.
They began the consensus process by completing clinical practice surveys, then reviewed questions and attended two virtual meetings.
Ryan Basen reports for MedPage’s enterprise & investigative team. He has worked as a journalist for more than a decade, earning national and state honors for his investigative work. He often writes about issues concerning the practice and business of medicine. Follow
Spectrum Therapeutics funded the group’s logistical efforts. No committee members received compensation.
International task force shares recommendations for dosing, administering
Navigating Cannabis Options for Pain and Related Symptoms
Edibles. CBD oil. Buds. When using medical marijuana for pain relief, the strain, dose, and route of administration can make a difference. Plus, a word about hemp.
With David Bearman, MD
A growing body of clinical research and a history of anecdotal evidence support the use of cannabis for the relief of some types of chronic pain, including neuropathic pain, and spasticity (ie, stiffness or tightness) associated with multiple sclerosis. 1 In a recent comprehensive review of existing data on the health effects of cannabis and cannabinoids, the National Academies of Science concluded that adult patients with chronic pain who were treated with cannabis/cannabinoids were more likely to experience a clinically significant reduction in pain symptoms. 2 They rated these effects as “modest.”
Studies also suggest some efficacy for cancer-related pain, migraines, and fibromyalgia, and other pain conditions. 3 However, how different species, routes of administration, and doses differ in their effect is less clear, and more research is needed.
- How Medical Marijuana Changed My Life
- How to Ask Your Doctor about Trying Medical Marijuana for Pain
- How to Talk to Your Physician About Medical Cannabis: 10 Points to Guide You
Cannabis is Complex: CBD Versus THC
The chemical complexity of cannabis itself has made it difficult for researchers to untangle its effects on pain and, at the same time, difficult for clinicians and patients to find the most effective species and route of administration. Cannabis is the genus name for a disputed number of plant species. The two most widely accepted species are Cannabis sativa and Cannabis indica, though hybrid species are also common.
Cannabis oil and edibles
Chemically speaking, cannabis is complicated. To date, 568 unique molecules have been identified in the cannabis; of these, more than 60 are cannabinoids — these are compounds that act on receptors in the body’s endocannabinoid sy stem. This system plays a key role in endogenous pain control. 4
Two of the cannabinoids found in cannabis, Δ 9 -tetrahydrocannabinol (THC) and cannabidiol (CBD), along with other cannabinoids, terpenes, and flavonoid compounds, are thought to exhibit synergistic effects that promote pain relief. 5 THC is the most psychoactive cannabinoid found in cannabis and is primarily responsible for the “high” associated with marijuana. It can also reduce nausea and increase appetite. CBD does not provide the euphoria associated with THC and is associated with reduced pain and inflammation. 6
The FDA’s View on Cannabis for Pain
Approval by the US Food and Drug Administration has, so far, been limited to synthetic or pharmaceutical-grade components of cannabis. In June 2018, the agency approved Epidiolex (GW Pharmaceuticals) — a high CBD, low THC whole-plant alcohol extract — for the treatment of seizures associated with Lennox-Gastaut syndrome or Dravet syndrome in patients age 2 and older. FDA has also approved Marinol (AbbVie) and Syndros (Insys Therapeutics), which both contain dronabinol, or synthetic THC. Both are indicated for weight loss associated with anorexia and HIV. Marinol is also indicated for severe nausea associated with cancer chemotherapy, as is FDA-approved Cesamet (Meda Pharmaceuticals). Cesamet contains the active ingredient nabilone, which has a chemical structure similar to THC.
Herbs, Oils, and Edibles, Oh My!
The form/route of administration may also play a role in the pain effects of cannabis. Medical cannabis comes in herbal (marijuana), tincture, oil, and edible forms. It can be smoked, vaporized, ingested in edible or other oral forms, taken sublingually (under the tongue), or applied topically (oil). Research on the efficacy of different routes of administration for pain is sparse. However, a 2013 randomized, placebo-controlled, double-dummy, double-blind study compared analgesic effects of smoked marijuana and dronabinol. 7 The results indicated that under controlled conditions, marijuana and dronabinol both decreased pain. However, compared with marijuana, dronabinol produced longer-lasting decreases in pain sensitivity and lower ratings of abuse-related subjective effects, which can be predictive of use and abuse patterns. Other studies suggest that smoking cannabis produces rapid effects, while oral forms take longer to work but may last longer. 8
Strains of cannabis may come with names like Purple Diesel and Blue Sky. While the term “strain” is commonly used by dispensaries, medical cannabis users and even physicians, it’s not a term used for plant nomenclature. 9 A strain name may come from a grower, producer, processor, or dispensary. A 2018 study out of Washington state found that commercial Cannabis strains fell into three broad chemotypes (chemically distinct plants that otherwise appear indistinguishable) that were defined by the THC:CBD ratio. 10
“There is little consistency in plant constituents between products’ strain names,” said David Bearman, MD, a physician in private practice who specializes in pain management and has more than 40 years of experience in managing substance abuse. “These names are mainly marketing tools and tell little about the constituents of the product. The best advice is to read the label and understand it.”
Dr. Bearman is also the co-founder of the American Academy of Cannabinoid Medicine, and a board member of Americans for Safe Access – a national member-based organization of patients, medical professionals, scientists and concerned citizens promoting safe and legal access to cannabis for therapeutic use and research,and of Patients Out of Time – a Virginia-based nonprofit that works to educate all disciplines of healthcare professionals, the legal profession, and the public about medical cannabis. It’s also important to know that dispensary cannabis is not regulated by the FDA so what you get in one state, or at one time, may be different from another.
A Word About Hemp
Hemp products — including oils, extracts, and even “gummies” — aimed at relieving pain and anxiety abound on the internet. But what is hemp and how does it differ from marijuana? The conventional answer is that hemp and marijuana are two different species of the Cannabis genus of plants.
Hemp, which is primarily used for industrial purposes (particularly fiber products), is considered to be the Cannabis sativa species; marijuana (used for medicinal and recreational purposes) is considered to be the Cannabis indica species. The two species differ not only in appearance but also in levels of THC and CBD.
C. sativa is associated with higher levels of THC while C. indica is associated with higher levels of CBD. The science is more complicated. A 2015 study 11 of genetic structures of marijuana and hemp suggests that “C. sativa and C. indica may represent distinguishable pools of genetic diversity but that breeding has resulted in considerable admixture between the two.” Researchers also found that hemp has more in common genetically with C. indica than with C. sativa. Differences in THC production held true.
See also, a 2019 blog on PainDr (managed by Jeff Fudin, PharmD, PPM editor-at-large) on hemp use and drug screenings).
State Legalization of Medical Marijuana
Medical cannabis is currently legal in 34 states (as of spring 2019), many of which require patient registry or identification cards for the purchase and use of the substance for specific diagnosed medical conditions. These conditions differ by state and continue to change. At the federal level, marijuana is classified as a Schedule I substance under the “Controlled Substances Act,” and there are no recognized medical uses. In many of the states with legalized cannabis, some type of product testing is required, however, testing varies by state and may be limited contamination tests or may include quantification of CBD and THC levels.
California, for example, requires dispensaries to sell only marijuana that has been tested for pesticides, contaminants, and microbial impurities. Beginning in July 2018, California also began to require testing to determine plant potency (ie, levels of THC and CBD). This information is included on the product label. 12 In addition to t he above, 12 states have enacted legislation allowing for limited use of medical marijuana (ie, low CBD: THC ratios).
These states, as of spring 2019, include: Alabama, Georgia, Indiana, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. It is important to know that consistency and quality of the product received may vary from dispensary to dispensary and from state to state. Stay up to date with the National Conference of Sttae Legislatures which lists current medical marijuana laws at http://www.ncsl.org/research/health/state-medical-marijuana-laws.aspx.
The Amount of CBD or THC You Use Matters
Where does this leave chronic pain patients interested in trying medical cannabis? Regardless of the strain or form of cannabis, the key is the amount of THC and CBD in the final product, according to Dr. Bearman.
For those with concerns about the psychogenic effects, he recommends starting with a one-to-one ratio of THC to CBD for chronic pain. “I usually suggest that people start with 7.5 mg [which, using a standard unit converter amounts to 0.003 oz.] of THC and 7.5 mg of CBD, three or four times a day,” he told Practical Pain Management. “I tell them that the most likely effect is that (a) it’s not going to make their pain go away, and (b) they’re not going to get high.”
For pain relief, he recommends a dose of 15mg THC (0.0005 oz) to 15 mg CBD. In his experience, doses of THC less than 15 mg generally don’t provide pain relief. Doses may be increased if necessary, best guided under a doctor’s orders, to achieve pain relief without unacceptable side effects.
The key to using medical cannabis for pain is two-fold. For starters, a personalized approach is needed. Each person is different, and many adjustments may be needed to zero in on the dose that controls pain with minimal side effects. It’s also important to start on a low dose of THC and CBD.
Dr. Bearman said he also prescribes dronabinol, the man-made or synthetic THC, for some patients. “It doesn’t work as well as cannabis, it’s more expensive than cannabis, and it has more side effects than cannabis. Nevertheless, there are some good reasons for prescribing it,” he noted. Specifically, because dronabinol is regulated by the FDA and must meet purity and manufacturing standards, he knows exactly how much THC a patient is getting.
Be sure to talk with your doctor about the right dose and route of administration before taking any prescribed of dispensed medical cannabis product for pain relief or related symptoms. Note that Medicare does not cover the product; check with your insurer for other program coverage.
Read more about CBD Oil and its risks on our sister publication.
In PPM online poll, about half of respondents said they had tried medical marijuana to help alleviate their pain and related symptoms.
- National Academies of Sciences, Engineering, and Medicine. 2017. The health effects of cannabis and cannabinoids: Current state of evidence and recommendations for research. Washington, DC: The National Academies Press.
- Hill KP. Medical Marijuana for Treatment of Chronic Pain and Other Medical and Psychiatric Problems: A Clinical Review. JAMA. 2015;313:2474-83.
- Fine PG and Rosenfeld MJ. The Endocannabinoid System, Cannabinoids, and Pain. Rambam Maimonides Med J. 2013;4:e0022.
- Lewis MM, Yang Y, Wasilewski E, et al. Chemical Profiling of Medical Cannabis Extracts. ACS Omega. 2017; 2: 6091–103
- Russo EB. Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage effects. Br J Pharmacol. 2011; 163: 1344–64.
- “Marijuana as Medicine.” National Institute on Drug Abuse, June 2018, https://www.drugabuse.gov/publications/drugfacts/marijuana-medicine Accessed September 11, 2018.
- Cooper ZD, Comer SD, and Haney M. Comparison of the Analgesic Effects of Dronabinol and Smoked Marijuana in Daily Marijuana Smokers. Neuropsychopharmacology. 2013;3;1984–92.
- MacCallum CA and Russo EB. Practical considerations in medical cannabis administration and dosing. Eur J Intern Med. 2018;49:12-9.
- United States Department of Agriculture, Natural Resources Conservation Service, National Plant Materials Manual, Fourth Edition (Washington, DC, 2010). Available at: www.nrcs.usda.gov/Internet/FSE_DOCUMENTS/stelprdb1042145.pdf. Accessed September 1, 2018.
- Jikomes N and Zoorob M. The Cannabinoid Content of Legal Cannabis in Washington State Varies Systematically Across Testing Facilities and Popular Consumer Products. Sci Rep. 2018;8:4519.
Sawler J, Stout JM, Gardner KM, et al. The Genetic Structure of Marijuana and Hemp. PLoS One. 2015;10(8):e0133292.
Before trying medical cannabis, or marijuana, for chronic pain, find out which strain, dose, and route of administration may be best to treat your symptoms. A review of CBD oil, edibles, flower buds, vaping, and more.