Recently new guidelines were issued on medical cannabis for chronic pain.
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.
- 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.
DFCR expert Mikhail Kogan, MD responded to these new guidelines.
The new guidelines on the use of Medical Cannabis is very timely and very welcomed. Now physicians who are not familiar with the topic of medical cannabis for pain can fall back on this. The start low and go slow dosing recommendation, especially in older adults practice, is also very important. However, recommendation of starting all patients with 5mg of CBD twice daily is in significant disagreement with clinical practice. This dose of CBD is not just too low but CBD with no THC is not highly evidenced for pain. In fact, all prior evidence on chronic pain including 2017 National Academy of Sciences report points toward using THC for pain as the main direction. While it is very true that some chronic pain patients can respond well to moderate doses of CBD (15-25mg twice daily) these patients are in the minority. Starting all patients on CBD and titrating up while waiting will leave most patients without adequate pain relief.
Dr. Kogan had discussed the MedPage report with Dr. Dustin Sulak, a well known medical cannabis expert, who provided additional important input to clarify several MedPage report inaccuracies: “To begin with, it doesn’t suggest CBD 5mg starting dose, it’s CBD-predominant formula up to THC:CBD 1:10. I know that’s still low, but the 0.5mg THC does make a difference in my opinion.” Dr. Kogan can’t agree more. It appears that MedPage original publication has misinterpreted the initial dosing recommendation. Additionally the consensus report is not guidelines but set of recommendations which have been already submitted for peer reviewed publication. We are looking forward to reading the publication in a near future.
*Updated 10/6/20 to include additional comments by Dr. Kogan and Dr. Sulak.