1 Expert Consensus on the Optimization of Cannabinoids and Opioids for Chronic Pain Control Aaron Sihota1, Brennan Smith2, Mirela Baranci3, Tim Mason3, Mark Ware3, MJ Milloy1 University of British Columbia, Vancouver, BC, Canada. 2CTC Communications, Mississauga, ON, Canada. 3Spectrum Therapeutics, Montreal, QC, Canada 1
Purpose Opioids have been commonly prescribed for chronic non-cancer pain management, yet there is increasing awareness of significant health risks associated with this family of compounds. Cannabinoids are increasingly being considered for the management of chronic pain, and have a more favourable adverse event profile and lower risk for dependence compared with opioids.1,2 In balancing the risks associated with opioids and the relatively favourable tolerability profile of cannabinoids, there is increasing clinical interest in the use of cannabinoids to treat chronic pain as well as reduce overall opioid use and therefore minimize opioid-related harms. Observational studies and early clinical trials have shown that cannabinoids have a synergistic effect with opioids leading to improved pain management and may have an opioid-sparing effect.3 Considering the degree of opioid-related harm is directly linked to the dose of opioid, strategies to taper opioid doses may reduce the associated health risks. Despite the potential for cannabinoids to impact prescription opioid use, there is a lack of clinical trial evidence to inform on how clinicians should approach the co-management of these medication classes. However, because cannabis is also used non-medically, there are reports of patients already co-administering the two medication classes. In addition, frontline clinicians are consistently faced with questions on how to effectively use cannabinoids to reduce pain and deprescribe concurrent opioid therapy. In other words, although there is a lack of clinical trial data, there is a need for clinical guidance around managing these two medication classes in concert. To provide guidance on how to manage opioids and cannabinoids in patients with chronic non-cancer pain, we are developing a consensus program built by subject matter experts from Canada and the United States that will address the most pertinent clinical questions surrounding the initiation, titration, tapering, monitoring, and dosage adjustments of opioids and cannabinoids in patients with chronic non-cancer pain. Ultimately, the purpose of this consensus program is to develop a report and a clinical practice tool that will provide guidance on the use of cannabinoids with opioids for chronic pain management and harm reduction. Methods A modified Delphi method will be used to develop this consensus program and the corresponding report.4 Briefly, a core scientific committee of cannabinoid subject matter experts from the United States and Canada will identify the key areas of focus and build a set of corresponding questions associated with the clinical management of opioids and cannabinoids. This initial set of consensus questions will be reviewed twice and then finalized with the support of additional subject matter experts. Following the finalization of the consensus questions, the scientific committee and the other subject matter experts will meet in-person in the Fall of 2019. During this meeting the questions will be discussed and debated followed by anonymous voting to elucidate where consensus may be found. A corresponding report will be generated to distribute the findings from this process and include a formal literature review of the evidence, the consensus questions and committee discussion of each question, and the key consensus statements surrounding management of cannabinoids and opioids in patients with chronic pain.