Simplified guideline for prescribing medical cannabinoids in primary care

We recommend against use of medical cannabinoids for most medical conditions owing to lack of evidence of benefit and known harms (strong recommendation)

-Potential exceptions are reviewed below: some types of pain, CINV, and spasticity due to MS or SCI

Management of pain

Acute pain: We strongly recommend against use of medical cannabinoids for acute pain management owing to evidence of no benefit and known harms (strong recommendation)

Headache: We recommend against use of medical cannabinoids for headache owing to lack of evidence and known harms (strong recommendation)

Rheumatologic pain: We recommend against use of medical cannabinoids for pain associated with rheumatologic conditions (including osteoarthritis and back pain) owing to lack of evidence and known harms (strong recommendation)

Neuropathic pain: We recommend against medical cannabinoids as first- or second-line therapy in neuropathic pain owing to limited benefits and high risk of harms (strong recommendation)

-Clinicians could consider medical cannabinoids for refractory neuropathic pain, with the following considerations (weak recommendation):

— a discussion has taken place with patients regarding the benefits and risks of medical cannabinoids for pain

— patients have had a reasonable therapeutic trial* of ≥ 3 prescribed analgesics and have persistent problematic pain despite optimized analgesic therapy

— medical cannabinoids are adjuncts to other prescribed analgesics

Palliative (end-of-life) cancer pain: We recommend against use of medical cannabinoids as first- or second-line therapy for palliative cancer pain owing to limited benefits and high risk of harms (strong recommendation)

-Clinicians could consider medical cannabinoids for refractory pain in palliative cancer patients, with the following considerations (weak recommendation):

— a discussion has taken place with patients regarding the risks and benefits of medical cannabinoids for pain

— patients have had a reasonable therapeutic trial* of ≥ 2 prescribed analgesics and have persistent problematic pain despite optimized analgesic therapy

— medical cannabinoids are adjuncts to other prescribed analgesics

Types of medical cannabinoids for pain:

-If considering medical cannabinoids, we recommend a pharmaceutically developed product (nabilone or nabiximols) as the initial agent (strong recommendation)

— Nabilone is off-label for pain and has limited evidence of benefit. However, it is less expensive than nabiximols and dosing is more consistent than for smoked cannabis

— Nabiximols is expensive and, in some provinces, only available through specialist prescribing or special authorization. However, nabiximols has better evidence than nabilone does

-If considering medical cannabinoids, we recommend against medical marijuana (particularly smoked) as the initial product (strong recommendation)

— Evidence for smoked cannabis has a very high risk of bias, and long-term consequences are unknown

— Products available can have far higher concentrations of THC and CBD than those researched

Management of nausea and vomiting

General: We recommend against use of medical cannabinoids for general nausea and vomiting owing to the lack of evidence and known harms (strong recommendation)

-We strongly recommend against medical cannabinoids for nausea and vomiting in pregnancy or hyperemesis gravidarum owing to the lack of evidence, known harms, and unknown harms (strong recommendation)

CINV: We recommend against use of medical cannabinoids as first- or second-line therapy for CINV owing to limited comparisons with first-line agents and known harms (strong recommendation)

-Clinicians could consider medical cannabinoids for treatment of refractory CINV, with the following considerations (weak recommendation):

— a discussion has taken place with patients regarding the risks and benefits of medical cannabinoids for CINV

— patients have had a reasonable therapeutic trial of standard therapies and have persistent CINV

— medical cannabinoids are adjuncts to other prescribed therapies

Types of medical cannabinoids for CINV:

-If considering medical cannabinoids, we recommend nabilone (strong recommendation)

— We recommend against nabiximols and medical marijuana (smoked, oils, or edibles), as it is inadequately studied (strong recommendation)

— While dronabinol has been studied, it is no longer available in Canada

Management of spasticity

General: We recommend against use of medical cannabinoids for general spasticity owing to lack of evidence and known harms (strong recommendation)

Spasticity in MS or SCI: We recommend against use of medical cannabinoids as first- or second-line therapy for spasticity in MS or SCI owing to limited evidence and known harms (strong recommendation)

-Clinicians could consider medical cannabinoids for refractory spasticity in MS and SCI, with the following considerations (weak recommendation):

— a discussion has taken place with patients regarding the benefits and risks of medical cannabinoids for spasticity

— patients have had a reasonable therapeutic trial of standard therapies (including nonpharmaceutical measures)§ and have persistent spasticity

Types of medical cannabinoids for spasticity:

-If considering medical cannabinoids, we recommend nabiximols (strong recommendation)

— We recommend against medical marijuana (smoked, oils, or edibles), as it is inadequately studied (strong recommendation)

— Clinicians could consider nabilone owing to its lower cost; however, it is off-label and lacks evidence for this use (weak recommendation)

CBD—cannabidiol, CINV—chemotherapy-induced nausea and vomiting, MS—multiple sclerosis, SCI—spinal cord injury, THC—tetrahydrocannabinol.

*Reasonable therapeutic trial is defined as 6 wk of therapy with an appropriate dose, dose titration, and monitoring (eg, function, quality of life).

Other prescribed therapies for neuropathic pain management include, but are not limited to (in no particular order), tricyclic antidepressants (eg, amitriptyline, nortriptyline), gabapentinoids (gabapentin, pregabalin), or selective norepinephrine reuptake inhibitor antidepressants (duloxetine, venlafaxine). The committee believed that ≥ 3 medications should be trialed before considering cannabinoids or opioids.

Other prescribed therapies for CINV include, but are not limited to (in no particular order), serotonin antagonists (eg, ondansetron), neurokinin-1 receptor antagonists (aprepitant, fosaprepitant), corticosteroids (dexamethasone), and dopamine antagonists (prochlorperazine, metoclopramide).

§Other therapies for spasticity in MS include, but are not limited to (in no particular order), daily stretching, range-of-movement exercises, baclofen, gabapentin, tizanidine, dantrolene, benzodiazepine, or botulinum toxin.

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