Disclosures None to declare
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Learning Objectives At the completion of this presentation, participants will be able to:
Understand the profile of those who consume marijuana use in Ontario
Know the level of evidence for use of dried cannabis for treatment of pain
Know the principles of how to select an appropriate patient for use of dried cannabis for pain management
Understand how to initiate, monitor, and stop the use of dried cannabis for pain management
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Outline History of Medical Marijuana Regulations
Profile of recreational and medical marijuana consumers
Evidence for use of medical marijuana for pain control
Identifying and treating neuropathic pain
Initiating dried cannabis prescribing for pain control
Monitoring use of dried cannabis for pain control
Stopping dried cannabis therapy
Prescribing and obtaining dried cannabis
Caveats
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Authorizing Dried Cannabis for Chronic Pain or Anxiety
Preliminary Guidance document provided by the College of Family Physicians of Canada
Presented September 2014
Comprehensively addresses how to manage requests for dried cannabis for chronic pain or anxiety
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
History of Medical Marijuana Authorization in Canada
Marijuana for Medical Purposes Regulations (MMPR) was initiated on April 1, 2014
Permits a physician to sign a medical document allowing patients to access a quantity of dried cannabis through a licensed producer
History of Medical Marijuana Authorization in Canada
MMPR replaces the Marijuana Medical Access Regulations (MMAR)
MMAR contained three main components
Authorization to possess dried marijuana
License to produce marijuana including ‘Personal-Use Production Licenses’ and ‘Designated-Person Production Licenses’
Access to supply of marijuana seeds or dried marijuana
History of Medical Marijuana Authorization in Canada
MMAR were repealed on March 31, 2014
Federal Court interim injunction granted on March 21, 2014 allows individuals previously authorized to grow marijuana under MMAR to continue to do so on an interim basis
Who has encountered a patient admitting to using marijuana for recreational purposes?
Marijuana is the most widely used illicit drug in Canada
10.2% of Canadians report past year use in 2012
Health Canada. (2013) Canadian Alcohol and Drug Use Monitoring Survey. Retrieved from: http://www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaire-eng.php#s3
Who has encountered a patient admitting to taking marijuana for medical reasons?
Telephone survey of the general population in 2000
Ontario adults 18 years or older
2508 people participated
Ogborne AC, Smart RG, and Adlaf EM. Self-reported medical use of marijuana: a survey of the general population. CMAJ 2000; 162 (12): 1685-1686.
Who has encountered a patient admitting to taking marijuana for medical reasons?
173 (6.8%) reported marijuana use for non-medical reasons
49 (1.9%) reported marijuana use for medical reasons
2305 (91.2%) reported no use
Ogborne AC, Smart RG, and Adlaf EM. Self-reported medical use of marijuana: a survey of the general population. CMAJ 2000; 162 (12): 1685-1686.
Who has encountered a patient admitting to taking marijuana for medical reasons?
Most frequently cited reason for using marijuana for medical purposes was for pain or nausea (41/49 or 85%)
Ogborne AC, Smart RG, and Adlaf EM. Self-reported medical use of marijuana: a survey of the general population. CMAJ 2000; 162 (12): 1685-1686.
Who is worried that when someone asks for marijuana for a seemingly legitimate medical reason, there might also be
a component of substance misuse?
Insert Poll Everywhere audience poll slide
Choices are either yes or no
Who is worried that when someone asks for marijuana for a seemingly legitimate medical reason, there might also be
a component of substance misuse?
Gourlay DL, Heit HA. Pain and Addiction: Managing Risk Through Comprehensive Care. J Addictive Dis 2008 27 (3): 23-30.
Who is worried that when someone asks for marijuana for a seemingly legitimate medical reason, there might also be
a component of substance misuse?
Users of marijuana for any reason tend to be younger, more likely to have alcohol problems, and more likely to have used cocaine in their lifetime
Those using marijuana for medical purposes are similar to other users but more likely to have used cocaine
Ogborne AC, Smart RG, and Adlaf EM. Self-reported medical use of marijuana: a survey of the general population. CMAJ 2000; 162 (12): 1685-1686.
Who is worried that when someone asks for marijuana for a seemingly legitimate medical reason, there might also be
a component of substance misuse?
Both groups of marijuana users differed from nonusers in age, lifetime use of cocaine, and scores on the Alcohol Use Disorders Test
Ogborne AC, Smart RG, and Adlaf EM. Self-reported medical use of marijuana: a survey of the general population. CMAJ 2000; 162 (12): 1685-1686.
What condition holds the most evidence for dried cannabis use as an analgesic?
No evidence to support the use of dried cannabis as a treatment for pain commonly seen in primary care (eg. Fibromyalgia, low back pain)
Kahan M. Prescribing smoked cannabis for chronic noncancer pain: Preliminary recommendations. Canadian Family Physician Dec 2014 60 (12): 1083-1090
What condition holds the most evidence for dried cannabis use as an analgesic?
5 controlled trials have evaluated smoked cannabis in the treatment of neuropathic pain
Small sample sizes
Duration of trials lasted 1 to 15 days
Functional status, quality of life, and other outcomes not measured
Included patients who had previously smoked cannabis
Kahan M. Prescribing smoked cannabis for chronic noncancer pain: Preliminary recommendations. Canadian Family Physician Dec 2014 60 (12): 1083-1090
Does this sound familiar? Evidence for opioid use in chronic non-
cancer pain
Evidence of long-term efficacy for chronic, non-cancer pain (> 16 weeks) is limited and of low quality
No randomized trials show long-term effectiveness of high opioid doses for chronic non-cancer pain
Many patients on high doses continue to have substantial pain and related dysfunction
Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004; 112: 372-80. Papaleontiou M, Henderson CR, Turner BJ, Moore AA, Olkhovskaya Y, Amanfo L, Reid MC. Outcomes associated with opioid use in the treatment of chronic non-cancer pain in older adults: A systematic review and meta-analysis. JAGS 2010 2010; 58: 1353-1369. Martell BA, O’Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med 2007; 146: 116-27.
Pain from HIV-Associated Neuropathy
Randomized placebo-controlled trial involving adults with painful HIV neuropathy
Randomly assigned to smoke cannabis (3.56% THC) or placebo cigarettes
Three times daily for 5 days – following a standard ‘puff procedure’
Primary outcome measure ratings of chronic pain and percentage achieving >30% pain relief
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, Petersen MD. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology 2007; 68: 515-521.
Pain from HIV-Associated Neuropathy
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, Petersen MD. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology 2007; 68: 515-521.
Pain from HIV-Associated Neuropathy
50 patients completed the trial
Greater than 30% pain reduction reported by 52% of the cannabis group
Greater than 30% reduction reported by 24% of the placebo group
P = 0.04
Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, Kelly ME, Rowbotham MC, Petersen MD. Cannabis in painful HIV-associated sensory neuropathy: A randomized placebo-controlled trial. Neurology 2007; 68: 515-521.
Identifying Neuropathic Pain
Sensory descriptions often used include ‘burning’, ‘electric shock’, ‘tingling’, ‘cold’, ‘pricking’ and ‘lancinating’
Screening tools
The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS)
ID-Pain
Douleur Neuropathique en 4 (DN4)
PainDETECT
Neuropathy Pain Scale (NPS)
Treating Neuropathic Pain
If neuropathic pain is identified, be certain the patient has had appropriate trials of neuropathic pain agents prior to the use of dried cannabis
Treating Neuropathic Pain
Moulin D, Boulanger A, Clark AJ, Clarke H, Dao T, Finley GA, Furlan A, Gilron I, Gordon A, Morley-Forster PK, Sessle BJ, Squire P, Stinson J, Taenzer P, Velly A, Ware MA, Weinberg EL, Williamson OD. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014 Nov-Dec; 19 (6): 328-35.
Treating Neuropathic Pain with
Cannabinoids
Lynch ME, Campbell F. Cannabinoids for treatment of chronic non-cancer pain: A systematic review of randomized trials. Br J Clin Pharmacol 2011; 72: 735044. Toth C, Mawani S, Brady S, et al. An enriched-enrolment, randomized withdrawal, flexible-dose, double-blind, placebo-controlled, parallel assignment efficacy study of nabilone as adjuvant in the treatment of diabetic peripheral neuropathic pain. Pain 2012; 153: 2073-82.
Cannabinoids have advanced to third-line agents for chronic neuropathic pain (NeP)
Increasing evidence of efficacy in pain models including HIV neuropathy, post-traumatic and surgical NeP, DPNP, and spinal cord injury
Treating Neuropathic Pain with
Cannabinoids
Canadian Neuropathic Pain Guidelines include the use of dronabinol (no longer available), oral mucosal spray, nabilone
Use of dried cannabis as a therapeutic agent is included with these cannabinoids in the guidelines
In contrast, Neuropathic Pain Guidelines from the International Association for the Study of Pain do not include use of dried cannabis (Jan 2015)
Moulin D, Boulanger A, Clark AJ, Clarke H, Dao T, Finley GA, Furlan A, Gilron I, Gordon A, Morley-Forster PK, Sessle BJ, Squire P, Stinson J, Taenzer P, Velly A, Ware MA, Weinberg EL, Williamson OD. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Res Manag. 2014 Nov-Dec; 19 (6): 328-35.
Treating Neuropathic Pain with
Cannabinoids
Adequate trials of pharmaceutical cannabinoids should be trialed first
Oral and buccal cannabinoids have a larger body of evidence of efficacy in the treatment of neuropathic pain
Oral cannabinoids are safer, with lower risk of addiction and milder cognitive effects
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Treating Neuropathic Pain with
Cannabinoids
Health Canada has not reviewed data on safety or effectiveness of dried cannabis
It is not approved for therapeutic use
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Initiating Dried Cannabis Therapy
“Unfortunately, it is impossible to determine before hand, with any degree of certainty, who will become problematic users of prescription medications.”
Gourlay D. Heit HA, Almahrezi A. Universal Precautions in Pain Medicine: A Rational Approach to the treatment of Chronic Pain. Pain Med 2005 6 (2): 107-112.
Universal Precautions in Pain Medicine
Make a diagnosis with appropriate differential
Psychological assessment including risk of addictive disorders
Informed consent
Treatment agreement
Pre- and Post- intervention assessment of pain level and function
Gourlay D. Heit HA, Almahrezi A. Universal Precautions in Pain Medicine: A Rational Approach to the treatment of Chronic Pain. Pain Med 2005 6 (2): 107-112.
Universal Precautions in Pain Medicine
Appropriate trial of therapy +/- adjunctive medication
Reassessment of pain score and level of function
Regularly assess the “Five A’s” of pain medicine
Periodically review pain diagnosis and comorbid conditions, including addictive disorders
Documentation
Gourlay D. Heit HA, Almahrezi A. Universal Precautions in Pain Medicine: A Rational Approach to the treatment of Chronic Pain. Pain Med 2005 6 (2): 107-112.
Risk of Addictive Disorders Use of screening tools to help identify at risk patients
CAGE-AID
Screener and Opioid Assessment for Patients with Pain (SOAPP)
Opioid Risk Tool (ORT)
Urine Drug Screen
Risk of Addictive Disorders Dried cannabis should not be prescribed in patients with a
current or past cannabis use disorder
Should not be prescribed with someone with an active substance use disorder
Cannabis Use Disorder Insists on cannabis prescriptions despite having a condition
amenable to alternative treatments
Uses cannabis daily or almost daily spending considerable time on this activity
Poor school, work, and social functioning
Addicted or misusing other substances
High risk for cannabis use disorder
Difficulty stopping or reducing use
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Cannabis Use Disorder Reports cannabis withdrawal symptoms after a day or more
of abstinence: anxiety/fatigue
Friends or family concerned about the cannabis use
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Psychological Assessment A strong association between cannabis use and mood
disorders/anxiety is observed
Acute cannabis use can trigger anxiety and panic attacks
Cannabis use may worsen psychiatric impairments in people with anxiety disorders
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Psychological Assessment Hospital Anxiety and Depression Scale (HADS)
Beck Anxiety Inventory (BAI)
Informed Consent/Treatment
Agreement Extensive recommendations are provided in the Preliminary
Guidance Document on authorizing dried cannabis for pain or anxiety
Suggestions for Harm Reduction must be discussed
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Monitoring Use of Dried Cannabis
If it is being used for pain… be certain it provides analgesia when used!
Patients should have pain assessed before and after use
Brief Pain Inventory (BPI) before and at each subsequent clinic visit can help document progress towards an analgesic or functional goal
Five A’s of Analgesia Analgesia
Activities of daily living
Adverse effects
Affect
Aberrant drug-related behaviors
Concerns with Diversion or Misuse
If diversion, stop prescribing the drug
Absence of THC in the urine would be suspicious for diversion
Could be difficult to identify diversion since THC can be detected in the urine for many days after use (depends on dose, chronicity of use, test cut off levels)
Concerns with Diversion or Misuse
Authorization for cannabis should be stopped if there is suspected misuse
Runs out early or uses cannabis from other sources
Begins to use alcohol, opioids, or other illicit drugs problematically
Shows signs of cannabis use disorder
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
An evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs
Screening – A healthcare professional assesses a patient for risky substance use using standardized tools
Brief Intervention – Engages the patient showing risky substance use behaviors in a short conversation, providing feedback and advice
Referral to Treatment – Provides a referral to brief therapy or additional treatment to patients who screen in need of additional services
Bien TH, Miller WR, Tonigan JS. (1993). Brief intervention for alcohol problems: A review. Addiction, 88: 315-335. Madras BK, Compton WM, Avula D et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and six months later. Drug and Alcohol Dependence 2009; 280-295.
Stopping Dried Cannabis Therapy
Insufficient analgesia and/or no improvement in function (BPI is helpful to identify these issues)
No improvement in sleep, mood, or quality of life
Impairing side effects: memory, sedation, fatigue, diminishing function
Cannabis use disorder
College of Family Physicians of Canada. (2014) Authorizing Dried Cannabis for Chronic Pain or Anxiety. Retrieved from http://www.cfpc.ca/Dried_Cannabis_Prelim_Guidance
Prescribing Dried Cannabis Physician is required to sign a Medical Document for the
Marijuana for Medical Purposes Regulations
Medical Document has the format and function similar to a prescription
Specify the daily quantity of dried marijuana in g/day
Specify the period of use in days, weeks, or months (not to exceed 12 months)
Prescribing Dried Cannabis Medical Document elements:
Patient name, date of birth
Address where patient consulted with health practitioner
Daily grams of dried marijuana, period of use
Healthcare practitioner’s name and administrative information
Attestation by the healthcare practitioner that the information is correct and complete
Prescribing Dried Cannabis How much to prescribe?
Guidance Document from CFPC offers comprehensive explanations regarding the recommended dosing
No more than 9% THC needed according to studies – this can be specified on the Medical Document
Current evidence supports a daily dose of 100-700 mg of dried cannabis
An average ‘joint’ contains 500 mg of herbal cannabis
Obtaining Dried Cannabis Patients can register as a client with a licensed producer of
their choice
Need to provide the original medical document
Dried marijuana is sent to the patient directly by the licensed producer
Legal possession is confirmed via the label on the marijuana package containing specific patient information or a separate document containing the same information with the shipment of marijuana
Caveat Emptor Wait list to obtain product can be up to 6 to 8 months
Not all licensed producers supply 9% THC or less strains
CFPC guidance document provides list of suppliers with 9% THC or less
Clients are sometimes required to buy a minimum quantity of strain type
Caveat Prescriber Asking for no more than 9% THC content on the Medical
Document is not enforceable – patients can buy higher THC % strains if they ask for it
Patient can possess either the lesser of 30 X the daily amount stipulated or 150 grams
Prescriber can not further restrict the maximum allowable amount of dried cannabis
Caveat Prescriber - Dispensaries
London Compassion Club: A dispensary located in London in operation for nearly 20 years
Provides medical marijuana for symptom management
Physicians must confirm they support the use of dried cannabis for symptom control before the LCC will engage with patients
Caveat Prescriber - Dispensaries
The only legal way to obtain dried cannabis for medical use is to choose from 13 government-licensed producers
LCC still operates in London but technically not legal
LCC reports that source of dried cannabis is from growers previously licensed under the old MMAR
Learning Objectives At the completion of this presentation, participants will be able to:
Understand the profile of those who consume marijuana use in Ontario
Know the level of evidence for use of dried cannabis for treatment of pain
Know the principles of how to select an appropriate patient for use of dried cannabis for pain management
Understand how to initiate, monitor, and stop the use of dried cannabis for pain management
Questions