dried cannabis for pain management - thames valley fht · pain from hiv-associated neuropathy...

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


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


MMAR were repealed on March 31, 2014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.


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



Most frequently cited reason for using marijuana for medical purposes was for pain or nausea (41/49 or 85%)


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



Gourlay DL, Heit HA. Pain and Addiction: Managing Risk Through Comprehensive Care. J Addictive Dis 2008 27 (3): 23-30.



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




Both groups of marijuana users differed from nonusers in age, lifetime use of cocaine, and scores on the Alcohol Use Disorders Test


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.


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


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


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.


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



Cannabinoids

Health Canada has not reviewed data on safety or effectiveness of dried cannabis

It is not approved for therapeutic use


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


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


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


Cannabis Use Disorder Reports cannabis withdrawal symptoms after a day or more

of abstinence: anxiety/fatigue

Friends or family concerned about the cannabis use


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


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


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


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

dried cannabis for pain management - thames valley fht · pain from hiv-associated neuropathy...

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