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Your patient has chronic low back pain and asks you about CANNABIS: Part 2






Here’s the patient/client:

Joe Smith is a 64-year-old cisgender male with a 10-year history of chronic low back pain (CLBP). Over the years, he’s received medical care for LBP including 2 surgeries, and medications “for the pain” including anti-inflammatories, muscle relaxants, and analgesics (aka pain killers), and has also been prescribed anti-depressants and sleep aids.

Joe has used the medications as prescribed but hasn’t achieved enough pain relief to tolerate their negative side effects. He has an opioid prescription which he takes “on really bad days” but won’t use the medication more than twice a week because he knows it’s not curing the problem and he doesn’t want to get addicted.

He tries to stay active by walking and despite having a desk job doing animation work, he can get up from his desk and move or walk several times a day.

Yes, there are many options that can be made available to Joe to help him manage CLBP. However, right now, he’s asked you, one of his healthcare providers about CANNABIS


From the best available research (see part 1), you know that cannabis is a reasonable and likely safe option for your client Joe. Everyone is good to go, pain relief is on the way. But is it?? Is everything clear and easily understood? Will going to a cannabis dispensary be just like a trip to the pharmacy to pick up an over-the-counter pain killer like acetaminophen or ibuprofen?

Without judgment as to better or worse, the answer is simply, no. A trip to the dispensary can be overwhelming and confusing. So many choices! Joints, vape cartridges, gummies, mints, chocolates, taffy, cookies, tinctures, patches, and those are only some of the options.

And then, of course, there’s the question of dosing, how much is best? In the pharmaceutical world, medication is prescribed by a licensed healthcare professional with a specific dose and mode of ingestion based on an abundance of research and study. In the botanical/plant, cannabis world, dosing and mode of ingestion questions are often (although not always) answered at a dispensary by a person with only a cursory understanding of medical symptoms and diagnoses. Recommendations are often based on crowdsourcing information, anecdotal reports, and best guesses. We know that this information may be surprising, but it’s important to know that even when physicians approve a medical marijuana card for patients with chronic pain, they don’t prescribe a dose, frequency, or delivery method. They simply verify that a patient is eligible, based on state regulation, to legally access cannabis.


Given what is known, or in this case NOT known about dosing, it’s no surprise that Joe will ask for assistance in understanding his options before he walks into a dispensary. Once, again you turn to the scientific literature.


The first thing to understand is the various ways that natural cannabis can be ingested. The 4 most typical ways of ingesting cannabis will be available at most dispensaries.


Smoking or vaping (inhalation): Dosing for smoked or vaped cannabis is expressed in % of dried weight (for example, a joint labeled as 18% THC). The onset of effect is very quick, most often 3 to 10 minutes after inhaling and the duration of the effect is short, generally lasting 2-4 hours. Experts recommend inhalation when quick pain relief is needed, for breakthrough pain, or for layering pain relief impact with other forms of cannabis. (1)


Edibles: Dosing for all edibles is expressed in milligrams of cannabinoids (for example, 10 mg THC:10 mg CBD). The onset of effect given that all edibles must be digested (first pass effect) is considerably slower than inhalation with peak impact at 1-2 hours after ingestion. The duration of effect is quite long lasting anywhere from 6-8 hours. Edibles are often used for relief of persistent pain when long-acting relief is warranted.


Tinctures (Oromucosal): Oromucosal preparations come in sprays, drops, or lozenges that are meant to be dissolved in the mouth, most often under the tongue where there is a rich blood supply. Dosing is expressed in milligrams (for example, 1 mg of THC per drop or spray). The onset of effect falls between that of inhalation and that of edibles with peak effect occurring 15 to 45 minutes after use. The duration of effect can be as long as 6-8 hours but often closer to 4-6 hours. Tinctures and sprays are often used for persistent pain relief as they are easier to titrate than edibles but have a similar duration of impact.


Topicals: Topicals come in the form of creams, oils, gels, and ointments. Dosing is expressed in milligrams of cannabinoids (for example, 100 mg CBD). Often there are other ingredients embedded in these products to promote effectiveness. Research is very limited on dosing, time to peak effect, and duration for topicals. Generally, topicals are not considered effective for systemic pain issues. They are most often used for localized pain in a small area such as arthritic joint pain or acute painful injuries.


With knowledge of common cannabis-based products and how long they take to have an effect and how long the effect can last, it’s time to look at dosing. In the medicinal cannabis world, there is an oft-quoted adage, “Start Low, Go Slow” (2). While this is a nice phrase and reads well for infographics, it doesn’t really provide any specific guidance. Again, the literature and the experience of expert clinicians will help us to educate our clients with the best available information.


Bhaskar, et al (2021) solicited information from 20 global experts, across 9 countries, specifically on dosing and administering medical cannabis for the treatment of chronic pain. (3) The consensus opinion of experts offers 3 dosing paradigms for edibles and tinctures regarding cannabis and chronic pain; a routine protocol, a conservative protocol, and a rapid protocol. Let’s look at them separately with regard to chronic pain.


The Routine Protocol: Used for the majority of people, this approach begins with CBD-dominant strains of cannabis. Remember that CBD purchased at a dispensary is not legally bound to have less than 0.3% THC, as it would if you purchased CBD through a website or a CBD store. At a dispensary, CBD products almost certainly contain small amounts of THC.

A recommendation for cannabis is that treatment begins with 5 mg of a CBD dominant strain twice daily, and titrated upward by 10 mg every 2-3 days (if needed) until the desired pain relief is achieved. If a client ends up taking 40 mg of CBD daily without enough relief, it’s suggested that the client continue with the CBD and add a product that contains 2.5 mg of THC. If relief is still not adequate, then titrating the THC upward by 2.5 mg every 2-7 days can be tried. If, however, a client gets to the level of 40 mg of THC without adequate pain relief, it’s time to take a different approach within or outside of the cannabis plant.


The Conservative Protocol: This approach is typically used for clients sensitive to drug effects, mental health issues, polypharmacy, and/or people with complex co-morbidities. Treatment with cannabis begins with a daily dose of 5 mg of CBD, titrated upward every 2-3 days to 40 mg of CBD per day, leveraging twice daily administration when needed. If the client hasn’t achieved their treatment goals even when taking a total of 40 mg of CBD daily (regardless of whether the 40 mg is taken all at once or divided into 20 mg twice a day), then it’s suggested that they add 1 mg THC once per day, titrating upward each successive week to a maximum of 40 mg CBD:40 mg THC. The total dosing of 40 mg of CBD and 40 mg of THC can be divided throughout the day to accommodate individual needs or circumstances.


The Rapid Protocol: This approach is typically used for people in significant pain, clients in palliative care, or experienced cannabis users. Treatment begins at 2.5 to 5 mg of THC and 2.5 to 5 mg of CBD (a 1:1 THC: CBD preparation) once or twice daily to be titrated upward in equal amounts every 2-3 days until treatment goals are met, not to exceed 40 mg of 1:1 THC: CBD.


What we haven’t yet addressed is dosing for inhalation, the method that has a rapid onset of effect with the shortest duration of impact. Remember, inhalation methods are typically expressed in percentages versus milligrams. For smoking and vaping, it is possible to purchase products with smaller or meaningfully larger percentages of cannabinoids (by example, 12% THC joints vs. 28% THC joints). The amount of cannabinoids needed for pain control may vary with these percentages. Arboleda and Prosk (2021) suggest the following: Begin with a single inhalation. Wait 10 to 15 minutes to assess the impact of cannabis on pain. If necessary, increase to 2 inhalations titrating upward by single inhalations and waiting an appropriate amount of time to assess impact. In an effort to standardize dosing, there are now devices on the market that deliver a measured dose of cannabis with each inhale. (1)


And now, armed with all this information, let’s look at our client, Joe. Remember that Joe has long-standing chronic pain. He’s working with you to manage the pain throughout his day but has decided to try cannabis.


Joe decides, based on what you taught him about onset of effect that he’d like to inhale cannabis in the morning when he first wakes up because he has a lot of pain. He understands that inhalation will provide quick relief but that the pain-relieving effect won’t last throughout the entire workday. Knowing about other products and his working conditions, he considers different products. It took some titrating and some finesse but with guidance from the available literature, Joe found a way to manage his chronic pain allowing him to get through his days more comfortably.


In the morning before work: Inhale 2 puffs of 18% THC, 1 hour before leaving for work


Upon arriving at work: 10 mg 1:1 THC: CBD oromucosal spray or tincture to cover the long hours at work sitting.


Evening before bed: Inhale 2 puffs of 18% THC to allow for pain relief and falling asleep.


The case of Joe provides an example of how the principles of evidence-based medicine (patient values, best-available evidence, and clinical expertise) can be applied to cannabis just like another medical, intervention and should be considered a reasonable strategy for dealing with bias and stigma and often associated with cannabis and its use.




References

(1) Arboleda, M.F. & Prosk, E. (2021). Practical recommendations for the use of medical cannabis. In S. N. Narouze and C.A. MacCallum (Eds.), Cannabinoids and pain. Springer. https://doi.org/10.1007/978-3-030-69186-8

(2) MacCallum, C. A., Eadie, L., Barr, A. M., Boivin, M., & Lu, S. (2021). Practical strategies using medical cannabis to reduce harms associated with long term opioid use in chronic pain. Frontiers in Pharmacology, 12, 633168. https://doi.org/10.3389/fphar.2021.633168

(3) Bhaskar, A., Bell, A., Boivin, M., Briques, W., Brown, M., Clarke, H., Cyr, C., Eisenberg, E., de Oliveira Silva, R. F., Frohlich, E., Georgius, P., Hogg, M., Horsted, T. I., MacCallum, C. A., Müller-Vahl, K. R., O'Connell, C., Sealey, R., Seibolt, M., Sihota, A., Smith, B. K., … Moulin, D. E. (2021). Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. Journal of Cannabis Research, 3(1), 22. https://doi.org/10.1186/s42238-021-00073-1

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