Disclosures None to declare
Polling Software Interactive component using Poll Everywhere Use your smart phone to answer poll questions Text the message GEOFFB to the number 37607 If you already have Poll Everywhere app, join at PollEv.com/geoffb
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 Text geoffb to number 37607 or join at PollEv.com/geoffb
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 Text geoffb to number 37607 or join at PollEv.com/geoffb
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History of Medical Marijuana Authorization in Canada MMAR were repealed on March 31, 2014 Federal Court interim injunction granted on March 21, 2014 allows individuals previously authorized to grow marijuana under MMAR to continue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/drugsdrogues/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 noncancer 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 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 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.
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)
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
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