American Pain Society Issues Guidance on Medical Marijuana for Pain

Advising patients on strains, explaining limitations

More and more patients are smoking marijuana or eating it as a means of treating chronic pain. Currently, 24 states have legalized medical use of the herb and that number is expected to grow considerably. Consequently, the American Pain Society (APS) has decided it is time to offer some guidance for physicians caring for patients who use cannabis. It has just published a consensus report with a balanced analysis from experts with diverse opinions about the value of cannabis as a pain treatment.                                                                                                          

“With over 70 cannabinoids and many other biologically active chemicals, cannabis offers great promise as a source of new medications. At least 2 cannabinoids have been demonstrated to have important analgesic properties and efficacy in control of symptoms such as nausea and cachexia and the full properties of these and many other cannabinoids are currently under study,” said lead author Seddon Savage, MD, medical director at the Silver Hill Hospital Chronic Pain and Recovery Center, New Canaan, CT.

The article reviews clinical research and policy issues related to herbal cannabis. It is hoped this information will help clinicians in advising and caring for patients who use cannabis. The authors recommend that all clinicians know the federal and state laws governing use of medical cannabis. They recommend that clinicians be clear with patients about goals for therapeutic cannabis and counsel patients about routes of administration.

“In the absence of a range of cannabinoid medications with known active constituents and demonstrated therapeutic effects and side-effects, some clinicians may responsibly choose to enable a carefully supervised trial of herbal cannabis or cannabis products for patients with serious symptoms for whom other available interventions are either not effective or pose greater risk and for whom the anticipated risk-benefit profile of a trial of cannabis is judged to be favorable,” Dr. Savage told Clinical Pain Advisor.

The guidance suggests that clinicians advise patients on cannabis strains, cannabinoid medications or extracts, explaining limitations due to lack of herbal/substance uniformity and regulatory oversight. Dr. Savage said clinicians should monitor patients much in the same fashion as when they are treating with opioids or other controlled substances. It is recommended that patient follow-up assesses progress toward achieving treatment goals, incidence of side effects, and evidence of psycho-behavioral changes.

“Hopefully, clinicians will not automatically authorize all patients who request cannabis for symptom control without careful clinical consideration and then leave them to self-medicate without medical support and supervision,” said Dr. Savage, who is also an Adjunct Associate Professor of Anesthesiology at the Geisel School of Medicine at Dartmouth, Hanover, NH. “The treatment of pain, particularly chronic pain, is often challenging.”

The authors of this white paper strongly advocate that a robust research agenda is adopted to fully realize the clinical potential of cannabinoid therapies. They recommend an increase in federal funding for pain-related cannabis research. They also call for broadening the number of pain conditions being studied to include cannabis for non-neuropathic pain. The authors urge easing of regulatory restrictions that impede approvals of cannabis and cannabinoid research. The paper encourages states to collect individual- and population-level data on patients receiving medical cannabis.

Co-author Mark Wallace, MD, a Professor at the University of California San Diego, La Jolla, CA, acknowledges that marijuana plays an important role in treating pain – he has  20 years of experience in using medical marijuana since it was legalized in California in 1996. “Compared to the opioids, it is safer, better tolerated, and more efficacious. However, this is my own personal experience and not supported by any studies,” Dr. Wallace told Clinical Pain Advisor.  “There has been an increasing comfort and use of cannabis by physicians. This will likely continue to increase with more states legalizing and more evidence emerging.”

He said the guidelines are long overdue. Medicinal marijuana will continue to increase and he said clinicians need to responsibly integrate it into medical practice.  “I do not think the guidelines put any physician in a difficult position. They are simply guidelines for those who choose to use cannabis. The guidelines clearly state it is the physician’s choice,” said Dr. Wallace.

He said cannabis is a pharmaceutical and should be viewed as such. As with any pharmaceutical, risks and benefits should be discussed with the patient and the patient should be monitored. However, unlike a traditional pharmaceutical, quality control is lacking and so that has to be factored into the risk-benefit discussion.

Neurologist Eve Klein, MD, an instructor at Oregon Health & Science University (OHSU), Portland, Oregon, specializes in treating chronic pain and said there are pros and cons to using cannabis. She said recommending it for chronic pain entails a thorough conversation and close monitoring. “I expect that pharmaceutical companies will be marketing new cannabis formulations in the next 2 to 3 years.  With that will come FDA approval and regulation followed by insurance coverage.  Once these regulated formulations become accessible, I expect that clinicians will prescribe them,” Dr. Klein told Clinical Pain Advisor.

She said there are significant barriers for clinicians to use cannabis in treating chronic pain. The Drug Enforcement Agency has not yet updated the scheduling of marijuana and currently still classifies it as having no accepted medical use.  “While the current administration has decided to allow states to manage marijuana laws, future administrations could take a different stance and could theoretically prosecute clinicians for past aiding and abetting in the trafficking of a Schedule I drug,” said Dr. Klein.  “I doubt it would come to that, but federal laws do need to change so that this possibility is no longer a threat.”

David A. Edwards, MD, PhD, an Assistant Professor in Multispecialty Adult Anesthesiology at Vanderbilt University, Nashville, TN, agrees.  He believes that attitudes about cannabis need to change among clinicians and patients. He said these guidelines are an important first step, and this guidance signals a new era in dealing with cannabis in a more practical manner.  “It is really nice to have it written down.  It is a starting point,” Dr. Edwards said in an interview with Clinical Pain Advisor. “We are looking for alternatives to opioids, so this is very welcomed.  There are so many potential levels where it could be used for treating pain.”

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1. Savage SR, Romero-sandoval A, Schatman M, et al. Cannabis in Pain Treatment: Clinical and Research Considerations. J Pain. 2016;17(6):654-68.


No financial disclosures relating to the subjects covered in this story were reported by Drs Savage, Wallace, Klein or Edwards.