• Aaron Sihota, Brennan K Smith, Sana-Ara Ahmed, Alan Bell, Allison Blain, Hance Clarke, Ziva D Cooper, Claude Cyr, Paul Daeninck, Amol Deshpande, Karen Ethans, David Flusk, Bernard Le Foll, M-J Milloy, Dwight E Moulin, Vernon Naidoo, May Ong, Jordi Perez, Kevin Rod, Robert Sealey, Dustin Sulak, Zachary Walsh, and Colleen O'Connell.
• Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
• Int. J. Clin. Pract. 2021 Aug 1; 75 (8): e13871e13871.

AimsOpioid misuse and overuse have contributed to a widespread overdose crisis and many patients and physicians are considering medical cannabis to support opioid tapering and chronic pain control. Using a five-step modified Delphi process, we aimed to develop consensus-based recommendations on: 1) when and how to safely initiate and titrate cannabinoids in the presence of opioids, 2) when and how to safely taper opioids in the presence of cannabinoids and 3) how to monitor patients and evaluate outcomes when treating with opioids and cannabinoids.ResultsIn patients with chronic pain taking opioids not reaching treatment goals, there was consensus that cannabinoids may be considered for patients experiencing or displaying opioid-related complications, despite psychological or physical interventions. There was consensus observed to initiate with a cannabidiol (CBD)-predominant oral extract in the daytime and consider adding tetrahydrocannabinol (THC). When adding THC, start with 0.5-3 mg, and increase by 1-2 mg once or twice weekly up to 30-40 mg/day. Initiate opioid tapering when the patient reports a minor/major improvement in function, seeks less as-needed medication to control pain and/or the cannabis dose has been optimised. The opioid tapering schedule may be 5%-10% of the morphine equivalent dose (MED) every 1 to 4 weeks. Clinical success could be defined by an improvement in function/quality of life, a ≥30% reduction in pain intensity, a ≥25% reduction in opioid dose, a reduction in opioid dose to <90 mg MED and/or reduction in opioid-related adverse events.ConclusionsThis five-stage modified Delphi process led to the development of consensus-based recommendations surrounding the safe introduction and titration of cannabinoids in concert with tapering opioids.© 2020 The Authors. International Journal of Clinical Practice published by John Wiley & Sons Ltd.

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