• Joanna L Starrels, Sarah R Young, Soraya S Azari, William C Becker, Jennifer Edelman E E Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut., Jane M Liebschutz, Jamie Pomeranz, Payel Roy, Shalini Saini, and Jessica S Merlin.
• Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York.
• Pain Med. 2020 Feb 1; 21 (2): 247-254.

BackgroundMarijuana use is common among patients on long-term opioid therapy (LTOT) for chronic pain, but there is a lack of evidence to guide clinicians' response.ObjectiveTo generate expert consensus about responding to marijuana use among patients on LTOT.DesignAnalysis from an online Delphi study.Setting/SubjectsClinician experts in pain and opioid management across the United States.MethodsParticipants generated management strategies in response to marijuana use without distinction between medical and nonmedical use, then rated the importance of each management strategy from 1 (not at all important) to 9 (extremely important). A priori rules for consensus were established, and disagreement was explored using cases. Thematic analysis of free-text responses examined factors that influenced participants' decision-making.ResultsOf 42 participants, 64% were internal medicine physicians. There was consensus that it is not important to taper opioids as an initial response to marijuana use. There was disagreement about the importance of tapering opioids if there is a pattern of repeated marijuana use without clinical suspicion for a cannabis use disorder (CUD) and consensus that tapering is of uncertain importance if there is suspicion for CUD. Three themes influenced experts' perceptions of the importance of tapering: 1) benefits and harms of marijuana for the individual patient, 2) a spectrum of belief about the overall riskiness of marijuana use, and 3) variable state laws or practice policies.ConclusionsExperts disagree and are uncertain about the importance of opioid tapering for patients with marijuana use. Experts were influenced by patient factors, provider beliefs, and marijuana policy, highlighting the need for further research.© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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