Consensus-based recommendations for titrating cannabinoids and tapering opioids for chronic pain control

AIMS

Opioid 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.

RESULTS

In 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.

CONCLUSIONS

This 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.

Canadian clinical practice guidelines for the use of plant-based cannabis and cannabinoid-based products in the management of chronic non-cancer pain and co-occurring conditions: protocol for a systematic literature review

INTRODUCTION

Chronic pain and co-occurring disorders, such as sleep disorders, anxiety, depression, post-traumatic stress disorder and substance use disorders, are among the most common conditions for which cannabis and cannabinoid-based products derived from the cannabis plant (CBP) are used for therapeutic purposes. However, healthcare providers report that they lack sufficient information on the risks, benefits and appropriate use of cannabis and CBP derived from the cannabis plant for therapeutic purposes.

METHODS AND ANALYSIS

We will conduct a systematic review of studies investigating the use of cannabis and CBP derived from the cannabis plant for the treatment of chronic pain and co-occurring conditions. Randomised controlled trials, meta-analyses and observational studies will be prioritised. We will exclude reviews of cannabinoid mechanisms of actions, commentary articles and narrative reviews. The primary outcome of interest will be efficacy in relieving chronic pain. Secondary outcomes will be efficacy in ameliorating conditions such as sleep disorders, anxiety, depression, post-traumatic stress disorder and substance use disorders. We will search electronic bibliographic databases including Academic Search Complete, Cochrane Database of Systematic Reviews, Evidence based Medicine Reviewes, OVID Medline, PsychINFO, PubMed, CINAHL and Web of Science. Two reviewers will conduct screening and data collection independently. Study level of bias will be assessed using the Cochrane Risk of Bias Assessment Tool for randomised controlled trials and non-randomised studies. Narrative analysis will be utilised to interpret the data.

ETHICS AND DISSEMINATION

The results of this systematic review will inform guideline development for the use of cannabis and CBP derived from the cannabis plant in the management of chronic pain and co-occurring conditions. Areas requiring further study will also be highlighted.

PROSPERO REGISTRATION NUMBER

CRD42020135886.

Persistence of use of prescribed cannabinoid medicines in Manitoba, Canada: a population-based cohort study

BACKGROUND AND AIMS

To estimate prevalence of continuous use (persistence) of prescribed cannabinoid medications for up to 1 year from initial prescription in Manitoba, Canada and predictors of duration of use.

DESIGN AND SETTING

A retrospective, population-based, cohort study using administrative data from the Manitoba Population Research Data Repository located at the Manitoba Centre for Health Policy, Canada.

PARTICIPANTS

People without a record of a previous prescription who were prescribed a cannabinoid medication from 1 April 2004 to 1 April 2016 followed for 1 year from the date of first prescription.

MEASUREMENTS

Continuous prescribed cannabinoid medication use was defined as use without a gap exceeding 60 days between prescriptions. The primary outcome was prevalence of continuous prescribed cannabinoid medication use for up to 1 year. A secondary outcome was duration of continuous use. Predictors were socio-demographic characteristics, medical diagnoses and type of cannabinoid medication.

FINDINGS

Among 5452 new users, 18.1% [95% confidence interval (CI) = 17.08-19.12] were still using cannabinoids at 1 year. Median duration of use was 31 days [interquartile range (IQR) = 25-193]. This was highest for nabilone (33 days, IQR = 25-199) and lowest for nabiximols (20 days, IQR = 7-30). Use was longest among 19-45- and 46-64-year-old users and those with the highest socio-economic status. Fibromyalgia [hazard ratio (HR) = 0.89, 95% CI = 0.84-0.95], osteoarthritis (HR = 0.91, 95% CI = 0.82-0.97) and substance use disorder (HR = 0.85, 95% CI = 0.76-0.94) diagnoses were associated with longer use (HR for discontinuation-HR < 1 less discontinuation and longer use). A diagnosis of cancer was associated with shorter use (HR = 2.73, 95% CI = 2.02-3.67).

CONCLUSIONS

In Manitoba, Canada approximately 18% of people prescribed cannabinoid medication continue using for at least 1 year. Duration of use varies with type of cannabinoid medication, age, socio-economic status and dagnosis.

Pharmaceutical cannabinoid use in Manitoba, 2004/05 to 2014/15: a population-based cross-sectional study

BACKGROUND

Pharmaceutically derived cannabinoids are used for several indications, particularly pain management. The extent of their use from a population perspective is unknown; hence, the aim of this study was to evaluate trends in pharmaceutical cannabinoid use in Manitoba.

METHODS

This was a retrospective population-based cross-sectional study using administrative data from the Manitoba Centre for Health Policy. Pharmaceutical cannabinoid users residing in Manitoba from Apr. 1, 2004, to Mar. 31, 2015 were identified. We assessed the annual prevalence and incidence of pharmaceutical cannabinoid use, and the sociodemographic characteristics and medical conditions of users.

RESULTS

We identified 5181 people who received at least 1 prescription for a pharmaceutical cannabinoid over the study period, 5033 of whom received their first prescription after Apr. 1, 2004. Nabilone accounted for 73 650 (96.0%) of all prescriptions dispensed; dronabinol was discontinued during the study period. The annual prevalence rate of use increased by 527.2%, from 21.5 (95% confidence interval [CI] 21.4-21.6) users per 100 000 people in 2004/05 to 134.9 (95% CI 134.7-135.1) users per 100 000 people in 2014/15. The annual incidence rate increased by 413.3%, from 12.1 (95% CI 12.1-12.2) users per 100 000 person-years in 2004/05 to 62.2 (95% CI 62.1-62.4) users per 100 000 person-years in 2014/15. The highest use was among older adults aged 46-64 years, females and urban area residents. One-third of incident users (1775 [35.3%]) had a diagnosis of fibromyalgia in a 2-year period before their first cannabinoid prescription. General practitioners initiated almost half (2350 [46.7%]) of first prescriptions, and anesthesiologists/pain specialists initiated one-quarter (1299 [25.8%]).

INTERPRETATION

The prevalence and incidence of pharmaceutical cannabinoid use increased over time. These findings provide insight into the use of cannabinoids before the introduction of recreational marijuana, which may affect this trend.

Cannabis in palliative care: current challenges and practical recommendations

Pain and symptom control challenges are common in palliative care, and the search for other therapeutic strategies is ongoing. Unfortunately, patients and their caregivers are receiving little information or support from healthcare providers regarding the increasingly popular cannabinoid-based medicines (CBM). Clinicians, meanwhile, feel understandably perplexed by the discrepancy between the available evidence and the rapid interest in which patients and their families have demonstrated for CBM. There is an urgent need to address the many challenges that are delaying the appropriate integration of CBM into clinical practice, notwithstanding the obvious need for a solid general knowledge of pharmacology, mechanism of action and available clinical evidence supporting its use. The authors will address these challenges and provide practical recommendations regarding patient assessment for the use of CBM. The authors will also make suggestions regarding patient expectations in order to define clear objectives, review the necessary precautions prior to initiating treatment, aid in selecting the appropriate strain and route of administration as well as establishing proper titration and monitoring protocols. The authors will also discuss the lesser known but potentially therapeutic psychoactive effects of cannabis. As this class of therapeutic agents are likely to play a major role in palliative medicine in the near future, clinicians would benefit from familiarizing themselves with CBM and we can expect that patients and their caregivers will appreciate receiving support in their search for safe and effective therapeutic alternatives.

Canadian recommendations for the management of breakthrough cancer pain

Breakthrough cancer pain (btcp) represents an important element in the spectrum of cancer pain management. Because most btcp episodes peak in intensity within a few minutes, speed of medication onset is crucial for proper control. In Canada, several current provincial guidelines for the management of cancer pain include a brief discussion about the treatment of btcp; however, there are no uniform national recommendations for the management of btcp. That lack, accompanied by unequal access to pain medication across the country, contributes to both regional and provincial variability in the management of btcp. Currently, immediate-release oral opioids are the treatment of choice for btcp. This approach might not always offer optimal speed for onset of action and duration to match the rapid nature of an episode of btcp. Novel transmucosal fentanyl formulations might be more appropriate for some types of btcp, but limited access to such drugs hinders their use. In addition, the recognition of btcp and its proper assessment, which are crucial steps toward appropriate treatment selection, remain challenging for many health care professionals. To facilitate appropriate management of btcp, a group of prominent Canadian specialists in palliative care, oncology, and anesthesiology convened to develop a set of recommendations and suggestions to assist Canadian health care providers in the treatment of btcp and the alleviation of the suffering and discomfort experienced by adult cancer patients.

Family members' experiences caring for patients with advanced head and neck cancer receiving tube feeding: a descriptive phenomenological study

CONTEXT

Head and neck cancer patients with dysphagia frequently require tube feeding. Family members are often involved in caring for such patients but feel ill prepared to do so. Health professionals are in a key position to support family members who undertake caregiving responsibilities. The ability to provide support requires that the experiences of family caregivers (FCs) are well understood; however, few studies examining these experiences have been conducted. To address this gap, research is needed that examines and describes the caregiving experience from the perspective of family members themselves. Such work will provide an empirical base to guide health professionals' practice with FCs.

OBJECTIVES

To explicate the lived experience of caring for a dysphagic relative with advanced head and neck cancer receiving tube feeding.

METHODS

A descriptive phenomenological approach was used. Six FCs participated in two in-depth interviews each. Spiegelberg's three-step approach guided data analysis.

RESULTS

The essence of FCs' experience was "negotiating a new normal" and includes the themes of 1) negotiating changing roles, 2) negotiating an altered lifestyle, 3) negotiating ways of coping, and 4) negotiating the meaning of the feeding tube. Themes 1 and 2 are reported on here.

CONCLUSION

FCs experience significant challenges. Study findings provide direction for health professionals who work with FCs and underscore the need for future research geared toward developing and testing psychoeducational interventions aimed at supporting FCs in the important and difficult caregiving work they do.

A review of nabilone in the treatment of chemotherapy-induced nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) in cancer patients places a significant burden on patients' function and quality of life, their families and caregivers, and healthcare providers. Despite the advances in preventing CINV, a substantial proportion of patients experience persistent nausea and vomiting. Nabilone, a cannabinoid, recently received Food and Drug Administration approval for the treatment of the nausea and vomiting in patients receiving cancer chemotherapy who fail to achieve adequate relief from conventional treatments. The cannabinoids exert antiemetic effects via agonism of cannabinoid receptors (CB1 and CB2). Clinical trials have demonstrated the benefits of nabilone in cancer chemotherapy patients. Use of the agent is optimized with judicious dosing and selection of patients.

The emerging role of cannabinoid neuromodulators in symptom management

INTRODUCTION

The cannabinoids nabilone (Cesamet) and dronabinol (Marinol) are indicated for the management of chemotherapy-induced nausea and vomiting (CINV) in cancer patients who have failed to respond adequately to conventional antiemetic therapy.

DISCUSSION

The endocannabinoid (CB) system interacts with numerous other systems and pharmaceutical cannabinoids target ubiquitous CB1 and CB2 receptors in the central nervous system and periphery, relieving nausea and vomiting and pain.

SUMMARY

The benefits of this novel class of medications in cancer may extend beyond CINV, as indicated by data from preclinical studies and animal models.

Palliative sedation: Nurses’ perceptions

Patients with advanced illnesses suffer from a myriad of distressing symptoms. Palliative care aims to alleviate the distress caused by such symptoms. In extreme circumstances palliative sedation may be implemented to manage symptom distress that is not responsive to standard treatment modalities. Nurses are involved in the care of patients receiving palliative sedation as well as their families. To date, however, little research has been conducted examining the nurses' experiences with, and perceptions about the use of palliative sedation in end-of-life care. In order to redress this gap in the literature a descriptive-exploratory study guided by the theory of symbolic interactionism was conducted. Face-to-face interviews were conducted with 10 nurses working on an adult in-patient palliative care unit within a long-term care facility in Canada. The major theme emerging from content analysis of interview transcripts was that of 'Working your way through the quagmire'. The metaphor of the quagmire captured the difficult and complex issues nurses grappled with in instances where palliative sedation was used, and integrates the major categories into the key analytic model emerging from this study.

Nurses' perceptions of quality end-of-life care on an acute medical ward

AIM

This paper reports the findings of a study that generated a conceptual model of the nursing behaviours and social processes inherent in the provision of quality end-of-life care from the perspective of nurses working in an acute care setting.

BACKGROUND

The majority of research examining the issue of quality end-of-life care has focused on the perspectives of patients, family members and physicians. The perspective of nurses has generally received minimal research attention, with the exception of those working within palliative or critical care. The vast majority of hospitalized patients, however, continue to be cared for and die on medical units. To date, little research has been conducted examining definitions and determinants of quality end-of-life care from the perspective of nurses working in acute adult medical settings.

METHOD

Grounded theory method was used in this study of 10 nurses working on acute medical units at two tertiary university-affiliated hospitals in central Canada. Data were collected during 2002 by interview and participant observation.

FINDINGS

The basic social problem uncovered in the data was that of nurses striving to provide high quality end-of-life care on an acute medical unit while being pulled in all directions. The unifying theme of 'Creating a haven for safe passage' integrated the major sub-processes into the key analytic model in this study. 'Creating a haven for safe passage' represents a continuum of behaviours and strategies, and includes the sub-processes of 'facilitating and maintain a lane change'; 'getting what's needed'; 'being there'; and 'manipulating the care environment'.

CONCLUSION

The ability of nurses to provide quality end-of-life care on an acute medical unit is a complex process involving many factors related to the patient, family, healthcare providers and the context in which the provision of end-of-life care takes place.

A survey of PDA use by palliative medicine practitioners

This paper describes the results of a Web survey on the use of personal digital assistants (PDAs) by physicians across Canada involved with the delivery of palliative medicine in different settings. Seventy-two physicians responded to the survey from April to July 2005. The survey revealed 58.3% of respondents currently use PDAs on a daily basis, mostly to organize their practice and to look up medical references. Some use their PDAs to store patient information and to access a central electronic patient record (EPR). In terms of potential PDA use in palliative medicine, six thematic areas are suggested: medical references, EPR, staying connected, personal productivity, clinical research, and issues/concerns. For implications, healthcare organizations should consider mobile technology as part of their information systems strategy. The feasibility of a portable EPR for palliative medicine should be explored, and an information-based approach can help advance palliative medicine research in Canada.

"Beauty is only skin deep": prevalence of dermatologic disease on a palliative care unit

Skin disease affects the palliative care patient population because of their immunosuppressed state and decreased mobility; however, the prevalence of skin disease in this population has not been studied. We collected dermatologic histories and examinations of patients admitted to a hospital-based tertiary palliative care unit. Repeat examinations were performed to assess the incidence of cutaneous disease, as well as the progression of existing conditions. Sixteen of 65 patients admitted during 9 consecutive weeks participated in regular examinations. Six patients developed decubitus ulcers or had progression of existing ulcers. Dermatitis, xerosis, and pruritus were common diagnoses. Six patients sustained cutaneous trauma. Of the 49 non-participating patients, 4 developed decubitus ulcers, 1 had a drug reaction, and 3 had cutaneous infections. Palliative care patients are prone to developing decubitus ulcers and cutaneous infections. Aggressive control of systemic symptoms may exacerbate skin disease. Consideration of dermatologic conditions is an important factor in optimizing skin control in this population.

Daily journal club: an education tool in palliative care

Journal clubs are a valuable tool for medical education. This paper describes a unique daily journal club format utilized by our palliative care programme and presents the results of a questionnaire sent to trainees exploring satisfaction with its educational value. We reviewed the number and type of articles presented at the journal club over 1 year. A questionnaire was mailed to participating family medicine residents and palliative care fellows. The number of articles presented over 1 year was 252. Pain and symptom control, psychosocial issues and drugs other than opioids were topics accounting for 72% of the presentations. Half were given by attending physician staff, 38% by trainees and 12% by multidisciplinary visitors. Palliative care fellows indicated significantly higher levels of satisfaction than family medicine residents, particularly in the areas of clinical applicability, acceptability of the daily schedule and overall educational value. The increased emphasis on evidence-based practice in palliative care suggests that a journal club could be a useful educational tool. The results from our experience could be applied to other palliative care programmes.

P53, MDM-2, BAX and BCL-2 and drug resistance in chronic lymphocytic leukemia

Most antitumor agents exert their cytotoxic effect through the induction of apoptosis, and this process may be mediated through an elevation in p53 protein, with a subsequent increase in bax and decrease in bcl-2. p53 also increases mdm-2 expression and mdm-2 may then bind and inactivate p53. Cells from 31 patients with chronic lymphocytic leukemia (CLL) were treated in vitro with 2-chlorodeoxyadenosine (CdA), arabinosyl-2-fluoroadenine (F-ara-A), or chlorambucil (CLB) and drug sensitivity measured using the MTT assay. The protein levels of bax and bcl-2 were measured in CLL cells from 25 patients, and were found to be higher in leukemic cells than in normal B cells. The bcl-2 levels varied three-fold, the bax levels fifteen-fold, and the bax:bcl-2 ratios ranged from 0.44 to 2.91. The expression of mdm-2 mRNA was measured in CLL cells from 28 patients and was found to vary twenty-fold. However, no correlation was observed between drug sensitivity to CdA, F-ara-A, or CLB and the cellular levels of mdm-2 mRNA, or the protein levels of bax or bcl-2, or the bax:bcl-2 ratio. Treatment of CLL cells having wild type p53 with CdA, F-ara-A or CLB produced an increase in p53 protein and mdm-2 mRNA. This was not observed in cells having a p53 mutation, and these cells were highly resistant to both CLB and the nucleoside analogs. In contrast to the nucleoside analogs and CLB, dexamethasone and vincristine had no effect on mdm-2 mRNA levels. Treatment of CLL cells containing a wild type p53 gene with CdA, F-ara-A, or CLB, did not produce any consistent changes in bax or bcl-2. Thus, CdA, F-ara-A and CLB appear to act in CLL cells through a p53-dependent pathway, whereas this does not occur with dexamethasone or vincristine. The cellular levels of mdm-2, bcl-2, bax or the bax:bcl-2 ratios are not predictive indicators of clinical sensitivity in CLL, but an increase in mdm-2 levels after drug treatment is indicative of p53 function in these cells.