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Bhaskar A, Bell A, Boivin M, Briques W, Brown M, Clarke H, Cyr C, Eisenberg E, de Oliveira Silva RF, Frohlich E, Georgius P, Hogg M, Horsted TI, MacCallum CA, Müller-Vahl KR, O'Connell C, Sealey R, Seibolt M, Sihota A, Smith BK, Sulak D, Vigano A, Moulin DE. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. J Cannabis Res 2021; 3:22. [PMID: 34215346 PMCID: PMC8252988 DOI: 10.1186/s42238-021-00073-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Globally, medical cannabis legalization has increased in recent years and medical cannabis is commonly used to treat chronic pain. However, there are few randomized control trials studying medical cannabis indicating expert guidance on how to dose and administer medical cannabis safely and effectively is needed. METHODS Using a multistage modified Delphi process, twenty global experts across nine countries developed consensus-based recommendations on how to dose and administer medical cannabis in patients with chronic pain. RESULTS There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed. A routine protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg CBD twice daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 2.5 mg and titrate by 2.5 mg every 2 to 7 days until a maximum daily dose of 40 mg/day of THC. A conservative protocol where the clinician initiates the patient on a CBD-predominant variety at a dose of 5 mg once daily and titrates the CBD-predominant dose by 10 mg every 2 to 3 days until the patient reaches their goals, or up to 40 mg/day. At a CBD-predominant dose of 40 mg/day, clinicians may consider adding THC at 1 mg/day and titrate by 1 mg every 7 days until a maximum daily dose of 40 mg/day of THC. A rapid protocol where the clinician initiates the patient on a balanced THC:CBD variety at 2.5-5 mg of each cannabinoid once or twice daily and titrates by 2.5-5 mg of each cannabinoid every 2 to 3 days until the patient reaches his/her goals or to a maximum THC dose of 40 mg/day. CONCLUSIONS In summary, using a modified Delphi process, expert consensus-based recommendations were developed on how to dose and administer medical cannabis for the treatment of patients with chronic pain.
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Affiliation(s)
- Arun Bhaskar
- Pain Management Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Alan Bell
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Matthew Brown
- Department of Pain Medicine, The Royal Marsden Hospital, London, UK
- The Institute of Cancer Research, London, UK
| | - Hance Clarke
- Department of Anesthesia and Pain Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Claude Cyr
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Elon Eisenberg
- Institute of Pain Medicine, Rambam Health Care Campus, The Technion, Israel Institute of Technology, Haifa, Israel
| | | | - Eva Frohlich
- Department of Anaesthesiology and Pain Management, Helen Joseph Hospital, Johannesburg, South Africa
| | | | - Malcolm Hogg
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | | | | | - Kirsten R Müller-Vahl
- Hannover Medical School, Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover, Germany
| | - Colleen O'Connell
- Department of Physical Medicine and Rehabilitation, Stan Cassidy Centre for Rehabilitation, Fredericton, NB, Canada
| | - Robert Sealey
- Cannabinoid Medicine Specialist, Victoria, BC, Canada
| | - Marc Seibolt
- Algesiologikum- Centers for Pain Medicine, Day Clinic for Pain Medicine, Munich, Germany
| | - Aaron Sihota
- The University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Brennan K Smith
- CTC Communications, Medical Division, Mississauga, ON, Canada
| | | | - Antonio Vigano
- Department of Oncology, McGill University, Montreal, QC, Canada
| | - Dwight E Moulin
- Departments of Clinical Neurological Sciences and Oncology, Earl Russell Chair of Pain Medicine, Western University, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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Hendricks O, Andersen TE, Christiansen AA, Primdahl J, Hauge EM, Ellingsen T, Horsted TI, Bachmann AG, Loft AG, Bojesen AB, Østergaard M, Lund Hetland M, Krogh NS, Roessler KK, Petersen KH. Efficacy and safety of cannabidiol followed by an open label add-on of tetrahydrocannabinol for the treatment of chronic pain in patients with rheumatoid arthritis or ankylosing spondylitis: protocol for a multicentre, randomised, placebo-controlled study. BMJ Open 2019; 9:e028197. [PMID: 31167870 PMCID: PMC6561449 DOI: 10.1136/bmjopen-2018-028197] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Rheumatoid arthritis (RA) and ankylosing spondylitis (AS) are chronic, systemic, inflammatory diseases, primarily in the musculoskeletal system. Pain and fatigue are key symptoms of RA and AS. Treatment presents a clinical challenge for several reasons, including the progressive nature of the diseases and the involvement of multiple pain mechanisms. Moreover, side effects of pain treatment pose an implicit risk. Currently, no well-controlled studies have investigated how medical cannabis affects pain and cognitive functions in RA and AS. The present study aims to evaluate the efficacy and safety of medical cannabis in the treatment of persistent pain in patients with RA and AS with low disease activity. METHODS AND ANALYSIS A double-blinded, randomised, placebo-controlled study of cannabidiol (CBD), followed by an open label add-on of tetrahydrocannabinol (THC) with collection of clinical data and biological materials in RA and AS patients treated in routine care. The oral treatment with CBD in the experimental group is compared with placebo in a control group for 12 weeks, followed by an observational 12-week period with an open label add-on of THC in the primary CBD non-responders. Disease characteristics, psychological parameters, demographics, comorbidities, lifestyle factors, blood samples and serious adverse events are collected at baseline, after 12 and 24 weeks of treatment, and at a follow-up visit at 36 weeks. Data will be analysed in accordance with a predefined statistical analysis plan. ETHICS AND DISSEMINATION The Danish Ethics Committee (S-20170217), the Danish Medicines Agency (S-2018010018) and the Danish Data Protection Agency approved the protocol. The project is registered in the European Clinical Trials Database (EudraCT 2017-004226-15). All participants will give written informed consent to participate prior to any study-related procedures. The results will be presented at international conferences and published in peer-reviewed journals.
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Affiliation(s)
- Oliver Hendricks
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
- IRS, Syddansk Universitet Det Naturvidenskabelige Fakultet, Odense, Denmark
| | - Tonny Elmose Andersen
- Department of Psychology, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Afshin Ashouri Christiansen
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
- IRS, Syddansk Universitet Det Naturvidenskabelige Fakultet, Odense, Denmark
| | - Jette Primdahl
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
- Department of Regional Health Research, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | | | | | | | - Anja Godske Bachmann
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
- IRS, Syddansk Universitet Det Naturvidenskabelige Fakultet, Odense, Denmark
| | - Anne Gitte Loft
- Department of Rheumatology, Aarhus Universitet Health, Aarhus, Denmark
| | - Anders Bo Bojesen
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
| | - Mikkel Østergaard
- Department of Rheumatology, COPECARE, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Merete Lund Hetland
- Department of Rheumatology, COPECARE, Rigshospitalet Glostrup, Glostrup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Steen Krogh
- Department of Rheumatology, COPECARE, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Kirsten Kaya Roessler
- Department of Psychology, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Kim Hørslev Petersen
- Rheumatology, Danish Hospital for Rheumatic Diseases, Gråsten, Denmark
- IRS, Syddansk Universitet Det Naturvidenskabelige Fakultet, Odense, Denmark
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Horsted TI, Wanscher MCJ, Rasmussen LS, Lippert FK, Kjaergaard J, Hassager C. [Therapeutic hypothermia after cardiac arrest--status]. Ugeskr Laeger 2006; 168:458-61. [PMID: 16472432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Induced hypothermia in comatose patients resuscitated from cardiac arrest improves survival and neurological outcome when the initial rhythm is ventricular fibrillation. Results from 26 patients treated with early prehospital cooling, continued in hospital with cold fluids and body surface cooling, are presented. Sixteen patients had no or only minor neurological defects at discharge. Thirteen of 17 patients treated for ventricular fibrillation had a good cerebral outcome at discharge. Two patients had minor complications resulting from the treatment.
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Affiliation(s)
- Tina Ingrid Horsted
- Thoraxanaestesiologisk Klinik, Afsnit 4142, og Hjertemedicinsk Klinik B, Hjertecentret.
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