UPDATE: We do have an update from the guidelines co-author, Dr Dustin Sulak, well known medical cannabis expert. "To begin with, it doesn’t suggest CBD 5mg starting dose, it’s CBD-predominant formula up to THC:CBD 1:10. I know that’s still low, but the 0.5mg THC does make a difference in my opinion." Dr Kogan can't agree more. It appears that MedPage original publication has misinterpreted the initial dosing recommendation. We are looking forward to reading peer reviewed publication of the guidelines in the near future.
At a joint meeting of AAPM, ACPA, APS, ASPE, NADDI, Power of Pain Foundation, and the U.S. Pain Foundation, an international task force on September 13, 2020, released new guidelines on the use of CBD and medical cannabis for chronic pain. MedPage Today reports that chronic pain patients can be treated with medical cannabis following one of three protocols based on patient characteristics released during a virtual PAINWeek meeting.
Mikhail "Misha" Kogan, MD, Associate Professor of Medicine, George Washington School of Medicine and Health Sciences, is the university's subject matter expert on the use of medical CBD and THC. He is one of the first physicians in the Washington, D.C. metropolitan area to work closely with the DC Department of Health to develop online medical cannabis training modules for health professionals after medical marijuana was legalized in the nation’s capital. He is currently developing a local medical cannabis research team and protocols under mentorship of integrative oncologist Donald Abrams, MD, one of the world's leading clinical researchers on medical cannabis. Dr. Abrams is a member of the committee that authored the 2017 National Academies of Sciences report on “The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research.”
Dr. Kogan, who is a frequent speaker at a variety of international conferences on the topics of medical cannabis, Integrative Medicine and Geriatrics, and neurodegenerative diseases, issued a statement on the recently issued guidelines on using medical CBD and THC for chronic pain.
"The new guidelines on the use of Medical Cannabis is very timely and very welcomed. Now physicians who are not familiar with the topic of medical cannabis for pain can fall back on this. The start low and go slow dosing recommendation, especially in older adults practice, is also very important. However, recommendation of starting all patients with 5mg of CBD twice daily is in significant disagreement with clinical practice. This dose of CBD is not just too low but CBD with no THC is not highly evidenced for pain. In fact, all prior evidence on chronic pain including 2017 National Academy of Sciences report points toward using THC for pain as the main direction. While it is very true that some chronic pain patients can respond well to moderate doses of CBD (15-25mg twice daily) these patients are in the minority. Starting all patients on CBD and titrating up while waiting will leave most patients without adequate pain relief.
Patients should have options of starting with a low dose of THC containing products upon first meeting with a recommended provider. The ideal dosing and ratios are not known but likely a low dose of balanced THC:CBD ratio with gradual titration of several weeks. While safety wise this guideline makes good sense, unfortunately it misses the mark and fails to mention that there is no data comparing THC:CBD mixes to CBD alone. This gap in knowledge is critical to address.
To address this gap GW Medical Faculty Associates, in partnership with industry sponsor, is planning on initiating a randomized cross over trial comparing THC:CBD to CBD alone.
Another important point is that these guidelines fail to state that an oral dose of CBD should be kept under 100mg/day to minimize the risk of CBD interactions with other pain medications including opioids. Additionally, a number of other less commonly used cannabinoids such as CBDa and THCa have great promise in treating chronic pain. In fact, the data shows that CBDa mg per mg has more potency than most currently used Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) such as Motrin. However, similar to the lack of clinical data comparing different ratios of THC and CBD, more data on CBDa and THCa is very much needed.
One reason starting patients with chronic pain on CBD alone may make good sense is the fact that anxiety often plays a fundamental role in the experience of pain and is associated with increased pain intensity and decreased pain tolerance. CBD has been shown to be effective anti-anxiety treatment and thus may be best reserved for chronic pain patients who has significant anxiety.
In conclusion I’m very hopeful that this timely and new important guidelines will stimulate researchers and clinicians trying to initiate more clinical studies. Unfortunately, due to Cannabis being a schedule 1 DEA controlled substance, this puts a major hurdle on the research. The need to reschedule medical cannabis is obvious and I hope that this happens as soon as possible."
The 2017 NAS report Dr. Kogan referred to is one of the most comprehensive studies of research on the health effects of recreational and therapeutic cannabis use. It offers a rigorous review of scientific research published since 1999 about the health impacts of cannabis and cannabis-derived products – ranging from therapeutic effects to risks for certain cancers, diseases, mental health disorders, and injuries.
2017 National Academies of Sciences report, "The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research."
The International Cannabinoid Research Society, (ICRS), is a source for impartial information on cannabis and the cannabinoids that provides an open forum for researchers to meet and discuss their research.
The DC Department of Health’s Center for Rational Prescribing provides education courses on medical cannabis co-developed by Dr. Kogan that are eligible for CME or a free-non CME option. The program consists of 3 one-hour modules on biochemistry, pharmacology, efficacy, and side effects of medical cannabis.
GW Integrative Medicine Podcast: Dr. Kogan discusses the 2017 National Academy of Sciences report with Donald Abrams, MD, who is a co-author of the report.