MacCallum Caroline A, Eadie Lauren, Barr Alasdair M, Boivin Michael, Lu Shaohua
Department of Medicine, Faculty of Medicine, Division of Community Internal Medicine, University of British Columbia, Vancouver, BC, Canada.
Department of Medicine, Faculty of Medicine, Division of Palliative Care, UBC, Vancouver, BC, Canada.
Front Pharmacol. 2021 Apr 30;12:633168. doi: 10.3389/fphar.2021.633168. eCollection 2021.
Chronic non-cancer pain (CNCP) is estimated to affect 20% of the adult population. Current United States and Canadian Chronic non-cancer pain guidelines recommend careful reassessment of the risk-benefit ratio for doses greater than 90 mg morphine equivalent dose (MED), due to low evidence for improved pain efficacy at higher morphine equivalent dose and a significant increase in morbidity and mortality. There are a number of human studies demonstrating cannabis opioid synergy. This preliminary evidence suggests a potential role of cannabis as an adjunctive therapy with or without opioids to optimize pain control. In 2017, the Canadian Opioid Guidelines Clinical Tool was created to encourage judicious opioid prescribing for CNCP patients and to reevaluate those who have been chronically using high MED. Mirroring this approach, we draw on our clinical experiences and available evidence to create a clinical tool to serve as a foundational clinical guideline for the initiation of medical cannabis in the management of CNCP patients using chronic opioid therapy. Following principles of harm reduction and risk minimization, we suggest cannabis be introduced in appropriately selected CNCP patients, using a stepwise approach, with the intent of pain management optimization. We use a structured approach to focus on low dose cannabis (namely, THC) initiation, slow titration, dose optimization and frequent monitoring. When low dose THC is introduced as an adjunctive therapy, we observe better pain control clinically with lower doses of opioids, improved pain related outcomes and reduced opioid related harm.
据估计，慢性非癌性疼痛（CNCP）影响着20%的成年人口。美国和加拿大目前的慢性非癌性疼痛指南建议，对于吗啡等效剂量（MED）大于90毫克的剂量，要仔细重新评估风险效益比，因为在较高吗啡等效剂量下疼痛疗效改善的证据不足，且发病率和死亡率显著增加。有多项人体研究证明了大麻与阿片类药物的协同作用。这一初步证据表明，大麻在联合或不联合阿片类药物的情况下作为辅助治疗以优化疼痛控制方面具有潜在作用。2017年，创建了加拿大阿片类药物指南临床工具，以鼓励对CNCP患者谨慎开具阿片类药物处方，并重新评估长期使用高MED的患者。借鉴这种方法，我们利用临床经验和现有证据创建了一种临床工具，作为在使用慢性阿片类药物治疗的CNCP患者中启动医用大麻管理的基础临床指南。遵循减少伤害和最小化风险的原则，我们建议采用逐步方法，在适当选择的CNCP患者中引入大麻，以优化疼痛管理。我们采用结构化方法，专注于低剂量大麻（即四氢大麻酚）的起始、缓慢滴定、剂量优化和频繁监测。当引入低剂量四氢大麻酚作为辅助治疗时，我们在临床上观察到较低剂量的阿片类药物能更好地控制疼痛，改善与疼痛相关的结果，并减少与阿片类药物相关的伤害。
