CBD for Chronic Pain: Experts Developed Dosage Protocols

The world experts in medical cannabis and cannabidiol have developed three dosing and administration protocols for patients with chronic pain. For those who are using CBD for chronic pain, oil or capsules are found to be the best way of administration. 

At the last US national conference on pain management, organized in September 2020 by PainWEEK, dr. Allan Bell from the University of Toronto and his colleagues presented a new publication – The Consensus Recommendations on Dosing and Administration of Medical Cannabis to Treat Chronic Pain. The recommendations are the results of a modified Delphi process. The process is one of several methods developed to identify the collective opinion of experts.

Chronic pain affects around two billion people worldwide. It is associated with impairment in physical and emotional function, reduced participation in social and vocational activities, and lower perceived quality of life.

As it’s well known, medical cannabis has been used to treat chronic pain for centuries. The patient-reported data shows that chronic pain management is one of the most common reasons for medical cannabis use. However, there is not enough scientific data on the effects of cannabis in the treatment of chronic pain. 

We are witnessing an increase in the number of countries in which medical cannabis use got approved in recent years. The World Health Organization has recommended rescheduling cannabis in the international drug control framework to a less stringent schedule. Consequently, on December 2nd, 2020, the United Nations Commission on Narcotic Drugs removed cannabis and cannabis resin from Schedule IV of the 1961 Single Convention on Narcotic Drugs. This vote should clear the way for further research in the area of medical use of cannabis.

Bridging the Evidence Gap

As the scientists behind the new recommendations point out, there are so far low or moderate levels of evidence to support the use of cannabinoids for the treatment of chronic pain. As a result of this evidence gap, there are limited scientific data to guide dosing and administration of medical cannabis in clinical practice.

To bridge the gap between a lack of evidence and increased use of medical cannabis, they conducted a modified Delphi process with 20 medical cannabis leaders across nine countries to develop consensus-based recommendations for the safe and effective use of medical cannabis to treat chronic pain.

CBD for Chronic Pain: Global Taskforce

They conducted a multi-stage modified Delphi process. The 20-member global task force received an initial clinical practice survey. It helped in the understanding of how patients are being treated with medical cannabis across different countries. A draft of consensus questions was developed and reviewed twice by the 9-member scientific committee before being sent out to all task force members for two rounds of pre-voting. A threshold of ≥75% agreement was predetermined for declaring consensus. Following the pre-voting rounds, there were two virtual meetings for voting on the remaining key questions.

Three Protocols: Routine, Conservative and Rapid

There was consensus that medical cannabis may be considered for patients experiencing neuropathic, inflammatory, nociplastic, and mixed pain. Three treatment protocols were developed and categorized as Routine, Conservative, and Rapid. The clinician and patient may choose to move between the protocols as necessary.

The experts found that oral administration with oil or capsules should be considered a recommended administration format. If breakthrough pain management is necessary, dried flower vaporization was found to be the recommended mode.

The routine stream is designed for the majority of patients with chronic pain. The recommendations included: Initiate on CBD-predominant variety at a dose of 5 mg CBD twice daily. Titrate 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. When up-titrating either cannabinoid, the total daily dose can be divided into 2-4 administrations.

The conservative protocol is recommended for patients who may be more sensitive to medical cannabis effects and who would prefer to prioritize safety. Clinically frail patients, the elderly, those with complex comorbidities, polypharmacy, and/or mental health disorders, may also be appropriate for the conservative approach. The recommendations included: Initiate on CBD-predominant variety at a dose of 5 mg once daily. Titrate 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.

The rapid stream was designed for individuals who require more rapid titration or earlier initiation of THC such as patients with severe pain or functional impairment, or cannabis experienced patients. The recommendations included: Initiate on a balanced THC: CBD variety at 2.5-5 mg of each cannabinoid once or twice daily. Titrate 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.

Individualized Therapy

It is important to note that every patient is different, and medical cannabis treatment, like most other therapies, should be individualized to the patient, the experts concluded. Sharing treatment decision-making with the patient is necessary, and establishing treatment goals during the initial medical consultation may enhance patient outcomes and adherence to medical cannabis treatment. Future randomized control trials examining the safety and efficacy of medical cannabis will be required to clarify if the developed protocols result in improved patient outcomes. In this light, the expert recommendations on the dosage of CBD and THC for chronic pain will be updated as soon as new clinical trial evidence becomes available.

Reviewed by Sasha Bajilo, founder of ILESOL Pharmaceuticals, an industrial scale producer of CBD products and formulations. Expert on Hemp/Cannabis policy, member of the Croatian Ministry of Health regulatory commission for medical cannabis.