Research ArticlePractice

Simplified guideline for prescribing medical cannabinoids in primary care

G. Michael Allan, Jamil Ramji, Danielle Perry, Joey Ton, Nathan P. Beahm, Nicole Crisp, Beverly Dockrill, Ruth E. Dubin, Ted Findlay, Jessica Kirkwood, Michael Fleming, Ken Makus, Xiaofu Zhu, Christina Korownyk, Michael R. Kolber, James McCormack, Sharon Nickel, Guillermina Noël and Adrienne J. Lindblad
Canadian Family Physician February 2018; 64 (2) 111-120;

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Medical cannabinoid prescribing algorithm

    CINV—chemotherapy-induced nausea and vomiting, MS—multiple sclerosis, SCI—spinal cord injury.

  • Figure 2.
    Figure 2.

    Neuropathic pain: Pharmacotherapy treatment.

    *60–110 mg of oral morphine per day.

    †Go to the full text of the article online and click on the CFPlus tab.

Tables

  • Table 1.

    Medical cannabinoids’ estimated benefit when treating chronic pain, chemotherapy-induced nausea and vomiting, or spasticity with GRADE rating of evidence

    ESTIMATED BENEFIT
    INDICATIONCANNABINOIDSCONTROL (PLACEBO UNLESS INDICATED)NNTGRADE QUALITY OF EVIDENCE
    Chronic pain (median follow-up 4 wk)
      • ≥ 30% reduction in chronic (neuropathic plus cancer) pain*39%30%11Very low
      • ≥ 30% reduction in neuropathic pain38%30%14Very low
      • ≥ 30% reduction in palliative pain30%23%NS (approximately 15)†Very low
      • Change in chronic pain scales (possible score 0–10)‡Baseline: approximately 6
    Decrease: 1.2–1.6    		Baseline: approximately 6
    Decrease: 0.8    		NAVery low
    Chemotherapy-induced nausea and vomiting (median follow-up 1 d)
      • Control of nausea and vomiting (cannabinoids vs placebo)47%13%3Moderate
      • Control of nausea and vomiting (cannabinoids vs neuroleptics)31%16% (vs neuroleptics)7Low
    Spasticity (median follow-up 6 wk)
      • Global impression of change50%35%7Low
      • ≥ 30% improvement in spasticity35%25%10Low
      • Change in spasticity (possible score 0–10)‡Baseline: 6.2
    Decrease: 1.3–1.7    		Baseline: 6.2
    Decrease: 1.0    		NAVery low

    • GRADE—Grading of Recommendations Assessment, Development and Evaluation, NA—not applicable, NNT—number needed to treat, NS—not statistically significant. Data from accompanying systematic review by Allan et al (page e78).12

    • ↵* Meta-analysis results included 13 studies on neuropathic pain and 2 studies on cancer pain.

    • ↵† Confidence intervals suggest that benefit is likely (risk ratio = 1.34, 95% CI 0.96 to 1.86), so estimated NNT provided.

    • ↵‡ Scales are visual analogue scales or numeric rating scales with higher scores indicating worse pain or spasticity. Changes with cannabinoids are given as a range based on varying results.

  • Table 2.

    Adverse events and estimated event rates for medical cannabinoids, with GRADE of evidence rated high

    TYPE OF ADVERSE EVENTCANNABINOID EVENT RATE, %PLACEBO EVENT RATE, %NNH
    Overall81626
    Withdrawal due to adverse events11Approximately 3%14
    Serious adverse eventsNSNSNS
    Central nervous system effects60274
    “Feeling high”3534
    Sedation50305
    Speech disorders3275
    Dizziness32115
    Ataxia or muscle twitching30116
    Numbness2146
    Disturbance in attention or disconnected thoughts1727
    Hypotension25118
    Dysphoria130.38
    Psychiatric1759
    Euphoria1529
    Impaired memory11212*
    Disorientation or confusion9215
    Blurred vision or visual hallucination6017
    Dissociation or acute psychosis5020

    • GRADE—Grading of Recommendations Assessment, Development and Evaluation, NNH—number needed to harm, NS—not statistically significant. Data from accompanying systematic review by Allan et al (page e78).12 Examples of harms were selected from the largest statistically significant meta-analyses providing event rates. Grouping of adverse events follows the combinations used in the original research.12

    • ↵* Confidence intervals suggest that harm is likely (risk ratio = 3.41, 95% CI 0.95–12.27), so estimated NNH provided.

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Simplified guideline for prescribing medical cannabinoids in primary care
G. Michael Allan, Jamil Ramji, Danielle Perry, Joey Ton, Nathan P. Beahm, Nicole Crisp, Beverly Dockrill, Ruth E. Dubin, Ted Findlay, Jessica Kirkwood, Michael Fleming, Ken Makus, Xiaofu Zhu, Christina Korownyk, Michael R. Kolber, James McCormack, Sharon Nickel, Guillermina Noël, Adrienne J. Lindblad
Canadian Family Physician Feb 2018, 64 (2) 111-120;
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