Marijuana often is used to self treat chronic pain and, with 24 states legalizing medical use of the herb, the American Pain Society published guidance in The Journal of Pain for physicians caring for patients who use cannabis. The paper also identified opportunities for future research required to better understand the health effects of cannabinoids.

The article is a consensus report with a balanced analysis from experts with diverse opinions about the value of cannabis as a pain treatment. The authors range from legalization advocates to opponents of using cannabis, even for medical purposes.

"We looked at the evidence that is available on the use of clinical cannabis and extrapolated to some degree on management strategies from our experiences with the prescribing of controlled substances," said lead author Seddon R. Savage, M.D., medical director, Silver Hill Hospital Chronic Pain and Recovery Center, in an interview with Medscape at the recent American Pain Society annual meeting.

The article reviews clinical, research and policy issues related to herbal cannabis to counsel clinicians in advising and caring for patients who use cannabis, while recognizing there is a broad range of opinion among pain clinicians and researchers regarding use of herbal cannabis. However, the authors note that many pain clinicians and researchers agree that cannabinoids are clinically promising chemical compounds, and there is a critical need for robust research on herbal cannabis to identify targets for medical development.

Clinical practice recommendations include:

• Know the federal and state laws governing use of medical cannabis

• Be clear with patients about goals for therapeutic cannabis

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• Counsel patients about routes of administration and potential benefits and risks, based on scientific evidence and individual symptoms, conditions and comorbidities

• Advise patients on cannabis strains, cannabinoid medications or extracts, explaining limitations due to lack of herbal/substance uniformity and regulatory oversight

• Monitor patients the same as for treatment with opioids or other controlled substances.

• Patient follow up should assess progress toward achieving treatment goals, incidence of side effects, and evidence of psycho-behavioral changes.

The authors strongly advocate that a robust research agenda is needed to fully realize the clinical potential of cannabinoid therapies. They recommend:

• Increase federal funding for pain-related cannabis research

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• Broaden pain conditions being studied to include cannabis for non-neuropathic pain

• Ease regulatory restrictions that impede approvals of cannabis and cannabinoid research

• Improve access to high-quality plant cannabis for research studies

• Encourage states to collect individual and population level data on patients receiving medical cannabis.

The authors concluded that research on the cultivation of cannabis also is needed. Expanded medical use will require high-quality medicinal grade cannabis with strict quality control and known constituents.