Domain 4: Evaluating clinical outcomes and guiding patient monitoring and safety
The fourth domain examined questions around monitoring, safety, and efficacy measures in patients with chronic pain taking opioids and cannabinoids. The key consensus findings for this domain are:
1) During the early phase of opioids and cannabinoids co-administration, it was recommended to follow-up with patients once or twice monthly until the patient is stable. Once the health care professional and the patient are comfortable, it was agreed that follow-up could occur every three months. It was also agreed that the monitoring of these patients could be led by health care professionals other than the treating physician, and that these follow-ups could be done via phone call or home visit depending on what works best for the health care professional and patient. At this point, even though a patient may be stable with respect to their chronic pain control, variations in dosing and administration of medical cannabis may be required for optimal pain control.
2) When considering the safety of a patient taking both opioids and cannabinoids, health care professionals should screen for opioid withdrawal, illicit opioid use, cannabinoid-related adverse effects, use of other illicit substances, and symptoms of psychosis. Cannabinoid titration should be halted: when the patient’s goals are met; when cannabinoid treatment reaches an efficacy plateau (ie, no change in pain relief after a dose increase); or, if the patient experiences a cannabinoid-related adverse event. If the patient experiences a cannabinoid-related adverse event, it is recommended to reduce the dose of the associated cannabinoid. If a patient experiences opioid withdrawal symptoms, it was agreed that the health care professional should consider slowing or pausing the patient’s opioid taper.
3) When considering treatment success, no consensus was found on the need to use a validated questionnaire to establish efficacy. However, there was consensus on initiating and documenting discussions with the patient around the degree of pain relief, sleep quality, and everyday functionality throughout treatment. In concert with this, it was agreed that clinical success when titrating cannabinoids and tapering opioids is most clearly defined by an improvement in patient function.