The Modified Delphi Process
A modified Delphi process was used to develop this consensus guidance document and associated algorithm.37–39 The methods used for this report have been previously published in abstract form.40 The participants were recruited based on extensive clinical experience with prescribing and managing patients on medical cannabis and/or extensive research expertise with cannabis. The consensus process incorporated a five-step modified Delphi method similar to previous reports41–43 and took place between July 2019 and November 2019 (Figure 1 and Table 1). In step one a core scientific committee of cannabinoid subject matter experts from the United States and Canada (n = 9) identified key areas of focus. From these areas of focus, an initial draft of consensus questions was developed, and these questions were incorporated into four domains:
  1. When to consider introducing cannabinoids in patients with chronic pain taking opioids
  2. How to introduce cannabinoids in patients with chronic pain taking opioids
  3. When and how to taper opioids in patients with chronic pain taking cannabinoids
  4. Evaluating clinical outcomes and guiding patient monitoring and safety
In step two the core scientific committee reviewed the initial draft of questions and provided comments. Following the inclusion of the suggested changes to the consensus questions, a teleconference was conducted to gain verbal approval from the scientific committee to send out the questions for review by the rest of the consensus summit participants (n = 13).
In step three the consensus summit participants were provided a reference package and sent the consensus questions for their review and associated comments. Twelve of the 13 participants provided their comments and suggestions.
Following the inclusion of these updates into the consensus questions, step four was initiated and all summit invitees, which included the core scientific committee and the participants, reviewed the consensus questions and prevoted using an online software. Sixteen of the 22 summit invitees provided a prevote. These prevote results were then used at the live event to focus the discussion on topics where a lack of consensus was apparent. In step five a formal voting session took place at an in-person meeting in Toronto, Canada: The Opioids and Cannabinoids Consensus Summit. The voting was public but anonymous using live polling software (Slido, www.slido.com). Nineteen participants took part in the live voting session, however the opportunity to abstain from answering questions was available.
For consensus to be declared, a predetermined threshold of ≥ 75% of the voters had to agree on a specific answer, or, ≥ 75% of the voters had to strongly agree or agree (or strongly disagree or disagree) on an answer. This consensus threshold is similar to previous studies using a modified Delphi method. 41,44 At the in-person event, revisions to the questions and associated answers, and revotes, were permitted. The voters were instructed that the patient they were considering was a patient with chronic pain taking opioids who was not currently using cannabis, recreationally or medically, to treat their chronic pain. The voters were instructed that the termcannabinoids refers to the most studied of the cannabinoids, ie, THC and CBD. The voters were instructed to assume there were no patient access or financial limitations to consider when choosing a given answer.