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.