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E73 - Opioid Taper with Cannabis Guidelines

We are in an opioid crisis. Wouldn't it be great if we had another tool to taper people to a lower opioid dose or off their opioids altogether? A group of almost 20 experts got together and drew up consensus guidelines on how to taper opioids with cannabis. We got Aaron Sihota - Pharmacist, Dr. Brennan K. Smith, PhD, and Dr. Colleen O'Connell MD from the consensus guidelines group together virtually to discuss how the guidelines were drawn up and how cannabis can help fight the opioid crisis

Episode Transcript

Trevor: Kirk we're back. 

Kirk: Hey, Trevor, how's it going? 

Trevor: I am doing well. How are you? 

Kirk: I'm all right. I'm all right. I just I just I went to a restaurant for the first time in many, many months. It was very odd. 

Trevor: That's what you're saying. So, I'm not sure I've been in a restaurant, physically, and I picked up stuff up from a restaurant. But yeah, sat down in one. I don't know. It might be a year. It's been a while anyway. 

Kirk: Well, it was. It was odd. Now, no, I guess I should qualify this last week I was in Steinbeck. I was taken vanHoot for a ride. Michelle and I bought an old van that we planned to travel Western Canada and soon things open up. But we did a trip in southern Manitoba and we did sit in a restaurant and had lunch. But I guess lunch isn't like having dinner, you know, going out for dinner and you have to wait in line. And I got asked. I got to ask for my address. Michelle and I had to show that we lived in the same house. I had to show my double vaccines. Then we had to figure out who is with us and where they from the same house. Did they have vaccines. And we had to give our. I mean, I did everything but give my firstborn over. So, it was odd. And then and then we sit in a restaurant and look around and it's like, it's very sparse, but we got to eat in a restaurant. 

Trevor: Very good. I yeah, you beat me. I would like to do that soon, but it hasn't quite come up. 

Kirk: So, you have brought another paper that's adding to our opiate and cannabis trilogy are we've got like three or four episodes focused on opiates, helping, cannabis helping with opiates. 

Trevor: Yeah. So, sort of off top of my head, we had Dr. Peter Grinspoon. He was a physician who admitted had had some of his own opioid addictions in the past and now with caveats, uses cannabis to help reduce opioids in some patients. We've had a self-described junkie talking about how he uses cannabis to help with his opioid addictions. 

Kirk: So, this is well, then we had then we had Tilray's study. 

Trevor: Yes. Sorry, I forgot about Dr. Lucas at the Tilray study. 

Kirk: Well, I was going to say that's episode 69, Episode 66 and Episode 70. Those are all other shows that are related to this episode. 

Trevor: And So, and the Tilray was put some more numbers behind it. When they weren't, they just sort of looked at what happened in their clinics and lo and behold, when people use cannabis, they use less opioids. So, I'm not saying it was all leading to this one, but this was, I think, it’s a nice tie tying things together that this is now a bunch of experts who have gotten together to say, Hey, if you have somebody on opioids, can you get them off or reduce the opioids with cannabis? And if you're going to do that, who who should it be? How do you do it and how do you monitor them afterwards? 

Kirk: Yeah, I am. I got into this paper and read it yesterday. I find the fact the technique of the Delphi, the Delphi technique of qualitative research. Interesting because essentially it's crowdsourcing. Right? They they have crowdsourced a handful of experts and the paper lists the experts and their affiliations, and they ask them questions about about how they're using cannabis. Now I'm looking at it. They call it a five a five point question study. So, they did. And you get into the talk, they talk about screening their patients, the initiation of how they initiate cannabis, how they titrate cannabis, how they taper people off opioids while they're on cannabis and then how they follow up and and a Delphi. Do you want to explain a Delphi technique of qualitative research? 

Trevor: Well, first I'm going to go into, you know, this was this episode was a lot of fun, but this is my my episode of humility or my anti hubris or the don't think too much of yourself Trevor. So, to back up when I was trying to organize this, So, I literally had people coast to coast to coast. I had West Coast, East Coast, Ontario, US. And so, you know, we got time zone issues. So, Dr. Colleen O'Connell, who you'll hear from, said, Well, why don't you just send out a doodle poll? For those of you who don't know, it's sort of a it's an app you can send out to let people sort of pick times. Though I have received many doodle poll requests for meetings in the past and, you know, selected my time at all work. I have never organized a meeting with a doodle poll before, and apparently I am a doodle poll idiot and kept sending them time request for the middle of the night because I kept then saying that my time zone was somewhere in Europe, So, after, you know, getting getting a bunch of confused e-mails from esteemed people across Canada finally admitted I wasn't So, good at the doodle poll, but we finally got it organized. And then during the interview, you'll hear Dr O'Connell again, school me just a little bit on Delphi. Maybe I was making light of it a little bit by saying, you know, basically, is this glorified anecdotes? And the answer is no, 

Kirk: no, no, no, no, no, no, it is not. Well, this is how experts get their opinions quantified, right? You, you you. This is this is you made a comment with Dr. Pinnock's about the first time, this first time that you know the first time a doctor leaves a baby, the first time a doctor gives cannabis. What this is? This is a study consensus based recommendations for treating cannabis and tapering opioids for chronic pain control, asking questions of experts. These are people who are considered cannabis prescribing experts who have been asked specific questions that relate to literature. So, this is actually a modified Delphi technique that they've done, and they ask a series of questions. And as I said, they had their categories. They the categories of screening the client there, you know, the initiation of the cannabis, the titration of the cannabis, the tapering of the opioids and the follow up processes. Those experts would have been asked a series of questions relating it to the relating to the literature and then the answers create more questions. And the and the the the facilitators of the research then pose more questions for the answers. And until they get to until they get to a consensus of opinion. So, this is this is the this is how this is how practitioners first learned to come together to create to create their their craft. So, this is this is a fascinating way of doing research and and as I said, it's a modified technique. Now I'm going to ask you, did you notice that that the that the series of professionals involved with this research? Two of them have been guests of our podcast. 

Trevor: I did. So, yeah, obviously this, you know, we're picking some good, good people. So, other than the people who are talking today, other people on the list who we have talked to before include Paul Daeninck, oncologist and palliative care guru from about two episodes ago and way back from Kids and Cannabis, we have Dr. Seeley. And yeah, So, yeah, no, we either we or they have a really good group of people. So, yeah, no, I quite like the fact we had and the other and they mentioned a few times and we'll let them talk shortly this group of almost 20 people they have on here are we have: clinicians, we have like scientists, like bench researchers, we have different professions like Aaron Sihota as a pharmacist and Colleen O'Connell is a physician. So, there's it's a big range of people too. So, it's it's nice to see they they got a lot of yeah and Dr. Brennan, Dr. Brennan Smith will mention it but yes, they wish and hope there will be more RCT. In case you missed that RCT is randomized controlled trial? But until we get more of them, this is a great way to sort of try to figure out what's going on by really rigorously asking these questions of experts and seeing where they agree. Yeah. 

Kirk: Now, just before the start, I'm just going to a quick review of the abstract of the study. I'm reading the the study from the International Journal of Clinical Practice and their aims was it goes back to opiate misuse, and overuse has contributed to a widespread overdose crisis. And many patients and physicians are considering medical cannabis to support to support opiate tapering and chronic pain control. So, they use a five step modified Delphi process and their aims to develop a consensus based recommendation on three components when and how to safely initiate and titrate cannabis cannabinoids in the presence of opioids. Number two, When and how to safely taper at opioids in the presence of cannabinoids. And number three, how to monitor patients and to evaluate outcomes when treating with opioids and cannabinoids. I will save the results because they get into the results, but I guess at the end, we can talk about that as well. So, yeah, I found I once again, Trevor, I compliment you. I think this is a wonderful contribution to the three episodes focused on opioids, and cannabis just makes a nice fourth. 

Trevor: Yeah, no, I agree. And yeah, rather than just hear us way wag our lips around about this, why don't we let the experts talk about what the experts talked about? 

Aaron Sihota: Yeah, please be on the podcast. My name's Aaron Sihota. I'm out here on the West Coast in Vancouver, and primary care pharmacists and I work in a multidisciplinary medical cannabis clinic where we assess and evaluate patients for various medical conditions. And one of the coauthors of the consensus guidelines we'll talk about today. 

Trevor: Fantastic. What? Brennan? 

Dr. Brennan Smith: Yeah. Thanks, Trevor, and thanks for having me on. This is great. Yeah. So, I work for a medical communications company. I'm the medical lead. They're doing quite a bit of work in project management and medical writing, facilitating different types of methodologies. And so, you know, there's modified Delphi process that we've leveraged for this project was, you know, was a really interesting way to get at, you know, I suppose, a difficult scientific question. 

Trevor: Thank you. And Colleen on the East Coast. 

Dr. Colleen O'Connell: All right. So, I'm Colleen O'Connell. I'm a physical medicine and rehabilitation physician in Fredericton, New Brunswick, and I work predominantly in neuro rehabilitation. So, I work with individuals who have fairly complex diagnoses that impact on their mobility, as well as can contribute to symptoms such as pain and spasticity. And I've been involved in working with patients in trying to achieve health goals and have been using medical cannabis and cannabinoid products now for over 20 years with my patients and certainly really enjoy working with this large transdisciplinary team and putting together this consensus guidance. 

Trevor: Thank you very much. So, just forever. So, I'll I'll say that I read it once properly. So, the official title is, Consensus-based Recommendations for Titrating Cannabinoids and Tapering Opioids for Chronic Pain Control. Before I ask that, there's sort of three main things I think I'm going to start with Brennan because it comes up a couple of times. And honestly, I didn't know before reading this what is this Delphi process that you guys use to come to these? It may be a shortened version because it sounds like it's relatively involved. 

Dr. Brennan Smith: And we set it up. I mean, here's the thing everyone would love randomized controlled trials. That's the gold standard. That's what we want. But currently we do not have them for for keeping opioids in the presence of cannabinoids. So, the medical cannabis, the use of cannabis to taper opioids in the presence of chronic pain is an interesting space because it's one of the very few spots, I think where you have patients doing it themselves or going to a physician or a pharmacist and asking them for their advice. So, it's this a clinical unmet need, and it's unusual. Usually you have RCT to provide some guidance, and if you don't it, then patients aren't going in and asking for it. But in this situation, they are. And So, in a situation like this, a modified Delphi process is a way to add scientific robustness to expert opinion. So, we'd like to have our RCT. We don't. What's the next best thing? We have people like Dr. O'Connell on the line who manage patients that do this. They've done it for 20 years. And So, we leverage their expert opinion in addition to having others on the line as well to add scientific robustness to expert opinion. 

Trevor: OK. And So, I guess this gets around the I was listening to a podcast with different researchers on a different topic and you know, these were bench researchers and they said the the the worst thing in the world is to have a physician say, in my experience, because then they just go off into anecdotes. So, this is a way to get, for example, Dr. O'Connell's 20 years of experience more, not to just be a bunch of anecdotes. 

Dr. Colleen O'Connell: OK, Trevor, the Delphi process is an actual recognized method for providing direction and recommendations in health care. It's not a new process. It was actually kind of invented during the Cold War to garner consensus among a large number of experts in order to provide information, and in this case in the Cold War, was to forecast the impact of technology on warfare. And it's a well-recognized way in health care, and it's reliable, too, to derive consensus for a certain clinical problem, using and iterated systematic process, repeated rounds of voting, using a large group of experts and and you, you have an index in place of areas where you are lacking, definitive expert and best practice is well-recognized in what we do. Clinical experience and expertize makes up a part of best practice. In addition to published literature, 

Trevor: no, and thank you. I think that explains it really well. I won't bore the listeners with the exactly how all the voting was done, but maybe Aaron or Brennan, who helped there was a lot of people involved in all this voting. Can you give me an idea about how many, how many bodies were involved in getting this consensus? 

Aaron Sihota: You know, I can kind of just just chime in here and mention that the strength of this paper and the strength of this particular guidance document is, as you mentioned, Trevor is the large group, but the multi-disciplinary nature of who we have. We have frontline clinicians with with real world experience helping the patients. We have researchers as well who studied cannabinoid science not only from Canada, but we have people from the US as well. And I believe and you guys can correct me if I'm wrong, I think we had 16. If I'm not mistaken, around 16 people come together from out of state to look at the best way of building sort of an easy to follow algorithm that frontline clinicians everywhere could could use as a guidance documents from the lens of a safety perspective. 

Trevor: OK, I'm convinced. So, I'll throw this open to anybody. So, there's three main questions that the consensus guidelines were looking at who wants to tackle what? Because there are three main questions where 

Dr. Colleen O'Connell: sure, I can start, Trevor. Our first question was identifying what patient would be someone that we would consider for introducing cannabinoids. And very specifically, this paper was looking at not the broad range of individuals who might be wanting to access and use cannabis because of chronic pain. But this was very specific initiative towards people who were already using opioids. So, one of the impetus for this and why we started with this paper even before just a general algorithm for cannabis in general in pain, was because of the opioid crisis. And that was really one of the sounding bells and said, you know, here in North America, the number of deaths and hospitalization due to opioid overdoses and misuses, whether they're prescription or not, was really quite alarming. And with emerging reports that individuals were replacing opioids with cannabis, we really felt it important that we provide physicians in advance of having large randomized controlled trials, which may never happened in this may never happen in this field with a guidance. So, the first is what patients are we looking at? And So, we reach consensus that essentially any patient with chronic pain who is on opioids would be appropriate for considering cannabinoids if they're not reaching their their goals. So, any patient who is being treated with pain has certain goals. They want to reduce their pain, they want to be more functional, they want to get back to work, they want to do something with their kids. So, despite adequate treatment with their opioids and physiotherapy, the modalities, psychology supports all everything else being optimized. They're still not reaching their goals. That might be an appropriate patient. Additionally, a patient who might be on opioids and is experiencing adverse effects from those opioids, and we could talk about all the various side effects and adverse effects of opioids. And then the third group are those with who are concerned about opioid related harm. So, those who might be at risk because of how they're using the opioids and as a health professional, we feel that they would be safer health wise by getting them off of or reducing their opioids. So, that was our first question. Who are we looking at? 

Trevor: Excellent. So, who wants to tackle number two? So, you've identified them now? Now what was the second question for the group? 

Aaron Sihota: Yeah, I think when you're looking at sort of when and how to safely taper opiates in the presence of cannabinoids. So, keeping in mind just going back to a little bit of what Colleen mentioned that as we conceptualize this project and I remember as initially speaking with Dr. M.J. Milloy, who a professor of cannabis science researcher here in the pharmaceutical sciences as well is, you know, understanding that we need. We found that clinicians were already doing this to some extent in their respective practices. It's kind of pretty different from the strategy to identify at what point a patient would fall into this algorithm and how to safely taper the opiates in the presence of cannabinoids. Because we know we can, a lot of patients that we're dealing with are on or it's for a long time. You know, we're not going to be sure we're talking about someone who maybe experience chronic pain issues, major trauma, an accident and they're looking for other alternatives. And also, at the same time, we're looking at sort of, you know, at what stepwise approach, how can how many milligrams of either CBD or THC can safely be titrated? And at what point do we measure, you know, you know, how do we assess levels of pain. At which point the clinician can look at having the discussion around tapering the opiate? So, I think that we looked at sort of putting all those elements and pieces together and coming up with guidance that what that's specific sort of like goal range of how many milligrams increase or decrease by and how to safely monitor the the conversation as well. 

Trevor: Thank you very much. And the third one was, how are you going to maintain health outcomes? I assume that's more about follow up afterwards. Is that sort of the third the third question? 

Dr. Colleen O'Connell: The third question is and So, Aaron kind of talked about our sort of our second and third question together, which is the actual doses to initiate somebody on the on the cannabinoid and then how to titrate that dose and then to start bringing down the opioid. And then then our third one is exactly as you were just saying, which is how do we monitor and how do we decide how often to see the patient, how to keep track of whether they're having good benefits. Side effects? When do we consider things a treatment success and when will we consider things a treatment failure? 

Trevor: Thank you. That was excellent. So, now we've got we've got what Delphi is and what are the questions that we're looking at. So, I guess the now the big reveal. So, what what consensus did you guys come to out? What sort of patients are we looking at? How do we decrease the dosing and how do we follow up? Who wants to start? 

Aaron Sihota: I can. I can chime, chime in here. So, I think first, it's kind of looking at sort of what type of patients could be considered and how these three patients the introduction of cannabinoids as part of their treatment plan. I think we we looked at obviously a few different populations and one of them being patients who are not reaching their chronic pain goals despite psychological and physical interventions. We know that those are key pillars as part of our overall treatment strategy and the modalities that we provide for for patient care when it comes to being management, as well as those experiencing opiate related adverse effects. So, you know, everything from CNS depressant effects, drowsiness, constipation, dry mouth, there's a lot of side effects that patients often we see in the front lines, complain about the effects of quality of life. And that certainly is one sort of, you know, one sort of hint for a clinician to consider as a patient who might fit well in an algorithm like this and then finally looking at sort of patients displaying risk factors for opiate related harm and and or abuse potential. And this often discussion, you know, with the clinician and the patient and other co-morbidities, a patient may be just going as well as if they're a higher risk. You know, obviously, we know the potential for addiction with cannabinoids is on the same par as we look at alcohol or cannabis use disorder. Comparing that to being on opiates So, we're looking at sort of those patient populations and and then moving on to as part of that screening process is is are we looking at initiating cannabinoids in the daytime or the evening? And then we move on to the initiation process, which, you know, I am happy to pass along to one of my and my colleagues. 

Trevor: Sure. Who wants to take on an initiation? 

Dr. Brennan Smith: If I can just add a little bit of color to the daytime? Absolutely. Thank you evening. And because So, yeah, my role was kind of in that was in the back end and managing like a lot of the voting responses. And there was a, you know, a lot of different conversations that went into, Hey, we should be considering cannabinoids first off, not just as cannabis, but we need to split it out of CBD and THC as a whole. But we alSo, need to split it by daytime and evening, especially when you're initiating these are these are all separate conversations. So, the delineation of that algorithm took place over months of time. And to end up at a daytime recommendation of CBD again, safety, tolerability were the two main factors that went into it. And then also, there is limited evidence for opioid tapering with CBD, but it is there and then certainly the evening recommendation of THC to perhaps, maybe not quite proven support sleep, which thinking positively influence or chronic pain symptoms. So, anyway, the take home point here is how we ended up with that CBD THC daytime evening that was months of back and forth. 

Trevor: No, it's good because you know, when when we've read guidelines and recommendations afterwards, you're right. Sometimes it seems a little bit arbitrary. Well, why would they do this? But but this was was well thought out and well argued over. And like you said, when you think about it makes a lot of sense. 

Dr. Colleen O'Connell: Mm hmm. Yeah. And So, I think one of the key points is really that we are if you're going to start with a daytime dose of anything, you're going to start with a CBD dose. And we actually provided and came up with an actual amount to recommend, which is between five and 20 milligrams of the CBD predominant product starting starting in the once a day. And you can increase that as required once or twice a week. So, it's important to the way that you increase. It is something that a lot of physicians or nurse practitioners may not be familiar with, but it's not something that you would try it for one day, see what happens and then increase or change the dose the next day. You've got to give it a few days in between each titration to see what your effects are both positive and negative. And and after getting up into into a comfort level with the CBD dose, if you're going to consider introducing THC, we recommended that the start doing dose of THC is a little bit lower, somewhere between half a milligram up to three milligrams, very cognizant of things like the person's age and their gender. Older persons being a lot more sensitive, typically to THC versus somebody who might be a non or naive user, perhaps has got some experience, might be able to manage a bit of a higher dose and similar to CBD, the increases in one or two milligram increments once or twice a week. And we actually did reach a consensus on the maximum dose of THC. And this is something that we might, you know, you may have listeners who disagree with us and who feel, Gosh, no, I can handle much more than that. But this is really where, you know, you had 20 ish experts across a broad range, along with evidence that has been published and was incorporated. But we did reach a consensus on a maximum of THC between 30 and 40 mg. Now I should alSo, highlight that there is definite consensus that we are recommending oral extracts as the main means of using this not smoked product, not vaporized or inhaled product, but but using an oral product that is coming from a licensed producer that is easy to measure. So, you know exactly what dose that you're using. 

Trevor: Thanks. No thanks, Dr. O'Connell. Actually, like Aaron, I'm a pharmacist, So, I was going to get to how we're getting it into the patient. So. So, yeah, So, you're you're not talking about inhaled, whether smoked or vaporized. This is we're all talking oral. So, we're talking either oils or capsules is pretty much what we're what we're looking at. 

Dr. Colleen O'Connell: So, then the next step is in the tapering of the opioid. So, I don't know if, Aaron, you want to jump in on that or Brennan?

Aaron Sihota: Yeah, I want to add that when we talk about consensus, here it was the group that the threshold was 75 percent or higher. So, just to define what consensus actually meant and that the group would have to vote in that sort of domain. Yes, So, the third domain we looked at sort of questions about when and how to taper the opiates and you know, when you look at a consensus finding, we'd basically discuss it depending on the patient, you know, beginning the opiate taper when any of the following criteria are basically achieved. So, you've had an improvement in their pain and function. That's one. The cannabinoid dose, if it's being optimized and the or the patient begins to seek less as needed medication. That's another key consideration. And it was recommended to not be tapering opiates at cannabinoid initiation or at a predefined or specific dose. That's key to it's not just for restarting that process right off the bat. And I think it's not a, you know, I think people do ask us in clinic about being a magic bullet and you know, can I get off it tomorrow? The reality is we're not we're not advocating for a really a rash decision making here. I think it's really a methodical and as some of my colleagues have mentioned, you know, there is some research into into we know the opiate side of things for sure. So, we're adding and layering it. Think of blurring that sort of thing and having conversations. So, when initiating the taper for the opiate, we were a gradual sort of dose reduction of five to 10 percent every one of four weeks was agreed upon the minimal effective dose. So, when you look at the timeline for the frequency of the reduction, it's meant to allow for sort of broad patient together. So, I think, you know, when you look at this consensus, it's specific, but it's broad at the same time. So, you can almost box your patient to some extent. And I think that we're not trying to be too prescriptive here. We're providing sort of keeping in mind general guidance that allows that each clinician that ultimately subscribes to this to tailor to who's in front of them and their unique circumstances their patient does present. And as I mentioned, you know, there are opiate tapering guidelines out there. They don't provide any specific targets and encouraging them. That's an individualized approach in the decision making process. So, that's what we really base it on. And you know, there are patients who could benefit from a 20 to 50 percent rapid taper after titrating it to an effective dose rates at once or on a steady state of the cannabinoid dose, depending, of course, then on their objectives and their needs. So, I think this is this particular domain as part of the publication was allowing for a little bit more flexibility in terms of who you're plugging in to the guidelines. 

Trevor: Oh, thank. Thank you very much. OK, So, we figured out who we've got on it, who who to enroll. We figured out how to taper them down. I guess the last part was, how are we following them up afterwards? Anybody want to jump in on that one? 

Dr. Colleen O'Connell: Sure, I can if we are going tag team here, I guess. So, the just like any patient with chronic pain in particularly patients who are on opioids, typically, particularly if you're following opioid guidelines, you'd be following them closely anyway. So, when changes are being made through that initiation and titration as well as the tapering, our consensus was that the patients are followed once or twice monthly until both pain control is stable and their doses stable. And thereafter, it's following every three months. One of the things that we, we recommended and we talk about is ensuring that you have that goal that you're able to track, because that's going to be able to help you define your success and to be able to measure your your progress against. So, having that improvement in function or that improvement in quality of life is really important and helps you identify whether or not you're meeting your goals.  In terms of just pain intensity. A clinical meaningful improvement on a pain scale of at 30 percent is usually what we consider to be a success. And certainly, anything greater than 25 percent or more reduction in an opioid dose, we feel, would be success. In Canada, we have what's called sort of your watchful dose of opioid level and So, and a level of opioid through which we really would hope that most people can be kept below, and that's the equivalent of 90 milligrams of morphine per day. So, just getting a patient under that that that ceiling would be considered successful, even if you're not entirely getting rid of an opioid. And So, also, any reduction in those opioid related harms would also, we can considered a success. 

Trevor: No, and that's a great thing to mention, because our College of Pharmacy, in conjunction with the Manitoba College of Physicians is mandating is a little too strong but strongly encouraging practitioners to get their patients under that magic 90 morphine and 90 milligram morphine equivalents. And so, yeah, if this is yet another tool to to get them there, I think that's a great idea. I want to just because we're getting close on time. So, just a few little bits. So, sex differences. It looks like you guys at least discussed it a little bit during the consensus. Any thoughts on whether dosing should be different in males, females who wants to tackle that one? 

Dr. Brennan Smith: I can make a quick comment because it comes from Doctor Le Folls work here and published a nice, placebo controlled trial looking at the male female interactions in difference. And I mean, the take home point of his paper is at a given dose of THC, women do have a stronger, I guess it has a stronger impact on females, basically. And then there was also, another paper that looked at in females the rate at which they might progress into some type of call it a cannabis use disorder was higher. And So, you just I think the take-home point here is you just have to be maybe just a little bit more careful with with females. Maybe Dr. O'Connell, you want to address? 

Dr. Colleen O'Connell: No, no, that's true. And the other thing that it's also, patients in terms of some of their comorbid conditions as well. So, for instance, I work with a lot of individuals who have fairly complex neurologic conditions. And So, sometimes we can find a benefit with much lower doses, perhaps than someone who might be working in an injured workers clinic, for instance. So, each individual really has to be taken as as as their own unique circumstances and So, their gender, their age, their comorbid conditions. And you know, our parameters always start low, go slow. It's just how low is low might be different for each patient. 

Trevor: No. And that actually segues nicely into into age. So, in reading through the paper, it looked like everybody was pretty comfortable with CBD in kids. And that makes sense because we, you know what Epidiolex and other things we wear. It's now semiofficial that we can use CBD and seizures in children, but looks like there was a lot of discussion about whether or not to have a magic cutoff of age twenty-five for THC. Anybody want to talk a little bit about how you guys got to that? 

Aaron Sihota: Trevor, I just want to mention one thing just to the prior conversation here is, you know, the role of other medications when it comes to, you know, components like CBD. So, there are real drug drug interactions. It's metabolized by the liver, right? So, if there's compromised liver function as well as kind of you look at the six and three or four pathways patients on a blood thinner or some other medications from a safety lens, we saw me in clinic counseled them on what to monitor for in terms of adverse events. So, just wanted to add that there as part of the conversation. I think for some of your listeners who may be pharmacists and you're right, there was there was consensus that no age restrictions per se were or recommended for CBD or THC use with CBD. We reach consensus as high doses of CBD have been shown to be safe in children. But with a patient population that is not necessarily typical as a chronic pain sort of scenario or more to do with epilepsy. With regards to minimum age recommendations for THC, I think that there certainly should be guidance around and being more, I guess, prudent around screening for patients under 25. And we usually do this in clinic because we know that there is a developing nervous system and there may be an impact in terms of the role of cannabinoids and THC specifically, that might impact that. But if a young patient, let's say someone who's under 25, is already coming into the clinic who might be on a high dose of opiates, it didn't really make sense for them, for let's see for us as the authors to say, OK, you know, you're not 25 yet, therefore, you know, we we're going to hold any, any sort of guidance around introducing cannabinoids as part of your therapy. So, I think being sort of realistic and logical as to the patient that's presenting in front of you. But So, I think at the end of the day, there's no minimum or even a maximum age that was agreed to. When you look at sort of the elderly patient population like we spoke about, I mean, reverse effects, especially the CNS depression, CNS present effects of sometimes cannabinoids with other medications they may be on. We're obviously worried about the risk of falls and So, forth. So, just being mindful of that as part of the treatment strategy is very important. 

Trevor: I am I promise that we try to get this done in under 40 minutes and we're getting close. So, I thought this is sort of a good a time as any to, you know, any sort of final thoughts or thoughts where you think this will be going. Any one to attack or whether this is. Might be good to. This could sort of leak over into the addiction sphere. Anything along those lines? Lots and lots left to talk about, but anyone sort of have any final thoughts on what what we learn from from this, this study and where we might be going next. 

Dr. Brennan Smith: I can go first. Colleen you can go at the end. Yes, certainly. At least, at least for me. From the research perspective, I'd love to see you like a nice trial designed, you know where you have patients on opiates in the randomized to either a placebo or THC or CBD or some combination of both. And basically apply this algorithm to see if it works. I think that's really the key because right now we have consensus guidance. We have, you know, a really nice document, a really nice way to go about it. But I think the next logical step is to test it. 

Trevor: Thank you very much. How about Aaron? Any any sort of last words. 

Aaron Sihota: I'm looking at looking at sort of again, how this project, how we started and it was it was really driven by the lack of sort of a cohesive and sort of guiding document to this unmet need of how do I layer on sort of the current best practices when it comes to opiate initiation and tapering for chronic pain management and and and the cannabinoid conversation? I think that's where we really started from. This came from sort of seeing what was going on the front lines with clinicians from all across the spectrum. And certainly there is in the lens of sort of addictions management because we knew this was going on, I mean, in clinics across Canada and the United States, and it's about sort of getting a way to to build something that I would liken, like a tree with tree branches and kind of having sort of this, this this tree that set up and the leaves will be filled over time. So, it's it's a living document. It's something that I think will be added over time as we get more evidence that is hopefully randomized controlled trial evidence, as Brennan mentioned. But I think it's really a first step that is exciting and honestly has been driven from the unmet need that identifies it. And as I just mentioned, you know, you know, I've worked in the Downtown Eastside of Vancouver and, you know, some of the things I've seen there with some the patients who, you know, are potential candidates for, you know, being being being enrolled in an algorithm like this. I think that initially we looked at sort of how do we create this expert guidance and this is just the start. And I think for the viewers and those who are skeptics about sort of the lack of evidence, I think that from a lens of safety, keep that in mind that we're not saying we've done an RCT here. We're looking at the practical guidance that's based on years of clinician experience that we've come up with. And again, it's it's just a start. 

Trevor: Thank you very much, Aaron and Colleen final word to you. 

Dr. Colleen O'Connell: No, I just I just reiterate what Aaron just said and that, you know, we are not claiming to be presenting a robust results of a randomized clinical trial. But I think in in medicine, in health, we still have a responsibility to try and optimize our patients’ health, optimize your quality of life in a safe manner. And you know, this would be the equivalent of walking down a hallway and trying to stop your local experts and ask them, Hey, I've got this guy. And here's the problem what would you do in this situation? And here you have the benefit of a robust methodology to provide you with a consensus of experts experience and opinion that is based on published evidence to inform that expertise. And this is a step to help towards guidance and I think a very effective one. While we work towards gathering greater evidence, both of how this algorithm helps in future research insights as well. 

Trevor: That was fantastic. Thank you, everybody. Couldn't, couldn't have asked for more. You know coast to coast to coast, we have people on here talking about a very interesting document and people who all put up with my complete failure as a doodle poller. I'm getting better. I'll do better next time. But yes, thank you very much for everybody. Have a fantastic afternoon. 

Dr. Colleen O'Connell: Thanks, Trevor. 

Dr. Brennan Smith: Thanks for having me. 

Trevor: So, Kirk, one of the things I like that they did touch on a little bit was sex differences. Now, I don't know if there's been any consensus, really. On exactly what the sex differences are, but on effects of cannabinoids, but I'm glad they discussed it and and Brennan Smith talked about that a little bit. Anything else sort of jump out at you about things that they they use to consider what they considered? 

Kirk: Not really. I mean, I was more interested in I like I read the study and I'm looking at the the results. I mean, you know, the questions asked is what patients can be considered for cannabinoid introduction. And I just think it's a real good pathway. And that's what they essentially said that they're developing clinical guidelines through consensus; crowd sourcing of experts. So, I thought I thought it was just fantastic because there's, you know, when one of the, you know, talking to Dr. Susy Pinnick, you know, an episode in episode 72, one of her big concerns when she first got into it was she didn't have anything to follow. So, what these guys have done this this team of consensus building experts, is that they've provided clinicians a guideline in which to start and it's consensus and it's it meets it meets current research and current applications. So, that's what jumped out at me. It's I'm looking forward. 

Trevor: My my brilliant thought came back. OK? Dr. O'Connell, Colleen O'Connell was talking about sort of address kind of in passing, but I thought was really interesting is why did they release this one? You know, opioids... Reducing opioids with cannabis, you know, because this group are very similar group with like a lot of the same authors, did actually release one on just general how do you dose cannabis for for like pain? And she said, So, why would we do opioids first before like a general, how to dose just pain? And it's because the opioid crisis, like, you know, we're hopefully now coming out of the the COVID crisis, but there's still a lot of people out there dying of of opioids and opioid overdose. So. So, this group thought thought it was really important to do cannabis and opioids first, which, you know, I commend them for. 

Kirk: Well, I mean, right now, like I said to you in past episodes, there are more people dying of opioid overdoses in inner cities and and it's hidden again, right? So, yeah, this this is this is another this is another bullet in my in my belt that helps me argue and it is arguing, it is debating hard about let's look at cannabis to help people who are on opioids. So, let's look at it again. It's another, it's another. It's it's another what am I looking for, another tool in the toolbox, right? So, So, yeah, I know that's what jumped out on me. I I think I think once again, I'm going to I'm going to recommend people come to our web page, where have the paper up there and read it for yourself and the physicians out there. The prescribers out there have a look. It's it's well researched and these guys are guys have been dealing with cannabis for 20-30 years. Some of these people. So, 20 years anyways, I exaggerate for 30 years. 

Trevor: No, I don't have. I think I really appreciate that the we had. So, make sure I've mentioned all their names again here at the end. So, our guest, this time Aaron Sihota he is the pharmacist from B.C., Brendan Smith, he's the Ph.D. for this. It sounded like he was really kind of more the background, making sure the Delphi process thing worked right. I looked in his Ph.D. is in physiology metabolism, So, it's interesting, I had a few cannabis papers aside with his name and then, you know, stuff on on insulin and and stuff he's giving to mice to see what happened to their glucose level. So, just interesting you see, he's got a bit of a rage on what he does research on. And Colleen O'Connell, Dr. Colleen O'Connell, she is a physician out on East Coast. So, yeah, we they had 20 people. We only had three, but it was that that was quite the quite quite the group and thanks to all of them for agreeing to talk and share their knowledge with the listeners. 

Kirk: Yeah, yeah. So, did any of them pick music? 

Trevor: No, they didn't pick music. So, we might have to. Unless you've got something on your mind, we might have to get...

Kirk: Desiree Dorion has got some new music out. Maybe we'll play some new Desiree Dorion. She's local. 

Trevor: Can't go wrong, can't go wrong with Desiree? And she she's got our theme, our theme song.

Kirk: So, I do that, So, I guess we should do our end of episode, I'm Kirk, I'm the nurse and this is ReeferMEDness - The Podcast. 

Trevor: And I'm Trevor Shewfelt I'm the pharmacist 

Kirk: We are obviously eager for people to get on to our web page. Check out the web page. You can listen to the podcast, you can read the you can read the transcripts of each episode, and you can look at all the research that our experts are talking about. Very comprehensive. And if you're interested in supporting the podcast, you can drop us an email and I'll gladly accept assistance to move this post epidemic podcast a little further up. And what else can we talk about? 

Trevor: I'm now king of Doodle Pop. 

Kirk: He got some learning to do, I think. Yeah, yeah, 

Trevor: See you later everybody. 

Rene: Well, that's great. Guys, thank you very much. It's Rene here with two quick things I should mention that Reefer MEDness -  The podcast is recorded within unceded territory of Treaty two of the Anishinaabeg. The other thing is we do have a song by Desiree Dorion, and she's got a new song. It's called Sometimes I Drink. We're very proud of her here in Dauphin. And here it comes.  

Trevor: So, Kirk, one of the things you talked about before we had them was how, oh, I've lost my train of thought. It was a really good thought. Really, really good gone.