title: Prescribing smoked cannabis for chronic noncancer pain: preliminary recommendations.
abstract: OBJECTIVE
  To offer preliminary guidance on prescribing smoked cannabis for chronic pain before the release of formal guidelines.
  
  
  METHODS
  We reviewed the literature on the analgesic effectiveness of smoked cannabis and the harms of medical and recreational cannabis use. We developed recommendations on indications, contraindications, precautions, and dosing of smoked cannabis, and categorized the recommendations based on levels of evidence. Evidence is mostly level II (well conducted observational studies) and III (expert opinion).
  
  
  RESULTS
  Smoked cannabis might be indicated for patients with severe neuropathic pain conditions who have not responded to adequate trials of pharmaceutical cannabinoids and standard analgesics (level II evidence). Smoked cannabis is contraindicated in patients who are 25 years of age or younger (level II evidence); who have a current, past, or strong family history of psychosis (level II evidence); who have a current or past cannabis use disorder (level III evidence); who have a current substance use disorder (level III evidence); who have cardiovascular or respiratory disease (level III evidence); or who are pregnant or planning to become pregnant (level II evidence). It should be used with caution in patients who smoke tobacco (level II evidence), who are at increased risk of cardiovascular disease (level III evidence), who have anxiety or mood disorders (level II evidence), or who are taking higher doses of opioids or benzodiazepines (level III evidence). Cannabis users should be advised not to drive for at least 3 to 4 hours after smoking, for at least 6 hours after oral ingestion, and for at least 8 hours if they experience a subjective "high" (level II evidence). The maximum recommended dose is 1 inhalation 4 times per day (approximately 400 mg per day) of dried cannabis containing 9% delta-9-tetrahydrocannabinol (level III evidence). Physicians should avoid referring patients to "cannabinoid" clinics (level III evidence).
  
  
  CONCLUSIONS
  Future guidelines should be based on systematic review of the literature on the safety and effectiveness of smoked cannabis. Further research is needed on the effectiveness and long-term safety of smoked cannabis compared with pharmaceutical cannabinoids, opioids, and other standard analgesics.
authors.affiliation: Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario and Medical Director of the Substance Use Service at Women's College Hospital. meldon.kahan@wchospital.ca.
authors.forename: Meldon
authors.initials: M
authors.lastname: Kahan
authors.affiliation: Assistant Professor and Research Scholar in the Department of Family and Community Medicine at the University of Toronto and a staff physician with the St Joseph's Health Centre Family Health Team.
authors.forename: Anita
authors.initials: A
authors.lastname: Srivastava
authors.affiliation: Staff physician with the Women's College Hospital Family Health Team.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Spithoff
authors.affiliation: Staff physician at Sandy Hill Community Health Centre in Ottawa, Ont.
authors.forename: Lisa
authors.initials: L
authors.lastname: Bromley
mesh_terms: D059350:Chronic Pain / Q000188:drug therapy*; D000075202:Contraindications; D006801:Humans; D008385:Marijuana Smoking; D064086:Medical Marijuana / Q000627:therapeutic use*
chemical_list: D064086:Medical Marijuana