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Evidence-based guidelines

Opioid use disorder              Delta-8 THC and related synthetic/derived cannabinoids             Oral cannabis

Guidance on the suggested use of medical cannabis for opioid use disorder (OUD)

This evidence-based guidance was reviewed and approved on 1/12/2021.
There is insufficient evidence to support the conclusion that medical cannabis or cannabinoids are effective or ineffective treatments for opioid use disorder (OUD).

The Department of Health and Human Services (DHHS), in collaboration with a group of recommending medical providers and researchers, reviewed the current literature about cannabis and cannabinoids for the treatment of opioid use disorder (OUD). Additionally, a recognized expert, Dr. Adam Gordon, presented his review of current literature and knowledge to the DHHS and a group of recommending medical providers and researchers. Dr. Gordon was selected to review and present this information based on his qualifications as Professor of Medicine and Psychiatry, Director of the Program for Addiction Research, Clinical Care, and Advocacy (PARCKA) at the University of Utah, and Chief of Addiction Medicine at the VA Salt Lake City Health Care System. He is nationally and internationally recognized as a preeminent clinician and researcher in addiction medicine and substance use disorder prevention and treatment, including cannabis use disorder. Based on his review of current literature and knowledge, the following summary points were made:

  • There have been no prospective clinical trials of cannabis or cannabinoids for the treatment of OUD, nor trials that compare such compounds to existing medication treatment for OUD, such as buprenorphine, or other evidence-based medication treatments for OUD;
  • There are no data at present to support the listing by some states of cannabis or cannabinoids as a treatment for OUD;
  • Evidence suggests against recommending cannabis or cannabinoids as a substitute for existing medications for treating OUD;
  • Until we have more research to show their efficacy, policymakers, and clinicians should refrain from portraying cannabis and cannabinoids as evidence-based treatments for OUD;
  • Prospective longitudinal research has shown an association between state- approved medical cannabis use and increased opioid overdose mortality.
  • OUD is a lethal disease, and FDA-approved medications, including long-acting injectable naltrexone, buprenorphine, and methadone, in combination with cognitive behavioral therapies, counseling, and monitoring, have been shown in clinical trials to reduce mortality from OUD.
  • The American Society of Addiction Medicine (ASAM), 2020 policy statement concludes, “Healthcare professionals should not recommend cannabis use for the treatment of OUD.”

References

  1. ASAM, 2020. Public Policy Statement On Cannabis. [online] Available at: https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2020/10/10/cannabis [Accessed 22 January 2021]. 
  2. Aviram, J. and Samuelly-Leichtag, G., 2017. Efficacy of Cannabis-Based Medicines for  Pain Management: A Systematic Review and Meta-Analysis of Randomized Controlled  Trials. Pain Physician, 20(6), pp.E755-E796. 
  3. Bachhuber, M., Saloner, B., Cunningham, C. and Barry, C., 2014. Medical Cannabis  Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010. JAMA  Internal Medicine, 174(10), p.1668. 
  4. Center for Behavioral Health Statistics and Quality, 2016. Key Substance Use And  Mental Health Indicators In The United States: Results From The 2015 National Survey  On Drug Use And Health. SMA 16-4984, NSDUH Series H-51. [online] HHS Publication. Available at: https://www.samhsa.gov/data/ [Accessed 22 January 2021]. 
  5. Hasin, D., Sarvet, A., Cerdá, M., Keyes, K., Stohl, M., Galea, S. and Wall, M., 2017. US  Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws. JAMA  Psychiatry, 74(6), p.579. 
  6. Humphreys, K., & Saitz, R. (2019). Should Physicians Recommend Replacing Opioids  With Cannabis? JAMA, 321(7), 639. https://doi.org/10.1001/jama.2019.0077 
  7. Hurd, Y. L., Spriggs, S., Alishayev, J., Winkel, G., Gurgov, K., Kudrich, C., Oprescu, A.  M., & Salsitz, E. (2019). Cannabidiol for the Reduction of Cue-Induced Craving and  Anxiety in Drug-Abstinent Individuals With Heroin Use Disorder: A Double-Blind  Randomized Placebo-Controlled Trial. American Journal of Psychiatry, 176(11), 911– 922. https://doi.org/10.1176/appi.ajp.2019.18101191 
  8. Le Strat, Y., Dubertret, C. and Le Foll, B., 2015. Impact of age at onset of cannabis use on cannabis dependence and driving under the influence in the United States. Accident  Analysis & Prevention, 76, pp.1-5. 
  9. Levesque, A. and Le Foll, B., 2018. When and How to Treat Possible Cannabis Use  Disorder. Medical Clinics of North America, (102(4), pp.667-681. 
  10. Lev-Ran, S., Imtiaz, S., Rehm, J. and Le Foll, B., 2013. Exploring the Association between Lifetime Prevalence of Mental Illness and Transition from Substance Use to  Substance Use Disorders: Results from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC). The American Journal on Addictions, 22(2), pp.93- 98.
  11. Lopez-Quintero, C., Cobos, J., Hasin, D., Okuda, M., Wang, S., Grant, B. and Blanco, C.,  2011. Probability and predictors of transition from first use to dependence on nicotine,  alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug and Alcohol Dependence, 115(1-2), pp.120- 130. 
  12. Madras, B., Ahmad, N., Wen, J. and Sharfstein, J., 2020. Improving Access to Evidence Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers  Within the Treatment System. NAM Perspectives,. 
  13. McBrien, H., Luo, C., Sanger, N., Zielinski, L., Bhatt, M., Zhu, X. M., Marsh, D. C.,  Thabane, L., & Samaan, Z. (2019). Cannabis use during methadone maintenance treatment for opioid use disorder: a systematic review and meta-analysis. CMAJ Open,  7(4), E665–E673. https://doi.org/10.9778/cmajo.20190026 
  14. Mücke, M., Phillips, T., Radbruch, L., Petzke, F. and Häuser, W., 2018. Cannabis-based medicines for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews. 
  15. Olfson, M., Wall, M., Liu, S. and Blanco, C., 2018. Cannabis Use and Risk of Prescription Opioid Use Disorder in the United States. American Journal of Psychiatry,  175(1), pp.47-53. 
  16. Shover, C., Davis, C., Gordon, S. and Humphreys, K., 2019. Association between medical cannabis laws and opioid overdose mortality has reversed over time. Proceedings of the National Academy of Sciences, 116(26), pp.12624-12626. 
  17. Suzuki, J., & Weiss, R. D. (2020). Cannabinoids for the Treatment of Opioid Use  Disorder. Journal of Addiction Medicine, Publish Ahead of Print, 1–2.  https://doi.org/10.1097/adm.0000000000000711 
  18. UNITED NATIONS OFFICE ON DRUGS AND CRIME, 2016. World Drug Report.  [online] Vienna: United Nations publication. Available at:  https://www.unodc.org/wdr2016 [Accessed 22 January 2021].
  19. 19. Volkow, N. and Collins, F., 2017. The Role of Science in Addressing the Opioid Crisis. New England Journal of Medicine, 377(4), pp.391-394.

Position statement on delta-8 THC and related synthetic/derived cannabinoids

This position statement was reviewed and approved on 2/8/2022.

The Department of Health and Human Services (DHHS), in collaboration with a group of recommending medical providers and researchers, reviewed available research and literature to provide recommendations to recommending medical providers regarding the use of cannabis and cannabinoid products for the treatment of certain qualifying conditions.

Delta-8 THC is a psychoactive cannabinoid found in trace amounts in cannabis plants, and readily synthesized from cannabidiol (CBD). Because concentrated, synthesized, or otherwise derived formulations of delta-8 THC are available to consumers in Utah, the DHHS, in collaboration with a group of recommending medical providers and researchers, reviewed the available literature on delta-8 THC.

At this time, there is no evidence of therapeutic benefit of the analog/derived/synthesized cannabinoids (including delta-8 THC). Risks have been described by federal regulatory bodies and peer-reviewed publications regarding delta-8 THC. At this time, we do not support any therapeutic uses of analog cannabis products.

Guidelines for recommending oral cannabis products in adults

This evidence-based guidance was reviewed and approved on 3/27/2023.

Background

The lack of validated condition-specific dose-response studies evaluating safety and efficacy for cannabis and its cannabinoid constituents supports the need for consensus recommendations on dosing and administration. The Department of Health and Human Services (DHHS), in collaboration with a group of recommending medical providers and researchers, created these guidelines to support qualified clinicians initiating and titrating oral cannabis products in adult patients. 

General guidelines

  • These recommendations are made with the expectation that medical providers recommending cannabis products will be educated in the basic pharmacology of cannabis and its most common cannabinoid constituents. 
  • R3ecommending medical providers should use their judgment based on individual clinical circumstances (e.g., medication adherence, frailty, risks of cognitive impairment, balance disturbances, falls, potential drug-drug and drug-disease interactions, patient's experience with cannabis,  etc.).  
  • Potential modifications may include starting with a lower or higher dose of tetrahydrocannabinol (THC) relative to cannabidiol (CBD), a slower or more rapid titration interval, or a lower or higher ceiling dose of THC relative to CBD. 
  • Consult with a pharmacist at a Utah medical cannabis pharmacy to identify a product for your patient that best conforms to these recommendations and allows for step-wise initiation and titration.  

Oral cannabis protocol

Initial dose: CBD 5 to 10 mg + THC 1 to 2.5 mg, once to twice daily1. 

  • Increase CBD by 10 mg (5 mg twice daily) every 2 to 3 days as tolerated until the patient reaches their goals or to a maximum of 40 mg/day. 
  • If goals are not met with this ratio of CBD to THC, titrate THC by increasing it by 2.5 mg/day every 2 to 7 days as tolerated to a maximum daily dose of 40 mg/day THC and 40 mg/day  CBD. 

1Adapted from Bhaskar A, et al. Consensus recommendations on dosing and administration of medical cannabis to treat chronic pain: results of a modified Delphi process. Journal of Cannabis Research, 2021; 3 (1):22.