ACP: Best Practice Advice on Cannabis or Cannabinoids Use for Chronic Noncancer Pain Save

Jack Cush, MD

Apr 07, 2025 6:00 pm

The American College of Physicians published a best practice advisory on cannabis or cannabinoids in the Annals of Internal Medicine.

They acknowledge there are areas where evidence is uncertain or emerging or practice does not follow the evidence to provide clinical advice based on scientific evidence or studies. Their review panel provides advice on the use of cannabis and cannabinoid treatments for chronic noncancer pain, summarized in 4 directives:

Best Practice Advice 1a

Clinicians should counsel patients about the benefits and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain.

Best Practice Advice 1b:

Clinicians should counsel the CERTAIN subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: THIS INCLUDES young adult and adolescent patients, patients with current or past substance use disorder, patients with serious mental illness, and frail patients and those at risk for falling.

Best Practice Advice 2:

Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive.

Best Practice Advice 3:

Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain.

Cannabinoids are compounds that exert effects through their interaction with the endocannabinoid system and can be plant derived or synthetic. Cannabis is currently a federally illegal substance in the United States. However, as of 2024, cannabis was legal for adult recreational and medical use in 24 U.S. states and the District of Columbia and legal only for medical use in an additional 14 states.

There are 3 prescription cannabinoids approved by the U.S. Food and Drug Administration:

dronabinol (a synthetic form of delta-9-tetrahydrocannabinol [THC] approved for chemotherapy-induced nausea or HIV-associated cachexia)
nabilone (a cannabinoid receptor 1 or CB1 agonist approved for chemotherapy-induced nausea)
highly purified formulation of cannabidiol (CBD) (approved for the treatment of Dravet syndrome, Lennox–Gastaut syndrome, and seizures associated with tuberous sclerosis)

Currently, no cannabinoids are approved for the treatment of chronic pain.

Yes, patients may legally access cannabis for chronic pain in many states, without a prescription in most.

Cannabis is accepted for recreational and medical use. A national survey estimates that 81% of U.S. adults believe cannabis has at least 1 health-related benefitm with chronic pain and the most common reason or self-identified symptom.

The Benefits?

2 whole plant–derived oromucosal spray studies (of THC and CBD) called nabiximols (not U.S. FDA approved) showed moderate-certainty evidence that nabiximols probably improve chronic noncancer pain severity and function or disability to a small degree.
There is low-certainty evidence that synthetic or purified THC preparations with a high THC–CBD ratio may improve chronic noncancer pain severity to a small degree
There is moderate-certainty evidence that synthetic or purified oral CBD alone with a low THC–CBD ratio probably has no effect on pain response, pain severity, and function or disability.
There is insufficient evidence on benefits of other cannabinoid preparations (whole plant cannabis, topical CBD, and other cannabinoids)

The Harms?

Low certainty evidence that THC and CBD (the whole plant–derived oromucosal spray nabiximols) may result in a large increased risk for dizziness and sedation and a modest increased risk for nausea
Moderate certainty evidence that ynthetic or purified THC preparations with a high THC–CBD ratio probably result in a large increase in the risk for dizziness and may cause nausea or a modest increase in the risk for sedation; probably worse in frail individuals.
Systematic review finds too little data on the long term (mos-yrs) risks for adverse effects - this may including cannabis use disorder, cannabis withdrawal syndrome, and cognitive effects, as well as cardiovascular, gastrointestinal, and pulmonary effects and pregnancy-related harms.

Cannabis or Cannabinoids for the Management of Chronic Noncancer Pain: Best Practice Advice From the American College of Physicians