ACP issues Best Practice Advice on cannabis for chronic pain management

The American College of Physicians (ACP) has issued Best Practice Advice for clinicians whose patients are considering or using cannabis or cannabinoids for management of chronic, noncancer pain. Cannabis or Cannabinoids for the Management of Chronic Noncancer Pain: Best Practice Advice From the American College of Physicians, was published today in Annals of Internal Medicine. 

ACP's Best Practice Advice paper is intended to inform clinicians about the evidence regarding the benefits and harms of cannabis or cannabinoids in the management of chronic noncancer pain and to provide advice for clinicians counseling patients seeking to use cannabis or cannabinoids for chronic noncancer pain. 

Cannabis use for medicinal purposes has grown among patients with chronic noncancer pain. When referring to any product derived from the plant, many use the term cannabis, but the term has become interchangeable with colloquial terms such as marijuana, weed, and pot. As of 2024, 24 states in the U.S. and the District of Columbia have legalized cannabis for adult recreational and medical use, and it is legal for medical use only in an additional 14 states. 

In its Best Practice Advice ACP says 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. 

• Counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: 

  • Young adult and adolescent patients 

  • Patients with current or past substance use disorders 

  • Patients with serious mental illness 

  • Frail patients and those at risk of falling 

• 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. 

• Advise patients against the use of inhaled cannabis to manage chronic noncancer pain. 

This Best Practice Advice is important for practicing physicians when counseling our patients on the potential use of cannabis and cannabinoids to treat their chronic noncancer pain. As the use of cannabis for medicinal purposes grows it's critical to open that dialogue and review the emerging evidence related to benefits and harms. We need to raise awareness and get the word out to ensure that patients have the information they need to make informed decisions." 

Isaac O. Opole, President, ACP

For many patients, evidence suggests that the known harms of cannabis and cannabinoid use outweigh the potentially small degree of benefit to ease chronic noncancer pain. Additionally, cannabis can be addictive, even if being used to manage chronic noncancer pain. It's also difficult to apply the information from clinical studies to practice in the U.S. because the potency (delta-9 tetrahydrocannabinol or THC content) of products in dispensaries is typically far higher than that used in studies. Another challenge is that in most U.S. states, patients will obtain cannabis for chronic pain through a dispensary with less medical oversight than they would receive for FDA-approved medications. 

Clinicians are best positioned to provide evidence-based information about the benefits and harms most relevant to an individual patients' needs and comorbidities so that patients can make an informed decision about starting or continuing cannabis or cannabinoid use for chronic noncancer pain. For most patients, common treatments and analgesic medications should be recommended first given the limited evidence of small benefit and the known harms associated with cannabis and cannabinoid products. 

ACP has also published a position paper where it recommends a public health approach to address the legal, medical, and social complexities of cannabis use. 

This Best Practice Advice is based on a review and assessment of scientific work including a living, systematic review on cannabis and cannabinoid treatments for chronic noncancer pain, a series of living systematic reviews, as well as additional evidence from primary studies.