Clinical Resources

Clinical Recommendation

Consider cannabinoids as adjunct therapy when first- and second-line treatments (gabapentinoids, SNRIs, TCAs) have failed. Balanced THC:CBD formulations preferred.

Starting Dose

THC:CBD 1:1 — 2.5mg THC / 2.5mg CBD twice daily

Contraindications

• ✗ Personal or family history of psychosis
• ✗ Severe hepatic impairment
• ✗ Pregnancy or breastfeeding
• ✗ Age <25 (developmental risk)

Monitoring Parameters

• Pain NRS at each visit
• Mood and cognitive function
• Liver enzymes at baseline and 3 months
• Substance use disorder screening

Clinical Recommendation

Nabiximols (Sativex) is the best-evidenced formulation for opioid-refractory cancer pain. Use as adjunct to existing opioid regimen, not as replacement.

Starting Dose

Nabiximols: 1 spray (2.7mg THC / 2.5mg CBD) oromucosal at bedtime

Contraindications

• ✗ Serious cardiovascular disease
• ✗ Psychosis history
• ✗ Concurrent CNS depressants (caution)
• ✗ Pregnancy

Monitoring Parameters

• Pain NRS and opioid consumption
• Adverse effects (dizziness, sedation)
• Cognitive function
• Mood

Clinical Recommendation

CBD may be considered for social anxiety disorder and PTSD-related anxiety when first-line treatments (SSRIs, SNRIs, CBT) have been trialed. High-dose CBD only — commercial low-dose products are not evidence-based.

Starting Dose

CBD 150mg/day (oral, with food)

Contraindications

• ✗ Concurrent clobazam or warfarin without monitoring
• ✗ Hepatic impairment
• ✗ Pregnancy

Monitoring Parameters

• GAD-7 or LSAS at baseline and monthly
• Liver enzymes (baseline, 3 months)
• Drug interaction review
• Mood

Clinical Recommendation

Epidiolex (pharmaceutical-grade CBD) is FDA-approved and should be used rather than artisanal CBD products. Requires specialist (neurology) initiation. Significant drug interactions require AED dose adjustments.

Starting Dose

Epidiolex: 2.5mg/kg twice daily (5mg/kg/day)

Contraindications

• ✗ Hypersensitivity to CBD
• ✗ Severe hepatic impairment (Child-Pugh C)

Monitoring Parameters

• Seizure diary (frequency, duration, type)
• LFTs at baseline, 1, 3, 6 months
• Clobazam levels (reduce dose by 25–50%)
• Valproate levels if co-prescribed

Clinical Recommendation

Evidence supports short-term use only. Tolerance develops within 2–4 weeks. Not recommended as first-line — CBT-I remains gold standard. Consider only when CBT-I and approved pharmacotherapy have failed.

Starting Dose

THC 2.5mg oral, 1–2 hours before bed

Contraindications

• ✗ Psychosis history
• ✗ Sleep apnea (may worsen)
• ✗ Pregnancy
• ✗ Substance use disorder history
• ✗ Age <25

Monitoring Parameters

• Sleep diary (onset latency, WASO, quality)
• Daytime function and cognition
• Mood
• Signs of dependence at each visit

Clinical Recommendation

Dronabinol (synthetic THC) or nabilone are FDA-approved second-line antiemetics. Use when 5-HT3 antagonists + NK1 antagonists + dexamethasone are insufficient. Not recommended as monotherapy.

Starting Dose

Dronabinol: 5mg/m² 1–3 hours before chemotherapy, then every 2–4 hours after (max 4–6 doses/day)

Contraindications

• ✗ History of cannabinoid hypersensitivity
• ✗ Severe psychiatric disorder
• ✗ Concurrent CNS depressants (caution)

Monitoring Parameters

• Nausea/vomiting frequency and severity
• Adverse effects (dizziness, dysphoria, tachycardia)
• Psychiatric symptoms