With a growing number of products containing cannabidiol (CBD) and kratom available in the marketplace, many pharmacists and pharmacy students are increasingly being asked to discuss the use of these products, especially in relation to pain relief.

In order to support this process of engagement, presenters at the American Association of Colleges of Pharmacies’ Virtual Pharmacy Education 2020 conference discussed some educational strategies for the pharmacy curriculum that can support a comprehensive approach to student practice-readiness in answering questions regarding patient use of CBD and kratom products.

The most commonly cited reason for using CBD is pain relief, T.J. Sayre, PharmD, MPH, BCPP, BCPS, an assistant professor of pharmacy at Regis University, explained during the presentation. However, most data on CBD for pain involve the use of cannabis products that also contain THC, rather than CBD alone.

There have been 2 published studies on CBD-only products for chronic pain, but these were small studies with several limitations that showed there may be some potential benefits, according to Sayre.

“Overall, the data to support CBD for pain are severely lacking, and the majority of research comes from preclinical data using mice and models, as well as applying some proposed mechanisms of action to determine a therapeutic rationale that it could be used in pain,” Sayre said during the presentation.

Additionally, kratom, or mitragyna speciosa, has also been lauded in some communities as being a beneficial natural tool for pain management. During her presentation, Shawn Taylor, PharmD, CPP, CDCES, an associate professor of pharmacy at Wingate University, explained that kratom can be commonly found and purchased at convenience stores or vape shops.

“It has a dose-dependent effect, so people are often starting to take it on the lower end of the dose spectrum, somewhere between 1 and 5 grams, and they’re getting a stimulatory effect. It’s acting almost like an amphetamine that helps with work productivity, which is the use it has historically been used for,” Taylor said.

She explained further that as the dose is escalated up to 10 or 15 grams, it starts to take on more of an opioid analgesic effect. Due to the lack of regulation, the purity of the products may also be questionable, Taylor said. Studies have found that adverse events from kratom may include seizures, jaundice, tolerance, and withdrawal, with multiple case reports of death when taken with other substances.

Sayre noted that some patients have found kratom to be useful in the cessation of opiates. However, whenever discussing treatment options with patients, it almost always comes down to a risk versus benefit assessment, Sayre explained. This is especially true when discussing alternative products such as CBD and kratom.

“Difficult conversations in health care are not usually an innate skill, and they often require some foundational theory and often a lot of practice,” Sayre said. “So even experienced pharmacists or health care providers may still struggle through these uncomfortable patient conversations. A good starting point for this conversation is establishing a positive relationship with your patients.”

Sayre noted that one model for engaging in uncomfortable conversations with patients is the REDE model developed by the Cleveland Clinic.

“The REDE model is a conceptual framework for teaching relationship-centered health care communication,” Sayre said. “I personally find it to be helpful and excellent for students because it provides some of the concepts, while still allowing flexibility for students to utilize skills they already have.”

Overall, the conversation should explore the patient’s understanding, values, and beliefs regarding their pain and medications or treatment, Sayre explained. In order to do this, whenever possible, reframe the issue toward the highest quality patient care while being sure to create a safe space for the patient. This safe space may allow for an open conversation without any judgement regarding the benefit-harm trade-offs.

Additionally, Sayre noted that it can be helpful to repurpose the evidence available on the use of kratom or CBD for pain by providing a print-out with a bullet point list of risks, summaries of research, or top 3 other options that the patient can access later. This could either be an existing pamphlet on the subject or one created by pharmacists for their practice.

“Anything you can do to direct them towards comprehensive pain management resources or reengage them in the evidence-based treatment is going to go a long way,” Sayre said.

REFERENCE
Taylor S, Sayre TJ. Fake News? Instructing Learners on CBD and Kratom as Alternatives for OTC Pain Relief. Presented at: American Association of Colleges of Pharmacy’s Virtual Pharmacy Education 2020; July 13, 2020; Virtual. virtualpharmed2020.aacp.org/meetings/virtual/YZYL6PhzhuRTjyqwh. Accessed July 31, 2020.