The Scottish Intercollegiate Guidelines Network (SIGN) does not recommend the routine use of opioids and medical cannabis in the management of chronic non-malignant pain.
In draft guidance, published on 17 February 2025, SIGN says that while it notes that “anecdotal evidence from patients and historical reports of cannabis use do indicate a potential analgesic effect”, it does not recommend medicinal cannabis for chronic pain.
Developed by a multidisciplinary group of practising healthcare professionals, including pharmacists, the draft guidance is an update to guidance that was originally published in 2013 and revised in 2019.
Unlike previous versions, the draft guidance discusses the use of medicinal cannabis.
“Medicinal cannabis-based products are not recommended for routine use in the management of chronic pain. This takes into consideration the very limited evidence of clinically significant improvements in pain or wider impact… combined with consistent evidence of adverse effects/harms,” the guidance says.
It adds that it is “essential to avoid a situation such as that which occurred with opioids, which were used widely for chronic pain management despite limited evidence of long-term effectiveness and accumulating evidence of major harms”.
However, the SIGN guidance says that “high-quality RCTs [randomised controlled trials] with appropriate duration of follow up are needed to identify clinically relevant harms and benefits of medicinal cannabis in the treatment of chronic pain”.
SIGN also says that opioids should not be considered routinely for patients with chronic non-malignant pain, noting that for “most people with chronic non-cancer pain, opioid treatment provides minimal-to-no benefit and is likely outweighed by adverse effects, especially after three months, in terms of both pain intensity and overall function”.
However, the guidance adds that the “possibility that some people who use opioids may experience greater short-term benefits cannot be excluded” and that some “carefully selected individuals” could be considered for short-term opioid treatment when other therapies have been fully explored.
In addition, cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) “may be useful in addressing the complexity of the pain experience”, the guidance says.
It notes that CBT could be offered to adults experiencing chronic pain and that clinicians could consider “offering face-to-face ACT to manage chronic pain in people where there is a preference for an acceptance approach to pain”.
Commenting on the guidance, Ashley Simpson, trustee and chair of the clinical advisory board at Pain UK — an alliance of charities that support people living with chronic pain — said that the charity welcomed the draft guidance’s “focus on evidence-based management strategies for chronic pain and acknowledges the challenges in balancing effective pain relief with the risks associated with certain treatments”.
She added: “[Pain UK] supports the guidance that opioids should not be routinely prescribed for chronic pain. Many of our members report challenges with long-term opioid use, including dependence and diminishing effectiveness over time.
“However, we emphasise the need for robust support for those currently reliant on opioids, including clear deprescribing pathways, access to specialist pain services and education for healthcare professionals on safer prescribing practices.”
In terms of medicinal cannabis, Simpson said: “We agree with the recommendation that medicinal cannabis should not currently be recommended outside clinical trials due to insufficient high-quality evidence.
“However, we support the call for further high-quality RCTs to explore its role, as many individuals with chronic pain report anecdotal benefits, and there remains significant interest in its potential application.”
A review published in the journal Addiction in August 2024 suggested that almost one in ten people with chronic, non-cancer-related pain, who take prescription opioid painkillers, experience opioid dependence or opioid use disorder.
The draft guidance is open for consultation until 17 March 2025.
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