First documented in Chinese Pharmacopeia (circa 2700 B.C.E.) in the Pen Ts’ao (“The Herbal”), cannabis has been used to treat arthritic-related conditions for thousands of years. However, cannabis didn’t reach Western medicine until the 19th century. After learning about medicinal cannabis in India — where it had been used to treat numerous ailments (including pain and inflammation) — British physician Sir William Brooke O'Shaughnessy introduced the therapeutically versatile botanical to the West.
O'Shaughnessy meticulously documented his experiments on animals and humans. As part of his research, he reported three case studies of cannabis as a treatment for rheumatoid arthritis. O'Shaughnessy described two patients who were "much relieved of their rheumatism; they were discharged quite cured in three days after." The third patient who didn't experience relief was apparently "habituated to the use of gunjah in the pipe," suggesting the patient had developed a tolerance from chronic recreational use.
O'Shaughnessy's research generated considerable interest in England and cannabis was enthusiastically adopted into western medicine. Several decades later, Queen Victoria's personal physician, Dr. Russell Reynolds, claimed cannabis to be "one of the most valuable medicines we possess,” and that “in almost all painful maladies," cannabis was "by far the most useful of drugs."
Research and medical use of cannabis came to a halt in the 20th century for two reasons: First, unsophisticated cannabis cultivation techniques caused a high degree of chemical variability, making it difficult to reproduce therapeutic effects consistently. Secondly, governments became increasingly concerned about the abuse of narcotics. Cannabis, although not a narcotic, was associated with opioids and subsequently highly controlled or banned. Ironically, opioids which are narcotic and much more addictive than cannabis continued to be widely used in medicine.
In recent years medicinal cannabis has experienced a renaissance in research and medicine. In fact, a significant amount of preclinical and clinical research — particularly in the past decade — has emerged demonstrating the efficacy of cannabis to treat pain and inflammation. The timing is right: as opioid abuse has reached epidemic proportions, cannabis offers a far less harmful and addictive alternative to opioids. According to Mike Hart, MD, a Canadian physician who treats patients suffering from chronic pain, “Compared to opioids, cannabis is a safer and more effective long-term solution. Opioids have killed more people than all illegal drugs combined, while cannabis has never killed a single person.”
What is Arthritis?
The word arthritis comes from “artho-” meaning joint and “-itis” meaning inflammation. Most people think of arthritis as a chronic joint pain condition that is a common part of aging. It’s true, arthritis disproportionately affects the elderly, however, it’s not a homogenous disorder. The term “arthritis” is an umbrella term used to describe a spectrum of over 100 related joint pain conditions and joint-related diseases. It can affect individuals at any age, even children. The spectrum includes mild forms such as tendinitis and bursitis to severe (and often debilitating) forms including rheumatoid arthritis and systemic lupus erythematosus; fibromyalgia is often characterized as an arthritic-related condition.
From 2010 to 2012, according to estimates from the U.S. Center for Disease Control and Prevention (CDC), 22.7% of U.S. adults (52.5 million) suffered from some form of arthritis, including nearly 50% of adults age 65 and older. As medicinal cannabis becomes legal in more jurisdictions across the U.S. and around the world, predictably more and more people are treating (or considering treating) arthritis with cannabis.
Arthritis conditions can be broadly divided into two categories — rheumatoid arthritis (RA), an autoimmune disorder that typically progresses to all joints; and osteoarthritis (OA), a condition that can be caused by multiple factors such as injury and overuse (“wear and tear”), obesity, and genetics. Both types affect the joints, and can cause stiffness, redness, mobility difficulties, pain, inflammation, and swelling:
Rheumatoid arthritis (RA) causes cells from the immune system to malfunction and attack the synovial membrane including joint tissues, resulting in inflammation and RA’s characteristic warmth, redness, swelling, and pain. (The synovium — also known as the synovial membrane — refers to the soft tissue that lines the bursae, tendons, and the entire inner surface of the joint, except where the joint is lined with cartilage; it is responsible for promoting joint mobility.)
Rheumatoid arthritis induces an inflammatory response that causes a proliferation of synovial cells, and an infiltration of tissue by inflammatory cells. As RA advances, it attacks and destroys cartilage and bone within the joints causing surrounding tendons, muscles, and ligaments responsible for stabilizing the joints to weaken and malfunction. Ultimately, RA erodes cartilage and bones. The risk for RA increases with age as the immune system becomes less resilient.
Osteoarthritis (OA) is less complex than RA, although it can be just as painful and potentially debilitating. OA is arthritis of the bones where cartilage has degenerated from years of use or injury. Like RA, the synovium also becomes inflamed. The condition predominantly affects elderly persons.
Left untreated (or undertreated), arthritic conditions can lead to permanent and debilitating joint damage and destruction; some forms of arthritis can even damage the body’s internal organs.
Commonly prescribed medications are designed to either ease symptoms or slow disease activity. Many treatments include the use of painkillers, which too often provide limited benefits and can cause serious side effects (including dependency).
Analgesics (such as Tylenol, Percocet, and Vicodin) are designed to alleviate pain, but do nothing to reduce inflammation (a primary source of arthritic pain). Long-term use of many commonly used drugs such as aspirin and acetaminophen are associated with serious side effects including stomach pain and damage. Similarly, pain medications containing opioid derivatives such as codeine, oxycodone, propoxyphene and tramadol can cause physical and psychologic dependence, nausea, constipation, mood changes. Combined with alcohol they can depress breathing which can be potentially fatal.
Steroids and non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to treat inflammation. Side effects can range from moderate to severe including digestive issues, insomnia, anxiety, elevated blood sugar, bruising, cataracts, and hypertension.
Disease-modifying anti-rheumatic drugs (DMARDs) are used to treat rheumatoid arthritis by reducing pain and inflammation, and preventing the immune system from attacking inflamed joints to reduce or prevent joint damage. Associated side effects can include gastrointestinal issues, nausea (sometimes with vomiting or diarrhea), liver problems, and blood issues.
Corticosteroids (such as prednisone and cortisone) are sometimes prescribed to reduce inflammation and suppress the immune system. Side effects can include increased appetite and weight gain, insomnia, mood changes, acne, increased sweating, dry or thinning skin, bruising, slow wound healing, headaches, dizziness, spinning sensation, nausea, stomach pain, and bloating.
Lifestyle changes: Meats and foods high in sugar and carbohydrates often exacerbate inflammation, so healthy dietary changes can help manage arthritis. Although as many as one in four adults with arthritis lead physically inactive lifestyles, exercise is known to alleviate stress and pain.
As baby boomers age, arthritis will affect increasing numbers of the population. Clearly, there is a need for innovative new treatments, yet remarkably, joint pharmacology is often overlooked in research. However, cannabis with its versatile therapeutic profile can fill some of the treatment gaps that currently exist.
How Can Cannabis Help Treat Arthritis?
Although cannabis-derived treatments have been used for millennia, it wasn’t until the discovery of the endocannabinoid system that we developed a better understanding of why cannabis-derived medications can be highly effective and versatile in treating a broad range of conditions including arthritis.
The endocannabinoid system, the body's own cannabinoid system, has a profound influence on our physical and emotional health including pain sensation, immune function, inflammation, appetite, and mood. According to Bradley Alger, Ph.D. professor in the Department of Physiology at the University of Maryland School of Medicine and author of Getting High on the Endocannabinoid System, the endocannabinoid system is “one of the most important physiologic systems involved in establishing and maintaining human health.”
The cannabis plant contains hundreds of cannabinoids, terpenes, flavonoids and essential oils that when consumed, interact with our body’s endocannabinoid system to exert therapeutic effects such as relief from pain and inflammation. In a comprehensive review of scientific literature published in the Journal of Neuroimmunology, researchers from the National Institute for Neuroscience in Tokyo concluded, "Cannabinoid therapy of RA could provide symptomatic relief of joint pain and swelling as well as suppressing joint destruction and disease progression."
Cannabis can be useful independently or as an adjunct to other drugs. Polypharmacy (the concurrent use of two more drugs to treat a single condition) is common in pain management. Cannabis may be added at the lowest effective dose as an adjunct to treatment with drugs such as opioids or NSAIDs allowing patients to reduce reliance on drugs that sometimes come with intolerable side effects.
In fact, evidence suggests cannabinoids can potentiate (increase efficacy) the effects of opioids, improving and extending their efficacy, while allowing pain sufferers to reduce opioid intake. THC’s analgesic effects appear to be partly mediated through delta and kappa opioid receptors, suggesting an intimate relationship between cannabinoid and opioid signaling pathways in pain sensation.
A study from the Centre for Addictions Research of BC in Canada concluded:
“There is a growing body of evidence to support the use of medical cannabis as an adjunct to or substitute for prescription opiates in the treatment of chronic pain. When used in conjunction with opiates, cannabinoids lead to a greater cumulative relief of pain, resulting in a reduction in the use of opiates (and associated side-effects) by patients in a clinical setting. Additionally, cannabinoids can prevent the development of tolerance to and withdrawal from opiates, and can even rekindle opiate analgesia after a prior dosage has become ineffective.”
Another compelling explanation for why cannabis can be such a useful part of an arthritis treatment protocol is that unlike many commonly prescribed drugs, often either anti-inflammatory or analgesic, cannabis targets multiple therapeutic pathways. It is analgesic, in a manner similar, but pharmacologically distinct from opioids. It also exerts anti-inflammatory actions (to reduce inflammation); antinociceptive effects that block pain sensation; and, immunomodulatory actions that target the immune system (which is implicated in rheumatoid arthritis). In fact, preclinical studies suggest cannabinoids could induce apoptosis (programmatic cell death) in affected immune cells and inhibit production of cytokines and chemokines at affected areas.
What about cannabidiol (CBD)? While most human studies have focused on THC, cannabidiol (CBD), the second most prominent ingredient in cannabis, has generated significant interest because it can produce therapeutic effects without causing psychoactivity (the “high”). Interestingly, studies using experimental animal models (with mice carrying disease resembling arthritis), show CBD can not only alleviate symptoms but inhibit progression of arthritis and protect against developing severe joint damage.
CBD also plays an important synergistic role with THC. CBD tempers THC’s intoxicating, sedative, and cognitive impairing effects while enhancing the analgesic and anti-inflammatory actions of cannabis, reducing pain intensity and discomfort.
Dr. Sunil Aggarwal and a team of physicians and scientists from the University of Washington published a paper in the Journal of Opioid Management, Medicinal Use of Cannabis in the United States: Historical Perspectives, Current Trends, and Future Directions, concluding:
“It is clear that, as an analgesic, cannabis is extremely safe with minimal toxicity. Unlike opioids, cannabinoid medicines to not promote appetite loss, wasting and constipation, but instead can be used therapeutically to treat these symptoms. The synergistic effect of administering multiple active plant constituents and an entourage effect involving endocannabinoid signaling molecules and cannabinoid receptors CB1 and CB2 probably results in the superior analgesia of whole plant cannabis.”
Aggarwal, a physician-scientist, argues three properties make cannabis ideally suited for pain management: established safety; remarkably low toxicity; and documented efficacy to relieve a broad range of pain states. Aggarwal cites a comprehensive review of 31 clinical studies on the adverse effects of medical cannabinoids that found few adverse events associated with cannabis reported in studies. In fact, of the few adverse events, the vast majority were not serious (96.6%). "There was no evidence of a higher incidence of serious adverse events following medical cannabis use compared with control [drugs].”
Further, Aggarwal notes there have been no overdose deaths attributed to cannabis, whereas a person could suffer a fatal overdose after ingesting just 2 grams of dried opium poppy sap. While it is possible to "overdose" from oral ingestion (e.g. edibles or tincture), generally at worst, the effects are agitation and confusion, progressing to sedation. Effects disappear relatively quickly (within 3 to 4 hours) — after the cannabis is metabolized and excreted.
However, as is widely known, consuming cannabis can produce euphoria (the “high”). While patients in many studies report finding the “high” manageable (and often desirable), not all patients want to experience psychoactive effects. Patients can minimize these effects by consuming the lowest effective dose by self-titrating. (Self-titration means to start with a low dose and gradually increase the dose until achieving the desired effects.) Moreover, patients can seek strains high in CBD. Combining CBD and THC improves the efficacy and safety of using cannabis while tempering the psychoactive effects.
It’s important to keep in mind that cannabis is a complex plant with dozens of cannabinoids and terpenoids that can affect outcomes. Therapeutic effects can vary considerably from strain to strain, so finding the ideal strain requires a little bit of “trial and error.” Moreover, effects can vary according to consumption method. For example, edibles can produce slightly different effects from vaping or smoking. Often, patients will find they prefer one method over the other. Vaping produces effects more quickly and it is easier to self-titrate, but effects don’t last as long. Edibles, on the other hand, may take longer, but the effects last longer and some patients report better pain relief. Ultimately, it comes down to personal preference.
Do you use medical marijuana to help manage your arthritis? If so, which strains have you found help best? Share your experience in the comment section below!
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