If an alien came down from space and asked you to define “pain,” how would you respond? We’ve all had it. We know it’s awful. But, defining it is another story. How do you define a highly subjective experience? Those who live with pain on a near daily basis will likely describe it as “debilitating,” “exhausting,” and “intolerable.” Describing it easy, but defining it is more difficult. The International Association for the Study of Pain (IASP) offers a useful definition: “[Chronic pain] is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
20 percent of American adults report suffering from chronic pain, a staggering number that is only expected to increase over coming years. As science advances, it may seem incomprehensible that more people will suffer from chronic pain in the future than they do now. But, paradoxically, as science advances, people live longer and survive conditions that previously would have ended their lives. Conditions such as cancer, severe injuries, HIV, that were once a death sentence are now treatable. And, while the patients survive, they’re often left to deal with severe persistent neuropathic pain.
Legal medical marijuana is available to more than half of America. Given how widespread chronic pain is and how limited truly efficacious treatment options are, predictably, an increasing number of sufferers are turning to cannabis to treat their condition.
However, whether cannabis is right for you is a highly personal decision. What works for others, may not be appropriate for your situation. Likewise, deciding on whether cannabis should be an adjunctive therapy to your your current treatment protocol or a replacement, is yet another consideration.
We have accumulated more evidence supporting a therapeutic role for cannabis to treat chronic pain than we have for most other conditions. Nonetheless, before you decide to use cannabis, it’s important you develop a fundamental understanding of the dynamics of chronic pain, and how cannabis may (or may not) fit into your treatment program.
What is Chronic Pain?
Broadly speaking, if you have pain that has persists for more than three months and has not been relieved by medical or surgical care, you may have a chronic pain condition. Chronic pain is a condition characterized by generalized muscle or nerve pain, that persists well beyond reasonable expectations of recovery; it affects 100 million Americans — approximately two out of five adults.
Nociceptive - Caused by tissue damage or inflammation, it is usually described usually described as sharp, aching, or throbbing pain.
Neuropathic - Caused by nervous system damage or malfunction. Sufferers commonly describe the pain as causing numbness or a burning sensation.
Conditions and Diseases Associated with Chronic Pain:
- Rheumatoid arthritis
- Spinal diseases
- Complex regional pain syndrome (CRPS)
- Recurrent headache, including migraines
- Painful neurological disorders resulting from damage to the nerves
Issues Commonly Caused by Chronic Pain:
- Immobility, followed by wasting of muscle and joints
- Health issues from immune system issues that can cause increased vulnerability to disease
- Insomnia and sleep disturbances
- Depressed appetite and poor diet
- Dependence on medications.
- Job performance issues
- Isolation from friends and family
- Fear and anxiety
- Depression which can become severe leading to a higher risk of suicide
What Causes Chronic Pain?
Anyone can develop chronic pain, although it most commonly affects older adults and people with health conditions like diabetes, arthritis, or back problems. There are also a number of specific diseases that associated with chronic pain, including shingles, diabetes, blood vessel problems, HIV, and most types of cancer. While treatment may cure one of these diseases, it’s common for chronic pain symptoms to persist.
Treatment may bring the disease under control, or even cure it completely, but the chronic pain persists. Similarly, in the event a pain-inducing disease may not be able to be cured, does not mean the pain cannot be mitigated. Effective pain management requires ongoing attention in conjunction with a qualified medical professional.
What Treatments Are Available to Treat Chronic Pain?
- Anticonvulsant analgesic
- Anti-inflammatory drugs
The downside of these treatments is that for many patients they are only nominally effective and can come with intolerable and potentially debilitating side effects, including:
- Constipation with opioids
- Gastrointestinal issues
- Cardiovascular damage from NSAIDs
Because of the unpredictable efficacy, often intolerable side effects, and risk of addiction, an increasing number of patients are turning to cannabis.
How Does Cannabis Treat Chronic Pain?
The endocannabinoid system (ECS) is responsible for a number of physiological functions related to health, including pain modulation and inflammation. The ECS, through two receptors, CB1 and CB2, help modulate a variety of functions, including:
CB1: Appetite, muscle control, pain, cognition, and reward
CB2: Immune function, cell proliferation, inflammation, and pain
When you ingest cannabis, cannabinoids such as THC and CBD, act on the endocannabinoid system’s receptors and periphery to provide anti-inflammatory and analgesic effects.
“I believe that the reason we and all animal species have the complex system of cannabinoid receptors and endocannabinoids is to help us modulate the experience of pain,” notes Dr. Donald Abrams, professor of clinical medicine at the University of California, San Francisco and chief of hematology & oncology at San Francisco General Hospital. “It is no wonder, therefore, that the plant cannabinoids also seem to have a significant analgesic activity.”
How Effective Are Cannabinoids in Treating Chronic Pain?
Over 200 studies have been conducted evaluating the efficacy of cannabis and cannabinoid-derived formulations to treat chronic pain conditions. One comprehensive systematic study conducted by Harvard professor and addiction psychiatrist, Dr. Kevin Hill, reviewed 28 well-designed studies. The author concluded, “[The] use of marijuana for chronic pain, neuropathic pain, and spasticity due to multiple sclerosis is supported by high-quality evidence.”
Summary of Key Findings:
- Six out of six general chronic pain studies demonstrated significant improvement in symptoms.
- Five out of five neuropathic pain studies found a significant improvement in symptoms. (Three out of five studies investigated “smoked” cannabis, while two examined an oral spray preparation).
Canadian researchers came to similar conclusions in their 2011 Review Study of 18 trials, identifying 15 trials that demonstrated efficacy in treating chronic non-cancer pain. They noted several trials reported significant improvements in sleep, with no serious side effects. Further, the studies found just a few adverse effects which were mild to moderate and well tolerated.
Can Cannabis Help Patients Eliminate (Or Reduce) Opioids?
In recent years, North America has been ravaged by an ever-growing epidemic: opioids. Since Purdue Pharma brought OxyContin to the market in the mid 1990s, prescriptions have increased four-fold. Following the increase in prescriptions, rates of heroin addiction and the number of opioid-related overdoses have skyrocketed.
Data from the Centers for Disease Control (CDC) illustrate how dire the situation is:
- Fatal overdoses have increased by 400%: sales and overdoses of prescription opioids quadrupled between 1999 and 2014.
- More than 165,000 people have died in the U.S. from overdoses related to prescription opioids between 1999 and 2014
- At least half of all U.S. opioid overdose deaths involve a prescription opioid.
- More than 14,000 people died from overdoses involving prescription opioids in 2014.
Evidence suggests opioids are only effective for acute pain, and many patients find they must progressively increase their dosage to achieve the same effect; within a short period of time, their pain isn’t responsive to opioid treatment.
How could medical marijuana help? By providing an efficacious substitute to opioids, or helping patients reduce their opioid intake. The Centers for Disease Control argue that the overprescribing of opioid is fueling the epidemic, so it would be a sensible strategy to encourage physicians to consider cannabis as an alternative (or, adjunct) to opioid-based treatment programs.
Cannabis Acts Synergistically With Opioids
There is evidence that cannabis (or, more specifically, cannabinoids) may act synergistically with opioids, allowing patients to lower dosage of opioids while achieving comparable pain relief.
Dr. Abrams conducted a small study to investigate cannabis as an opioid potentiator. His team found that while vaporized cannabis didn’t affect morphine or oxycodone blood levels, patients reported (on average) a 27% decrease in pain. By augmenting “the analgesic effects of opioids without significantly altering plasma opioid levels,” Abrams and his team concluded vaporized cannabis produces a “synergistic effect.”
“We have studied the effectiveness of cannabis in painful nerve damage (neuropathy) as well as in combination with opiates. From my own oncology practice I am impressed that cancer patients are able to decrease their use of narcotic analgesics when adding in cannabis medicines.” — Dr. Abrams
Dr. Mike Hart, Head Physician at Marijuana for Trauma (Ontario, Canada), agrees: “In my clinical practice I frequently work with patients who are able to significantly reduce their dependence on opioids,” said Dr. Hart. “In hundreds of cases, I’ve seen patients who’ve been able to wean off them altogether by integrating cannabis into their treatment protocol.”
Cannabis Can Reduce Opioid Use
Studies support the role of cannabis as part of a strategy to reduce opioid use. A University of Michigan March 2016 Study provided evidence that cannabis may be superior to opioids and provide a valuable harm reduction strategy.
Cannabis use by chronic pain patients was associated with the following outcomes:
- Decrease in Opioid Use: 64% lower opioid use
- Quality of Life: Cannabis use associated with improved quality of life
- Reduces Side Effects: Reduction in side effects from other medications
The authors also noted that previous studies found that when states enacted medical marijuana laws, they went on to experience (on average) a 25% decline in fatal opioid overdoses.
Dr. Daniel Clauw, one of the study’s researchers and a professor of pain management anesthesiology at the University of Michigan Medical School, commented: "We are learning that the higher the dose of opioids people are taking, the higher the risk of death from overdose. This magnitude of reduction in our study is significant enough to affect an individual's risk of accidental death from overdose."
“Cannabis can play an important role in pain relief — with or without opiates — and, given the epidemic level of opioid overdoses, clearly more physicians should seriously consider cannabis as part of their patients’ therapeutic protocol. Not to, would be irresponsible, if not unethical.” — Dr. Michael Hart, Marijuana for Trauma
Case Study: Kevin Ameling, A Real World Success Story
A “real-world” success story comes from Kevin Ameling, a chronic pain patient who now works for the IMPACT Network in Colorado (a cannabis research advocacy non-profit), is a success story. After getting injured from a fall in 2007, his doctor prescribed him a combination of prescription drugs that included Clonazepam, Tramadol, Lexapro, and OxyContin.
As his chronic pain progressed, Ameling had found the drugs to be less effective, particularly the OxyContin. A resident of Colorado, he became a medical marijuana patient. Cannabis helped him reduce reliance on on prescription drugs, allowing him to cut his dosages significantly:
- Clonazepam: 3 mg to .5mg
- Lexapro: 30 mg to 5 mg
- Tramadol: 300 mg to 75 mg
- OxyContin: Reduced daily intake by more than 50% (and, reports being able to skip doses)
“I was well aware of the dangers associated with benzodiazepines and opioids, and didn’t want to be a statistic. OxyContin became less effective and I didn’t want to up my dosage,” recounts Ameling. “By using cannabis as an adjunct to my therapy, I was able to cut back on all my medications. Most impressively, while reducing my OxyContin intake, it didn’t become less effective, and in fact, I believe cannabis allows OxyContin to be maintain efficacy far longer than typical.
Ameling noted everyone responds differently, but for him, “low dose edibles work much better than smoking. In fact, smoking seems to worsen my symptoms, while edibles clearly improve them.”
Final Considerations & Tips
Chronic pain sufferers have turned to cannabis for years, long before more than half of the U.S. legalized medical marijuana. Encouragingly, over recent years, research is starting to catch up — although far more is needed — and, an ever-increasing body of evidence validates what medical marijuana chronic pain patients have known for years.
While the evidence is compelling — particularly for the treatment of neuropathic pain — it’s important for patients to recognize that strains can vary considerably in chemical composition. Moreover, choice of delivery device influences outcomes. It may take a little trial and error before you find the most effective strain and preferred form of administration. Most importantly, if you are currently using opioids, it would be unwise to radically change your treatment protocol without professional medical supervision.
- Administration Method Matters: Keep in mind that method of administration is important. An edible will have a different effect than vaporizing. Vaporizing will elicit different effects from a tincture. And, of course, prescription formulation. While anecdotally, many patients report a preference for edibles, everyone is different, so you may want to experiment with different methods until you find what works best.
- It May Take Some Trial & Error: Different strains will elicit different effects that are THC and CBD dose-dependent Further, differing ratios of THC will impact the effect. Similar to how people respond differently to the same drug, people will have different experiences that may be affected by the diverse composition among strains.
- Most (But, Not All) Patients Prefer Indica: A 2016 study published in the Journal of Studies in Drugs and Alcohol found that pain patients preferred indica strains over sativa.
- Exercise Caution If Currently Using Opioids: If you’re currently taking prescription opioids, exercise caution as withdrawal from opioids can be severe. Protocol changes should be monitored by a physician. Withdrawal from opioids can be severe!
Dr. Michael Hart, head physician at Marijuana for Trauma in Canada, advises: “When considering cannabis to treat chronic pain, the adage — less is more — rings true. Patients seem to find more relief in Indica strains which are higher in THC than most Sativa or Hybrid strains. But, what we’ve found is that these strains can be highly effective in low to moderate doses, but could actually make pain worse in higher doses. So it’s important to start low, and titrate up as appropriate.”
Cannabis & Pain Management
Donald I. Abrams, MD.
Department Anesthesia, Psychiatry, Dalhousie University, Halifax, Canada. Mary Lynch, MD; et, al.
Harvard Medical School. Kevin Hill, MD.
Ethan Russo, MD.
Department of Pain Pharmacology, Polish Academy of Sciences. Barbara Przewlocka, Katarzyna Starowicz, Ph.D.
J Manzanares, MD; et, al.
The Endocannabinoid System as a Potential Therapeutic Target for Pain Modulation. Department of Medical Pharmacology, Trakya University Faculty of Medicine, Edirne, Turkey. Ahmet Ulugöl, MD.
Division of Hematology, Oncology and Transplantation and the Vascular Biology Center, University of Minnesota. Pankaj Gupta, MD; et, al.
Department of Psychological Brain Sciences, Indiana University. Andrea Hohmann, Ph.D., Ethan Russo, MD.
Cannabis & Opioids
Centers for Disease Control.
Division of Hematology-Oncology, San Francisco General Hospital, University of California, San Francisco. Donald Abrams, MD; et, al.
Cannabis as an adjunct to or substitute for opiates in the treatment of chronic pain. Research Affiliate, Centre for Addictions Research of BC. Philippe Lucas
National Center for PTSD, Veterans Affairs Palo Alto Health Care System. Marcel Bonn-Miller; et, al.
University of Michigan, Medical School. Kevin F. Boehnke, MD; et, al.
Department of Psychology, Ariel University, Ariel, Israel. D. Feingold, MD; et, al.