Chronic Pain and Medical Marijuana

Chronic pain is one of the most common medical issues in the United States, and according to the CDC there’s an estimated 20.4% of Americans having suffered chronic pain issues. A developing field of interest in medicine is the application of medical marijuana to alleviate chronic pain as an alternative to opiates. Medical marijuana has continued to gain traction in the medical community as a potential substitute to opiates, particularly due to medical marijuana’s lack of addictive properties as compared to opiates.

With that said, there are numerous claims about the benefits of medical marijuana, much of which is not supported by scientific testing. We at Marshall Kramer MD have made it our duty to provide accurate and rigorously peer-reviewed information to our readership. After providing said information, we will link/cite our sources for your personal research. Our goal is to enable you, the patient mulling over the merits of medical marijuana, to make your own informed decision. Remember, medical cannabis is not for any and all conditions.

One of the most supported claims when dealing with medical marijuana, when obtaining a medical marijuana card, is marijuana’s ability to alleviate those experiencing chronic pain [1]. We know the term “chronic pain” is vague, so let’s clarify what falls under that criteria:

MOST COMMON TYPES OF “CHRONIC PAIN”

- Neuropathic pain (damaged nerves, e.g. peripheral neuropathy)

- Headaches (including post-surgical pain, post-trauma pain, lower back pain, migraines [1])

- Fibromyalgia (widespread pain in the bones and muscles; inflammatory bowel disease, painful and/or chronic inflammation; see table 2[1])

- Cancer pain (related to either disease or treatment)

- Arthritis (most common forms: osteoarthritis, rheumatoid, gout)

- Trigeminal neuralgia (pain caused by inflammation of the facial nerve)

- Psychogenic pain (pain caused by psychological disorder such as depression or anxiety, can manifest in areas such as neck or back)

- Visceral pain (viscera means organs, also includes cavities containing the organs e.g. abdominal, chest)

- Tension headaches (caused by stress, fatigue, poor/incorrect sleep, ocular muscles become strained)


Glossary

“THC” delta-9-tetrahydrocannabinol, this the psychoactive property in marijuana, in essence - gets you high or stoned.
“CBD” cannabidiol, used for pain relief without psychoactive properties, in essence will not get you high or stoned.
“Efficacy” the power to produced desired result or effect
“Neuropathic” an abnormal and usually degenerative state of the nervous system or nerves
“Psychogenic” physical aspects of emotional, mental, or behavioral factors. Headache, back ache, or stomach pain is most common forms of psychogenic pain
“Analgesia” loss of the ability to feel pain when conscious

TREATING CHRONIC PAIN

“Medical cannabis has been employed to treat pain based on its actions on both CB1 and CB2 receptors. CB receptor agonists have been revealed to cause antinociceptive and antihyperalgesic effects by regulating neuronal and non-nervous system inflammatory activity. One theory proposes that activation of CB1 receptors in mast cells elevates cyclic adenosine monophosphate and suppresses degranulation. Analgesia may also result from CB1 receptor activation, causing negative modulation of the P2X3 receptor in primary afferent neurons. Activation of CB2 receptors can hinder the release of proinflammatory factors causing suppression of nerve growth factor induced mast-cell degranulation and neutrophil accumulation.” [2]

Translation: The positive effects linked to medicinal cannabis have to to with their effects on the CB (specifically 1 & 2) receptors. These receptors regulate neurons thereby the activity of our nervous system, specifically inflammation. Neurons carry messages to the nervous system, and use of medicinal marijuana (in varying forms) appear to alleviate information overload or overreaction which can lead to major causes of pain, for example inflammation.

The body of research for medical cannabis has been growing at a steady rate in the last few decades. Given the use of opioids to treat chronic pain, and the resulting opioid epidemic, chronic pain relief has shown considerable improvements from alternative uses, like that of medical marijuana. It has been show to be equally effective in it’s initial goal (treating chronic pain) while much more effective in it’s low-to-non addictive properties.

The National Academies of Sciences has determined that adult patients with chronic pain who were treated with medical cannabis / cannabinoids were more likely to experience a scientifically supported reduction in said pain symptoms. TNAS rated the evidence to pain relief as substantial.” [7] Of the positive findings in pain reduction, they go as follows: cancer-related pain, migraines [8], fibromyalgia [11]. Medical cannabis / cannabinoids have been suggested as valuable in dealing with the pain conditions of rheumatoid arthritis, osteoarthritis [13], and various other types of acute and chronic musculoskeletal pain. However, we will clearly state that the strains of cannabis, methods of use/ingestion, and dose efficacy is not particularly uniform in clarity. In this domain, more collaborative research is required.

CHRONIC PAIN, A DEEPER DIVE…

Neuropathic Pain

Neuropathic pain is another area where research strongly favors medical cannabis as an aid…

“This [medicinal marijuana] study [of cannabis cigarettes] adds to a growing body of evidence that cannabis may be effective in ameliorating neuropathic pain, and may be an alternative for patients who do not respond to, or cannot tolerate, other drugs.” [3] [4]

“The analgesia obtained from a low dose of [medical cannabis] (1.29%) in patients, most of whom were experiencing neuropathic pain despite conventional treatments, is a clinically significant outcome.” [6]

Headaches, Tension Headaches, Migraines

Migraine research for medical cannabis leans toward the positive…

2016 Study in Colorado where 121 migraine patients were recommended and prescribed medicinal marijuana found that over 85% of patients reported some level of decrease in their monthly migraine frequency. Falling from 10 to around 5 attacks on average per month. [8]

Fibromyalgia

Pain relief for Fibromyalgia varies in benefits, albeit a placebo group study has undermined the overall perceived success…

In a 2011 study, 28 participants who used medicinal marijuana for fibromyalgia ranked its perceived benefits for each symptom. Approximately 43% reported strong pain relief. Another 43% reported mild pain relief. [9] [10]

A 2018 study of 25 people with fibromyalgia tested pain relief among four types of marijuana, each with different CBD and THC properties. One of the four was a placebo (neither CBD nor THC). 44% of the patients reported a 30% reduction in pain, however, when compared to the placebo, marijuana did not have a significant effect on pain rankings among participants. [9] [11]

Cancer Pain

Research in analgesia of cancer pain appears to favor medicinal marijuana…

“…study compared oral THC at 5-, 10-, 15-, and 20-mg dosages [of oral medical cannabis/THC] in ten patients. It found that there was improved pain relief at 15- and 20-mg doses, but this was associated with substantial sedation and confusion. The second study compared oral THC at 10- and 20mg doses to codeine… Pain reduction scores with 10 and 20 mg were found to be roughly equivalent to 60 and 120 mg codeine, respectively. At 20 mg, patients complained of mental cloudiness and drowsiness, but the study found that 10 mg of oral THC was well tolerated, despite mild sedation, has analgesic potential.”[5]

Arthritis

The results in arthritis are not unanimous in favor of medical cannabis…

Mary Ann Fitzcharles, MD, and her colleagues mentioned that while the evidence is strong between medicinal marijuana use in treatment of chronic pain conditions (such as cancer and neuropathic pain) those types have a “different underlying mechanism [than rheumatic conditions].”

“Chronic pain is a symptom of rheumatoid arthritis, and when it comes to chronic pain, we have 9,000 patient years of data showing that THC [the active ingredient in cannabis] effectively treats it,” says Jahan Marcu, PhD, chief scientific officer for Americans for Safe Access… “Cannabinoids stop the transmission of pain and decrease inflammation, and that’s very important in people with joint issues.” [13]

Trigeminal Neuralgia

Not only has medical marijuana shown up well when tested in cases of Trigeminal Neuralgia, it has also been linked to lessened consumption of opioids…

In a 2019 study of patients with Trigeminal Neuralgia [TN] treated with medical cannabis, they concluded that “medical cannabis is well tolerated in the treatment of TN, with 81% of patients reporting improvement and 50% of patients reducing opioid consumption with medical cannabis. Most common efficacious dosage for these patients was a 1:1 ratio of THC to CBD. These results suggest that medical cannabis is a useful part to a comprehensive pain management plan for patients with TN, but future randomized placebo controlled trials are needed.” [14]

Psychogenic Pain

We do want to caution our readership in matters of anxiety and depression, medicinal use of marijuana has unconvincing findings. However, in form physically manifested psychogenic pain, the results are positive…

Americans for Safe Access say that medical cannabis has at least two roles to play in management of chronic pain, including neck and back pain. First, it can relieve the pain itself——either alone or with combination of other pain-relief medications. Second, it can control nausea associated with long-term pain and also the use of opioids (narcotic pain-relievers). [13][15]

Visceral Pain

In terms of pain to the organs and organ cavities, whether it be through cancer treatments, inflammatory bowel disease, and other viscera pain, results are promising…

“Current clinical research indicates that some conditions may be clinically improved by medical cannabis use. These include inflammatory bowel disease, multiple sclerosis, neuropathic pain, nausea and vomiting caused by cancer or chemotherapy… [16]
…One respective study in Israel asked 30 patients with Crohn’s disease about their disease severity before and after using medicinal cannabis and found great improvements. They found that 70% of the patients experienced a decrease in Crohn’s disease symptom severity, and that many were able to reduce or eliminate the medication they were using. [16]
This was a respective study, meaning it relied primarily on patient memory and subjective symptoms. The study isn’t as strong as a double blind study.
…One prospective study provided 13 IBD patients (11 with Crohn’s disease, 2 with ulcerative colitis) who were not using cannabis with 50g of medical cannabis to smoke as needed to relieve their symptoms over the course of three to nine months. After this time, all the patients had smoked the full 50g, and they saw improvements in their health. The Crohn’s disease group’s Harvey-Bradshaw index scores (an index that rates Crohn’s disease symptoms) dropped from an average of 11.36 to 2.68 (great result), with the largest improvements in general wellbeing and abdominal pain.” [16]

CONCLUSION

There has been a slew of research regarding medical marijuana and its efficacy when treating chronic pain. There is plenty of reason for optimism given the positive findings among various research groups. We do, however, caution any individuals seeking a medical marijuana card, that if they do receive one, they be responsible in educating themselves about methods of consumption, consumption amounts, and the likelihood of its efficacy.

Stay tuned, as we will have plenty more information for you to educate yourselves with. Our goal in prescribing medical marijuana cards is to help relieve you of your chronic pain.

Dr. Kramer is of the strong opinion that further research into the medical applications of cannabis will yield new methods of treatment and support for common, chronic illnesses. Patients shouldn’t have to suffer from symptoms that can be ameliorated or solved with the use of medical marijuana. We’ve reached a new period in healthcare where medical cannabis and medical marijuana is continuously being used in new, innovative ways - the more studies that can effectively measure and gauge potential uses of medical marijuana, the more options we’ll have as a society for healing and finding filling in the many gaps in our healthcare. Thank you for reading our blog, and for more information regarding medical marijuana or medical cannabis you can access the resources in the links below.

If you are interested in obtaining a medical marijuana card with Dr. Kramer, you can use this link to begin the process of obtaining one.

[1] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306710/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557112/
[3] https://www.foundationforpn.org/peripheral-neuropathy-treatment-medical-cannabis/
[4] https://www.jpain.org/article/S1526-5900(18)30735-1/fulltext
[5] http://link.springer.com/article/10.1007/s11916-015-0524-x
[6] http://www.sciencedirect.com/science/article/abs/pii/s1526590012008644
[7] http://www.nationalacademies.org/ocga/testimonies/116-session-1/the-health-effects-of-cannabis-and-cannabinoids
[8] http://migrainepal.com/medicinal-cannabis-for-migraine/#_edn7
[9] http://www.healthline.com/health/fibromyalgia/marijuana-fibromyalgia
[10] http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0018440
[11] http://www.researchgate.net/publication/329902313_An_experimental_randomized_study_on_the_analgesic_effects_of_pharmaceutical-grade_cannabis_in_chronic_pain_patients_with_fibromyalgia
[12] http://www.mcgill.ca/paincentre/mary-ann-fitzcharles
[13] http://www.everydayhealth.com/rheumatoid-arthritis/treatment/pros-and-cons-of-marijuana-for-joint-pain/
[14] http://n.neurology.org/content/92/15_Supplement/P5.10-020
[15] http://www.verywellhealth.com/medical-marijuana-for-chronic-pain-296609
[16] http://www.badgut.org/information-centre/a-z-digestive-topics/cannabis/