CBD for chronic pain: The science doesn’t match the marketing
If you ask health care providers about the most challenging condition to treat, chronic pain is mentioned frequently. By its nature, chronic pain is a complex and multidimensional experience. Pain perception is affected by our unique biology, our mood, our social environment, and past experiences. If you or a loved one is suffering from chronic pain, you already know the heavy burden.
People are looking for novel, nonaddictive ways to treat pain
Given the ongoing challenges of chronic pain management coupled with the consequences of the opioid epidemic, pain management practitioners and their patients are searching for effective and safer alternatives to opioids to alleviate pain. With the legalization of marijuana in many states and resulting cultural acceptance of this drug for recreational and medical use, there has been an increased interest in using cannabis for a myriad of medical problems, including pain.
Cannabis (most commonly obtained from the Cannabis indica and Cannabis sativa plants) has three major components: cannabinoids, terpenoids, and flavonoids. While there are over a hundred different cannabinoids, the two major components are tetrahydrocannabional (THC) and cannabidiol (CBD). Historically more attention has been paid to the psychoactive (euphoric “getting high”) component of the cannabis plant, THC; there have been fewer scientific studies on the medical use of CBD, a non-psychoactive component of the plant.
What’s the thinking behind using cannabis for chronic pain?
CBD is emerging as a promising pharmaceutical agent to treat pain, inflammation, seizures, and anxiety without the psychoactive effects of THC. Our understanding of the role of CBD in pain management continues to evolve, and evidence from animal studies has shown that CBD exerts its pain-relieving effects through its various interactions and modulation of the endocannabinoid, inflammatory, and nociceptive (pain sensing) systems. The endocannabinoid system consists of cannabinoid receptors that interact with our own naturally occurring cannabinoids. This system is involved in regulating many functions in the body, including metabolism and appetite, mood and anxiety, and pain perception.
What’s the research that CBD works in humans?
Given its promising results in animal models, along with its relative safety, non-psychoactive properties, and low potential for abuse, CBD is an attractive candidate to relieve pain. Unfortunately, there is a lack of human studies about the effectiveness of CBD. However, there is an abundance of commercial advertisements about the magical effects of CBD, and it is frequently presented as a cure-it-all potion that will treat everything including diabetes, depression, cancer, chronic pain, and even your dog’s anxiety!
So far, pharmaceutical CBD is only approved by the FDA as adjunct therapy for the treatment of a special and rare form of epilepsy. Currently, CBD alone is not approved for treatment of pain in the United States. But a combination medication (that contains both THC and CBD in a 1:1 ratio) was approved by Health Canada for prescription for certain types of pain, specifically central neuropathic pain in multiple sclerosis, and the treatment of cancer pain unresponsive to optimized opioid therapy. There is currently no high-quality research study that supports the use of CBD alone for the treatment of pain.
Why is CBD presented to the public this way, when it is not without risks?
Given the rapid change in the legality of cannabis coupled with the increased appetite for something new, and driven by unprecedented profit margins, the advertising for cannabinoids in general and CBD in particular has gone wild. The FDA is very clear that it is illegal to market CBD by adding it to a food or labeling it as a dietary supplement. And it warns the public about its potential side effects, as it’s often advertised in a way that may lead people to mistakenly believe using CBD “can’t hurt.” CBD can cause liver injury, and can affect the male reproductive system (as demonstrated in laboratory animal studies).
Most importantly, CBD can interact with other important medications like blood thinners, heart medications, and immunosuppressants (medications given after organ transplantation), potentially changing the levels of these important medications in the blood and leading to catastrophic results, including death. Also, more information needs to be gathered about its safety in special populations such as the elderly, children, those who are immunocompromised, and pregnant and breastfeeding women.
Many of the CBD products on the market are unregulated
In fact, the FDA has issued several warning letters to companies and individuals that market unapproved new drugs that allegedly contain CBD. The FDA has tested the chemical content of cannabinoid compounds in some of the products, and many were found to not contain the levels of CBD the manufacturers had claimed they contain.
Beware of powerful testimonials
Finally, there is anecdotal wisdom, when experiences by patients and health professionals have positive results. While the experience or medication could be beneficial, that doesn’t mean it is going to work for everyone. That’s because each and every person is unique, and what works perfectly for one patient could have no effect on another patient. This is especially true for pain, where many other factors (our mood and stress level, our environment and other medical conditions, and our previous experiences) can affect the perception of pain. Please be careful, and keep in mind that some of these incredible-sounding testimonials are merely marketing materials meant to lure consumers to buy more products, as the CBD market is expected to hit $20 billion by 2024.
The bottom line: Don’t make CBD your first or only choice for pain relief
If you or someone close to you is considering trying CBD, I would recommend Dr. Robert Shmerling’s advice about the dos and don’ts in choosing an appropriate product. Until there is high-quality scientific evidence in humans, it is difficult to make a recommendation for the regular use of CBD in chronic pain management.
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THC vs. CBD for Pain Relief: What’s Better?
People with arthritis and other chronic musculoskeletal pain are increasingly turning to cannabis products for relief from different symptoms, such as pain, fatigue, insomnia, and anxiety. In fact, a recent CreakyJoints survey of people with arthritis found that more than half had tried marijuana or CBD for a medical reason.
While cannabis plants are complex and different varieties have different chemical compositions, almost all of them contain some combination of two medically important compounds: tetrahydrocannabinol (THC) and cannabidiol (CBD).
THC is responsible for that “high” that people get from marijuana, which may also play a role in pain relief. CBD doesn’t usually cause an intoxicating feeling, but research suggests it, too, may help ease arthritis symptoms.
These two chemicals both show potential in easing pain, but in different ways. Choosing a product rich in THC, CBD, or both could make a difference in the kind of pain relief you experience — if any. (Here are reasons your CBD product might not be working for you.)
Here’s what experts say about the differences between THC and CBD for pain relief.
How THC and CBD May Offer Pain Relief
CBD and THC activate different cannabinoid receptors in your body that can stimulate or inhibit brain chemicals and cause certain effects.
“We know a lot more about how THC works in terms of the molecular mechanism [than CBD],” says Steve Alexander, associate professor of molecular pharmacology at the University of Nottingham Medical School, who researches cannabinoids.
“THC activates certain cannabinoid receptors, one of which is in the nerve cells and the other is in the immune cells. When it activates the one in the nerve cells, it reduces the sensation of pain,” he adds.
The high that THC provides can also play a role in how people experience pain. “A little bit of euphoria can help us not care that we’re experiencing quite as much pain, much in the same way that other pain medications work,” says Angela D. Bryan, PhD, professor of psychology and neuroscience at the University of Colorado Boulder, who has studied cannabis and health.
CBD is much less understood than THC by researchers, although there is anecdotal evidence that it may provide pain relief in some people.
“We’ve got a hypothesis that CBD might have some interference with [the brain chemical] serotonin and some influence on glycine receptors, which may be involved with pain. We think it may do what it does by hitting multiple targets with a fairly light touch,” says Dr. Alexander. “It’s difficult to pick apart — lots of people are trying [to study it], but no one has yet succeeded.”
Researchers have not found much evidence that CBD can offer mental relief from pain. However, the placebo effect may help some individuals experience less pain after taking CBD.
“The human mind is a very powerful thing, and a lot of the ways we experience medication is related to our expectancies about that medication,” says Dr. Bryan.
How CBD Can Help with Anxiety
Scientists suspect that CBD may help relieve anxiety, though. That, in turn, could affect someone’s perception of pain and potentially make them more comfortable. The research is still developing, though, and it’s too early to draw anything conclusive.
“We know that chronic pain patients also have a number of other morbidities, like stress, anxiety, and depression. I’m interested in the possibility that cannabidiol might also have mechanisms by which we can relieve some of those additional problems,” says Dr. Alexander.
That said, CBD may offer pain relief in more physical ways. It seems to show promise in reducing inflammation, which could provide pain relief from autoimmune diseases like rheumatoid arthritis, says Dr. Bryan.
The bottom line: THC seems to have a greater effect on the way the mind perceives pain, whereas CBD may work to ease pain at the local source.
Which Is Better for Pain Relief: THC or CBD?
There’s no definitive answer to the debate between THC and CBD for pain relief. Cannabis is still considered a Schedule 1 drug by the federal government — a legal status that limits the kinds of research that can be conducted.
Using the current research available, Dr. Bryan says she believes that a combination of THC and CBD together shows the most promise for pain relief.
“To the extent that we have good data, it’s unlikely that either THC or CBD on its own is going to be particularly effective for pain. It probably needs to be a combination of the two,” she explained. “We’re totally speculating at this point, but the way they work together might be that CBD has anti-inflammatory properties while THC has properties that can help us better cope with pain.”
CBD and THC: Side Effects and Legal Concerns
THC might not be an option for everyone, though. Some people may live in states where THC is illegal; while others simply don’t want the psychoactive effects of the substance. In those cases, it might be worth trying CBD on its own to see if it offers pain relief for you.
CBD isn’t legal everywhere either. And in states where CBD is legal, laws can vary as to how much THC is permissible in CBD products in order for them to be legally sold. Many states in which certain CBD products are legal require them to contain less than 0.3 percent THC.
Before trying either substance, it’s worth considering potential side effects they may cause. Side effects of CBD include nausea, fatigue, and irritability, according to Harvard Health. CBD can also interact with certain medications (such as blood thinners) and either increase or decrease the concentration of certain drugs in the bloodstream.
THC has its own set of side effects, including sleepiness and lethargy, increased appetite, increased heart rate, coordination problems, dry mouth, red eyes, slower reaction times, memory loss, anxiety, and mood changes.
“It’s quite likely that individuals will respond to different versions of these cannabinoids, and some may not respond at all,” says Dr. Alexander. “There’s a tendency for anecdotal evidence to highlight the positives of people who do respond [to CBD], which is useful, but it’s difficult to measure the numbers of people who don’t get a lasting benefit.”
If you’re interested in trying CBD or THC to manage your pain, talk to your doctor and experiment to see whether CBD or THC (or both) relieves some pain.
You can also learn more in a new, free course on the health effects of THC and CBD, created by Kent Hutchison, PhD, professor of psychology and neuroscience at the University of Colorado in Boulder.
“Start with low doses and go slowly to find out what works for you,” says Dr. Alexander. “I find it difficult to believe that there is one version of cannabis or CBD that will be best for everyone.” Learn more here about how to find your optimal CBD dose.
Should You Take CBD for Pain?
People looking for a safer pain reliever are turning to cannabis-derived CBD. Michigan Medicine experts weigh in on what’s currently known about the trendy supplement.
Want to learn more on this topic? Listen to this podcast from the Rogel Cancer Center on Medical Marijuana for Cancer Patients.
CBD, short for cannabidiol, is undergoing a surge in popularity as the hot new supplement, with a promise to treat a variety of conditions including pain, anxiety, and insomnia, just to name a few. It’s also available in all manner of forms, from lotions and oils to CBD-infused food and drink. But does it work?
CBD is one of the compounds in the cannabis plant, better known as marijuana. Unlike the famous cannabinoid tetrahydrocannabinol (THC), CBD doesn’t cause the psychological effects typical of being “high”. Both CBD and THC act on the body’s natural endocannabinoid system, which plays a role in many processes including appetite, pain and memory.
The scientific evidence around CBD use is thin, a fact that is mainly due to politics. “Cannabis has been a Schedule 1 drug for a long time, which has limited the type of research needed to figure out how best to use it therapeutically,” says Kevin Boehnke, Ph.D., research investigator in the department of anesthesiology and the Michigan Medicine Chronic Pain and Fatigue Research Center. Under the U.S. Federal Controlled Substances Act, Schedule 1 drugs are defined as having no currently accepted medical use and a high potential for abuse.
Yet marijuana has been used as a medicinal plant for thousands of years, he notes. In fact, one of the first recorded uses of cannabis was for rheumatism, also known as arthritis. Cannabis products were widely used as medicines in the 19th and early 20th centuries, and were listed in the U.S. Pharmacopoeia before the onset of Federal restriction in 1937 under the Marijuana Tax Act.
Much of the research literature around CBD in particular supports its use as a treatment for childhood epilepsy. Indeed, in 2018 the FDA approved the CBD-based drug Epidiolex as a drug for childhood epileptic conditions. In a substantial policy shift, Epidiolex was designated as Schedule V, which is the least restrictive drug schedule and indicates little potential for abuse.
While there aren’t any published clinical trials on CBD in pain, Boehnke notes that ongoing preclinical studies in animals have demonstrated that CBD reduces pain and inflammation, and studies of CBD in humans show that it is well-tolerated and has few negative side effects. “There are also observational studies that ask why people use CBD and if it’s effective, and results tend to be quite positive. People report using CBD for anxiety, pain, sleep — all things that go hand-in-hand with chronic pain,” he says. The passage of the 2018 Farm Bill removed hemp-derived CBD (
So many people are turning to CBD as an alternative pain reliever, especially in light of the opioid crisis, that in a commentary published in Annals of Internal Medicine, Boehnke and Daniel Clauw, M.D., director of the Chronic Pain and Fatigue Research Center, provided advice for clinicians on how to counsel their patients about CBD and cannabis use.
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They also provided guidance for the Arthritis Foundation, who recently surveyed 2,600 people with arthritis and found that 29% currently use CBD to treat arthritis symptoms.
Boehnke and Clauw recommend that people with chronic pain talk to their doctor about adding CBD to their treatment plan, and continue to use their prescribed medication. They offer the following advice for people wanting to try CBD:
Don’t smoke or vape. Bottom line is smoking anything harms the lungs. Vaping has been associated with a recent epidemic of lung disease, according to the Centers for Disease Control & Prevention.
Purchase from reputable sources. Like vitamins and other supplements, CBD products aren’t regulated or FDA approved to treat disease, so buyer beware. Look for products that have been tested by an independent third party lab “so you don’t end up with a product that has THC in it or a product contaminated with heavy metals or pesticides,” says Boehnke.
Route of administration matters. CBD is best taken in pill or capsule form for slow extended release or as an oral tincture (infused oil that contains CBD) for faster effect onset.
Start low, go slow. Take a small amount and slowly increase your dosage until you start to get symptom relief over a matter of weeks. Track your symptoms to get a sense of whether or not CBD is a helpful part of your treatment plan.
Check your state laws. While medical marijuana is legal in many states, it’s still illegal at the Federal level, putting CBD in a legal gray zone in many areas.