“In all of these systematic reviews, they mention the limitations of existing studies,” says Boehnke. “They are typically small studies. They don’t give cannabis or cannabinoids to people for a long period of time. They don’t do a good job of figuring out the exact underlying pain phenotype. And, maybe most important, they don’t use cannabis products that are representative of what people are using today.”
But safe and effective are two different things. When it comes to treating pain, does CBD actually work, and how well?
“There’s a lot of studies that have been done in animals and those tend to show that it’s anti-inflammatory and that it does have some analgesic effect,” says Boehnke. “Unfortunately they haven’t been well translated in humans.”
Why experts are still hopeful
A 2017 review by the Department of Veterans Affairs found “low-strength evidence that cannabis preparations with precisely defined THC-cannabidiol content (most in a 1:1 to 2:1 ratio) may alleviate neuropathic pain but insufficient evidence in populations with other types of pain.”
“In the [research] group that I’m part of, we think of pain as coming in three different flavors,” says Boehnke. “One of them is neuropathic pain, and that’s caused by damage to or inflammation of the nerves.” Think: carpal tunnel syndrome or sciatica.
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But a report from the National Academies of Sciences, Engineering and Medicine (NASEM) published that same year concluded that there was “conclusive or substantial evidence” that cannabis is effective in treating chronic pain, as well as nausea and vomiting after chemotherapy and multiple sclerosis-related muscle spasms and stiffness.
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.
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.
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!
Many of the CBD products on the market are unregulated
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).
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.
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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.